Scenario — Head injury following a fall from a horse

intermediate Trauma · Adult · 35yr · female

Patient Information

Dispatch	You are called to a patient (Sarah Calloway, 35YO female) who has fallen from a horse during the equestrian display at the Claremont Showgrounds. Bystanders report she struck her head on the ground and was briefly unresponsive.
Patient	Sarah Calloway — 35yr (65kg)
Incident History	Pt was competing in a show-jumping display when her horse refused a jump and she was thrown, landing heavily on her right side and striking the right side of her head on the arena surface. She was wearing a helmet. Witnesses say she was unresponsive for approximately 30–60 seconds before coming around. She is now conscious but confused.
Emergency Contact	Daniel Calloway (Husband) — 0412 774 391

Initial Rapid Assessment

Response	Voice
Airway	Patent. Nil audible stridor. Nil visible obstruction. Helmet removed by event staff prior to EHS arrival — c-spine not maintained during removal.
Breathing	Spontaneous. RR slightly elevated. Nil audible wheeze or crackles.
Circulation	Radial pulse present, regular, normal rate. Skin warm and dry. Small laceration to right temporal region with minor active bleeding controlled by bystander direct pressure.
Disability	GCS 13 (E3V4M6). Confused — not oriented to time or place. Pupils assessed: right pupil 4mm sluggish, left pupil 3mm reacting normally. Complains of headache and nausea.
Exposure	Right temporal laceration approximately 3cm, actively oozing, controlled with direct pressure. No obvious deformity to skull on palpation. Nil raccoon eyes or battle's sign. Nil CSF noted from nose or ears. Right shoulder pain on palpation — mechanism of fall.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	96% (RA)	Nil	18	78	128/82	<2s	13	4 3 R sluggish L normal	37.1	5.4 mmol/L	6
10 mins	98% (O2 NRB 10L/min)	Nil	16	64	138/88	<2s	11	5 3 R sluggish L normal	37.1	5.4 mmol/L	7

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a traumatic brain injury (moderate) with a right temporal laceration, suspected intracranial pathology indicated by the asymmetric and sluggish right pupil, GCS deterioration, worsening headache, and rising blood pressure with relative bradycardia consistent with early Cushing's response.

Facilitator Triggers — if trainees miss a critical step

! (If trainees do not identify the asymmetric pupils or fail to reassess GCS serially — GCS drops to 11 at 10 minutes and the patient becomes increasingly difficult to rouse; prompts should include the patient becoming less responsive to voice.)
! (If oxygen is not applied within 3 minutes of contact — SpO2 drops to 93% on room air; patient becomes more agitated and confused.)
! (If the 30° head elevation is not applied and the patient is positioned flat — patient vomits; facilitator prompts trainee to manage airway and reassess positioning.)
! (If trainees attempt to hyperventilate the patient using BVM — facilitator advises this is not clinically indicated and that normal ventilation rates apply.)
! (If BGL is not checked — facilitator prompts: 'The patient is confused — have you considered all reversible causes?')
! (If the right temporal laceration is not dressed with direct pressure — facilitator states: 'Bleeding is increasing through the bystander's cloth.')

Treatment Objectives

1. Don appropriate PPE and ensure scene safety at the showgrounds arena.
2. Perform Primary Survey with c-spine consideration — patient was thrown from height; assume c-spine injury until cleared. Apply manual inline stabilisation.
3. Assess and maintain airway — patent, no adjunct required at this time. Position patient supine with 30° head elevation if not hypovolaemic.
4. Assess breathing — spontaneous, RR 18, nil distress. Apply oxygen via non-rebreather mask (NRB) at 10–15 L/min targeting SpO2 94–98%.
5. Assess circulation — control right temporal laceration haemorrhage with direct pressure and trauma bandage dressing.
6. Perform disability assessment — GCS 13 (E3V4M6). Note pupils: right 4mm sluggish, left 3mm reactive. Document findings and time stamp.
7. Perform blood glucose level (BGL) test — all patients with altered GCS require BGL. Expected result: 5.4 mmol/L — no treatment required.
8. Complete Secondary and CNS Survey — assess for raccoon eyes, battle's sign, CSF from ears/nose, neck midline tenderness, limb motor and sensory function. Document all findings including negatives.
9. Serially reassess GCS every 5 minutes — note any deterioration. At 10 minutes GCS is 11 — this is a time-critical sign.
10. Recognise early Cushing's response: rising BP (138/88), relative bradycardia (HR 64), worsening headache, and GCS deterioration — indicates raised intracranial pressure.
11. Maintain 30° head elevation throughout. Do NOT hyperventilate. Ventilate at a normal rate only if ventilatory support is required.
12. Do NOT administer any analgesia (pain relief is outside EHS Primary Care scope for TBI).
13. Request ambulance Priority 1 backup via State Operations Centre — pre-notify receiving facility of a time-critical TBI with GCS deterioration and anisocoria.
14. Continue serial vital signs monitoring every 5 minutes until ambulance arrival — document all observations.
15. Keep patient warm with blanket. Reassure patient continuously. Minimise patient movement and prevent patient from standing.
16. Scenario ends on arrival of ambulance and IMISTAMBO handover.
17. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Traumatic Brain Injury · Primary Survey · Secondary & CNS Survey · Haemorrhage · Direct Pressure and Trauma Bandages · Oxygen Delivery · Blood Glucose Monitor · Glasgow Coma Scale (GCS) · Pulse Oximetry · Spinal assessment

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Signs/Symptoms	Headache (right-sided, worsening), nausea, confusion, right shoulder pain. Reports her vision feels 'strange' in the right eye.
Allergies	Nil known.
Medications	Oral contraceptive pill (Levlen ED). Nil other regular medications.
Pertinent History	No prior head injuries. No seizure history. No known neurological conditions. Fit and well — competes in equestrian events regularly.
Last Oral Intake	Water approximately 1 hour ago. Light meal 3 hours ago.
Events Leading	Pt was mid-competition during the equestrian show-jumping display when her horse refused a jump, throwing her forward and to the right. She struck her head and right shoulder on the arena surface.
Treatment Prior	Helmet was in place at time of fall. Bystander applied direct pressure to temporal laceration. No medications administered.

Onset	Immediately following the fall approximately 10 minutes ago.
Pain	Right-sided headache, described as pressure and throbbing. Right shoulder pain.
Quality	Headache — throbbing, pressure-like. Shoulder — sharp on movement.
Radiates	Headache does not clearly radiate. Nil chest pain.
Severity	Headache 6/10, shoulder pain 5/10.