The Gauntlet — Sim Wars Round 3

SIM WARS · ROUND 3 · FACILITATOR GUIDE

EM RESIDENTS 5 TEAMS 15 MINUTES MAX 75 POINTS
Complex Multi-System Case

The Gauntlet

A 15-minute progressive trauma simulation with 4 evolving clinical states, 6 critical actions, and time-sensitive decision points. Teams are scored on systematic assessment, speed of recognition, and correct disposition. Each state escalates if the prior one is missed.

15
Minutes
4
States
75
Max Pts
6
Critical Actions
Facilitator Timer
15:00
MTP Bonus: activate before 10:00 remaining (+5 pts)
Initial Presentation — Read Aloud to Teams
Clinical Vignette
A 28-year-old unrestrained male driver is brought in by EMS following a high-speed head-on motor vehicle collision at approximately 55 mph. Airbags did not deploy. EMS reports significant intrusion into the passenger compartment, prolonged extrication of 18 minutes, and one episode of emesis on scene. He is combative on arrival. His girlfriend, who was a passenger, was pronounced at the scene.
Vitals on Arrival
BP90/60 mmHg
HR130 bpm
RR28 /min
SpO₂89% on 15L NRB
GCS10 (E3V3M4)
Temp36.9°C
Weight (est.)85 kg
Primary Survey Findings
AirwayPatent but threatened — blood in oropharynx, combative, GCS 10
BreathingTachypneic, decreased BS left base, trachea midline
CirculationTachycardic, weak radial pulse, cool diaphoretic extremities, 2 large-bore IVs placed by EMS
DisabilityGCS 10, pupils 3mm equal reactive, moving all extremities
ExposureObvious deformity mid-shaft left femur, seatbelt sign across abdomen, multiple abrasions chest wall
EMS Report / Available Data
Mechanism55 mph head-on, unrestrained, significant intrusion
EMS IVF500 mL NS en route, no response
eFASTAvailable — free fluid in perihepatic space, LUQ, pelvis. No cardiac effusion.
Pelvic XROpen book pelvic fracture
CXRLeft lower lobe haziness, no obvious PTX on AP film
Blood typePending — O-negative on hand
Progressive States — Facilitator Controls Escalation
1

Hypotensive Shock + Respiratory Distress

Begins at case start — active from minute 0

ACTIVE ON ARRIVAL
⌄

State 1 Vitals

BP90/60
HR130
RR28
SpO₂89%
GCS10

Facilitator Cues — If Asked

eFAST: free fluid perihepatic, LUQ, and pelvis — no effusion
CXR: left lower lobe haziness, no clear pneumothorax on AP
Left chest auscultation: decreased but breath sounds present
Pelvis XR: open book fracture confirmed
Left thigh: mid-shaft femur fracture, traction splint not yet applied
2 large-bore IVs bilateral antecubital — IO available if requested

Critical Actions This State

✓
Complete ATLS Primary Survey (ABCDE) — verbalize each component systematically
10 pts
✓
Airway Decision — recognize threatened airway (GCS 10, blood, combative) and decide: RSI vs BVM vs awake intubation. Must state drug choice and plan.
5 pts
✓
Activate Massive Transfusion Protocol (MTP) — hemorrhagic shock with positive eFAST. 1:1:1 ratio (pRBC:FFP:Platelets). Call blood bank.
5 pts
✓
Administer Tranexamic Acid (TXA) — 1g IV over 10 min within 3 hours of injury. Must be stated explicitly.
5 pts
✓
Pelvic Binder Application — open book fracture with hemorrhagic shock. Reduces pelvic volume and tamponades venous hemorrhage.
5 pts
✓
Traction Splint to Left Femur — femur fractures can lose 1–2L into thigh compartment. Reduces dead space.
5 pts

Common Errors This State

Giving crystalloid boluses instead of activating MTP — worsens coagulopathy (lethal triad)
Skipping TXA — must be given within 3 hours of injury; efficacy drops sharply after
Not applying pelvic binder — open book fracture is a major hemorrhage source
Rushing to CT scan before hemodynamic stabilization — "CT is the tunnel of death"
Intubating without RSVP preparation — need suction, positioning, surgical airway kit ready in trauma
2

Tension Pneumothorax Develops

Triggers at ~4 minutes if chest not decompressed — or after intubation if missed

TRIGGERED IF MISSED
⌄

State 2 Vitals — Acute Deterioration

BP70/40 ↓↓
HR148 ↑↑
SpO₂72% ↓↓
Vent (if intub.)Peak pressures ↑↑
JVDDistended

Exam Findings — Facilitator Discloses

Absent breath sounds left side — completely
Tracheal deviation to the RIGHT
JVD now prominent
Ventilator: extreme resistance, high peak pressures if intubated
Hypotension worsening despite MTP blood products running
Note: CXR is NOT required — this is a clinical diagnosis

