Blue is bad OSCE by Michael

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

Scenario:

The ambulance has brought in a 65 year-old man with severe dyspnoea. The patient has a history of Chronic Obstructive Pulmonary Disease (COPD), with regular use of bronchodilators. He is still a heavy smoker, but has no other relevant past history.

On arrival, he is sweaty, distressed and peripherally cyanosed.

Instructions for the candidate

You are the consultant on in the resus area where the patient has arrived. An ABG has been taken. You will be required to interpret the ABG and manage the patient's condition. You will be working with an experienced ED nurse and registrar.

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Leadership and Management
  • Scholarship and Teaching
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

Nurse:
Experienced ED nurse, able to perform simple procedures and set up equipment if detailed orders given (eg, including settings)

Registrar:
Junior registrar, limited experience in resus. Asks questions about management choices:;

"What does the gas show? Is this acute?"
"Is there anything else we should give? What bronchodilators can we use?"
"Why use bilevel NIV rather than CPAP?"
"Is there anything we should consider before starting NIV?"

"If we have to intubate this patient, what ventilator settings would we use?"

For the examiner

Kit required: monitoring, mannequin, BiPAP machine, resus environment

Initial obs: patient on NRB at 12L
HR 125
BP 180/90
RR 45/min, incr WOB
SaO2 90%
T 38.5C

Initial gas on 12L O2 via NRB mask:

pH 7.15 (7.35-7.45)
pO2 80 (80-95)
pCO2 95 (35-45)
HCO3 42 (22-28)
BE +17 (-3 - +3)

Domains Assessment Objectives

Medical Expertise
Management of severe COPD exacerbation

Prioritisation And Decision Making
Sensible and safe approach to management

Leadership and Management
Clear communication and teamwork

Scholarship and Teaching
Good explanation of findings and management plan
Appropriate answers to registrar's questions

Other Assessment Notes

1. ABG
- moderate acidaemia - respiratory acidosis
- acute on chronic metabolic alkalosis and compensation
- borderline hypoxaemia - likely high for patient
- low SaO2 for pO2
- suggestive infective exac COPD

2. NIV
- identify as required
- justify use bilevel vs CPAP
- appropriate initial settings
- identify risks/contraindications (altered mental state, aspiration risk, hypotension)
- monitoring (serial ABG, SaO2, titrate O2 and pressures)

3. Medications
- bronchodilators - neb via NIV, IV unlikely required
- ipratropium
- steroids
- MgSO4 unlikely indicated
- antibiotics

4. Ventilation
- recognise difficult, other issues (eg limitations of care, potential difficult airway with rapid desaturation, agents to use)
- low volume, long expiration, aim oxygenation, permissive hypercarbia
- risk barotrauma, monitor plateau pressures
- optimise position, ventilation
- ongoing bronchodilators

Other points:
- disposition
- limitations of care
- family

Based on SCE from 2010.2 (http://lifeinthefastlane.com/facem-sce-2010-055/)


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