Concussion and mild traumatic brain injury — branching viva

Stem 1 — Fourteen-year-old rugby player dazed after a tackle (5 minutes)

A fourteen-year-old boy is tackled, strikes his head on the ground, is briefly dazed, sits out for two minutes, and returns to play. That evening he has a headache, feels foggy, has vomited once, and is sensitive to light. His GCS is 15 and his neurological examination is normal. [6]

Branch A (examiner): Identify the principle breached at the sideline and explain why a concussed athlete does not return to play the same day. Define concussion using the Amsterdam 2022 consensus. [4] [6]

Branch B (examiner): State your imaging decision and reproduce the decision rule you apply. Explain why the single vomit does not, on its own, mandate a computed tomography, and what feature you must monitor. [1] [2]

Branch C (examiner): Outline the graduated return to learn and return to sport, stating the duration of relative rest and the order of the two pathways. Explain the role of his previous concussion in your counselling. [4] [9]

Stem 2 — Eighteen-month-old infant who fell from a change table (5 minutes)

An eighteen-month-old infant is brought to the emergency department after rolling off a change table onto a carpeted floor. She cried immediately, but has since become clingy and quiet, and has vomited twice in the first hour. There is a small occipital scalp haematoma. The GCS is 15, the anterior fontanelle is soft and flat, and the neurological examination is normal. The parents give a clear and consistent history. [1]

Branch A (examiner): State which age-specific prediction rule you apply and reproduce its predictors. Explain whether the occipital scalp haematoma and the two vomits place this child in the imaging pathway. [1] [2]

Branch B (examiner): The parents ask whether a computed tomography is safe and necessary. Explain how the rule balances the radiation risk against the missed-injury risk, and describe your observation plan. State the features that would change your decision. [1] [3]

Branch C (examiner): Name the features in the history that would shift your focus to a safeguarding assessment, and describe how a non-accidental head injury changes your workup. [3]

Stem 3 — Eleven-year-old with symptoms persisting six weeks after a fall (5 minutes)

An eleven-year-old girl fell off her scooter six weeks ago and has had a daily headache, fatigue, poor concentration, and sensitivity to noise ever since. She has missed many school days, has withdrawn from netball, and is tearful. She has a history of migraine and anxiety. Her neurological examination is normal. [8]

Branch A (examiner): Define persistent post-concussion symptoms and state the threshold this child has crossed. Explain why the prolonged rest she was given likely worsened her course. [7] [4]

Branch B (examiner): List the predictors of a prolonged recovery that are present in this girl, and explain why a normal examination does not exclude the diagnosis. [9] [8]

Branch C (examiner): Outline the active rehabilitation plan, naming the specific therapies and the role of each. Explain why further rest is the wrong prescription and how you would coordinate the school reintegration. [7] [3]