What now, what now? OSCE by Michael

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

Scenario:

You are called in to assist with a deteriorating patient in the resus room.

The patient is a 69yo female who complained of a headache and then had an unconscious collapse at home. Her husband called the ambulance service and she arrived GCS 3, HR 80, BP 140/70, SaO2 89% on 8L O2.

She was promptly intubated, but your registrar has had troubles ventilating the patient immediately following intubation.

The attachment is for examiner use.

View attached:  Attachment 1

Instructions for the candidate

You are the consultant on in an urban district ED. You are to assist the registrar with management of this patient.

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 a middle-level registrar who has completed an anaesthetics term. You are confident that you intubated the trachea. The intubation was uncomplicated, with grade 2 view, size 7 ETT seen to pass through the cords.

The patient, however, has been very difficult to ventilate. The ventilator is alarming with high pressures, and you have not seen a rise in SaO2.

You used propofol and rocuronium for induction. You have not started any ongoing sedation or other infusions.

You think you should remove the tube, and reintubate. You are seeking help to troubleshoot the difficult ventilation.

For the examiner

The ETT is correctly sited. To simulate difficult ventilation, you could use a small size tube (eg 5) tape the end of the ETT to replicate high pressures.

Monitor could show:
HR 90
BP 120/45
SaO2 90%
EtCO2 45

The ventilator is set to volume-control:
RR 12
TV 500
PEEP 5
FiO2 1.0

You will need a bag-valve, suction, intubation and airway rescue equipment.

Domains Assessment Objectives

Medical Expertise
Management and troubleshooting of difficult ventilation
Management of intubated patient

Prioritisation And Decision Making
Clear, prioritised, stepwise approach to management of intubated patient and difficult intubation

Communication
Clear instruction and explanation to registrar

Other Assessment Notes

- Structured approach to situation
-- eg consider DOPES, disconnect from vent, use bag-valve, adjust vent settings
-- investigate cause

- Consider other management
-- sedation, analgesia
-- CT head, ICU
-- discuss with family


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