Traumatic Brain Injury — paediatric fall from height

Patient Information

Dispatch: You are called to a patient (Liam Nguyen, 8-year-old male) who has fallen from a jumping castle at the Fremantle Community Family Fair. Bystanders report he struck his head on the ground after falling approximately 1.5 metres.
Patient: Liam Nguyen — 8yr (26kg)
Incident History: Pt fell from the side of a jumping castle, landing head-first on compacted grass. Witnessed by parents. Brief loss of consciousness reported by bystanders — approximately 10–15 seconds. Pt is now conscious but confused and crying.
Emergency Contact: Minh Nguyen (Father) — 0412 774 391

Initial Rapid Assessment

Response: Voice
Airway: Patent. No visible obstructions. No stridor. Nil airway compromise. C-spine consideration applied — nil forced movement of neck.
Breathing: Increased work of breathing. RR elevated. Shallow and irregular. SpO2 93% on room air.
Circulation: Radial pulse rapid and weak. Skin pale and diaphoretic. No catastrophic external haemorrhage. Small laceration noted to right temporal region with minor ooze.
Disability: GCS 11 (E3V3M5). Disoriented to time, place and person. Pupils unequal — Right 4mm sluggish, Left 3mm reactive. Not following commands consistently.
Exposure: Right temporal laceration approximately 2cm. No step deformity to skull. No periorbital bruising or Battle's sign evident at this time. No other external injuries identified.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	93% (RA)	Moderate	26	112	100/68	3s	11	4 3 SL	37.1	4.8 mmol/L	7
10 mins	99% (O2 NRB 15L/min)	Mild	20	100	104/70	2s	13	4 3 SL	37.1	4.8 mmol/L	5

History Taking

Treatment Response

Diagnosis

This patient is suffering from a moderate Traumatic Brain Injury (TBI) with associated scalp laceration, post-traumatic confusion, and concerning signs of raised intracranial pressure including unequal pupils and GCS 11.

Facilitator Triggers — if trainees miss a critical step

! (If oxygen is not applied within 3 minutes of patient contact, SpO2 drops further to 89% on room air and respiratory distress worsens to Severe — prompt trainee to reassess airway and breathing.)
! (If unequal pupils are not identified and documented during initial rapid assessment or secondary CNS survey, patient's GCS begins to drop to 9 at 10 minutes and father asks 'Is he getting worse?' — prompt trainee to reassess disability and escalate.)
! (If 30-degree head elevation is not applied and patient is left supine flat, facilitator should ask the trainee 'What position should this patient be in?' to prompt recall of TBI positioning.)
! (If BGL is not checked, facilitator should cue: 'The patient's father mentions Liam seemed a bit unsteady before the fall — could there be another cause?' to prompt trainee to perform BGL.)
! (If trainee attempts to apply a nasopharyngeal airway without considering base of skull fracture precaution, facilitator reminds: 'Is there any reason to be cautious with that airway adjunct in a head injury patient?')

Treatment Objectives

1 Ensure scene safety and don appropriate PPE before approaching patient.
2 Perform Primary Survey with C-spine consideration — do not force neck movement; apply manual inline stabilisation if moving patient.
3 Manage catastrophic haemorrhage first — apply direct pressure dressing to right temporal laceration using non-adherent pad and crepe bandage.
4 Open and maintain airway using jaw thrust (double airway manoeuvre) given C-spine consideration — do NOT use triple airway manoeuvre (head tilt) until spinal injury excluded.
5 Apply high-flow oxygen via Non-Rebreather Mask at 15 L/min — target SpO2 above 94% and maintain above 90% as minimum per TBI CPG.
6 Assess breathing — rate, depth, work of breathing; assist ventilations via BVM if inadequate respiratory effort.
7 Assess circulation — radial pulse, CRT, skin signs. Note pale, diaphoretic skin and CRT 3s.
8 Perform full GCS assessment — document as GCS 11 (E3V3M5).
9 Assess pupils — document unequal pupils: Right 4mm sluggish, Left 3mm reactive. This is a RED FLAG for raised ICP.
10 Perform BGL — document 4.8 mmol/L (normal — does not explain altered GCS).
11 Position patient with 30-degree head elevation if haemodynamically stable (BP maintained) to improve venous drainage — do NOT elevate if hypotensive.
12 Avoid hyperventilation during any BVM use — ventilate gently at age-appropriate rate (approximately 20 breaths/min for 8-year-old) to avoid cerebral ischaemia.
13 Perform Secondary and CNS Survey — assess for periorbital bruising (Raccoon eyes), Battle's sign, CSF from ears or nose, limb motor/sensory function.
14 Do NOT insert Nasopharyngeal Airway without considering base of skull fracture precaution — use OPA if airway adjunct required and patient tolerates.
15 Apply spinal precautions as appropriate — apply lanyard and coach patient to keep head and neck still; use headblocks on stretcher.
16 Monitor and record full observations every 10 minutes or 5 minutes if condition deteriorates.
17 Treat this patient as time-critical — urgent ambulance support via CSP — IMISTAMBO handover to CSP (nearest paediatric-capable ED).
18 Reassure patient and father throughout — maintain calm environment.
19 Scenario ends on arrival of ambulance and IMISTAMBO handover.
20 Attention to hand hygiene will be given throughout the scenario.

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

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