((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.'))

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.

• Don appropriate PPE and ensure scene safety at the showgrounds arena.
• Perform Primary Survey with c-spine consideration — patient was thrown from height; assume c-spine injury until cleared. Apply manual inline stabilisation.
• Assess and maintain airway — patent, no adjunct required at this time. Position patient supine with 30° head elevation if not hypovolaemic.
• Assess breathing — spontaneous, RR 18, nil distress. Apply oxygen via non-rebreather mask (NRB) at 10–15 L/min targeting SpO2 94–98%.
• Assess circulation — control right temporal laceration haemorrhage with direct pressure and trauma bandage dressing.
• Perform disability assessment — GCS 13 (E3V4M6). Note pupils: right 4mm sluggish, left 3mm reactive. Document findings and time stamp.
• Perform blood glucose level (BGL) test — all patients with altered GCS require BGL. Expected result: 5.4 mmol/L — no treatment required.
• 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.
• Serially reassess GCS every 5 minutes — note any deterioration. At 10 minutes GCS is 11 — this is a time-critical sign.
• Recognise early Cushing's response: rising BP (138/88), relative bradycardia (HR 64), worsening headache, and GCS deterioration — indicates raised intracranial pressure.
• Maintain 30° head elevation throughout. Do NOT hyperventilate. Ventilate at a normal rate only if ventilatory support is required.
• Request ambulance urgent backup via CSP — advise CSP of findings of a time-critical TBI with GCS deterioration and anisocoria.
• Continue serial vital signs monitoring every 5 minutes until ambulance arrival — document all observations.
• Keep patient warm with blanket. Reassure patient continuously. Minimise patient movement and prevent patient from standing.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• 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