Appendix 1. ISTS Case
Scenario: A 5-year old boy fell 15 feet onto his head while climbing a tree
Duration: 20 minute case, 30 minute debrief
Target audience: Pediatric and/or emergency medicine residents, fellows, faculty, nurses
and ancillary staff
Participants and roles (optimal):
MD 1 Team Leader, MD2 Airway, MD3 Breathing/survey physician, MD4 Medication
physician, MD5 Family advocate
RN1 Documenting, RN2 Bedside, RN 3 Medication, Social work/chaplaincy, Respiratory
therapy, Radiology, Transport, Security
Actor(s): cast as mom
Environment/Set-up:
Location: Pediatric ED
Manikin/Moulage: HAL with small contusion on head, TWO WORKING IVs
Resources: PALS cards, Broselow Tape, Harriet Lane, Documentation forms
Equipment/Props: Blood, C-collar
IMAGES: Head CT with bleed, CXR with normal (w/ hyperinflation pre-intubation) and
post intubation, Pelvic XRay, C-spine XRay, iSTAT blood gas, c-collar
Medications: RSI meds with lidocaine, IVF, Blood, Mannitol, solumedrol, 3% Saline
GOALS
1 Improve
recognition of
head trauma
+/- spine injury
2 Improve
management of
head trauma
+/- spine
trauma
3 Improve
team-work and
communication
skills
OBJECTIVES
o Recognize time critical head injury
o Recognize herniation based on vital sign changes
o Request and interpret appropriate imaging tests (CXR, cspine films, CT)
o Request appropriate fluids +/- blood and medications
(premed lidocaine, mannitol, solumedrol)
o Contact neurosurgery, OR, ICU
o Hyperventilate and elevate head of bed
o Intubate for poor mental status
o Effectively brief at the start of the scenario, huddle
during the scenario/debrief after the scenario
o Receive directions and/or direct available resources and
communicate with team members using closed loop
communication, call-outs and check backs
o Demonstrate family centered care
CASE: Introduction (1-2 minute): Participants read scenario introduction by medical
control who sign out over phone and given few minutes to brief/assemble the team.
Time
History/Progression
0-10
Paramedic handoff:
5 year old fell 15 feet from a
tree in the yard onto his head
with brief seizure on hitting
the ground and loss of
consciousness reported to be
10 minutes per mom
HR 170 sinus
BP 100/80 RR 30 Pox 100%
On arrival patient crying in
pain (responsive to verbal and
pain) at scene
On trip to ED became
“stopped crying and became
less responsive”
PHA
SE 1
Meds
One 20 cc/kg bolus initiated
by medics
One IV in place
Mom with patient on arrival
if asked mom states:
5 year old fell 15 feet from a
tree in the yard onto his head
with brief seizure on hitting
the ground and loss of
consciousness reported to be
10 minutes per mom
Allergies- none, Vaccines
UTD
Medications- none
PMH- none
Last ate lunch 1 hour prior to
event
Vaccines UTD,
Lives with mom dad and two
younger sibs
Developmentally appropriate
Physical/Simulator,
Facilitator Prompts
Vital signs on monitor (if
electrodes are attached)
HR 130 trend to 80 over
10 min (sinus)
BP 100/50 trend to 150/90
over 10 min
RR 20 trends to 45 over
10 minutes- decreased to 0
if paralyzed
SpO2 98% T 36.0
Airway/Breathing
chest, clear, symmetric air
entry
abdomen soft
Circulation
Normal heart sounds,
Extremities cool to touch,
good pulses, Capillary
refill 2 seconds
Disability
CNS : Cspine collar on
patient
Moaning in pain, doesn’t
answer questions, no
moving, not responsive to
verbal stimulation
Normal tone diffusely
Exposure
Contusion to top of head
No other injuries noted
Expected actions (checklist)
Obtain history : from EMT/mom
 Primary survey
 Assesses breathingrespirations noted without
bagging
 Clears / suctions the airway
as needed
 Maintains Cspine precautions
during intubation and
replaces c-spine collar
 Intubation performed with
LIDOCAINE premedication
with c-spine immobilization
 Successful positioning and
taping of ETT (confirmed by
auscultation, end-tidal CO2,
& CXR request)
 Identifies two working IVs
and flushes
 Orders trauma bloodwork
including type and cross,
istat, cbc, dex +/- PRBCs
 Activates trauma team
 Applies warm blankets
 Provides family centered care
11-15
PHA
SE 2
Continued deteriorating mental
status and responsiveness
mom asks questions
1 why he is so sleepy
2 can he get something for
pain
3 what is going on
Vital Signs on monitor
HR 100 increased to 150 if
mannitol, 3% saline,
intubation or elevate bed
BP 150/100 decreased to
100/60 if mannitol, 3%
saline, intubation or
elevate bed
RR 40- decreased to 0 if
paralyzed
SpO2 98% T 36.0
Exam:
STOPS MOANING
When intubated and paralyzed,
prepares for transfer to OR or
CT sign-out to new team
 Secondary survey
 Neuro-interventionsmannitol/saline/elevate bed
 Neurosurgery team contacted
CNS bleed
 Orders imaging: xrays :
cspine, chest, pelvis, NCHCT
+ C1/2 +/- abd imaging
 Inserts OG tube
 Inserts foley catheter
 Request blood products