Run the survey, not the label — major trauma and the trauma team

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, leadership of a team-led <C>ABCDE trauma primary survey, catastrophic-haemorrhage-first reasoning, weight-based fluid with early blood, cervical spine protection, communication, reassessment, escalation and safe transfer of information. [6] [8]

Candidate instructions

You are the paediatric registrar leading the trauma team in the resuscitation bay. Assess the child from the pre-alert and say aloud what you see. Run a team-led <C>ABCDE primary survey and treat each problem as you find it. Speak directly to the child and parent. Reassess from the top after every action. Call senior, surgical 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. [6]

Room setup and observable starting state

The encounter. Mia is seven and is brought to the bay on a trolley by ambulance officers. They report a pedestrian-versus-car impact at speed. There is an open right femoral wound with active bleeding and a seat-belt-like abrasion across the abdomen from being thrown. Mia is drowsy, opens her eyes to voice, and looks pale with mottled knees. These are abnormalities in appearance, circulation to skin and mechanism. The candidate should describe these signs objectively, declare concern, confirm the team is activated, control the external bleeding first, and begin the primary survey. [8] [6]

Simulation safety. Mia remains on the trolley and is never forcibly positioned or made to hyperventilate. Cards or the assessor supply bleeding rate, monitor readings and examination findings. The parent does not obstruct urgent care. [6]

Actor cues

Parent actor

• Begin with "She just didn't see the car." If asked what has changed, answer: "Mia is usually running everywhere. She flew up onto the bonnet and her leg is bleeding badly and she's gone quiet and white."
• If analgesia is offered, accept gratefully. If safeguarding is raised, answer factually and do not obstruct the pathway. [6]

Child actor

• Respond briefly to voice early in the encounter; become drowsier and harder to rouse if the assessor's cue card indicates deterioration, and cry out with any leg movement. [6]

Assessor cues and clinical data

Release findings as the candidate reaches each step. Reward catastrophic-haemorrhage-first behaviour and penalise airway work before bleeding is controlled. [6]

<C> and A — Catastrophic haemorrhage and airway

There is brisk bright-red bleeding from the open femoral wound; the cervical spine is at risk from the mechanism. Expected strong behaviour: apply direct pressure and a tourniquet to the femoral wound, apply a pelvic binder if the pelvis is unstable, and do this before airway work; then maintain manual in-line stabilisation, assess airway patency, and call airway expertise early. [5]

B — Breathing

Respiratory rate 32, reduced air entry on the left, oxygen saturation 92% on air with a reliable waveform. Expected strong behaviour: give high-flow oxygen, recognise possible tension or haemo-pneumothorax clinically, and decompress or drain without waiting for imaging if tension is present. [6]

C — Circulation

Heart rate 145, weak central pulses, capillary refill 4 seconds, blood pressure low-normal for age, cool mottled limbs. Expected strong behaviour: diagnose shock from the whole picture despite a non-hypotensive blood pressure; gain intravenous or intraosseous access; give weight-based aliquots of 10 to 20 mL per kilogram with early blood for haemorrhagic shock; minimise crystalloid; crossmatch early. [8] [5]

D — Disability

Responds to voice but cannot sustain interaction; pupils equal and reactive; no seizure yet; bedside glucose normal. Expected strong behaviour: screen with AVPU and plan a formal paediatric Glasgow Coma Scale; check pupils and glucose; state that a falling Glasgow Coma Scale or lateralising sign triggers a definitive airway, near-normal carbon dioxide, imaging and neurosurgery. [1]

E — Exposure

Open femoral wound, seat-belt abrasion, no rash; temperature 35.6 degrees Celsius. Expected strong behaviour: expose fully but briefly, look for every wound, warm actively, and run safeguarding documentation in parallel because the mechanism and history are so far consistent. [6]

Escalation event — the lethal triad

A venous gas returns with a base deficit and a raised international normalised ratio; the haemoglobin falls despite blood; the temperature drops to 34.9 degrees Celsius. Expected strong behaviour: recognise the lethal triad, escalate to a massive transfusion protocol with balanced components near 1 to 1 to 1, give tranexamic acid within 3 hours, warm actively above 35 degrees Celsius, and arrange urgent surgical control of the source. [5]

Weight and imaging

The candidate must obtain a working weight for drug and device sizing, and decide on imaging. Expected strong behaviour: use a measured or length-based weight and the local paediatric cognitive aid; in this high-risk child image the head and cervical spine urgently because she is not low-risk, while stating that PECARN rules would guide imaging in a lower-risk child; scan only with a safe transfer plan, monitoring and escort. [1] [2]

Marking domains

Debrief prompts

• What was the failing system at each stage, and what did you expect each action to change?
• Why did you control haemorrhage before managing the airway, and how did you protect the cervical spine throughout?
• How did you decide between crystalloid and blood, and how did you prevent the lethal triad?
• When would you have applied the PECARN rules, and when would imaging be unsafe?
• What made the handover and disposition defensible for this child and family? [6] [1]