Scenario — Head injury following a fall at an AFL game

intermediate Trauma · Elderly · 75yr · male

Patient Information

Dispatch	You are called to a 75YO male (Brian Calloway) at Optus Stadium who has slipped on wet concrete steps and struck the back of his head. A bystander reports he was briefly confused after the fall.
Patient	Brian Calloway — 75yr (75kg)
Incident History	Pt was descending the stadium steps during the quarter-time break when he slipped and fell backwards, striking the back of his head on the concrete edge. Bystander states pt was dazed for approximately 30 seconds and had difficulty standing.
Emergency Contact	Margaret Calloway (Wife) — 0412 883 541

Initial Rapid Assessment

Response	Voice
Airway	Patent. No visible obstructions, no airway swelling or stridor. Blood-stained saliva noted at corner of mouth.
Breathing	Spontaneous. RR 16, equal bilateral chest rise, no accessory muscle use.
Circulation	Radial pulse present — regular, moderate strength. Laceration to posterior scalp with active bleeding. Skin pale and slightly cool.
Disability	GCS 13 (E3V4M6). Disoriented to time and events. Moving all four limbs on command. Pupils — see vitals.
Exposure	Approx 4 cm scalp laceration to posterior right occiput with active bleeding. No visible deformity to skull. No periorbital bruising or Battle's sign at this time. No other visible injuries.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	96% (RA)	Nil	16	62	148/88	2s	13	4 4 ++	36.7	6.4 mmol/L	6
10 mins	99% (O2 NRB 15L)	Nil	15	60	144/86	<2s	14	4 4 ++	36.7	6.4 mmol/L	4

History Taking

Scenario Progression and Treatment Objectives

Diagnosis

This patient is suffering from a traumatic brain injury (TBI) — closed head injury with loss of orientation and post-traumatic confusion — compounded by anticoagulant use (Warfarin), which increases the risk of intracranial haemorrhage.

Facilitator Triggers — if trainees miss a critical step

! (If trainee does not perform BGL within the first 5 minutes — Brian becomes increasingly agitated and confused; GCS drops to 12. Prompt: 'Brian is now not answering your questions and is trying to stand up.')
! (If trainee does not identify Warfarin use during history taking — facilitator prompts: Brian's wife Margaret arrives and volunteers the information: 'He takes a blood thinner for his heart, it's called Warfarin.')
! (If trainee does not apply oxygen within 3 minutes — SpO2 drops to 93% on room air and Brian's confusion worsens.)
! (If trainee does not control scalp haemorrhage — facilitator states: 'The handkerchief bystander applied has soaked through and blood is now dripping onto the steps.')
! (If trainee attempts to administer paracetamol or any analgesic — remind trainee that pain relief administration is outside EHS Primary Care scope for TBI.)
! (If trainee attempts to sit Brian fully upright without concern for BP — no consequence, but prompt trainee to consider whether 30° head elevation is appropriate given no signs of hypovolaemia.)

Treatment Objectives

1. Ensure scene safety — wet concrete steps, crowd management, request event security to assist with crowd control.
2. Don appropriate PPE — gloves minimum; blood present.
3. Perform Primary Survey with C-spine consideration — mechanism involves axial loading; maintain manual cervical spine stabilisation.
4. Control scalp haemorrhage — apply direct pressure with trauma dressing or bandage to posterior scalp laceration.
5. Administer Oxygen via non-rebreather mask at 10–15 L/min — target SpO2 94–98%.
6. Perform full Vital Signs Survey — GCS, BGL, SpO2, BP, HR, RR, temperature, pupils.
7. Obtain BGL — required for all patients with altered GCS; result 6.4 mmol/L (normal, no treatment required).
8. Position patient — semi-recumbent with 30° head elevation if BP permits; do NOT use 30° elevation if patient becomes hypotensive.
9. Perform Secondary and CNS Survey — assess for: skull deformity, periorbital bruising (Raccoon eyes), retroauricular bruising (Battle's sign), CSF from ears/nose, pupil equality and reactivity, limb strength and sensation, any Cushing's triad signs (hypertension + bradycardia + irregular respirations).
10. Obtain IMISTAMBO history — note Warfarin use and document clearly; communicate anticoagulant use to ambulance crew as this significantly elevates intracranial haemorrhage risk.
11. Avoid hyperventilation if assisting ventilations — maintain normal rate.
12. Do NOT administer pain relief — analgesia for TBI is outside EHS Primary Care scope.
13. Monitor patient persistently — record full observations every 10 minutes (or 5 minutes if time critical); watch for deteriorating GCS, asymmetric pupils, Cushing's triad, or seizure activity.
14. Brief confusion post-impact + anticoagulant use = time-critical patient; prepare for Priority 1 transport and request ambulance early.
15. Scenario ends on arrival of ambulance and IMISTAMBO handover.
16. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Traumatic Brain Injury · Haemorrhage · Oxygen · Primary Survey · Secondary & CNS Survey · Blood Glucose Monitor · Direct Pressure and Trauma Bandages

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Signs/Symptoms	Headache at site of impact, dizziness, mild confusion — disoriented to time and cannot clearly recall the fall.
Allergies	Penicillin — rash.
Medications	Warfarin (for atrial fibrillation), Perindopril (for hypertension), Atorvastatin.
Pertinent History	Pt has known atrial fibrillation and is on Warfarin — delayed clotting time. Also has a history of hypertension. No previous head injuries reported.
Last Oral Intake	Meat pie and a beer approximately 90 minutes ago.
Events Leading	Pt was walking down wet concrete stadium steps to return to his seat after using the bathroom during quarter-time. He slipped on the wet surface and fell backwards.
Treatment Prior	Bystander applied direct pressure to the scalp laceration with a handkerchief prior to EHS arrival.

Onset	Approximately 15 minutes ago following the fall on stadium steps.
Pain	Occipital headache at laceration site, pt also describes a generalised dull ache across the back of his head.
Quality	Throbbing, constant.
Radiates	Nil radiation — pain localised to posterior head.
Severity	6/10