Critical Actions This State

✓
Recognize Tension Pneumothorax Clinically — absent BS + tracheal deviation + JVD + hypotension + high vent pressures. Must NOT wait for CXR.
5 pts
✓
Immediate Needle Decompression — 2nd ICS midclavicular line OR 4th/5th ICS anterior axillary line (larger needle, more reliable). 14g angiocath, 8cm length in trauma.
5 pts
✓
Finger Thoracostomy / Chest Tube — follow needle decompression with definitive chest decompression. Finger thoracostomy is preferred in intubated trauma patient.
5 pts

Common Errors This State

Waiting for CXR before decompressing — tension PTX is a clinical diagnosis, immediate action required
Needle decompression at 2nd ICS MCL in obese patient — unreliable, prefer 4th/5th ICS AAL in trauma
Attributing deterioration to hemorrhage only — always reassess airway/breathing when patient crashes
Not following needle decompression with chest tube — needle will kink and tension will re-accumulate
3

Hemorrhagic Shock Worsens — MTP Not Adequate

Triggers at ~8 minutes if surgical source not controlled — pelvic and abdominal hemorrhage ongoing

ESCALATES AT 8 MIN
⌄

State 3 Vitals — Deteriorating

BP60/30 ↓↓↓
HR158 ↑↑↑
SpO₂84% (post chest tube)
Urine outputNone — anuria
Temp35.1°C — hypothermic
pH (if requested)7.12 — severe acidosis

New Data — Facilitator Discloses

pH 7.12, lactate 9.2, base deficit −14 — severe metabolic acidosis
INR 2.4, fibrinogen 80 — MTP-related coagulopathy developing
Temp 35.1°C — patient is becoming hypothermic
4 units pRBC given, still hypotensive — ongoing surgical bleeding
eFAST repeat: free fluid increased significantly in all quadrants
Pelvic binder in place — hemorrhage still ongoing from abdominal source

Critical Actions This State

✓
Recognize Lethal Triad — hypothermia (35.1°C) + coagulopathy (INR 2.4) + acidosis (pH 7.12). Name it and escalate.
5 pts
✓
Emergent Trauma Surgery Consultation for OR — refractory hemorrhagic shock with positive eFAST and pelvic fracture. Not improvable in ED. Damage control surgery is the only option.
5 pts
✓
Permissive Hypotension — target SBP 80–90 (MAP 50–65) in penetrating; SBP 90 in TBI. Avoid aggressive crystalloid. Restrict IVF — blood products only.
5 pts
✓
Correct Lethal Triad Components — warm blankets + warm IVF + blood warmer for hypothermia; calcium replacement; cryoprecipitate for fibrinogen <150; consider FFP escalation.
5 pts
✓
CT vs OR Decision — patient is NOT stable for CT. Direct to OR for damage control laparotomy + pelvic packing. Verbalize the decision explicitly.
10 pts

Common Errors This State

Sending hemodynamically unstable patient to CT — "You can't CT a dead patient"
Continuing to push crystalloid — worsens all three components of lethal triad
Failing to recognize that MTP products are not enough — surgical hemorrhage control is needed
Not calling for calcium — ionized calcium drops rapidly with massive transfusion of citrated blood
Delaying OR call because "want one more set of vitals" — every minute of delay increases mortality
4

TBI Signs Emerge — Secondary Brain Injury

Triggers if hypotension and hypoxia persist uncorrected beyond 10 minutes

TRIGGERS IF UNTREATED
⌄

State 4 Neurological Changes

GCS6 ↓↓ (was 10)
PupilsRight 6mm fixed ↓
Left pupil3mm reactive
PosturingDecerebrate right
BP (Cushing)HTN + bradycardia

Facilitator Cues

Unequal pupils — right blown pupil indicates uncal herniation
Cushing's triad: hypertension + bradycardia + irregular respirations
GCS dropped from 10 to 6 — secondary brain injury from sustained hypotension and hypoxia
This state is PREVENTABLE — it occurs because the team did not correct hypotension/hypoxia early
If team managed States 1–3 correctly, this state does NOT trigger

