ACEM example: Out of hospital cardiac arrest OSCE added anonymously 

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

Scenario:

60 year brought in after out-of-hospital cardiac arrest. Initial ROSC but deteriorated on arrival in emergency department

View attached:  Attachment 1

Instructions for the candidate

You have 1 minute to prepare your team which will consist of two nurses and an ED registrar.
You will then be given handover by the paramedic and you are to manage the scenario as it unfolds.

Domains being examined

  • Medical Expertise
  • 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

Nurses. Experienced ED nurses, usual capabilities including IV access, take bloods, CPR, use defib machine. You are to respond to directions from the candidate correctly and efficiently. You should report changes in observations as you normally would.

Doctor. You are a junior ED registrar, recently completed first part exam, have done a little anaesthetics as a junior doctor but not a full anaesthetics term. You are happy to have a go at intubating if asked, but will be (deliberately) unsuccessful. You will think that the tube is in, but it will be in the oesophagus. When asked, you should say that you think the tube is OK but not completely sure.

The patient will have no air entry on auscultation and will become increasingly hypoxic, visible as oxygen saturation decreases.

Otherwise you are able to take bloods, insert IO, check blood gases etc.
Once the patient has been successfully intubated you should assist as requested with post resuscitation care including active cooling.

For the examiner

You will give the introduction and then the paramedic handover.
Mr Smith is a 60 year old man who collapsed at home. His wife called the ambulance. On arrival he was in cardiac arrest, VF, with bystander CPR in progress by wife and neighbour for approximately 10 minutes before your arrival. He responded after two DC shocks with ROSC but persistent hypotension. BP just before arrival 80/60, P 60, unresponsive GCS 3, pupils fixed and dilated. You have given no medications en route. No aspirin, no GTN.

It is expected that the candidate will check obs on arival. P 60, BP 80/60, SpO2 100% on high flow oxygen, GCS 3. Pupild fixed and dilated.
It is expected that the candidate will ask for a 12 lead ECG which is done, showing STEMI, 1 cm ST elevation, III, AVF, 2 mm ST elevation V5 V6, ST depression V3. Suggests RV AMI

The candidate is expected to consider causes of persisting hypotension esp RV infarct, but also tamponade, tension pneumothorax, hyperkalaemia, and manage accordingly. IV access is quickly and easily obtained and bloods are sent off including VBG.
pH 7.2
PO2 50,
PaCO2 45,
HCO3 24,
BE -5,
Lactate 4 mmol/l
Na 135,
K 4.5,
Cl 100,
HCO3 24,
Ur 7.5,
Cr 120.
It is expected that the candidate will ask the ED Reg to intubate. They do this as asked, but intubate the oesophagus. The patient becomes increasingly hypoxic. The ETT should be removed and either replaced or ventilatory support/guedel, LMA used. The candidate may at this stage decide to intubate the patient himself. That would be acceptable.

ECG RV4 shows 1 mm ST elevation, The diagnosis is RV AMI, (prox dominant right main) so treatment should be given including fluid bolus, possibly inotropes, urgent PCA or thrombolysis and avoidance of nitrates. Urgent priority is referral to ICU and cath lab/cardiology. The candidate is asked to make the referral to the cardiologist at 12 minutes if they have not already done so. Examiner 2 is the cardiologist who takes the call.

After the referral is made the candidate should then commence post arrest care incuding repeat ECG, CXR and active cooling as well as asking to speak to the wife. The examiner should ask “what would you say to the wife” and then listen for the response.

Domains Assessment Objectives

Medical Expertise
Should demonstrate good knowledge of the management of cardiac arrest.

Communication
Must demonstrate clear communication between candidate and team members.

Teamwork and Collaboration
Must demonstrate good teamwork skills including clear leadership with appropriate delegation of tasks.

Leadership and Management
Must demonstrate good leadership skills during the resuscitation scenario

Other Assessment Notes


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