Scenario — Suspected spinal injury following mountain bike collision

Facilitator Triggers — if trainees miss a critical step

• ! (If the trainee attempts to sit the patient up or encourages self-mobilisation without completing NEXUS assessment: patient reports sudden increase in bilateral hand tingling and increased neck pain — prompt trainee to reassess neurological status and apply spinal precautions immediately.)
• ! (If NEXUS criteria are not assessed or bilateral tingling in hands is not identified as a focal neurological deficit: facilitator prompts — 'The patient mentions his hands feel funny, like pins and needles in both of them. Can you tell me more about what you found on your neuro assessment?')
• ! (If the trainee attempts to apply a semi-rigid collar without coaching patient on keeping head and neck still first: patient becomes anxious and starts to turn head — remind trainee that at Primary Care level, verbal instruction and lanyard placement precede collar consideration, and that collar application without neurological symptoms is not routine; however, with confirmed neurological deficit the situation must be escalated and managed accordingly.)
• ! (If the trainee does not identify this as a Priority 1 transport with pre-notification: facilitator asks — 'Based on your findings, what is your transport priority and who do you need to notify?')
• ! (If the trainee does not perform a secondary CNS survey including motor and sensory assessment of all four limbs: patient spontaneously mentions — 'My legs feel okay but my fingers keep going numb. Is that bad?')

Treatment Objectives

1. 1. Ensure scene safety — confirm gravel track is clear of other cyclists, establish safe working area around patient.
2. 2. Don appropriate PPE — gloves minimum, consider eye protection given mechanism.
3. 3. Perform Primary Survey with C-spine consideration — approach patient from front, instruct patient to remain still and not move head or neck.
4. 4. Manage catastrophic haemorrhage — assess for and control any significant external bleeding. Minor abrasions to chin and right forearm noted — apply dressings as required.
5. 5. Assess airway — patent, patient speaking in full sentences, nil intervention required.
6. 6. Assess breathing — RR 18, adequate depth, nil distress, SpO2 98% on room air — no supplemental oxygen required at this time. Monitor SpO2 continuously.
7. 7. Assess circulation — radial pulse present, strong, regular. CRT <2s. Apply SpO2 probe.
8. 8. Assess disability — GCS 15 (E4V5M6). Perform AVPU initially then full GCS. Test PERL — 4mm bilaterally, brisk and equal.
9. 9. Identify and document bilateral upper limb tingling/numbness — this constitutes a FOCAL NEUROLOGICAL DEFICIT and NEXUS criteria cannot be satisfied. C-spine CANNOT be cleared.
10. 10. Apply NEXUS Clinical Decision Rule — FAIL criteria met: (1) Posterior midline cervical tenderness present; (2) Focal neurological deficit present (bilateral hand tingling/numbness). C-spine injury cannot be excluded.
11. 11. Identify dangerous mechanism of injury — high-speed ejection from bicycle with head-first impact meets SPEED assessment high-risk criteria.
12. 12. Instruct patient clearly: 'Daniel, I need you to keep your head and neck completely still. Do not turn or nod your head for any reason. Can you do that for me?'
13. 13. Place lanyard around patient's neck prior to any movement consideration.
14. 14. Apply manual cervical spine immobilisation — one officer maintains inline stabilisation of head and neck in neutral position.
15. 15. Perform Secondary and CNS Survey — systematic head-to-toe assessment. Assess motor function, sensory response, and distal circulation in all four limbs. Document findings including bilateral upper limb tingling, confirm lower limb sensation and power intact.
16. 16. Assess helmet — visible cracking noted. Perform Helmet Removal as per clinical skill with assistant maintaining inline cervical immobilisation throughout.
17. 17. Measure and apply appropriately sized semi-rigid cervical collar — with confirmed neurological deficit present, collar is indicated. Maintain manual in-line immobilisation until head blocks and spider harness are in situ.
18. 18. Position patient for extrication — with manual in-line stabilisation maintained, prepare scoop stretcher. Perform log roll as per clinical skill with three-person team, officer at head directing all movements.
19. 19. Place patient on scoop stretcher and transfer to stretcher — apply head blocks, spider harness using T.H.E. principle: Thorax (straps to prevent horizontal and vertical movement), Head (head blocks padded to neutral), Extremities (legs immobilised, arms secured with additional bandage).
20. 20. Re-evaluate primary survey post-packaging — reassess motor, sensory and circulation in all four limbs. Confirm GCS unchanged.
21. 21. Record full observations — BP, pulse, RR, SpO2, GCS, PERL, pain score, temperature. Document bilateral upper limb neurological findings.
22. 22. Transport Priority 1 — pre-notify receiving facility of suspected cervical spinal injury with neurological deficit. Transport to nearest Emergency Department capable of CT imaging.
23. 23. Record full observations every 10 minutes en route — monitor for any change in GCS, respiratory effort, or neurological status.
24. 24. Maintain verbal reassurance throughout — keep patient calm, explain each procedure before performing it.
25. 25. Scenario ends on arrival of ambulance and IMISTAMBO handover.
26. 26. Attention to hand hygiene will be given throughout the scenario.