Resuscitate before you decontaminate — the poisoned child

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 resuscitation before decontamination, the four-question ingestion history, reading the toxidrome, calling the Poisons Information Centre, deciding on activated charcoal within the first hour, communication, reassessment, safeguarding in parallel, handover and disposition. [1] [9]

Candidate instructions

You are the paediatric registrar called to the acute assessment room. Assess the child from the doorway and say aloud what you see. Secure the airway, breathing and circulation first, and confirm a bedside glucose, before any decontamination work-up. Take the four-question ingestion history with the container. Read the toxidrome from the vital signs and pupils. Call the Poisons Information Centre early. Decide on activated charcoal only if the airway is safe and the toxin is adsorbable and within the window. Speak directly to the child and parent. Reassess 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. [9]

Room setup and observable starting state

The encounter. Leo is two and is supported on the assessment trolley by a parent. The parent holds a pill organiser and says, "He got into Grandad's tablets." Leo is drowsy but rousable, pink, with mild tachycardia. These are abnormalities in appearance with an uncertain ingestion. The candidate should describe these signs objectively, declare concern, call for help, confirm the primary survey, obtain a working weight, bring the container into the assessment, and begin the structured ingestion history rather than reach for charcoal first. [9]

Simulation safety. Leo remains on the trolley and is never forcibly positioned or made to vomit. Cards or the assessor supply observations, monitor readings and examination findings. The parent does not obstruct urgent care and supplies the container on request. [9]

Actor cues

Parent actor

• Begin with "He got into Grandad's tablets." If asked what has changed, answer: "About forty minutes ago I found him with the pill organiser open. I think some tablets are missing but I'm not sure how many."
• If asked for the container, hand over the pill organiser and any loose tablets, and add: "Grandad takes a few different tablets, I'm not sure what they all are."
• If asked about access and storage, answer: "The organiser was on the low table. We're staying at Grandad's for the weekend." [9]

Child actor

• Remain drowsy but rousable early in the encounter; follow the assessor's cue card for any change in observations or conscious level. [9]

Assessor cues and clinical data

Release findings as the candidate reaches each step. Reward resuscitation-first behaviour and the structured history, and penalise decontamination-before-resuscitation behaviour. [1] [9]

Primary survey

Airway is patent, breathing is adequate, circulation is stable. Heart rate 125, respiratory rate 28, oxygen saturation 98 percent on air, capillary refill 2 seconds. Expected strong behaviour: confirm the primary survey is intact, obtain a bedside glucose, establish monitoring and IV access, and obtain a working weight before any decontamination decision. [9]

Bedside glucose and weight

Bedside glucose is normal. Working weight 12 kg from a recent reliable value. Expected strong behaviour: record the glucose as excluded as a reversible cause, document the working weight for any drug or decontamination dosing, and re-weigh at the first safe opportunity. [9]

The ingestion history and the container

The container confirms a sustained-release medication; the exact number of missing tablets is uncertain. Expected strong behaviour: take the four-question history (what, how much, when, what else), read the label with the Poisons Information Centre, and document the time of ingestion against the charcoal window. [9]

Toxidrome and ECG

Leo is drowsy but rousable with dilated pupils; no clear toxidrome yet. Expected strong behaviour: read the vital signs and pupils, keep the toxidrome differential broad, and request an ECG for any cardiotoxic possibility while observing for delayed and sustained-release toxicity. [1]

The Poisons Information Centre call

Expected strong behaviour: call the Poisons Information Centre early (Australia 13 11 26) with the substance, dose, time, weight and physiology, document the advice and reference, and let it shape the decontamination and observation plan. [9]

The activated charcoal decision

It is now about fifty minutes since ingestion; the airway is protected, Leo is not vomiting, and the toxin is confirmed adsorbable by the Poisons Information Centre. Expected strong behaviour: state the conditions for charcoal (airway safe, within the window, toxin adsorbable, significant exposure), give activated charcoal at 1 g/kg to a maximum of 50 g, and observe for delayed toxicity because the formulation is sustained-release. [3] [12]

Safeguarding and disposition

This is an unintentional toddler exposure. Expected strong behaviour: document objectively, offer poison-prevention and safe-storage advice, and observe for the formulation-specific window before discharge with a defensible safety net. Note that if the history were inconsistent or access were neglected, the local safeguarding pathway would run in parallel. [9]

Marking domains

Debrief prompts

• What was the first principle at the doorway, and why does resuscitation precede decontamination in every poisoned child?
• How did the four-question history and the container change your decontamination decision?
• Which conditions had to be met before you gave activated charcoal, and how did the Poisons Information Centre shape the plan?
• How did the sustained-release formulation change your observation window, and what would have escalated you to whole bowel irrigation?
• How did safeguarding and family communication run in parallel with medical care, and what made your safety net defensible? [9]