Setup

Chief complaint: Difficult to arouse, poor feeding
Patient age: 4 months old
Weight: 5 kg

Recommended Supplies

• Manikin: Infant
• Moulage: Bruise to abdomen (supplemental photo available), flank (red-purple color make-up). Torn frenulum (apply red dried blood under upper lip at central incisor teeth, clinical photograph to supplement oral exam).
• Resources: PALS cards and/or length-based tape (e.g., Broselow Tape)
• Manikin set up: No IV line – ability to place IO
• Equipment:
  • Cardiac monitor and leads
  • Pulse oximetry
  • Pediatric airway equipment of various sizes/airway cart
    • Nonrebreather mask
    • Bag valve mask
    • Oxygen tubing
    • Suction
    • Intubation equipment (3.5 cuffed ETT, Miller 1 blade, stylet, suction, ET CO2 monitor)
    • Cervical collar
    • Intraosseous equipment including E-Z IO, needle, stabilizer, and connectors, saline flushes
• Medications: Normal saline, lorazepam, fosphenytoin, levetiracetam, phenobarbital, ceftriaxone, RSI medications as per hospital protocol, mannitol, 3% normal saline
• Bedside ultrasound

Supporting Files

• Chest XR
• Head CT
• Oral cavity photograph showing torn superior frenulum
• Photograph showing abdominal bruise
• Lab results

Participants/Roles

• Team leader
• Airway manager
• Survey physician
• Medication preparer
• Medication giver
• Family liaison/history taker
• Standardized patient (actor or faculty) to play patient’s parent

* Team roles may need to be adjusted in order to suit local practices and norms

Faculty or other embedded participants can play a nurse, respiratory therapist, or tech, if there are not enough learners to perform the above roles.

Prerequisite Knowledge

• Faculty
  • PALS protocols
  • General knowledge of emergency medicine
  • Simulation implementation and debriefing experience

• Emergency medicine residents
  • Any stage of training (preferably PGY-2 or higher)
  • Completed PALS certification
  • Intubation, IO placement

Case Alternatives

• The patient may have refractory seizures requiring multiple rounds of anti-seizure medications. Emergent management of increased intracranial pressure could be incorporated into the case.

Milestones

PC1. Emergency Stabilization
PC2. Performance of Focused History & Physical Exam
PC3. Diagnostic Studies
PC5. Pharmacotherapy
PC9. General Approach to Procedures (PC9)
PC10. Airway Management (PC10)
PC14. Other Diagnostic and Therapeutic Procedures
ICS1. Patient Centered Communication
ICS2. Team Management
ICHP01. Effective communication with Parents ICHP08. Delivering Bad News
TR12. Pediatric Trauma Resuscitation: Primary, secondary, interventions
TR02. D&M of Major Traumatic Brain Injury
TR07. D&M of Common Traumatic Conditions: Blunt abdominal trauma
CP2_01. Place an Intraosseous Line

Resources

1. Paul A, Adamo M. Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment. Transl Pediatr. 2014;3: 195–207. PMID: 26835337
2. Ronning M, Carolan P, Cutler G, Patterson R. Parasagittal vertex clots on head CT in infants with subdural hemorrhage as a predictor for abusive head trauma. Pediatr Radiol. 2018;48:1915-1923. PMID: 30187091
3. Christian CW. Committee on Child Abuse and Neglect. The evaluation of suspected child physical abuse. Pediatrics. 2015;135:e1337–e1354. PMID: 25917988
4. Interfacility Transfer Toolkit for the Pediatric Patient, in M.a.C.H.B. Health Resources and Services Administration, EMSC (EMSC) Program, Editor. 2018. p. 1-42.
5. Bhananker, S., J. McFadyen, and R. Ramaiah, Initial assessment and management of pediatric trauma patients. International Journal of Critical Illness and Injury Science(2012. 2(3): p. 7.
6. Committee On Pediatric Emergency Medicine, C.O.I., et al., Management of Pediatric Trauma. Pediatrics, 2016. 138(2).
7. Nakayama DK, Gardner MJ, Rowe MI. Emergency endotracheal intubation in pediatric trauma. Ann Surg. 1990;211(2):218-223. PMID 2301999
8. Rotondo M, Cribari C, Smith R. Resources for Optimal Care of the Injured Patient. Committee on Trauma. 2014, Chicago, IL: American College of Surgeons. p 1-215.
9. Starnes AB, Oluborode B, Knoles C, Burns B, McGinnis H, Stewart K. Direct Air Versus Ground Transport Predictors for Rural Pediatric Trauma. Air Med J. 2018;37(3):165-169. PMID 29735228
10. Khanna S, Davis D, Peterson B, et al. Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury. Crit Care Med. 2000;28(4):1144- 1151. PMID 10809296
11. Fox S. Pediatric trauma pitfalls. Ped EM Morsels 2019.
12. Sobolewski B. Clinical predictors and evaluation of blunt abdominal trauma in children. PEM Cincinnati 2015.
13. Sobolewski B. Why we do what we do: Benzodiazepines as first line therapy for status epilepticus. PEM Cincinnati 2019.
14. American College of Surgeons Trauma Quality Programs. Best practices guidelines for trauma center recognition of child abuse, elder abuse, and intimate partner violence. 2019.
15. Ann & Robert H. Lurie Children’s Hospital TEN-4 FACESp inforgraphic.
16. TREKK Suspected Physical Child Maltreatment Guidelines. 2018.

