Intubation is Coming OSCE by Michelle Johnston

 
You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.

Scenario:

You are the duty ED Consultant at a tertiary hospital. You receive a phone call from a rural GP who is manning a single doctor ED 200km away. He is managing a 28 year old woman, who has brittle asthma, and is tiring despite his maximal treatment. He does not have access to non-invasive ventilation, and there are no other doctor nearby. He is confident with intubation, but has never intubated a patient with critical asthma. He is requesting advice on how to proceed.

Instructions for the candidate

You will advise this doctor over the phone as to how to optimise treatment, how to intubate this patient, then advise on basic aspects of retrieval.

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Communication
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

You are an experienced rural GP. You are experienced in intubation, but have not previously intubated a critically ill asthmatic.
The treatment thus far has consisted of back to back salbutamoI nebulisers and IV hydrocortisone 200mg.
No parenteral drugs have yet been commenced.
The clinical features of the patient are currently:
- agitated, pulling off mask
HR - 138
BP - 156/87
SaO2 - 90% (mask on and off)
VBG = pH - 7.29 pCO2 - 49mmHg
CXR shows no pneumothorax
Your primary concern is how to intubate the patient safely, in particular with reference to induction drugs/paralysis/patient positioning/ventilator settings/anything to be concerned about post intubation
You would also like to be advised about the best way to transport the patient

For the examiner

The bulk of the answer should centre around the preparation for, and the procedure surrounding intubation of the patient, including ventilator settings, and immediate post-intubation care.

Domains Assessment Objectives

Medical Expertise
Management of severe asthma
Discussion of escalating to maximising care
- adjuncts - ipratropium, consider aminophylline
- parenteral beta agonist choice
- ?role of magnesium? evidence
- other 'last resort' ketamine, manual chest decompression
Discussion of all issues related to intubation.
- staff, area, equipment
Detailed discussion of choice of induction and paralysis agents, with doses.
Positioning of pt
Options for pre-oxygenation
First pass success
Immediate confirmation of tube
Immediate post intubation concerns
Ventilator settings - TV/RR/Plat Pressures/I:E ratios/PEEP
Retrieval options

Prioritisation And Decision Making
Priorities of management in the critically unwell asthmatic

Communication
Establishing level of competence of rural DR
Respectful communication
Ability to succinctly and quickly put vital information across

Other Assessment Notes


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