Scenario — Head injury following fall at AFL game

intermediate Trauma · Adult · 35yr · male

Patient Information

Dispatch	You are called to a patient (Marcus Henley, 35YO male) who has been found on the ground in the stadium concourse after reportedly slipping and striking his head on the concrete steps. Bystanders state he was briefly unresponsive.
Patient	Marcus Henley — 35yr (80kg)
Incident History	Pt slipped on wet concrete steps while descending to his seat during the third quarter of an AFL game at Optus Stadium. Witnesses report he fell backwards and struck the back of his head on the edge of a step. Pt was unresponsive for approximately 30 seconds before regaining consciousness. Pt is now conscious but confused and complaining of headache and neck pain.
Emergency Contact	Claire Henley (Wife) — 0412 774 391

Initial Rapid Assessment

Response	Voice
Airway	Patent. No foreign bodies or obstructions. No audible stridor. Nil airway swelling.
Breathing	Self-ventilating. Breathing is adequate but shallow. RR elevated. No cyanosis.
Circulation	Radial pulse present, regular, normal rate. Skin warm and dry. Small laceration to posterior scalp with active but controlled bleeding — approximately 3 cm.
Disability	GCS 13 (E3V4M6). Disoriented to time and place. Pupils equal and reactive to light. No focal neurological deficit detected on brief assessment. Pt reports headache 7/10 and neck pain.
Exposure	Laceration to posterior scalp approximately 3 cm, actively bleeding. No obvious deformity to skull on palpation. No visible periorbital bruising or retroauricular bruising. No visible CSF from ears or nose. No other injuries identified.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	96% (RA)	Mild	20	94	138/86	<2s	13	4 4 ++	36.8	5.4 mmol/L	7
10 mins	98% (O2 NRB 15L)	Nil	18	88	134/84	<2s	14	4 4 ++	36.8	5.4 mmol/L	5

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a traumatic brain injury (TBI) — moderate closed head injury with brief loss of consciousness, GCS 13, scalp laceration with active haemorrhage, and posterior cervical pain requiring spinal precautions.

Facilitator Triggers — if trainees miss a critical step

! (If cervical spine is NOT assessed and spinal precautions are NOT applied within 5 minutes, the patient reports increasing tingling in both hands — prompt the trainee: 'The patient says his hands feel strange — do you want to do anything else?')
! (If scalp haemorrhage is NOT controlled within 3 minutes, facilitator reports bandage becoming visibly soaked — 'You notice blood has soaked through the bystander's cloth')
! (If oxygen is NOT applied within 4 minutes, GCS drops to 12 and patient becomes more agitated)
! (If BGL is NOT checked, facilitator prompts: 'The patient is still confused — is there anything else you want to assess?')
! (If head elevation to 30° is performed on a patient not adequately assessed for haemodynamic stability, facilitator notes: 'Consider whether the patient has any features of haemodynamic compromise before elevating the head')
! (If alcohol intake is NOT identified in history, facilitator prompts: 'The patient's friend approaches and says — he had a couple of drinks before the game')

Treatment Objectives

1. Ensure scene safety — approach patient on concourse, request crowd to move back, do not move patient until assessed
2. Don appropriate PPE including gloves — blood exposure risk from scalp laceration
3. Perform Primary Survey with C-spine consideration — establish response level (Voice), assess airway, breathing, circulation; identify scalp laceration with active haemorrhage as immediate threat
4. Apply manual C-spine stabilisation — patient reports posterior neck pain following mechanism consistent with axial loading; maintain throughout assessment
5. Control scalp haemorrhage — apply direct pressure via non-adherent pad and trauma bandage to posterior scalp laceration; monitor for re-bleeding
6. Administer Oxygen via Non-Rebreather Mask (NRB) 10–15 L/min — titrate to maintain SpO2 above 94%; TBI management requires avoidance of hypoxia
7. Perform Vital Sign Survey — GCS (13: E3V4M6), SpO2, RR, BP, HR, BGL, temperature, pupils (PERL 4mm bilateral)
8. Check Blood Glucose Level — all patients with altered GCS require BGL; result 5.4 mmol/L, no treatment required
9. Perform Secondary and CNS Survey — palpate scalp for deformity (nil), assess pupils (equal and reactive), assess for CSF from nose/ears (nil), check for periorbital/retroauricular bruising (nil at this time), assess four-limb neurological function (intact), note posterior midline cervical tenderness present
10. Apply spinal precautions — NEXUS criteria NOT met for clearance due to: altered mental status (GCS 13, disoriented), posterior midline cervical tenderness, intoxication history (alcohol); do NOT clear C-spine
11. Apply C-spine collar (measured and appropriately sized) once manual stabilisation established — inform patient: 'You have neck pain and we cannot rule out a neck injury, so we need to keep your neck still'
12. Position patient — maintain supine with 30° head elevation if haemodynamically stable (BP 138/86, HR 94, no features of hypovolaemia); contraindication: do NOT elevate if hypotensive
13. Administer Ondansetron 4 mg oral wafer — patient reports nausea; nausea and vomiting prophylaxis appropriate for suspected spinal injury and head injury; confirm GCS allows safe oral administration
14. Monitor patient persistently — record full observations every 10 minutes; monitor for signs of clinical deterioration including falling GCS, asymmetric pupils, Cushing's triad (bradycardia, hypertension, abnormal breathing), seizure activity
15. Brief patient and provide reassurance — explain all procedures clearly; patient may be anxious or confused
16. Prepare for ambulance arrival — this patient is time critical and requires transport Priority 1 with pre-notification of receiving facility; document time of injury, duration of LOC, GCS trend, haemorrhage control, medications administered, BGL, spinal precaution status
17. Prepare IMISTAMBO handover — include: mechanism, LOC duration (~30 seconds), GCS 13 improving to 14, scalp laceration controlled, neck pain, spinal precautions applied, alcohol intake, BGL 5.4, Ondansetron 4 mg oral given, oxygen applied
18. Scenario ends on arrival of ambulance and IMISTAMBO handover.
19. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Traumatic Brain Injury · Primary Survey · Secondary & CNS Survey · Spinal Trauma · Spinal assessment · C-Spine Collar · Haemorrhage · Direct Pressure and Trauma Bandages · Oxygen Delivery · Ondansetron · Glasgow Coma Scale (GCS) · Blood Glucose Monitor · Unconsciousness

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Signs/Symptoms	Headache, neck pain, confusion, nausea. Pt reports feeling 'foggy' and cannot clearly recall the fall.
Allergies	Nil known drug allergies.
Medications	Nil regular medications.
Pertinent History	Nil relevant past medical history. Nil previous head injuries. Pt consumed 2 beers approximately 90 minutes prior to incident.
Last Oral Intake	2 beers approximately 90 minutes ago. Pie approximately 1 hour ago.
Events Leading	Pt was descending concrete stadium steps to return to his seat when he slipped on a wet step and fell backwards, striking the back of his head on the step edge. No preceding dizziness, chest pain or loss of balance reported by bystanders.
Treatment Prior	Bystanders applied hand pressure to scalp laceration. No other treatment prior to EHS arrival.

Onset	Sudden onset following fall approximately 15 minutes ago. Brief loss of consciousness for approximately 30 seconds reported by bystanders.
Pain	Headache — posterior, 7/10. Neck pain — midline, 4/10.
Quality	Headache described as throbbing and constant. Neck pain described as aching and worsened with movement.
Radiates	Headache does not radiate. Neck pain does not radiate to limbs.
Severity	7/10 headache. 4/10 neck pain.