Altered Mental Status in an Infant

Start through 3 minutes

Critical Actions

• Team leader assigns tasks
• Obtain history from parent
• Perform primary survey
• Administer supplemental oxygen
• Place patient on continuous cardiac monitor
• IO Access after failed IV
• Labs sent once access obtained (point of care glucose, VBG, CBC, blood culture, CMP, lipase, PT/PTT/INR, UA, urine culture, urine tox)
• Discuss progress and plan of care with the parent (and involve them in decision-making)

Physical Exam

Instructor Notes: Changes and Case Branch Points

Respiratory Failure and Intubation

3 minutes into case through administration of 2 doses of benzodiazepines AND review of labs

Critical Actions

• Demonstrate appropriate BMV using head tilt/chin lift, C and E, or two handed technique
• Perform endotracheal intubation (direct laryngoscopy or video laryngoscope, adequate preparation- suction, stylet) with appropriate RSI medications, if ordered
• Appropriately manage a seizure (benzodiazepine as first line x 2 doses, and fosphenytoin or alternative as second line. Alternatives include: phenytoin, levetiracetam, phenobarbital)
• Request and correctly interpret CxR: Post-intubation CxR identifies posterior rib fractures

Physical Exam

Instructor Notes: Changes and Case Branch Points

Secondary Survey

Cessation of seizure and review of labs through ordering of head CT

Critical Actions

• Obtaining a CT head
• Trauma surgery and neurosurgical consult
• Precautions taken to protect against increasing intracranial pressure and consider cervical spine immobilization

* Unbolded items may be excluded depending on local practices and norms

Physical Exam

Instructor Notes: Changes and Case Branch Points

Case Conclusion

Completion of head CT through discussion with father

Critical Actions

• Identify child abuse as likely cause of patient’s presentation
• Verbalize need for social work consult, ophthalmology consult, skeletal survey, c-spine immobilization
• Discuss with parent why child abuse is likely cause and discuss standard care and policy, initiate phone call to CPS

* Unbolded items may be excluded depending on local practices and norms

Physical Exam

Describe signs/symptoms and findings suggestive of non-accidental trauma in an infant (comprehension)

• Recognize sentinel injuries of a frenulum tear, bruising on non- bony prominences, healed rib fractures, and intracranial injury as findings suggestive of child abuse in an infant. Remember sentinel injuries with the mnemonic “TEN-4-FACES-P,” standing for bruises of the Torso, Ears, and Neck; any bruise in infants less than 4 months of age, bruises of the Frenulum, Angle of the jaw, Cheek, Eyelid, and Subconjunctival hemorrhage; and Patterned bruises. The American Academy of Pediatrics guideline states that any injury to a young pre ambulatory infant suggests child abuse. Note that this 4 month-old infant is pre-ambulatory.
• Identify parasagittal vertex clots on head CT in infants with subdural hemorrhage as a predictor for abusive head trauma
• Abusive abdominal trauma: Relatively rare (0.5-11% of cases), but is the 2nd leading cause of child abuse associated mortality (head injury is 1st). Mortality rates are as high as 45%. Because it is estimated that abdominal trauma contributes ~50% of abusive fatalities, providers should be vigilant for occult abdominal trauma and consider obtaining screening labs.

