Trial OSCE exam: 'Exam' by tom glover

You are taking part in a trial exam created by tom glover. There are 9 OSCEs in this exam (90 minutes).
 

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

Scenario:

An ambulance crew arrive in your resus room with a 27yo man who was witnessed to have a generalised tonic-clonic seizure. On their arrival he was post-ictal, and then had a further seizure that terminated with 5mg midazolam IV.

Instructions for the candidate

You are the resuscitation consultant. You are to take handover and then manage the scenario as it unfolds.You will be working with an emergency registrar and an ED nurse.

Domains being examined

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

For the actor

Paramedic:
You have transported a 27yo man who was witnessed to have a generalised tonic-clonic seizure. On arrival he was post-ictal GCS 12 (E3V4M5), and then had a further seizure that terminated with 5mg midazolam IV. You have established 1 IV access and given 500mL IV normal saline.

You are told he is a known epileptic who is non-compliant with his carbemazepine. He smells of alcohol and is dishevelled. He appeared homeless with a trolley of possessions and alcohol.

Nurse and Doctor:
Experience ED staff with surprisingly no initiative. Can competently do tasks assigned.

If not progressing with treatment options, prompt "Is this status epilepticus?" "Is there anything else we can give?" "Could there be another cause?"

After intubation "What do we need to do now?" "Is there anything else we should give?" (if not on sedation)

For the examiner

The seizures will briefly respond to further midazolam but recur. It is expected to progress to anaesthesia and intubation to control seizures (and allow for CT). The candidate should assess for other causes of status epilepticus.

If intubation is decided upon, if a sensible plan is made, then the candidate can be prompted that the intubation was successful

Domains Assessment Objectives

Medical Expertise
Management of status epilepticus

Prioritisation And Decision Making
Stepwise approach to management, consideration of other differentials

Leadership and Management
Clear leadership and team management

Other Assessment Notes

Consider differentials (at least 2-3 of these during assessment)
- Epilepsy
- Hypoglycaemia
- Hyponatraemia, hypocalcaemia
- Alcohol intoxication or withdrawal
- Other drug withdrawal
- Stimulant toxicity
- Head injury
- Overdose (eg TCA)
- CNS infection

Stepwise management
- First line - benzos + phenytoin
- Second line - phenytoin, levetiracetam
- Third line: general anaesthesia and intubation, ongoing sedation, use of short-acting relaxant
- thiopentone traditional induction agent 3-5mg/kg
- consider continuous EEG monitoring to confirm seizures ceased

Other considerations
- Oxygenation, simple airway support (eg NPA)
- Safety of patient and staff
- CT head
- Collateral history
- Investigations - CBE, electrolytes, drug levels, CK
- Referral to neurology and ICU