Abdominal trauma with haemodynamic compromise and peritoneal signs

Patient Information

Dispatch: You are called to a patient (Marcus Donovan, 29-year-old male) at the Subiaco Oval AFL community day event. Bystanders report he was struck heavily by another player during a demonstration game and has been on the ground for several minutes complaining of severe abdominal pain.
Patient: Marcus Donovan — 29yr (80kg)
Incident History: Pt was playing in a community AFL demonstration match when he received a heavy collision — an opponent's knee struck him forcefully in the upper left abdomen during a marking contest. He walked two steps before going down. Has been on the ground approximately 5 minutes. Initially alert but bystanders report he has become increasingly pale and distressed.
Emergency Contact: Renee Donovan (Wife) — 0412 774 093

Initial Rapid Assessment

Response: Voice
Airway: Patent. No obstruction, no stridor, no blood in oropharynx.
Breathing: Breathing present but shallow and rapid. Splinting of left upper abdomen on inspiration. RR elevated. SpO2 93% on room air.
Circulation: Radial pulse rapid, weak and thready. Skin pale, cool and diaphoretic. No external haemorrhage visible. Abdomen visibly tensed.
Disability: GCS 13 (E3V4M6). Oriented to person only. Confused and increasingly agitated.
Exposure: Uniform intact over trunk. On exposure: significant guarding of entire abdomen. Rigid, board-like rigidity most pronounced left upper quadrant. Mild bruising developing over left lateral abdomen. No open wounds. Left shoulder tip pain reported by patient when asked.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	93% (RA)	Moderate	24	128	88/60	4s	13	4 4 ++	36.8	5.8 mmol/L	9
10 mins	97% (O2 NRB 15L)	Moderate	26	138	82/55	4s	11	4 4 ++	36.8	5.8 mmol/L	9

History Taking

Treatment Response

Diagnosis

This patient is suffering from blunt abdominal trauma with suspected splenic injury causing intraperitoneal haemorrhage, presenting with haemodynamic instability (hypotension, tachycardia, poor perfusion) and signs of developing peritonitis (guarding, rigidity, left shoulder tip pain consistent with Kehr's sign).

Facilitator Triggers — if trainees miss a critical step

! (If trainees fail to identify haemodynamic instability — low BP 88/60, HR 128, CRT 4s — within the first 2 minutes, patient becomes increasingly confused with GCS dropping to 11 and radial pulse becomes impalpable. Prompt: bystander states 'he seems worse, he's not making sense anymore'.)
! (If trainees fail to apply high-flow oxygen via non-rebreather mask within 3 minutes, SpO2 drops to 89% on room air and respiratory distress escalates to Severe.)
! (If trainees attempt to palpate the abdomen aggressively or repeatedly after identifying guarding and rigidity, patient cries out in pain, vomits, and GCS drops by 1 point. Prompt: 'Gentle palpation only — do not repeatedly spring or press the abdomen once rigidity is confirmed.')
! (If trainees fail to recognise Kehr's sign — left shoulder tip pain — as a significant finding indicating diaphragmatic irritation from intraperitoneal haemorrhage, facilitator prompts trainee: 'The patient mentions his shoulder is hurting too — what does that make you think about?')
! (If trainees do not call CSP for urgent ambulance support and ambulance backup within 5 minutes, patient's GCS falls to 10 and BP drops to 78 systolic. Facilitator states: 'Your supervisor asks you — what's your transport plan for this patient?')
! (If trainees attempt to provide oral fluids or oral medications given the likelihood of surgical intervention, facilitator interjects: 'Consider — what is likely to happen to this patient at hospital? Is oral intake appropriate?')

Treatment Objectives

1 Ensure scene safety and don appropriate PPE. Identify mechanism of injury — high-energy blunt abdominal trauma.
2 Perform Primary Survey: identify airway patent, breathing rapid and shallow (splinting), circulation compromised — radial pulse rapid and weak, pale/diaphoretic skin, no external haemorrhage.
3 Recognise haemodynamic instability: BP 88/60, HR 128, CRT 4s — identify signs consistent with internal haemorrhage and hypovolaemic shock.
4 Apply oxygen via non-rebreather mask at 10–15 L/min targeting SpO2 94–98%.
5 Position patient supine — do NOT sit up or elevate legs. Maintain comfort and limit movement.
6 Perform gentle abdominal assessment: palpate all four quadrants with minimal pressure — identify guarding and board-like rigidity most pronounced in left upper quadrant. Do NOT repeat aggressive palpation once rigidity is confirmed.
7 Identify Kehr's sign: left shoulder tip pain — recognise as diaphragmatic irritation secondary to intraperitoneal blood or free fluid (indicative of significant intra-abdominal pathology).
8 Complete Vital Sign Survey: GCS 13, BP 88/60, HR 128, RR 24, SpO2 93% RA, CRT 4s, BGL 5.8 mmol/L, Temp 36.8°C.
9 Perform Secondary/CNS Survey: assess all four abdominal quadrants, back (log roll if safe), pelvis for concurrent injury (avoid pelvic springing), limbs for distracting injuries.
10 Recognise this as a time-critical patient — call CSP for urgent ambulance support and call for ALS ambulance backup immediately. Pre-advise CSP (major trauma centre).
11 Minimise on-scene time — ongoing management should be undertaken during transport.
12 Keep patient warm — cover with blanket to prevent heat loss and manage sympathetic response.
13 Reassure patient continuously and provide calm, clear communication.
14 Monitor and record full observations every 5 minutes given time-critical status. Anticipate deterioration: falling GCS, dropping BP, rising HR.
15 Prepare for clinical deterioration: have BVM and airway adjuncts (OPA/NPA) available. Be prepared to manage airway if GCS falls below 8.
16 Do NOT administer oral medications or fluids — patient is likely to require urgent surgical intervention.
17 Scenario ends on arrival of ambulance and IMISTAMBO handover.
18 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Abdominal Trauma · Haemorrhage · Hypovolemic Shock · Primary Survey · Secondary & CNS Survey · Oxygen Delivery · Trauma Management Principles

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