Demonstrate early evaluation of a critically ill patient (application)

Recognize an ill-appearing infant given the presentation of lethargy, decreased level of responsiveness, and decreased feeding. These findings are often the only signs of a seriously ill infant given the young age of the patient. Inability to arouse the patient or decreased desire to feed should be seen as red flags.

Demonstrate airway management of a sick child including BMV and intubation (application)

• Airway management is a critical component of pediatric resuscitation, especially in trauma patients
• This is not limited to endotracheal intubation, and should also include your adjuncts of BMV and OPA/NPA
• Two-person BMVpreferred to one-person BMV: One person with two-hand C&E hold to ensure proper seal, and one person to bag the patient
• If two people not available, one hand should maintain C&E hold to ensure proper seal and one hand to bag
• The goal of intubation is to ensure optimal gas exchange
• The most common indications for intubation in a trauma patient are: Coma, shock, apnea, and airway obstruction, GCS <8.
• Common airway complications include: Right mainstem intubation, esophageal intubation, massive aspiration, unilateral or bilateral vocal cord paralysis, subglottic stenosis, failure to adequately preoxygenate, and extubation during transport.
• Rapid Sequence Intubation: Adding medications should not prolong the time to intubation in emergency situations. If the infant is lethargic and apneic, like in the current case, one can proceed to intubate without medication.
  • Pre-medications
    • Atropine (0.02 mg/kg IV – max 1 mg) may benefit
      infants under 1 year to blunt the vagal response that can cause significant bradycardia. Strongly consider in patients that have very irritated myocardium (myocarditis, cardiogenic shock etc.)
    • Fentanyl (1-3 mcg/kg IV at 3 minutes prior to induction) may blunt the transient increase in ICP that can occur with induction in patients with severe head trauma; however, the evidence is not strong for its use.
    • Lidocaine is another medication that has been used in the past to prevent a rise in ICP; however, its use has not been supported in children and is no longer considered the standard of care.
  • Sedatives
    • Ketamine, etomidate, and propofol are good options each with their own side effects.
    • Ketamine (1-2 mg/kg) is generally the preferred agent as it is hemodynamically advantageous. It once had been reported with a theoretical risk of increased ICP, but this is NO longer considered true.
    • Etomidate (0.3 mg/kg) is relatively hemodynamically neutral; however, it has a theoretical risk of adrenal suppression and therefore should not be used in septic patients.
    • Propofol (1-2 mg/kg) has a rapid onset; however, it has no analgesic properties and can cause profound hypotension. Has antiepileptic properties.
  • Paralytics
    • For neuromuscular blockade, both rocuronium (1- 1.5 mg/kg) and succinylcholine (1-2 mg/kg) are good options. Rocuronium is the preferred agent at most institutions.
    • Succinylcholine has a more rapid onset and a shorter duration; however, it can cause hyperkalemia and can trigger malignant hyperthermia in susceptible patients.

Construct a differential diagnosis for altered mental status/status epilepticus in an infant (synthesis)

Provide possible etiologies for seizure in this scenario as a shared mental model: Trauma, toxin, infection, electrolyte abnormality, metabolic etc. or consider AEIOU-TIPS mnemonic for altered mental status (Alcohol/Acidosis, Endocrine/Epilepsy, Infection, Opiates/ Overdose, Uremia, Trauma , Insulin, Poisoning, Stroke). Utilize bedside point-of-care labs in evaluation and management of severe status epilepticus. Use lorazepam as a first line treatment agent.

Formulate an initial diagnostic plan for a critically ill infant with altered mental status/seizure (synthesis)

Initial evaluation should target the evaluation for the possible causes listed above. Laboratory evaluation should look for hypoglycemia, acid/base status derangements, abnormal electrolytes, kidney and liver dysfunction, and signs of infection. Point of care labs followed by more detailed evaluation is warranted. Blood and urine can often be obtained emergently during the initial resuscitation period. While a lumbar puncture to evaluate for meningitis/encephalitis may be needed, this should be deferred until the patient is stable which may be after administration of empiric antibiotics. A targeted toxicology evaluation and ECG may be required. Neuroimaging such as CT should be performed when needed after the child has been stabilized, and the airway is protected or secured.

Construct and implement initial management of status epilepticus in an infant with first and second line medications (application)

Benzodiazepines are recommended as the first-line medication for pediatric seizures; two doses are recommended before proceeding to second-line medications like fosphenytoin or levetiracetam. Consider phenobarbital for refractory seizures or in infants ≤2 months old.

