Trial OSCE exam: 'jen and deb ' by Deborah Maher

You are taking part in a trial exam created by Deborah Maher. There are 8 OSCEs in this exam (80 minutes).
 

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

Scenario:

You attend to an emergency bell in a cubicle in your ED. Mrs Hetterley, a 76-year-old lady, has been found to have a reduced conscious state.

Mrs Hetterley presented with a right-sided CVA with hemiplegia and expressive dysphasia. She received thrombolysis for her stroke, and is admitted under the Stroke Unit. Her last observations 30 minutes ago were normal, with a GCS of 15.

Instructions for the candidate

You are the consultant on. The patient has been transferred to a resuscitation bay where you are working with 2 nurses. You are to assess the patient and manage the scenario as it unfolds.

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

Resus nurses:
You are senior ED nurses. You can competently perform any tasks including IV cannulation, BVM ventilation and ventilator tweaking.

You understand the patient was a previously fit and well lady, living independently at home. She had presented soon after onset of weakness and had undergone thrombolysis with no immediate complications. The thrombolysis is completed.

For the examiner

Equipment - intubatable mannequin, monitoring, resus equipment.

On examination:
HR 50
BP 210/120
RR 10
SaO2 87% RA
GCS 7 (E2 V2 M3)
Pupils are equal but sluggish to react

For intubation, a plan should be provided, and if appropriate, the candidate can be prompted that intubation was successful.

Curveball if going well: Mrs Hetterley has an advanced care directive stating she does not want to be intubated.

Domains Assessment Objectives

Medical Expertise
Management of raised ICP
Reversal of thrombolysis
Safe intubation plan

Prioritisation And Decision Making
Identify multiple tasks at hand (eg intubation, reversal of thrombolysis, neuroprotection, CT scan, contacting speciality teams) and appropriately prioritise and delegate

Leadership and Management
Clear leadership and team management during resuscitation

Other Assessment Notes

1. Assessment
- Identify low conscious state
- Identify Cushing reflex
- Diagnosis likely intracranial bleed post thrombolysis

2. Airway
- Identify need for securing airway
- Sensible plan including plans B & C & D and safe medication doses

3. Neuroprotection
- Avoid hypoxia, hypercarbia
- Head up, loose ties
- Lower ICP - hyperventilate, hypertonic saline or mannitol
- Euglycaemia, normothermia
- Analgesia and sedation

4. Reversal thrombolysis
- Stop infusion (already complete in this case)
- Cryoprecipitate 10 units
- Platelets
- TXA or aminocaproic acid
- FFP
- Protamine if on heparin / LMWH

5. Referrals
- Radiology for CT scan
- Neurology
- Neurosurgery
- ICU

6. Family discussion
- Identify need to inform family of events