Going round round round OSCE by Michael

 
You have 3 minutes reading time. This OSCE will run for a maximum of 17 minutes. DOUBLE

Scenario:

You receive notification that an ambulance is 3 minutes away from your ED with a 34yo female who appears to have taken an overdose of unknown ingestion. She was drowsy when the ambulance arrived and has now become unconscious. Her vital signs are:

HR 130
BP 80/40
RR 24
SaO2 92% on 15L
GCS 7 (E1V2M4)

The attachments are for the examiner's use. Do not view prior.

View attached:  Attachment 1

Instructions for the candidate

You are the consultant in the resuscitation area of a tertiary ED. You will have 2 minutes to prepare your resus team consisting of 2 experienced ED nurses and an ED registrar with airway competency prior to the patient arriving. You are to then manage the patient as the scenario unfolds.

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Communication
  • Teamwork and Collaboration
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 17 minutes. DOUBLE

For the actor

Paramedic handover:
This is 34yo female who was noted to become drowsy, and her family called the ambulance. She has a history of depression with prior suicide attempt 5 years ago and chronic back pain. On arrival, she was drowsy, but able to say she had taken some tablets. She could not name them, and the packets were not immediately available. You were able to gain IV access and obtain obs. During transport to hospital, her GCS declined from 13 (E3V5M6) to 7, prompting the advance notice. She has no allergies and it is unclear which medications she is on.

Dr:
You are a competent ED registrar with airway capabilities. You can perform most tasks quickly and competently. You have checked all of the intubating equipment and are able to intubate this patient on the first attempt with a Grade I view when asked to.

Nurses:
You are competent, experienced ED nurses. You can perform requested tasks quickly and competently, including IV access, monitoring and ventilator settings.

For the examiner

Requires: Intubatable mannequin with monitoring, intubation equipment, resus environment

It is expected the scenario will progress through the following stages:
1. Handover
2. Initial resuscitation
3. ECG and interpretation - provide when requested
4. ABG interpretation - provide when requested
5. RSI
6. VF arrest (if insufficient HCO3 or resuscitation given, delay to intubation & hyperventilation, or if time allows)

The ABG obtained on 15L O2 via NRB mask is:

pH 7.12
pCO2 23
pO2 221
HCO3 9

Na 130
K 4.5
Cl 109
glu 8.4
lac 1.4

Domains Assessment Objectives

Medical Expertise
Identification and management of life-threatening tricyclic antidepressant overdose
ECG interpretation of sodium channel blockade
ABG interpretation of metabolic acidosis

Prioritisation And Decision Making
Clear and directed management approach

Communication
Articulate presentation of information and plan to team members

Teamwork and Collaboration
Clear and succinct team leadership

Other Assessment Notes

Resuscitation
- IV fluid bolus
-- consider inotrope if refractory
- O2
- early HCO3 when cause identified

Risk Assessment
- identify TCA overdose, likely >10mg/kg
- identify risks of acidosis, hypotension, seizures, dysrhythmias
- identify need for early intubation and management

Supportive
- IDC, NGT, sedation, analgesia
- Benzos for seizures, short acting muscle relaxant to allow identification of seizures
- RSI
-- consider HCO3 prior to induction
-- maintain hyperventilation

Investigation
- ECG and ABG
- BSL
- Paracetamol
- Others done routinely...

Decontamination
- Charcoal could be considered post intubation, but time since ingestion unknown

Antidote
- HCO3 in boluses aiming for pH >7.5 and perfusing rhythm

Elimination
- None

Disposition
- ICU!



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