'They're not themselves' — paediatric sepsis structured encounter

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 sepsis recognition and Phoenix classification, the first-hour bundle, fluid and vasoactive escalation with reassessment, source control, communication and safe handover. [3] [11]

Candidate instructions

You are the paediatric registrar called to an acute assessment room. Recognise and classify Daniel's sepsis using the Phoenix criteria. Lead the first-hour bundle: cultures before antibiotics only if it does not delay the dose, a broad-spectrum weight-based antibiotic within one hour, and judicious fluid aliquots with reassessment. Speak directly to Daniel and his mother. Call senior and critical-care support early. Address source control in parallel. Finish with a structured handover and disposition plan. Do not perform painful manoeuvres on the actor; say what you would assess or do instead. [3] [11] [12]

Room setup and observable starting state

The encounter. Daniel is 4 and has had two days of fever and cough. He is seated with his mother. His mother begins: "They're not themselves." [11] [12]

What is visible before touch. Daniel looks only briefly towards his mother. He is mottled from the knees down, with cool peripheries. These are abnormalities in appearance, work of breathing, and circulation to skin consistent with sepsis. The candidate should describe the signs, classify the syndrome, call for help, and begin the bundle. The candidate should not diagnose from the doorway, but should treat the threat immediately. [1] [12]

Simulation safety. Daniel remains seated. Cards or the assessor supply observations, examination findings and monitor readings. No painful or distressing manoeuvre is performed on the actor. [11]

Actor cues

Child actor

• When the candidate uses Daniel's name and simple words, look towards them briefly, then look away. [12]

Caregiver actor

• Begin with "They're not themselves." If asked what changed, answer: "He usually runs around and chats. Today he's quiet, cold, drinking nothing, and hasn't weed since this morning." [11] [12]

Assessor cues and clinical data

Give each finding only when the candidate reaches that step or asks for it. Interpret observations using Daniel's exact age, measurement conditions, trend and active local chart. The Royal Children's Hospital Melbourne Sepsis guideline is one example pathway; it is not a universal rule. [3] [12]

The Surviving Sepsis Campaign 2026 children's guideline supports the first-hour bundle. This encounter gives no universal fluid target or specific dose; the candidate should follow the active local pathway, use age- and weight-appropriate equipment, and judge the response after every intervention. [3]

Reassessment cue within the same encounter

Once the candidate has called help, given the antibiotic and one or two fluid aliquots, say: "Daniel now has hepatomegaly, crackles at both bases, and his lactate is 5.0. His blood pressure is 80/45." This is not a second case. The candidate should recognise fluid intolerance and refractory shock, stop further boluses, start or escalate adrenaline for cold shock, request early PICU involvement, and continue source control in parallel. [3] [8] [12]

Expected candidate sequence

1. Recognise and classify. Describe the bedside signs, state the Phoenix cardiovascular score, and classify the syndrome as septic shock. Explain that a normal-range blood pressure does not exclude shock. Call the senior and critical-care teams now. [1] [3]
2. First-hour bundle. Assign a leader and estimate weight. Draw two blood cultures before antibiotics only if it does not delay the dose. Give a broad-spectrum weight-based antibiotic within one hour. Give a 10 mL/kg aliquot and reassess. [3] [11]
3. Escalate on deterioration. Recognise hepatomegaly and crackles as fluid intolerance. Stop fluids, start adrenaline for cold shock, involve PICU, and consider hydrocortisone for catecholamine-resistant shock. [3] [8]
4. Source control, handover and disposition. Image the chest and arrange empyema drainage if present. De-escalate antibiotics to the organism. Give a structured handover carrying the diagnosis, Phoenix score, timed interventions, pending cultures and deterioration plan. Retrieval is arranged before local capability is exceeded. [11] [12]

MedVellum formative marking domains

This educational rubric has 10 domains scored 0–3, giving a MedVellum formative total of 30. Score 0 for omitted or unsafe, 1 for named but incomplete, 2 for clear and safe, and 3 for integrated, prioritised and reassessed. This is not an official board mark or pass standard. Feedback should identify the first unsafe step, not only the total. [3] [11]

Critical fails

Any item below overrides a reassuring formative total because it creates immediate avoidable risk. [3] [8]

• Delays the antibiotic beyond one hour for imaging or an unsafe procedure.
• Continues fluid boluses past the ceiling despite hepatomegaly or crackles.
• Waits for refractory shock before starting vasoactives.
• Omits source control or fails to escalate to PICU or retrieval.

Examiner prompts

Use as few neutral prompts as possible. A prompted behaviour can receive no more than 2/3 in the affected MedVellum formative domain. This is an educational feedback convention, not an official examination rule. [3] [11]

1. "What syndrome does Daniel have, and how do you classify it?"
2. "What is your antibiotic timing target, and what about cultures?"
3. "When do you stop the fluids and start the vasoactive?"
4. "How will you control the source?"

Model performance

Daniel has suspected infection with life-threatening organ dysfunction — a Phoenix cardiovascular score from his impaired perfusion, oliguria and lactate — so this is septic shock. I call for help, take cultures before antibiotics only if it does not delay the dose, give a broad-spectrum weight-based antibiotic within one hour, and give a 10 mL/kg aliquot with immediate reassessment. When he develops hepatomegaly and crackles with a rising lactate, I stop fluids, start adrenaline for cold shock, involve PICU early, and consider hydrocortisone. I control the source by imaging and draining any empyema, de-escalate antibiotics to the organism, retrieve before local capability is exceeded, and hand over the diagnosis, timed interventions, pending cultures and deterioration plan. [1] [3] [12]

Disposition and safety-net standard for this encounter

Daniel is not safe for discharge. He transfers to the service agreed with PICU or retrieval. A brief improvement does not make discharge safe. The team states the next sign of failure, the action, the owner, and the plan if retrieval is delayed. Handover includes the diagnosis, pending results and specific warning changes. Check understanding directly with Daniel's mother. [11] [12]