Head impact at a music festival — concussion without loss of consciousness

Patient Information

Dispatch: You are called to a 21-year-old female (Sophie Nguyen) near the main stage area of a music festival. Her friends say she was in the mosh pit and took a hard elbow to the side of the head. She did not fall but became briefly confused. She is now saying she is fine and wants to go back in.
Patient: Sophie Nguyen — 21yr (60kg)
Incident History: Patient received a forceful elbow strike to the right temporal region while in the festival mosh pit. She did not lose consciousness but her friends describe a brief period of approximately 30 seconds where she 'didn't make sense' and seemed 'blank'. She has a headache, feels dizzy, and cannot remember anything from approximately 5 minutes before the impact. She now appears alert but is still confused about some details.
Emergency Contact: Hana Nguyen (Sister) — 0412 881 374

Initial Rapid Assessment

Response: Alert
Airway: Patent. Speaking clearly in full sentences.
Breathing: Comfortable. RR 14. No respiratory distress.
Circulation: Radial pulse strong and regular. Skin warm. CRT <2s.
Disability: GCS 15 (E4V5M6) — HOWEVER: disoriented to time (does not know what hour it is), cannot name the last two performers she saw before the incident, and has retrograde amnesia for approximately 5 minutes before the impact. Pupils equal and reactive. No focal motor deficit.
Exposure: Right temporal region — mild soft tissue swelling and tenderness over the temporal area. No visible laceration. No periorbital bruising. No battle's sign. No haemotympanum visible.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	99% (RA)	Nil	14	82	118/74	<2s	15	4 4 ++	36.9	–	6
15 mins	99% (RA)	Nil	14	80	116/72	<2s	15	4 4 ++	36.9	–	5

History Taking

Treatment Response

Diagnosis

Concussion (mild traumatic brain injury) — direct head impact with brief post-traumatic confusion and retrograde amnesia. GCS remains 15, which can falsely reassure trainees. The key concussion indicators in this scenario are: post-traumatic confusion (immediately after impact per witnesses), retrograde amnesia for 5 minutes before impact, headache, dizziness, nausea, and cognitive fogginess. Patient MUST NOT return to the mosh pit or any physical activity today — 'return to play' after concussion requires medical clearance. The patient must be observed, and if any of the following develop, CSP must be called immediately: GCS drops below 15, repeated vomiting, worsening headache, new focal neurological deficit, unequal pupils, seizure, or increasing confusion. This scenario should also familiarise trainees with the concept that 'no loss of consciousness' does NOT mean no concussion.

Facilitator Triggers — if trainees miss a critical step

! (If trainees accept the patient's claim that she is fine and agree to let her return to the mosh pit — facilitator stops the scenario. Facilitator note: a patient with active concussion indicators (amnesia, headache, dizziness, confusion) must NOT be returned to physical activity. 'I feel fine now' is not a concussion clearance. The patient is cognitively impaired and cannot self-assess reliably.)
! (If trainees do not identify the retrograde amnesia — prompt: 'She says she is fine — ask her to tell you about the last few minutes before the impact.' Expected: patient cannot recall the 5 minutes before the hit. Friends confirm this. Retrograde amnesia is one of the most reliable indicators of significant concussion.)
! (If trainees do not ask friends for a witness account of the post-impact period — prompt: 'What did you see happen immediately after she was hit?' Friends describe 30 seconds of confusion and 'blank stare' — this is a critical collateral history finding.)
! (If trainees do not assess for red flags requiring escalation — prompt at 15 minutes: 'What specific findings would make you call for CSP?' Expected: worsening headache, repeated vomiting, GCS decline, seizure, pupil asymmetry, focal deficit. If the patient vomits once during the scenario — this is a single episode. If she vomits a second time, escalate to CSP.)
! (If trainees note the patient is sober — reinforce: 'She has not had alcohol today — the confusion and amnesia are not attributable to intoxication.' This removes a common dismissal.

Treatment Objectives

1 Ensure scene safety — move patient to a quiet area away from the crowd and loud music; the sensory environment will worsen her symptoms.
2 Don appropriate PPE.
3 Perform Primary Survey — GCS 15, no life-threatening injury. Confirm no cervical spine tenderness (mechanism is a lateral temporal impact, not axial load — low spinal risk but still ask about neck pain).
4 Obtain full history — confirm mechanism (direct head impact), witness account (30 seconds post-impact confusion), absence of LOC, nature of amnesia (retrograde — cannot recall 5 minutes before impact).
5 Confirm sobriety — patient has not consumed alcohol. Symptoms are from the head impact, not intoxication.
6 Perform neurological assessment — GCS components individually, pupils (equal and reactive), orientation to time/place/person (impaired — cannot state the time or recall the last performers she saw), balance assessment (unsteady), upper and lower limb gross motor and sensation (intact).
7 Identify concussion indicators present: post-traumatic confusion, retrograde amnesia, headache, dizziness, nausea, sensitivity to noise/light, cognitive fogginess.
8 Complete Vital Sign Survey — all parameters normal.
9 Advise patient clearly and specifically — do NOT return to the mosh pit or any physical activity today. 'Return to play' after concussion requires medical clearance. Returning too early risks second-impact syndrome, which can be fatal.
10 If patient insists on returning — explain this is not a choice EHS can support and contact the patient's responsible friend or family member to assist.
11 Observation: observe patient for a minimum of 30 minutes. Monitor for worsening headache, repeated vomiting, GCS decline, new focal deficit, or seizure.
12 Escalation criteria — call CSP immediately if any of the following develop: GCS drops below 15, repeated vomiting (×2 or more), progressively worsening headache, unequal or non-reactive pupils, seizure, new motor or sensory deficit, increasing confusion beyond baseline.
13 Advise patient on discharge: she must not be left alone tonight, must not drive, must not consume alcohol, must not return to strenuous activity, and should seek medical review if headache worsens, she vomits again, develops vision changes, or feels increasingly confused.
14 Encourage the patient to have a responsible adult (sister or friend) stay with her overnight.
15 Document all findings including the retrograde amnesia duration, witness account of post-impact confusion, and all neurological assessment results.
16 Scenario ends after observation period with appropriate discharge advice and a responsible adult nominated to stay with her.
17 Attention to hand hygiene will be given throughout the scenario.

Clinical references: Head Injury · Primary Survey · Secondary & CNS Survey · Pulse & Respirations · Blood Pressure

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