Demonstrate the evaluation of a pediatric patient with concern for trauma using a standard systematic approach (application)

• Evaluation of traumatic injuries follows a standardized approach taught in Advanced Trauma Life Support (ATLS)
• Evaluation begins with addressing any life-threats identified in the ABCs. This is followed by a head to toe exam known as the secondary survey. This includes continued reassessment and a return to ABCs as the clinical condition changes.
• The E-FAST ultrasound exam typically occurs during or after the secondary survey. E-FAST is a valuable tool – but more so in adults as children may have physiologic free fluid and injuries that will not require surgery as compared to adults with similar findings. It may be just as appropriate to screen those children with labs (AST/ALT, pancreatic enzymes, urinalysis, CBC) and CXR before considering CT.

Manage head trauma in an infant (application)

• Prevent hypotension, hypoxemia, hypercarbia, and hypovolemia. They will worsen secondary brain injury.
• Watch for raised Intracranial pressure. Mannitol 0.5 g/kg IV/IO or 3% saline 3-5 mL/kg IV/IO are commonly used for elevated ICP.
• Maintain the head of bed at 30 degrees to aid in venous drainage.
• Ensure the head is midline to ensure one side’s venous flow is not being constricted.

Demonstrate intraosseous placement (application)

IV access is often difficult to obtain in small children, especially given that this patient is likely dehydrated from decreased feeding. It is important to recognize that IO access is necessary and important to give fluids and medications.

Demonstrate focused history taking and discussion about concern about non-accidental trauma with a caregiver (application)

• Components of history taking: Past medical history, surgical history, family history, medications, allergies, social history, vaccination history
• SAMPLE mnemonic (S – signs and symptoms; A – allergies; M – medications; P – pertinent past medical history; L – last oral intake; E – events leading up to presentation) is helpful to quickly obtain necessary information. For this scenario, obtaining a quick history of falls/possible trauma, new caregivers, etc. is critical.

Explain diagnosis and management to caregivers (synthesis)

A shared mental model of concern for child abuse: Demonstrate effective communication with a parent, both with obtaining an appropriate history and delivering bad news. Ask for understanding and offer clarification. Show images to explain if appropriate.

Demonstrate teamwork and closed loop communication (application)

Teams may use different frameworks to improve team dynamics and communication. Below are a few definitions that may be helpful to discuss, adapted from the AHRQ TeamSTEPPS Pocket Guide.

• Brief: Short session prior to start of encounter to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies
• Huddle: Ad hoc team discussion to re-establish Situation Awareness; designed to reinforce plans already in place and assess the need to adjust the plan
• Callout: A strategy used to communicate critical information during an emergent event. Helps the team prepare for vital next steps in patient care. (Example: Leader- “Airway status?”; Surveying provider- “Airway clear”; Leader- “Breath sounds?”; Surveying provider- “Breath sounds decreased on right”)
• Check-back: A closed-loop communication strategy that requires a verification of information ensuring that information conveyed by the sender is understood by the receiver as intended. The sender initiates the message; the receiver accepts it and restates the message. In return, the sender verifies that the re-statement of the original message is correct or amends if not. (Example: Leader- “Give diphenhydramine 25 mg IV push”; Med Prep- “Diphenhydramine 25 mg IV push”; Leader- “That’s correct”)
• SBAR: A framework for team members to structure information when communicating to one another.
  • S = Situation (What is going on with the patient?)
  • B = Background (What is the clinical background or context?)
  • A = Assessment (What do I think the problem is?)
  • R = Recommendation (What would I do to correct it?)
• Situation monitoring: The process of continually scanning and assessing a situation to gain and maintain an understanding of what is going on around you.
• Situation awareness: The state of “knowing what’s going on around you.”
• Shared mental model: Result of each team member maintaining situation awareness and ensures that all team members are “on the same page.” An organizing knowledge structure of relevant facts and relationships about a task or situation that are commonly held by team members.
• STEP: A tool for monitoring situations during complex situations. A systematic method to review Status of patient, Team members’ performance and status, Environment, and Progress towards goal.
• Cross-monitoring: A harm error reduction strategy that involves 1. Monitoring actions of other team members 2. Providing a safety net within the team. 3. Ensuring that mistakes or oversights are caught quickly and easily. 4. “Watching each other’s back.”
• CUS: Signal phrases that denote “I am Concerned,” “I am Uncomfortable,” and “This is a Safety Issue.” When spoken, all team members should understand clearly not only the issue but also the magnitude of the issue.

