Simulated Patient Scenario

Fall with Loss of Consciousness

Scenario Details

Scenario: Fall with Witnessed Loss of Consciousness (LOC)

Simulated Patient: 78-year-old Female

Actor/Actress: Student Actor (Patient), Student Actor (Spouse/Witness)

MDT Information

Urgent Response - Fall / Collapse
78-year-old female fell at home
Witnessed brief loss of consciousness by spouse
Patient now conscious, complaining of head pain
Location: Home address

On Arrival

You arrive at a tidy house. The patient's spouse meets you, appearing worried. They lead you to the kitchen where the patient, a 78-year-old female, is sitting on a chair, holding a cloth to a small cut on her forehead. She appears pale and slightly confused but responds to your presence. The spouse explains she collapsed suddenly while standing near the sink.

Scene Safety Note: Assess for slip/trip hazards in the immediate area.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Elderly female, alert but potentially confused, minor head laceration, recent LOC.
Response	Opens eyes spontaneously, slightly confused conversation, obeys commands. (AVPU = A, GCS 14: E4 V4 M6)
Airway	Clear and self-maintaining.
Breathing	Rate and depth appear normal. No respiratory distress.
Circulation	Skin pale, slightly cool peripherally. Radial pulse palpable, regular rate and rhythm.
Disability	Alert but confused (GCS 14). Complains of headache. Small forehead laceration.
Exposure/Environment	Indoor kitchen environment. Assess head and consider C-spine due to fall/LOC.

Secondary Survey and Simulation Progression

History (obtained from patient - may be unreliable due to confusion, and spouse)

Allergies	NKDA (Spouse confirms)
Medications	Metoprolol, Perindopril, Aspirin, Atorvastatin.
Past Medical History	Hypertension, Ischaemic Heart Disease (previous MI 5 years ago), Atrial Fibrillation (on Aspirin, not full anticoagulation), Osteoarthritis.
Last Oral Intake	Breakfast ~ 1 hour ago.
Events Preceding / Fall Details:	Witness Account (Spouse): Patient was standing at the kitchen sink, suddenly went pale and collapsed to the floor without warning (~15 mins ago). Appeared unresponsive for approx 15-20 seconds, then started to groan and slowly regained consciousness over the next minute. Did not witness specific head strike but heard a thud. No seizure activity witnessed. Patient Account: Patient remembers feeling slightly lightheaded just before everything "went black". Does not remember falling or hitting her head. Now feels confused and has a headache. Preceding Symptoms: Patient denies chest pain, palpitations, or significant dizziness before the lightheadedness. Spouse confirms no complaints prior. Post-Fall Symptoms: Headache (forehead, 4/10), confusion ("feeling foggy"). Denies neck pain, vomiting, visual changes, weakness, or numbness.

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	18
Lung Sounds (L/R)	Clear bilaterally.
SpO2 (%)	96% (Room Air)
EtCO2 (mmHg)	Not indicated
Pulse Rate (/min.)	70, Irregularly irregular (AF)
CRT (sec.)	< 3 sec
ECG rhythm	Atrial Fibrillation (known)
12-lead ECG	Atrial Fibrillation, rate 70 bpm. No acute ST changes or significant pauses. Compare with previous if possible.
BP (mmHg)	115/70 (Consider orthostatics if safe/feasible)
Skin	Pale, cool peripheries, dry.
Pain (/10)	4/10 headache over forehead.
GCS (/15: E,V,M)	14/15 (E4, V4 - confused, M6)
BGL (mmol/L)	5.8
Pupils (mmL/mmR)	3mm L / 3mm R, Equal and Reactive (PERL)
Temp. (°C)	36.6

Physical Examination

General Appearance: Alert but appears frail, slightly confused.
Head: ~1cm clean laceration to right forehead, minimal bleeding. No palpable step deformity or significant haematoma. No Battle's sign/raccoon eyes.
Neck/Spine: No obvious deformity. Midline cervical spine tenderness elicited on palpation. Full assessment limited by patient positioning/compliance initially.
Neurological: GCS 14 (confused). Pupils equal and reactive. Moves all limbs spontaneously, strength appears grossly equal but formal testing limited. No gross focal deficits noted.
Cardiovascular: Irregularly irregular pulse (AF). Heart sounds normal. No significant oedema.
Respiratory: Chest clear.
Other: Check hips/other limbs for injury related to fall. No other obvious injuries found.

Assessment and Treatment

Appropriate Management Focus

Primary Survey (ABCDE): Address immediate life threats. Note altered GCS.
Consider Syncope vs Trauma: High index of suspicion for syncope (sudden collapse without warning) leading to secondary head injury. Need to manage both possibilities.
Cervical Spine Motion Restriction: Apply manual in-line stabilisation initially due to fall, LOC, and C-spine tenderness. Consider appropriate immobilisation (e.g., collar, head blocks) for transport based on assessment and local protocols.
Head Injury Management:
- Assess for red flags (GCS <15, vomiting, seizure, focal deficit, signs of skull #). Age >65 is a risk factor.
- Manage forehead laceration (clean, dress).
- Perform serial neurological observations (GCS, pupils).
Syncope Workup Considerations:
- Obtain 12-lead ECG to look for underlying cardiac causes (arrhythmias, ischaemia, blocks, long QT). Note known AF.
- Check BGL.
- Consider orthostatic vital signs if safe and patient condition allows (likely deferred).
- Gather detailed history about events preceding, during, and after LOC from witness.
Oxygen Therapy: Apply oxygen only if hypoxic (SpO2 < 94%).
IV Access: Establish IV access.
Pain Management: Provide analgesia for headache/laceration (e.g., Paracetamol).
Monitoring: Continuous ECG, SpO2 monitoring. Frequent vital signs and GCS reassessment.
Transport Decision: Mandatory transport to ED is required due to witnessed LOC, age >65, head strike, ongoing confusion (GCS 14), C-spine tenderness, and underlying cardiac history.
Teamwork & Communication: Clear roles. Communicate findings and plan to patient/spouse. Provide comprehensive pre-notification to ED (Elderly fall, witnessed LOC, GCS 14, C-spine tender, known AF/IHD, minor head lac). Clear handover.

Debrief Focus Points

Approach to falls in the elderly, considering both trauma and underlying medical causes.
Differentiating syncope from other causes of collapse/LOC.
Importance of witness accounts in assessing LOC events.
Assessment and management of minor head injury, including red flag identification and risk stratification.
Indications for and application of cervical spine motion restriction.
Importance of 12-lead ECG in syncope/collapse assessment.
Communication with elderly patients (potentially confused) and their families.
Rationale for transport decisions in patients with falls/LOC.