Protect the brain — initial stabilisation of major paediatric head injury

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 recognition of severe traumatic brain injury, leadership of the neuroprotective primary survey with cervical spine control, airway threshold, ventilation target, fluid strategy, raised intracranial pressure management, communication, reassessment, neurosurgical escalation and safe transfer. [8] [11]

Candidate instructions

You are the paediatric registrar called to the resuscitation room. Assess the child from the doorway and say aloud what you see. Lead the neuroprotective primary survey and treat each problem as you find it. Speak directly to the child and parent. Reassess from A after every action. Call senior, neurosurgical or retrieval support early. Run safeguarding alongside urgent care. 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. [1]

Room setup and observable starting state

The encounter. Mia is six years old and is brought to the resuscitation room by paramedics on a scoop stretcher with manual in-line cervical stabilisation. The paramedic reports she was struck by a car at speed and was briefly unconscious. Mia opens her eyes only to pain, makes incomprehensible sounds, and withdraws to pain, giving a Glasgow Coma Scale of 7. The candidate should describe these findings, declare a severe head injury, call for help, and begin the neuroprotective primary survey immediately. [1] [11]

Simulation safety. Mia is an actor on a stretcher and is never forcibly positioned or made to simulate distress physically. Cards or the assessor supply vital signs, monitor readings and examination findings. The parent does not obstruct urgent care. [1]

Actor cues

Parent actor

• Begin with "She was hit by a car. She was out cold for a bit but then came around on the way here." If asked what has changed, answer: "Mia is usually so lively. After the accident she kept falling asleep and wouldn't answer me properly." [1]

Child actor

• Respond to pain only: open eyes to pain, make incomprehensible sounds, withdraw to pain. Become less responsive following the assessor's cue card as the scenario progresses. [1]

Assessor cues and clinical data

Release findings as the candidate reaches each step. Reward neuroprotective reasoning and penalise delayed intubation, prophylactic hyperventilation, hypotonic fluid or unescorted imaging. [1]

Cervical spine and A - Airway

Manual in-line stabilisation is in place. The airway is patent but not protected. There is blood in the mouth from a facial laceration. Expected strong behaviour: maintain manual in-line stabilisation; state that GCS 7 is the threshold for definitive airway; summon the airway-skilled team; prepare for rapid sequence intubation with a neuro-friendly agent and muscle relaxant; confirm with waveform capnography. [1]

B - Breathing and ventilation

Respiratory rate is 8 and irregular; oxygen saturation is 92 percent on air. Expected strong behaviour: state the ventilation target is normocapnia; give high-flow oxygen; avoid prophylactic hyperventilation; use waveform capnography after intubation; state that hypocapnia causes cerebral vasoconstriction and ischaemia. [1]

C - Circulation

Heart rate is 130, blood pressure is 95 over 60, capillary refill is 3 seconds, and there is a grazed knee with minor bleeding. Expected strong behaviour: state that hypotension doubles mortality after severe TBI; use isotonic crystalloid in aliquots; avoid hypotonic fluid; maintain age-appropriate blood pressure; control external bleeding. [7]

D - Disability

GCS is 7 (E2 V2 M3). Pupils are initially equal and reactive. Bedside glucose is 6.2 mmol per litre. Expected strong behaviour: record GCS score, time and trend; check pupils and repeat; check bedside glucose; position head 30 degrees up and midline with C-spine protected; state that a falling GCS by 2 or more points is an emergency. [1]

Escalation event — unilateral dilated pupil

After intubation and stabilisation, the right pupil becomes 6 mm and poorly reactive. Expected strong behaviour: recognise impending uncal herniation; give hyperosmolar therapy now (3 percent saline bolus or mannitol); ensure head 30 degrees up and midline; confirm adequate sedation and paralysis; arrange urgent CT; call neurosurgery immediately. [2]

Imaging result

CT confirms a right extradural haematoma with 5 mm midline shift. Expected strong behaviour: state this is a surgical emergency needing urgent evacuation; call neurosurgery and retrieval; discuss transfer plan, destination, escort and contingency; continue neuroprotection bundle throughout. [8]

Weight and drug dosing

The candidate must obtain a working weight. Expected strong behaviour: use a measured weight if available; otherwise document a working weight from a recent reliable value, a credible parent estimate, or the trained length-and-habitus tool; use the local paediatric cognitive aid; state the hyperosmolar agent dose per kilogram. [1]

Marking domains

Debrief prompts

• What was the most important neuroprotective decision you made, and why was timing critical?
• How did you balance the urgency of CT against the need to stabilise the child first?
• What would you do differently if the child arrived already hypotensive?
• How did cervical spine control feature in every airway manoeuvre?
• What is the evidence for your choice of hyperosmolar agent? [1] [8]