Chest X-ray

Head CT

Examination of the mouth

Examination of the abdomen

Download Case 10 supporting files

Notes:

• CXR Interpretation: Post-intubation chest x-ray with posterior rib fractures. Image from Dr. Rebekah Burns.
• Head CT Interpretation: Head CT with a subdural hematoma. Image from Dr. Manu Madhok.
• Examination of the Mouth – findings: Upper lip frenulum tear. Used with permission from owner Dr. James Metz.
• Examination of the Abdomen – findings: Circular bruise on left abdomen. Used with permission from owner Dr. Caitlin Crumm.

For the embedded participant playing the patient’s parent

Case Background Information

A 4-month-old girl arrives atto the Emergency Department by ambulance, accompanied by her father/mother, because she seems less alert. Both parents were at work today. The father/mother was called by the babysitter because upon waking, the baby was difficult to arouse and did not want to feed as she usually does. She was fine when the parents left for work in the morning. When her father/ mother arrived home the infant would not wake up. He/she was concerned and called EMS. The other parent is on his/her way home from work now and will be meeting at the hospital.

The infant has a seizure with visible shaking during the case. The father/mother will be appropriately concerned and the team will need to explain what is happening to the child. Also, the patient will then require an airway tube to be placed to help the infant breathe. The father/mother will be extremely worried while all this activity is happening around the patient. Finally, bruises, rib fractures, and an internal bleeding in the brain are identified. The father/mother will be approached with concern of child abuse, and the team will discuss the concern with them as well as the process of involving Child Protective Services.

Who are the Learners?

Emergency medicine residents of different training levels

This case is aimed at residents who have a fair understanding for the care of injured children. They should be competent in any emergency procedures pertaining to stabilization of this patient.

Standardized Patient Information

You have arrived via ambulance with your infant because you are concerned she is not acting right. When you arrived home from work, your babysitter told you she was not acting herself and you noticed that she was difficult to arouse. The infant seems to be breathing on her own but is not waking up or crying with stimulation.

You are very concerned about your baby and appropriately worried this situation is very serious. You cannot understand why she is acting this way.

You do not interrupt the case with questions but you answer whatever questions are asked of you. Other than the information provided above, you do not offer additional information and say “I don’t know, she was fine when I left this morning”. You are cooperative but visibly upset. You are concerned but are not overly emotional.

You will be watching while critical actions occur, including the infant will have a seizure with visible shaking, and asking “what is happening”. The team will need to place a tube into the baby’s airway to assist with breathing. You will be visibly concerned, not obstructive to the case, and will not ask too many questions to allow the team to proceed.

Patient Information

(Please remember not to offer any of this information, but when asked please respond while remaining in character.)

• CHIEF COMPLAINT (your response to open-ended questions such as “what’s going on?” or “what can we do for you? Or “what happened?”): “I don’t know, she was fine this morning. Now she’s not acting herself.”
• AGE: 4 months old
• ADDITIONAL HISTORY: Not moving around even when I try to wake her. Been fussy lately for a week and no bowel movement since yesterday. No reported fever, URI, or vomiting.
• PAST MEDICAL HISTORY: None
• SOCIAL HISTORY: Lives at home with mom and dad. Has had the same babysitter for 2 months. No other caregivers / family members / friends / siblings regularly around the baby.
• FAMILY HISTORY: Unremarkable
• PAST SURGICAL HISTORY: None
• MEDICATIONS: None
• ALLERGIES: No known drug allergies
• IMMUNIZATIONS: Up-to-date with 2 month vaccinations
• FEEDINGS: Initially breast fed but now on formula (Similac Sensitive). She is a spitty baby and PMD is managing gastroesophageal reflux without any medications. Normal feeding prior to today. This morning took a 4 oz bottle of formula. Babysitter told parents that the infant had difficulty taking her afternoon feeding.
• WET DIAPERS: Normal
• BIRTH HISTORY: She was born at 37 weeks, normal vaginal delivery, no issues with pregnancy or delivery

Potential Dialogue

IMPORTANT: Do not offer unsolicited information. Please allow the learners to ask questions. Do not offer information unless they ask you.

