Time to pull (part 2) OSCE by Michael

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

Scenario:

David, a 32yo man was brought to the ED overnight after being found with a reduced conscious state after using GHB. He was intubated soon after arrival for a GCS of 7. His CT head is normal, and no significant injuries have been identified. He has been assessed as appropriate for extubation in ED. He is on minimal ventilatory support and has roused to a cooperative state when sedation was weaned.

Instructions for the candidate

You are the consultant on in the resuscitation area. You are to perform the extubation and provide an ongoing management plan. You will be assisted by an experienced emergency nurse.

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

Nurse:
Experienced and able to perform tasks requested.

The patient has been assessed as appropriate for extubation and weaned off sedation and ventilatory support in preparation. He is now off sedation and is eyes open, obeying commands. There are no significant secretions.

For the examiner

Requirements: intubated mannequin, ventilator, monitor, resus equipment

The focus is not on determining if extubation is appropriate, although a brief assessment is reasonable.

Ventilator - pressure support
PEEP 5
Pinsp 5
FiO2 0.3
TV ~550mL

HR 75
BP 125/70
RR 14
SaO2 99%

ABG on FiO2 0.3

pH 7.37
pO2 145
pCO2 37
HCO3 25

Domains Assessment Objectives

Medical Expertise
Safe practice of extubation and post-extubation care

Prioritisation And Decision Making
Safe approach and ongoing management plan

Communication
Clear communication with nurse and patient

Other Assessment Notes

1.Appropriateness of extubation (see part 1)
- indication identified and has now resolved (in this case, GHB should have worn off)
- no other reason to remain intubated
- easy to re-intubate
- adequate mental state when sedation weaned
- haemodynamically well, no inotropes
- minimal ventilatory support
- good gas exchange on ABG

2. Preparation
- identify potential complications: aspiration, resp failure, hypoxia, laryngospasm
- for procedure: preoxygenate, suction, syringe to deflate cuff
- for complications:
-- intubation equipment and drugs
-- BVM with PEEP valve
-- NIV

3. Procedure
- sit up
- suction tube and oropharynx
- preoxygenate on 100% O2
- large inhale, deflate cuff and remove tube
- immediate high flow O2
- ready to manage laryngospasm (PEEP, jaw thrust, re-induction and intubation)

4. After-care
- observation for 1 hour in monitored conditions
- markers of failure:
-- RR <8 or >35
-- SaO2 < 88%
-- resp distress, agitation, arrhythmia, hypotension
- discharge criteria:
-- normal mental state
-- no O2 requirement
-- normal obs
-- eat and drink
-- responsible companion
- counselling:
-- no alcohol/drugs 24/24
-- no driving/heavy machinery 24/24
-- using drugs is bad, man

Bonus:
- consider departmental resources and staffing


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