← Back
Scenario — Abdominal trauma with haemodynamic compromise and peritoneal signs
Patient Information
Dispatch
You are called to a patient (Marcus Donovan, 35-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.
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
Signs/Symptoms
Severe left upper abdominal pain, radiating to left shoulder tip. Nausea present. Progressive dizziness and light-headedness. Increasing confusion reported by bystanders.
Onset
Sudden onset at time of collision approximately 8 minutes ago.
Pain
Severe constant left upper abdominal pain, worst at site of impact. Left shoulder tip pain present (Kehr's sign).
Quality
Sharp, constant, worsening with any movement or palpation. Patient tensing abdomen on approach.
Radiates
Left shoulder tip (Kehr's sign — diaphragmatic irritation).
Severity
9/10
Allergies
NKDA
Medications
Nil regular medications.
Pertinent History
Fit and well. No previous abdominal surgery. No known bleeding disorders. Non-smoker, social drinker.
Last Oral Intake
Ate a sausage roll and water approximately 2 hours ago.
Treatment
Bystanders placed him in a comfortable position on the ground. No other interventions prior to EHS arrival.
Events Leading
Was contesting a mark during the AFL community demonstration match when an opponent's knee struck him in the upper left abdomen. Immediate severe pain and he was unable to continue.
Scenario Progression and Treatment Objectives

((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 for Priority 1 transport 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?'))

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).

  • Ensure scene safety and don appropriate PPE. Identify mechanism of injury — high-energy blunt abdominal trauma.
  • Perform Primary Survey: identify airway patent, breathing rapid and shallow (splinting), circulation compromised — radial pulse rapid and weak, pale/diaphoretic skin, no external haemorrhage.
  • Recognise haemodynamic instability: BP 88/60, HR 128, CRT 4s — identify signs consistent with internal haemorrhage and hypovolaemic shock.
  • Apply oxygen via non-rebreather mask at 10–15 L/min targeting SpO2 94–98%.
  • Position patient supine — do NOT sit up or elevate legs. Maintain comfort and limit movement.
  • 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.
  • 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).
  • 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.
  • 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.
  • Recognise this as a time-critical patient — initiate Priority 1 transport request and call for ALS ambulance backup immediately. Pre-notify receiving facility (major trauma centre).
  • Minimise on-scene time — ongoing management should be undertaken during transport.
  • Keep patient warm — cover with blanket to prevent heat loss and manage sympathetic response.
  • Reassure patient continuously and provide calm, clear communication.
  • Monitor and record full observations every 5 minutes given time-critical status. Anticipate deterioration: falling GCS, dropping BP, rising HR.
  • Prepare for clinical deterioration: have BVM and airway adjuncts (OPA/NPA) available. Be prepared to manage airway if GCS falls below 8.
  • Do NOT administer oral medications or fluids — patient is likely to require urgent surgical intervention.
  • Scenario ends on arrival of ambulance and IMISTAMBO handover.
  • 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