Shake, Rattle and Roll OSCE by Katrina Romualdez

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

Scenario:

You are a locum emergency consultant at a regional hospital with an operating theatre and surgeons including obstetrics on-call. Your nearest tertiary hospital is 45 mins away. Paramedics are bringing you a 35/F, pregnant, from home after having a witnessed generalised tonic-clonic seizure --she was given a total of 10 mg Midazolam IV to terminate the seizure Her vital signs are currently as follows:

HR 110
BP 170/110
RR 16
O2 sats 95% on 15 L O2
GCS 11 (E3V3M5)







Instructions for the candidate

You have two minutes to prepare your team (a nurse +/- a junior doctor) before they arrive. Once the patient arrives, you are to lead your team and manage the scenario as it unfolds.

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Communication
  • Teamwork and Collaboration
  • Leadership and Management
 
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 - 35/F, found by husband to be having a generalised tonic-clonic seizure on the lounge. Husband reports that the patient intermittently complained of a headache and neck pain, mild blurring of vision, and abdominal pain for the past 2 days. The patient is 34 weeks pregnant, 1st pregnancy, has had few prenatal check-ups, last one was 12 weeks ago.
If prompted, no known drug use, no trauma, no other past medical history. BGL = 6.2
Treatment so far: Jelco x 1, Midazolam 10 mg IV, simple airway support

Paramedic/junior doctor: You are extremely competent but have no initiative. You need to guide/prompt the candidate to get through the various stages of the scenario as detailed below but should try not to influence the candidate's decisions.

Nurse: you are very competent but have no initiative.

For the examiner

Stage 1: 0-2 minutes
- Preparing the team
- Mention calling for obstetrics +/- retrieval
If team is asked re services at the hospital: general paeds, special care baby unit available, no paediatric or adult ICU

Stage 2: 3-7 minutes
- Ambulance handover (as above)
- Initial assessment:
- Sim woman
GCS 11 (E3V3M5)
HR 110
BP 160/100
Sats 97% on 15 L O2
RR 22
Self-ventilating
T 39 C

- During this stage, the candidate should:
-- Lead the team through an assessment of the patient: primary survey, physical exam (normal, no rash, supple neck) obstetric assessment (CTG looking for fetal distress, signs of active labour)
-- VBG: pH 7.30, pCO2 43 mmHg, pO2 152 mmHg, HCO3 18 mmol/L, BSL 5.4 mmol/L, Na 136, K 4.0, Lactate 4.2
-- Bloods inc tox (paracetamol, etc), cultures

-- Team members can prompt candidate
--"Why do you think she had a seizure?"
--"What do you think is going on with the patient?"

-- recognise and commence treatment for eclampsia
--MgSO4 5 gm IV
--BP control

-CTG monitoring: no active labour, FHT 155

Stage 3 : 8-12 minutes
8th minute: Pt starts seizing (Reg to prompt candidate that this is happening)
HR 140
BP 170/100
Sats to 90%

Treatment expected:
Midazolam
Magnesium if not already given
Consider anaesthetic + intubation (if Mg already given in 1st phase)

Minute 10: seizure terminates (prior to intubation)
Post-ictal vital signs
HR 120
BP 150/90
RR 14 O2 sats 97% on 15 L O2
GCS 10 (E2V3M5)

Stage 4: 13-17 Stabilisation and referral
Pt's CGS continues to improve to 14 (E4V5M6)
BP remains at 150/90
CTG reassuring trace with no contractions (FHR 150s)
Treatment expected:
Magnesium infusion +/- second agent
Steroids for fetal lung maturity


Discussion with locum Obstetrics Consultant (Examiner) re: patient and plan (should include plan for transfer to tertiary hospital --if not mentioned, can be asked "Do we have facilities to manage this patient at your hospital?")

Domains Assessment Objectives

Medical Expertise
Assessment and management of status epilepticus
- Broad differential that should include pregnancy but also other diagnoses, e.g
--hypoglycaemia and other electrolyte d/o
--toxins
--head injury and other neurologic causes (seizure d/o)

- Seizure management (benzos, sodium valproate, phenytoin, etc. ) vs eclampsia management (MgSO4)

Eclampsia management
- Mg SO4 4 gm IV bolus followed by 2gm/hr infusion
- Anti-hypertensives
-- Labetalol 20 mg - 40 mg IV boluses
-- GTN infusion
-- Hydralazine 5 mg IV every 10 mins

Management of the critically ill pregnant patient
-- Left lateral decubitus
-- Extra monitoring of foetus (CTG)
-- Early OB consultation re appropriate definitive management/disposition (observation, delivery)
-- Betamethasone 12 mg IM for foetal lung maturity

Prioritisation And Decision Making

Communication

Teamwork and Collaboration

Leadership and Management

Other Assessment Notes


You must be logged in to add a comment

Comments:

Seizures/altered conscious state DDs : AEIOUTIPS Blood glucose, eclampsia ABCDEFG

javed at 09:38 16 Feb 2017