Learners may ask you questions, such as the following. Your answers are provided.

• Any history of trauma or falls? Answer: No
• Any recent illnesses or fever? Answer: No
• What are these marks on her belly/back? Answer: I don’t know, not noted before.
• What is the blood in the mouth from? Answer: I don’t know, not noted before.
• Could the infant have gotten into any medications? Answer: No
• Any issues with development or growth? Answer: No
• Can you call the babysitter and ask additional questions? Answer: She is not available.
• Any other questions may answer “I don’t know.“

Things you could say without being asked:

• “Is she going to be ok?”
• “Why is she acting like this?”
• “Is she breathing?”

Things you might say triggered by events in the scenario:

The learners enter the room and see a lethargic inconsolable infant. They immediately place the patient on bedside monitors, provide supplemental oxygen, and attempt IV access. An IO line is placed after multiple failed attempts at IV access. Baseline labs are sent. The patient has a generalized tonic-clonic seizure, which is first refractory to two doses of lorazepam. The seizure breaks with second line medications, however, the patient becomes apneic. The decision to intubate the patient should be made, and the intubation is successful. The physical exam is significant for lethargy and altered mental status, abdominal bruising, and an upper lip frenulum team.

A CXR is then obtained to confirm placement of ET tube which shows multiple posterior rib fractures in different stages of healing. Learners should obtain a CT head due to the patient’s presentation, which reveals a subdural hematoma without a skull fracture, which should raise suspicion for child abuse, or non-accidental trauma. Cervical spine and increased intracranial precautions should be taken (head of bed elevated to 30 degrees, hyperventilation). Labs, if obtained, show an increase in AST/ALT >100 which further raises concern for blunt abdominal injury concerning for child abuse in conjunction of CXR and CT head findings. Bedside ultrasound with a FAST exam is not indicated. However if obtained, you can report no free fluid. In this case, the patient is not stable for CT abdomen/pelvis imaging, if requested. Abdominal CT and skeletal surveys can be deferred for later management.

Trauma surgery and neurosurgery are consulted. Communication with family regarding concerns are addressed, and child protective service is notified.

Anticipated Management Mistakes

1. Problem with bedside monitors: Learners may be unfamiliar with equipment and fail to correctly place monitor leads, apply an inappropriate cuff sizing for pediatric patient, or fail to ask for an estimated weight. The facilitator can cue learners to use the Broselow tape/bag/cart or other resource to select the correct equipment (depending on what is available in your simulation center). If an inappropriate cuff is selected, you can report that the blood pressure doesn’t result and have the nurse suggest the cuff is incorrectly sized.
2. Difficulty with access: After brief (no more than two) attempts at peripheral lines, the learners should proceed to IO access. The nurse (embedded participant) or instructor can say “I don’t see any available veins, we’ve already tried twice, is there anything else we could do” to prompt IO placement if needed.
3. Develop anchor bias towards sepsis: Learners may focus on central line access, IV antibiotics, fluid bolus/pressors as learners have proceeded down the sepsis pathway. If this continues after the first 3 minutes of the case, a seizure will start. The facilitator will exclaim that the child is shaking.
4. Failure to recognize the need for intubation: The patient has no obvious airway obstruction, but has diminished GCS. A seizure causes concern for airway protection. The patient will start desaturating and become apneic, if this is not addressed.
5. Failure to think of child abuse as a differential diagnosis: The nurse will ask about bruises and ask aloud how this non-mobile baby got bruises. If learners are not noting rib fractures, the nurse can ask for them to look at the ribs or can report a call from the radiologist confirming that the tube is in good position and the finding of rib fractures.
6. Failure to recognize frenulum tear and bruises as findings of child abuse: The nurse will attempt oral suction and ask the learners to look at the dried blood under upper lip in the mouth and ask the parent about it.
7. Failure to recognize need for Trauma Team consultation: Learners may decide to pursue advanced imaging or admission to a critical care setting. The nurse will advocate for a trauma physician and neurosurgeon to discuss appropriate imaging and disposition.
8. Failure to recognize vertex bleed as sign of abusive head injury: The facilitator can discuss sentinel injuries and cardinal signs of child abuse during debriefing.
9. Ignoring father in the room: Learners will likely forget that family is in the room if they stay quiet or get annoyed with them if they are in the way too much. They will have to balance informing the father what is going on while asking him to not be a hindrance to medical care.