Cool, resuscitate, safeguard — a scalded child in the resuscitation bay

Station status

This is one MedVellum formative structured clinical encounter. The scoring, prompts and performance descriptions are educational feedback tools. They are not an official college station, timing, mark allocation, pass score or reproduced examination format. The encounter assesses first-impression recognition, correct cooling, age-adjusted TBSA estimation, modified-Parkland fluid resuscitation titrated to urine output, recognition of the evolving airway, communication, safeguarding in parallel, and safe handover. [2] [3]

Candidate instructions

You are the paediatric registrar leading the resuscitation of a burned child in the bay. Assess the child from the doorway and say aloud what you see. Cool the burn correctly with running water for 20 minutes within 3 hours of injury while keeping the rest of the child warm. Estimate the percent TBSA with an age-adjusted Lund and Browder chart, exclude erythema, and judge depth. Start modified-Parkland fluid titrated to urine output for any burn at or above 10 percent TBSA. Speak directly to the child and the parent. Reassess from the top after every action. Run safeguarding in parallel. Finish with a structured handover and disposition plan. Say what you would assess or do; do not perform painful or distressing manoeuvres on the actor. [2]

Room setup and observable starting state

The encounter. Aria is three and is brought to the bay on a trolley by her father. He reports that she pulled a cup of hot tea onto herself at home about 30 minutes ago; he ran cool water over the area for a short time. The burn involves the right side of the face, the front of the chest and the front of the right arm. Aria is crying but alert and interactive, with a normal cry. The candidate should describe these signs objectively, declare concern, confirm the team is activated, start cooling correctly, keep the rest of the child warm, give weight-based analgesia, and begin the assessment. The face involvement is the cue that the airway and the special-site referral must be considered. [2] [8]

Simulation safety. Aria remains on the trolley and is never forcibly positioned or distressed. Cards or the assessor supply vital signs, burn extent and examination findings. The parent does not obstruct urgent care. [2]

Actor cues

Parent actor

• Begin with "She reached up for my cup, I only looked away for a second." If asked what has changed, answer: "She was crying straight away and the skin went red and blistered. I ran the cool tap but I wasn't sure how long." [9]
• If asked an open question about the mechanism, stay consistent and specific about the cup of tea, the timing, and the home setting. Do not volunteer information that is not asked for.

Child actor

• Cry and interact early in the encounter; remain alert and responsive. If the assessor's cue card indicates the airway is evolving, become hoarse and begin to drool. [8]

Assessor cues and clinical data

Release findings as the candidate reaches each step. Reward correct cooling and age-adjusted TBSA estimation, and penalise ice, the Rule of Nines, including erythema, and calculating fluid from arrival. [2]

Cooling and first aid

The father ran cool water briefly at home. Expected strong behaviour: continue cooling with running water for 20 minutes within 3 hours of injury, keep the rest of the child covered and warm, remove clothing and jewellery, and give weight-based analgesia. [4]

Airway and breathing

Alert, interactive, normal cry initially; oxygen saturation 97 percent on air; no soot and no singed hair at the start. Expected strong behaviour: assess for inhalation signs, give high-flow oxygen if the airway evolves, and state that face involvement and any hoarseness, drooling or stridor demand senior airway help and a low threshold for an early definitive airway. [8]

Circulation and fluid

Heart rate 130, capillary refill 2 seconds, blood pressure normal for age; weight 14 kg. Expected strong behaviour: estimate TBSA with the age-adjusted Lund and Browder chart (face, anterior trunk and anterior arm; exclude erythema); if the partial-thickness area is 10 percent or more, start modified-Parkland Hartmann at 3 mL per kilogram per percent over 24 hours with half in the first 8 hours from the time of injury, add glucose maintenance, and titrate to a urine output of 1 mL per kilogram per hour. [2] [7]

Depth and special sites

The burn is blistered, pale pink, blanching and very painful (superficial dermal) over most of the area, with a small fixed-red patch on the chest. The face, chest and arm are special-site involvement. Expected strong behaviour: state the depth and the special sites, draw the burn on a Lund and Browder map, photograph it with consent, and refer to the burns service for the face and hand involvement even if the area is modest. [3] [2]

Escalation event — the evolving airway

Halfway through, Aria becomes hoarse and begins to drool. Expected strong behaviour: recognise the evolving airway, call senior airway expertise early, prepare a calibrated difficult-airway plan, and have a low threshold for an early definitive airway; do not wait for stridor. [8]

Safeguarding

The father's account is consistent with the developmental stage and the splash distribution. There are no prior presentations. Expected strong behaviour: keep safeguarding open, ask open non-leading questions, document the burn objectively, photograph with consent, and state that a face burn in a three-year-old still requires the local pathway to be considered; do not confront the family. [9]

Marking domains

Debrief prompts

• What was the key action at each stage, and what did you expect it to change?
• Why does the age-adjusted chart matter, and what error does the Rule of Nines introduce in a small child?
• Why is the fluid clock counted from the time of injury, and why is the formula a starting point rather than a target?
• How did you decide when the airway needed securing, and what would you do differently if senior help were an hour away?
• How did you keep safeguarding running in parallel without confronting the family?