Simulated Patient Scenario

Scenario Details

MDT Information

• Urgent response - Fall from height
• 45-year-old male, fell approx 3-4 meters from ladder
• Patient confused, pale
• Patient breathing rapidly
• Bystander present

On Arrival

Patient is lying supine on grass at the base of a ladder leaning against a house. He is moaning, restless, and pale. A bystander states they saw him fall from the ladder while cleaning gutters. No obvious external haemorrhage noted initially.

Initial Impression and Primary Survey

Secondary Survey and Simulation Progression

History (Obtained from bystander initially, patient unable to provide)

Vital Signs/Assessment (Initial)

Physical Examination (Secondary Survey - Trauma Focused)

• **Head/Neck:** No obvious trauma, check C-spine tenderness (difficult to assess reliably).
• **Chest:** Rapid shallow breathing, equal air entry bilaterally on auscultation. Tenderness over left lower ribs on palpation. No crepitus or flail segment noted.
• **Abdomen:** Distended, tense, and generally tender on palpation, particularly left upper quadrant and flank. Guarding present. Bruising may start to appear over flank/abdomen (Grey Turner's/Cullen's sign - likely develops later).
• **Pelvis:** Appears stable on gentle compression/palpation (avoid 'springing').
• **Limbs:** Check for fractures/deformity. No gross deformity noted in limbs. Peripheral pulses weak.
• **Back:** Log roll required (maintain C-spine precautions) to assess spine and back for tenderness or deformity.
• **(Consider FAST scan if available and trained)**

Assessment and Treatment

Appropriate Management

• Recognise signs of decompensated hypovolaemic shock secondary to suspected intra-abdominal and/or retroperitoneal haemorrhage (e.g., splenic/hepatic/renal injury, pelvic fracture bleed) post-trauma. **Time critical.**
• Primary survey (ABCDE), manage immediate life threats.
• Airway management: Consider basic adjuncts (OPA/NPA) if tolerated, monitor closely for deterioration requiring advanced airway (RSI). High risk of aspiration.
• Breathing: High-flow oxygen via non-rebreather mask aiming SpO2 >94%. Assist ventilations if inadequate.
• Circulation:
  • Attempt haemorrhage control (limited pre-hospital options for internal bleeding). Pelvic binder if suspected pelvic involvement.
  • Establish large bore IV access x 2, preferably antecubital fossae. Consider IO access if IV difficult/delayed.
  • **Aggressive fluid resuscitation:** Initial bolus of warmed crystalloid (e.g., 1000ml Sodium Chloride 0.9% or Hartmann's solution) rapidly. Reassess response (BP, HR, mental status). Titrate further fluid to maintain radial pulse or target BP (e.g., systolic 80-90 mmHg - permissive hypotension until definitive haemorrhage control, follow local guidelines). Avoid excessive fluid resuscitation causing haemodilution/hypothermia.
  • Consider Tranexamic Acid (TXA) according to local trauma guidelines (e.g., 1g IV over 10 mins within 3 hours of injury).
  • Keep patient warm (blankets, warmed fluids) to prevent/treat hypothermia (part of lethal triad).
• Disability: Maintain C-spine precautions. Reassess GCS frequently. Manage pain cautiously with IV analgesia (e.g., small titrated doses of Fentanyl) once BP allows, monitor respiratory status.
• Exposure: Expose fully to assess injuries, then cover to prevent heat loss.
• Minimise on-scene time. Package patient safely (e.g., scoop stretcher, vacuum mattress) maintaining spinal alignment.
• **Pre-notify receiving hospital (Trauma Alert):** Provide age, mechanism, suspected injuries (intra-abdominal bleed), GCS, vital signs, treatments given (fluids, TXA), ETA. Specify need for trauma team activation / potential need for massive transfusion protocol.
• Rapid transport to the nearest appropriate Major Trauma Centre. Continuous monitoring en route.