Trauma

Bicycle vs kerb — suspected femur fracture with haemorrhage

Intermediate

Pediatric · 8yr · male

Patient Information

Dispatch	You are called to the first aid post at the Whitford Family Fun Ride — a community cycling event in Perth's northern suburbs. An 8-year-old male has been brought in by event marshals after coming off his bicycle at speed.
Patient	Lachlan Nourse — 8yr (26kg)
Incident History	Pt was riding downhill, clipped the kerb and was thrown from his bike. He landed on his right side. Bystanders report he cried out immediately and has not been able to move his right leg. There is visible deformity and active bleeding at the mid-thigh.
Emergency Contact	Debbie Nourse (Mother) — 0412 774 339

Initial Rapid Assessment

Response	Alert
Airway	Patent. Nil obstruction. Nil stridor. Speaking in full sentences.
Breathing	Adequate. Mild tachypnoea consistent with pain and distress. Equal chest rise. No accessory muscle use. No audible abnormal breath sounds.
Circulation	Radial pulse rapid and weak. Skin pale and cool to touch. Active bleeding noted at right mid-thigh wound — blood-soaked clothing. Capillary refill 3 seconds centrally.
Disability	GCS 15 (E4V5M6). Alert and orientated to time, place and person. Complaining of severe right thigh pain. Pupils equal and reactive.
Exposure	Obvious deformity and swelling to right mid-thigh. Laceration approximately 6 cm at right mid-thigh with active haemorrhage. Helmet worn — nil facial or head trauma evident. Grazing to right forearm. Road rash to right shoulder.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	97% (RA)	Mild	24	138	88	3s	15	4 4 ++	–	–	9
10 mins	99% (O2 NRB 10L)	Nil	20	118	96	2s	15	4 4 ++	–	–	6

History Taking

Treatment Response

Diagnosis

This patient is suffering from a suspected right mid-shaft femur fracture with associated haemorrhage and early compensated hypovolaemic shock secondary to bicycle trauma.

Facilitator Triggers — if trainees miss a critical step

! (If haemorrhage control is not initiated within 2 minutes of assessment, the wound begins to bleed more actively — blood visibly pooling beneath the leg.)
! (If oxygen is not applied within 3 minutes, SpO2 drifts to 94% on room air and the patient becomes more anxious and pale.)
! (If distal neurovascular observations are not checked before and after splinting, prompt the trainee: 'The mother asks if his foot looks the right colour to you — what do you check?')
! (If signs of shock are not recognised and escalation is not considered, patient's pulse increases to 148 and he becomes drowsy — GCS drops to 14.)
! (If traction splint is applied without first controlling haemorrhage from the laceration, prompt: 'You notice fresh blood is continuing to soak through — what do you do first?')

Treatment Objectives

1. Ensure scene safety and don appropriate PPE — hand hygiene throughout.
2. Perform Primary Survey with c-spine consideration — mechanism is consistent with possible spinal involvement; assess and document clinically.
3. Identify catastrophic haemorrhage as the immediate priority — apply firm direct pressure to right mid-thigh laceration using trauma dressing.
4. If direct pressure is insufficient to control haemorrhage, apply Combat Application Tourniquet (CAT) to right thigh — position at least 5cm proximal to wound, record time of application.
5. Administer Oxygen via non-rebreather mask at 10–15 litres per minute — titrate to SpO2 target ≥95% for paediatrics.
6. Assess and document distal neurovascular observations of right lower limb BEFORE splinting — pulse, colour, warmth, movement, sensation, capillary refill time.
7. Expose the right leg fully — cut clothing, remove footwear.
8. Apply appropriate traction splint to right femur fracture (Kendrick, Fernotrac, Sager, or Slishman) as per clinical skill — immobilise joint above and below injury.
9. Reassess distal neurovascular observations AFTER splinting — document any change.
10. Perform Vital Sign Survey — HR, BP, RR, SpO2, GCS, CRT. Recognise BP 88 systolic as hypotension in an 8-year-old (threshold: 70 + [2 x 8] = 86 mmHg — patient is at threshold, trending toward haemorrhagic shock).
11. Administer Methoxyflurane (Penthrox) 3 mL inhaled — hand to patient to self-administer for pain management (patient 8 years old, 26 kg, able to cooperate — meets criteria for self-administration).
12. Perform Secondary/CNS Survey — assess for additional injuries: right forearm abrasion, right shoulder road rash, abdomen, chest, pelvis.
13. Dress right forearm abrasion with appropriate wound dressing; apply RICE to forearm.
14. Keep patient warm — apply blankets to prevent hypothermia (injured paediatric patient at risk).
15. Request ambulance via State Operations Centre — Priority 1 transport for time-critical paediatric trauma with haemorrhage and haemodynamic compromise.
16. Record full observations every 5 minutes given time-critical status.
17. Pre-notify receiving facility (Perth Children's Hospital for paediatric trauma <14 years) — advise suspected femur fracture, active haemorrhage, early compensated shock.
18. Comfort and reassure patient continuously — keep mother involved and informed.
19. Scenario ends on arrival of ambulance and IMISTAMBO handover.
20. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Haemorrhage · Limb Trauma · Trauma Management Principles · Major Trauma Guidelines · Hypovolemic Shock · Fractures & Dislocations · Combat Application Tourniquet (CAT) · Direct Pressure and Trauma bandages · Kendrick Traction Splint · Pain Assessment · Oxygen Delivery

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Signs/Symptoms	Severe right thigh pain. Visible deformity and swelling right mid-femur. Active bleeding from mid-thigh laceration. Pale, cool, diaphoretic. Tachycardic.
Allergies	NKDA — confirmed with mother via phone.
Medications	Nil regular medications.
Pertinent History	Nil significant past medical history. No bleeding disorders. Nil previous fractures.
Last Oral Intake	Ate breakfast approximately 2 hours ago. Drank water during event.
Events Leading	Pt was competing in a family fun ride cycling event. Was riding downhill at moderate speed, clipped the kerb edge and was thrown over handlebars landing on his right side.
Treatment Prior	Event marshal applied direct pressure to thigh laceration with a cloth prior to EHS arrival. No splinting or immobilisation applied.

Onset	Approximately 10 minutes ago. Pt came off bicycle at speed, struck kerb and landed on right side.
Pain	Severe right thigh pain, worse on movement. Nil chest pain. Nil abdominal pain on questioning.
Quality	Pt describes pain as sharp and constant in right thigh.
Radiates	Nil radiation reported.
Severity	9/10