Trial OSCE exam: '' by Jordan Webb

You are taking part in a trial exam created by Jordan Webb. There are 9 OSCEs in this exam including 1 double stations (100 minutes).
 

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

Scenario:

A senior ED nurse approaches you about a patient who has just arrived in the ED. He is a 34yo male sustained a possible snake bite while walking in an area known to have both brown and tiger snakes. The bite occurred 1 hour ago.

Instructions for the candidate

You are to perform a brief assessment and manage the situation as it unfolds.

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Communication
  • Teamwork and Collaboration
  • 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

Patient:
You are a normally very well 34yo male. While walking you felt a scratch on your leg and saw the tail of snake disappearing under a bush. Your companion applied a pressure immobilisation bandage immediately and called the ambulance service.

It took an hour to come to hospital. You feel nauseated and have a headache, but have no other symptoms.

Nurse:
You are an experienced ED nurse. You have briefly seen the patient and performed obs. You have drawn bloods and sent them to the lab. You can prompt "Should we do a VDK?" and "Would he be eligible for antivenom?". You need clear guidance if antivenom is to be given. You can question regarding appropriate dose, route of administration and dilution.

For the examiner

This patient has systemic envenomation from a brown snake bite. The PIB is inadequately applied - too loose and too short.

There is blood oozing around the IV site. Examination findings are:
HR 110
BP 105/80
RR 24
T 37.6
SaO2 100% RA

If PIB is not reapplied and IV resuscitation given, he will deteriorate further.

Domains Assessment Objectives

Medical Expertise
Snake bite envenomation assessment and management

Prioritisation And Decision Making
Perform immediately required tasks
Develop clear management plan

Communication
Rapport and clear communication with the patient and staff

Teamwork and Collaboration
Clear team management and allocation of tasks

Scholarship and Teaching
Know of the controversies about antivenom use (eg dose)

Other Assessment Notes

1. Assessment
* History about bite and first aid
- location, time of day, geography, number of bites, witnessed snake, clothing, PBI
- medical conditions, allergies (prior antivenom allergy)
* Examination for signs of bleeding (bite, IV, gum, intracranial) and neurotoxicity (ptosis, opthamoplegia, bulbar)
- check site, bite marks, local reaction (cut hole in PBI, also swab, then rebandage), lymph tenderness
* Investigation
- appropriate bloods (CBE, EUC, LFT, CK, Coags, Fibrinogen and FDPs)
--- on presentation, 1 hour post PBI off, 4 hours post PBI off (~6 hours post bite), 12 hours post bite
- urinalysis for myoglobin (Hb ++)
- VDK use - skin swab (use diluent if doing VDK immediately, otherwise saline-moistened sterile swab; store in fridge), how to interpret

2. Immediate management
- reapply PBI
- fluid resuscitation

3. Antivenom
- Identify he is likely to benefit
- Describe rationale for choice of strain
- Obtain informed consent (indications, contraindications, complications (esp allergy, serum sickness), alternatives)
- Prepare patient (monitoring, IV access), team (roles and plan, environment (resus, able to manage anaphylaxis)