Critical Actions This State

✓
Recognize Herniation Syndrome — blown pupil + Cushing's triad + posturing. Call it by name. Do not miss this.
5 pts
✓
Emergent Neuroprotective Measures — HOB 30°, target SBP ≥90 (cerebral perfusion), SpO₂ ≥95%, avoid hyperthermia, normocapnia (PaCO₂ 35–45). Brief hyperventilation (PaCO₂ 30–35) ONLY as bridge to OR.
5 pts
✓
Hypertonic Saline or Mannitol — 23.4% NaCl 30mL IV push OR Mannitol 1g/kg IV for herniation. Reduces ICP acutely while awaiting OR.
5 pts
✓
Neurosurgery Consultation — concurrent with trauma surgery. TBI + herniation may require emergent craniotomy simultaneously with laparotomy. Verbalize dual OR plan.
5 pts

Common Errors This State

Prolonged hyperventilation — drops PaCO₂ too low and causes cerebral vasoconstriction and ischemia; use only as temporizing measure
Giving mannitol to a hypotensive patient without correcting BP first — worsens hemorrhagic shock
Forgetting that this state was PREVENTABLE — debrief around why it developed
Not recognizing dual OR need — competing priorities of hemorrhage control vs ICP — verbalize the tradeoff
Scoring Rubric

Point Breakdown

Maximum Score 75 pts
ActionPts
ATLS Primary Survey — verbalized systematically10
Airway management decision with drug plan5
Tension PTX — recognition and needle decompression5
Chest tube / finger thoracostomy5
MTP activation — correct ratio stated5
TXA administration — dose and timing correct5
Pelvic binder application5
Trauma surgery consult for OR5
CT vs OR decision — verbalized correctly10
Neuroprotective measures (if State 4 reached)5
MTP activated within first 5 minutes of case+5 bonus
TOTAL75
Deduction Triggers
Sending hemodynamically unstable patient to CT−5
Crystalloid bolus instead of blood products initiated−5
Nitroglycerin or vasodilator given during hemorrhagic shock−5
TXA not given within 3 hours of injury window−3
Prolonged hyperventilation without correction−3
State Escalation Logic
State 1 managed correctly → State 2 still triggers (trauma mechanism)
State 2 missed → patient crashes, State 3 accelerates
State 3 managed → OR activated → case ends (win)
State 3 missed → State 4 triggers (TBI / herniation)
State 4 + no response → cardiac arrest / case ends (loss)

Live Score Tracker — Enter Team Points

Team 1
Team 2
Team 3
Team 4
Team 5
Debrief Guide — Post-Case (5–10 minutes)

Clinical Decision-Making

  • What was your airway plan and why — what were the risks of RSI in this patient?
  • When did you recognize the tension pneumothorax — what was the first clue?
  • Why is crystalloid harmful in hemorrhagic shock — explain the lethal triad
  • At what point did you decide OR over CT — what was the threshold?
  • How does permissive hypotension change in the presence of TBI?

Teamwork & Communication

  • Who was the team leader — was the role explicitly stated?
  • Were critical actions closed-loop communicated?
  • How were simultaneous tasks (airway + MTP + pelvic binder) coordinated?
  • When did you call trauma surgery — was the consult clear and structured?
  • Was there a shared mental model of the patient's trajectory?

Common Errors to Highlight

  • Tunnel vision on one problem (femur) while missing the bigger picture (hemorrhagic shock)
  • Waiting for labs/imaging before activating MTP — recognize shock clinically
  • Forgetting TXA — it has a narrow time window and is commonly omitted under pressure
  • Not verbalizing the CT vs OR decision — this is a scored, explicit action
  • State 4 TBI is a consequence of poor early management — trace back the cascade

EM Pearl Takeaways

  • Lethal triad: hypothermia + coagulopathy + acidosis — each worsens the others
  • Tension PTX: clinical diagnosis — tracheal deviation is a late sign, don't wait for it
  • MTP 1:1:1 (pRBC:FFP:PLT) — mimics whole blood, prevents dilutional coagulopathy
  • TXA within 3 hours: every hour of delay reduces efficacy; after 3 hours it may cause harm
  • Damage control resuscitation: keep them alive for the OR — not your job to fix everything in the ED
  • Secondary brain injury from hypotension is preventable — SBP <90 even briefly worsens TBI outcomes

The One Thing — What Every Resident Should Leave Knowing

  • In traumatic hemorrhagic shock, your job is damage control resuscitation and getting the patient to the OR alive. Blood products over crystalloid. TXA early. Pelvic binder. Surgical source control. CT is for stable patients — the OR is for dying ones.
SIM WARS · ROUND 3 · THE GAUNTLET · MULTI-SYSTEM TRAUMA · EM RESIDENTS · FACILITATOR COPY