Simulated Patient Scenario

Scenario Details

MDT Information

• Non-Urgent Response - Fall / Minor Injury
• 25-year-old male tripped and fell, hit head
• Patient is conscious and alert, complaining of headache
• No loss of consciousness reported by caller (patient)
• Location: Patient's home

On Arrival

You arrive at an apartment. The patient, a 25-year-old male, meets you at the door. He is alert and walking but holding his forehead. He states he tripped over a rug and hit his head on the corner of a coffee table about 30 minutes ago. He appears slightly anxious.

Initial Impression and Primary Survey

Secondary Survey and Simulation Progression

History (obtained from patient)

Vital Signs/Assessment (Initial)

Physical Examination

• General Appearance: Alert, cooperative, appears well apart from headache.
• Head: Small (~2cm) superficial abrasion and slight swelling/tenderness over the right forehead. No palpable skull deformity or significant haematoma. No Battle's sign or raccoon eyes. No CSF/blood leak from nose/ears.
• Neck: No tenderness on palpation of cervical spine. Full range of active neck movement without pain.
• Neurological: GCS 15. Pupils equal and reactive. Cranial nerves grossly intact (assess eye movements, facial symmetry, tongue protrusion). Normal power, sensation, and coordination in all four limbs. Gait steady (if assessed).

Assessment and Treatment

Appropriate Management Focus

• Primary Survey (ABCDE): Confirm no immediate life threats.
• History Taking: Obtain thorough history focusing on mechanism, LOC, amnesia, vomiting, seizure, headache characteristics, anticoagulants, alcohol/drugs.
• Neurological Assessment: Perform comprehensive neurological exam including GCS, pupil assessment, and screening for focal deficits.
• Head/Neck Examination: Inspect and palpate head for signs of significant injury (depressed fracture, large haematoma, CSF leak). Assess C-spine if mechanism or symptoms warrant (low risk here based on history/exam).
• Identify Red Flags: Systematically assess for red flags indicating potential serious intracranial injury (e.g., GCS <15, suspected skull fracture, signs of basal skull fracture, vomiting >1 episode, seizure, focal neurological deficit, dangerous mechanism, age >65, coagulopathy).
• Risk Stratification (e.g., Canadian CT Head Rule - High Risk Factors):
  • GCS < 15 two hours post-injury? (No)
  • Suspected open or depressed skull fracture? (No)
  • Any sign of basal skull fracture? (No)
  • Vomiting ≥ 2 episodes? (No)
  • Age ≥ 65 years? (No)
  • (Medium Risk Factors: Amnesia before impact > 30 mins? Dangerous mechanism? - Fall from height/MVA etc - No)
  • Based on assessment, patient appears low risk according to CCHR criteria.
• Pain Management: Simple analgesia (Paracetamol already taken) usually sufficient. Avoid NSAIDs if intracranial bleed suspected (low suspicion here).
• Supportive Care: Reassurance.
• Disposition Planning:
  • Based on low-risk assessment (GCS 15, no LOC/amnesia/vomiting/seizure/focal deficit/red flags, low-risk mechanism), transport to ED is not strictly mandatory *if* reliable discharge advice can be given and understood, and a responsible adult can monitor the patient.
  • **Provide comprehensive Head Injury Advice:** Explain signs/symptoms requiring immediate return to ED (worsening headache, vomiting, drowsiness, confusion, seizure, weakness, visual disturbance). Provide written advice sheet if available. Advise rest, avoidance of alcohol/strenuous activity. Ensure patient understands advice and has support at home.
  • **Document Thoroughly:** Record detailed assessment findings, negative red flags, risk stratification (e.g., low risk per CCHR), discharge advice given, patient understanding, and confirmation of support at home.
  • **Offer Transport:** Always offer transport to ED for further assessment, even if deemed low risk, respecting patient autonomy. If patient refuses transport against advice, document capacity and refusal clearly.
• Teamwork & Communication: Discuss findings and plan with partner. Clear communication with patient regarding assessment, risks, and advice.

Debrief Focus Points

• Systematic assessment of minor head injury patients.
• Importance of detailed history taking (LOC, amnesia, vomiting etc.).
• Performing a focused neurological examination.
• Recognizing red flags indicating potential serious intracranial injury.
• Application of clinical decision rules (e.g., Canadian CT Head Rule) for risk stratification (context dependent).
• Appropriate discharge criteria and head injury advice for low-risk patients.
• Importance of thorough documentation, including patient understanding and support systems.
• Managing patient refusal of transport when deemed low risk.
• Differentiating minor head injury from more severe TBI.