((If trainees do not apply high-flow oxygen within 2 minutes of patient contact, SpO2 drops to 88% and respiratory distress worsens to Severe — facilitator prompts: 'The patient looks increasingly breathless and his lips are turning blue.'))

((If trainees do not recognise signs of hypovolaemic shock — low BP, tachycardia, poor CRT, confusion — and fail to request Priority 1 transport and ambulance backup within 5 minutes, patient GCS drops to 9 and BP falls to 76/50 — facilitator states: 'Marcus becomes increasingly unresponsive, barely opening his eyes when you call his name.'))

((If trainees attempt to splint bilateral lower limbs before oxygen and haemodynamic assessment are completed, facilitator prompts: 'Your partner asks — should we be doing something about his breathing and blood pressure first?'))

((If trainees do not recognise the prolonged entrapment duration as a crush syndrome risk factor and fail to communicate this to the incoming ambulance crew during handover, facilitator prompts during IMISTAMBO: 'The paramedic asks — how long were the legs trapped?'))

((If trainees do not assess and document bilateral lower limb neurovascular observations — CWMS — before and after any splinting attempt, facilitator states: 'After you apply the splint, Marcus says his foot feels completely numb now and he can't wiggle his toes on the right side.'))

((If trainees attempt to walk or mobilise the patient to the FAP rather than keeping him supine and managing on scene, facilitator states: 'As you ask Marcus to stand, he immediately becomes pale, diaphoretic and nearly collapses — his BP drops to 70 systolic.'))

This patient is suffering from crush injury with developing crush syndrome following prolonged bilateral lower limb entrapment, complicated by suspected bilateral lower leg fractures and hypovolaemic shock secondary to reperfusion injury and fluid shifts.

• Ensure scene safety — confirm DFES have declared the collapsed structure safe before approaching patient.
• Don appropriate PPE — gloves and eye protection given blood and body fluid exposure risk.
• Perform Primary Survey with C-spine consideration — mechanism does not suggest axial loading but note confusion and mechanism of injury.
• Administer Oxygen via non-rebreather mask at 10–15 litres per minute targeting SpO2 94–98%.
• Position patient supine — do NOT mobilise or walk patient; risk of cardiovascular collapse post-reperfusion.
• Perform Vital Sign Survey — GCS, SpO2, RR, BP, HR, CRT, BGL, Temperature.
• Identify and communicate signs of hypovolaemic shock: BP 88/60, HR 118, CRT >3s, GCS 13, pale and diaphoretic — call for Priority 1 ambulance backup and pre-notify receiving facility immediately.
• Perform Secondary Survey — assess bilateral lower limbs for deformity, swelling, bruising, open wounds, and neurovascular status (CWMS) distal to injury bilaterally.
• Document bilateral distal neurovascular observations: colour, warmth, movement, sensation, and capillary refill at toes — record findings before any intervention.
• Recognise prolonged entrapment >20 minutes as a crush syndrome risk factor — anticipate systemic deterioration including hyperkalaemia, metabolic acidosis, and acute kidney injury following reperfusion.
• Immobilise bilateral lower limbs with soft splinting in position found — do not attempt to realign; pad natural hollows and bony prominences.
• Re-assess distal neurovascular observations after splinting — document any change.
• Keep patient warm — apply blankets to prevent hypothermia (temperature 36.1°C and trending down; prolonged entrapment and shock increase hypothermia risk).
• Monitor and record full observations every 5 minutes given time-critical status.
• Do NOT attempt to administer pain relief — analgesia (Methoxyflurane) may be considered but note patient's altered GCS (13) — Methoxyflurane requires ability to self-administer and cooperate; GCS 13 with disorientation contraindicates Methoxyflurane in this presentation.
• Prepare for clinical deterioration and potential cardiac arrest — have AED and resuscitation equipment immediately available.
• Communicate crush syndrome risk clearly in IMISTAMBO handover: entrapment duration 25 minutes, bilateral lower limbs, signs of hypovolaemic shock, neurovascular compromise bilateral lower limbs, GCS declining.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Crush Injury · Haemorrhage · Hypovolemic Shock · Limb Trauma · Fractures & Dislocations — Splinting · Oxygen Delivery · Primary Survey · Secondary & CNS Survey · Pulse & Respirations · Blood Pressure · Pulse Oximetry · Blood Glucose Monitor · Tympanic Thermometer · Pain Assessment · Methoxyflurane (Penthrox)