Red balloon day OSCE by Hen Houng

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

Scenario:

This is a simulation double station

You are the consultant on duty in a tertiary emergency department on a weekday afternoon. You have received ambulance pre-notification of a 6 year old female with fever, headache and vomiting due to arrive in your department in 3 minutes.

Working with you are one experienced ED registrar and two skilled nurses

Your tasks are to:
• Lead the team in preparation for the patient’s arrival
• Receive clinical handover from the ambulance crew
• Lead the team in assessment and management
• Handover to a colleague after your initial management

Instructions for the candidate

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • 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

This is a paediatric resuscitation scenario in which a 6 year old presents with CNS sepsis, but develops anaphylaxis and PEA arrest after IV antibiotics are given.

The scenario requires:

  • Paediatric airway equipment
  • A simulation monitor with adjustable vital signs
  • A defibrillator
  • A whiteboard for documenting calculations and actions
  • Correct weight based dosed IV crystalloids, antibiotics and Adrenaline +/- other drugs

REGISTRAR

  • You are competent in paediatric resuscitation, including intubation
  • You will assess the patient and convey findings as instructed by the candidate
  • Provide vital prompts to ensure that the candidate progresses through the scenario within timeframes below

NURSES

  • You are skilled APLS trained nurses but lack initiative for the purposes of the scenario
  • Confirm and document calculations and actions on the white board
  • Do not initiate actions or suggest solutions for mistakes or omissions, merely emphasise the problem e.g. ‘the O2 sats are 90%’ (not ‘should we give oxygen?’)

 

STAGE 1 at 0-3 minutes: Preparation before ambulance arrives with patient

The candidate will arrive, and is expected to:

  • Inform the team of the imminent arrival of the sick child, with a brief summary and concerns
  • Assign roles and allocate tasks to begin on arrival
  • Prepare equipment and medications
  • Prompts for expected actions omitted by the candidate may be: - What should we get ready for the patient? - Is there anything we should do when the patient gets here?

 

STAGE 2 at 3-4 minutes: Ambulance arrival and handover

Ambulance crew script: ‘We called ahead with this 6 year old with headache and vomiting, and a temperature of 38.5c. Her parents called us because she became drowsy. We got her O2 sats at 94% RA and cap refill at 3 seconds and rushed her here. She has IV access in right cubital fossa; but no medications or IV fluid have been given'

IF ASKED:

  • No known allergies
  • No significant past medical history
  • Her parents will arrive by neighbour’s car in 30 minutes

 

STAGE 3 at 4-7 minutes: Initial assessment and management by resus team

Provide this information alluding to CNS sepsis to the candidate (preferably requested by candidate in structured format)

  • A: Patent and protected
  • B: O2 sats 94% RA, mild right-sided crackles
  • C: HR 120bpm, BP 80/50mmHg Central capillary refill 3 seconds
  • D: GCS 14 (E4, V4, M6) i.e. confused and disorientated, equal reactive pupils
  • E: T 38.5c, Faint non-blanching rash present on arms

Expected interventions from the candidate:

  • A/B: Supplementary O2
  • C: IV crystalloid in correct weight based volume (should have been calculated earlier); may slightly improve haemodynamic status
  • D: The candidate may suggest ‘Preparation for intubation,’ in which case you should agree but re-direct them to giving antibiotics (see below)
  • **E: Empiric antibiotic e.g. Ceftriaxone (PROMPT for this as it is KEY for the rest of the scenario)**

 

STAGE 4 at 7-9 minutes: Anaphylaxis post IV antibiotic (can be delayed by need to improve haemodynamic status if candidate ahead of time)

Inform the candidate of the signs below, alluding to anaphylaxis:

  • A: Lips appear swollen, there seems to be stridor
  • B: O2 sats now 80% - (diffuse wheeze on auscultation, if asked)
  • C: BP now 40/30 D: Rash looks different ‘now raised’ and all over limbs and trunk

Expected interventions:

  • Adrenaline 10mcg/kg IM anterolateral thigh, preferably with escalation plan i.e. repeat at 3-5 minutes +/- Prepare Adrenaline IV infusion
  • Increase FiO2 e.g. high flow, non-rebreathe if not previously initiated
  • Adrenaline via nebuliser may be started if requested by candidate
  • IV fluid bolus at weight appropriate volume e.g. N saline 20ml/kg

 

STAGE 5 at 9-15 minutes: PEA arrest with two complete cycles of CPR

Prompt for cardiac arrest: 'The O2 trace has gone - the patient has stopped breathing'

Expected interventions with role allocations (e.g. Airway, compressions, defibrillator management, time keeper) and confederate responses:

  • Initial Check pulse: 'No pulse'
  • Start CPR in correct ratio 15:2
  • Place defibrillation pads and charge ~ 4J/kg
  • Rhythm check: Non-shockable; dump charge - Check pulse: 'No pulse'

1st CPR cycle for 2 minutes (can truncate)

  • Immediately recommence CPR following on from previous pulse check
  • Adrenaline 10mcg/kg IV (then every alternate cycle)
  • Address likely reversible H and T causes e.g. O2, IV fluid, Adrenaline Charge defibrillator
  • Rhythm check at 2 minutes: Non shockable, Dump charge - Check pulse: 'No pulse'

2nd CPR cycle for 2 minutes (can truncate)

  • Immediately recommence CPR following on from previous pulse check
  • No Adrenaline
  • Charge defibrillator
  • Rhythm check at 2 minutes: Non shockable, Dump charge - Check pulse: 'Pulse present' (ROSC)

Intubation is successful if attempted during CPR but then ventilation and cardiac compressions should become asynchronous

POST-ROSC OBSERVATIONS:

  • A/B: 'Breathing spontaneously,' ‘Face less swollen,’ 'mild general wheeze present'
  • C: HR 130bpm, BP 70/50mmHg, Cap refill 2-3 secs
  • D: 'Eyes have open and limbs are moving, although drowsy'
  • E: 'The raised rash seems to be fading'

Give IV corticosteroid if candidate suggests (although they may have already been given for meningitis)

The candidate may want to discuss post ROSC care but interrupt with a phone call from ICU

 

STAGE 6 at 15-17 minutes: Phone call from Paediatric ICU/Ongoing management plan

Paediatric ICU consultant calls having 'heard about a sick child' and wanting a clinical handover which should include the following:

  • Succinctness
  • Prioritised information e.g. Post PEA Arrest>Anaphylaxis>CNS sepsis
  • Ongoing management plan e.g. Adrenaline infusion, intubation

The paediatric ICU consultant should accept the patient but prompt for features lacking in handover e.g. are there still signs of anaphylaxis, is the airway protected, is Adrenaline infusion going to be started?

For the examiner

Domains Assessment Objectives

Medical Expertise
Correct age and weight adjusted doses and equipment e.g. Adrenaline, Crystalloid, ET tube, Defibrillator energy selection
Anaphylaxis management plan
APLS algorithm

Prioritisation And Decision Making
Early CNS sepsis management
Anaphylaxis management with escalation according to timed review of vital signs
Reversible cause management relevant to anaphylaxis e.g. hypoxia, volume status

Teamwork and Collaboration
Closed loop communication
Role ascertainment and task allocation including changing roles during CPR
Succinct referral commencing with macro detail e.g. 'Post PEA arrest' > 'Anaphylaxis' > CNS sepsis

Other Assessment Notes


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