Scenario — Thoracic trauma with developing tension pneumothorax following crowd crush

Facilitator Triggers — if trainees miss a critical step

• ! (If oxygen is not applied within 2 minutes of first contact, SpO2 drops to 87% on room air and patient becomes more agitated and distressed — prompt: 'Marcus is becoming increasingly anxious and says he cannot breathe properly.')
• ! (If trainee does not perform respiratory auscultation and identify absent right-sided breath sounds, the facilitator announces at the 5-minute mark: 'Marcus tells you the right side of his chest feels like it is being squeezed tighter — his breathing is getting worse.')
• ! (If the developing tension pneumothorax signs — tracheal deviation LEFT, absent right breath sounds, worsening hypotension, and falling SpO2 despite high-flow oxygen — are not identified and communicated urgently to the facilitator/ambulance by the 8-minute mark, GCS drops to 12, BP drops to 88 systolic, and facilitator announces: 'You notice Marcus's trachea appears to be shifted slightly to the LEFT when you reassess his neck.')
• ! (If the occlusive dressing — three sides taped — is applied to a wound that does not exist and trainee has not correctly identified this is a CLOSED chest injury, facilitator corrects: 'On reassessment, there is no open chest wound — this is a closed injury. How does your management change?')
• ! (If paradoxical chest movement is not identified and documented, facilitator prompts: 'As Marcus exhales, you notice the right lateral chest wall moves inward — what does this suggest?')
• ! (If trainee attempts to remove or reposition the patient to standing to assist with breathing and SpO2 immediately drops further: 'Marcus states he feels faint when you try to stand him up — his blood pressure is now 88 systolic.')

Treatment Objectives

1. 1. Ensure scene safety — assess environment at Subiaco AFL stadium for ongoing crowd movement risk prior to approaching patient.
2. 2. Don appropriate PPE — gloves minimum; consider eye protection given mechanism.
3. 3. Perform Primary Survey with C-spine consideration — mechanism (crush/barrier impact) raises suspicion for spinal injury; use jaw thrust if airway manoeuvre required.
4. 4. Assess airway — confirm patent, patient speaking in short phrases; note increasing distress.
5. 5. Assess breathing — identify raised respiratory rate (24), reduced air entry right chest on auscultation, paradoxical movement right lateral chest wall (flail segment), accessory muscle use; document findings.
6. 6. Apply high-flow oxygen immediately via Non-Rebreather Mask (NRB) at 10–15 L/min — titrate SpO2 to target 94–98%.
7. 7. Reassess breathing after oxygen application — note SpO2 response; if SpO2 does not improve or deteriorates despite NRB oxygen, escalate urgency.
8. 8. Stabilise flail chest segment — apply gentle supporting hand pressure over right lateral chest wall to reduce paradoxical movement and improve ventilatory mechanics; position patient towards injured (right) side in a position of comfort.
9. 9. Perform Secondary/CNS Survey — systematic head-to-toe assessment; palpate chest wall for crepitus, tenderness, deformity; note bruising right ribs 4–8; reassess tracheal position (initially midline — monitor for deviation).
10. 10. Perform pain assessment — document pain score 9/10; note EHS analgesic options are limited to Methoxyflurane (Penthrox); however Methoxyflurane is CONTRAINDICATED in patients unable to cooperate or with significant respiratory distress and altered consciousness — reassess patient's ability to self-administer safely.
11. 11. Reassess vitals at 5-minute intervals given time-critical presentation — note any deterioration in SpO2, BP, HR, GCS, RR.
12. 12. Identify signs of developing tension pneumothorax — reassess for: tracheal deviation (LEFT shift), absent or further reduced breath sounds right, worsening hypotension (BP <90 systolic), increasing tachycardia, falling GCS despite oxygen — these are red flags for tension pneumothorax.
13. 13. Recognise tension pneumothorax is DEVELOPING and is outside EHS scope to treat definitively — needle thoracocentesis is Advanced Care and above; EHS role is RAPID identification and urgent escalation.
14. 14. Escalate immediately — call for ambulance Priority 1 via State Operations Centre; pre-notify receiving hospital of suspected tension pneumothorax; request Advanced Care Paramedic response.
15. 15. If occlusive dressing is considered — clarify this is a CLOSED chest injury with no open wound; occlusive dressing applies to open/sucking chest wounds only; do NOT apply to this patient.
16. 16. Position patient — position of comfort leaning towards injured right side; do NOT lay flat if SpO2 deteriorating; maintain spinal precautions if mechanism warrants.
17. 17. Assist ventilations via BVM if patient's spontaneous respiratory effort becomes inadequate — ventilate gently at no more than 4–6 breaths per minute to minimise air trapping and avoid worsening pneumothorax; do not over-ventilate.
18. 18. Monitor continuously — GCS, SpO2, RR, BP, HR, respiratory pattern, tracheal position; record full observations every 5 minutes given time-critical status.
19. 19. Reassure patient continuously — calm, clear communication; explain each intervention.
20. 20. Minimise on-scene time — package patient for urgent transport; perform ongoing management en route.
21. 21. Scenario ends on arrival of ambulance and IMISTAMBO handover.
22. 22. Attention to hand hygiene will be given throughout the scenario.