Research and Medical Events Blog

1) Improving your performance during an emergency OSCE station.
2) Today’s OSCE Exam preparation tips.
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1) Improving your performance during an emergency OSCE station:
“:
Rapid Primary Survey & resuscitation:
ABCDE

A Airway maintenance with C-spine control
B Breathing and ventilation.
C Circulation (pulses, hemorrhage control).
D Disability (neurological status).
EExposure (complete) and Environment (Temperature control).
Restart ABCDE if patient deteriorates.
Always deal with A & B first as they may kill the patient now not C.
Airway:
1.  Immobilize cervical spine with collar or sand bags. In Trauma case ONLY.

To the examiner/ nurse “A Collar or sand bags please to immobilize the C-spine.”

2.  Airway assessment: Assess ability to breath and speak.
If patient is already responded appropriately to you so far, indicates patent airway & ability to breath is normal.
“Mr./Ms.., Where are you now?…What day of the week is today?”

To the examiner “Patient is alert, oriented, speaking, no noisy breathing, airway is patent.”

3.  Airway management:

GO TO BREATHING if airway is patent.
OR Â To the examiner “Patient is…., an indication for endotracheal tube.”
2- Definitive airway management:
-Â Endotracheal intubation (ETT):
Find out them at the ebook ” A Step By Step Guide To Mastering The OSCEs”
Breathing:
1- LOOK: for:
1. Mental status: anxiety, agitation.
2. Color: cyanosis / pallor.
3. Chest movements.
4. Respiratory rate & effort.
5. JVP. (if collar on don’t remove it. If sand bags, do it.)
To the examiner “Patient is not agitated, no cyanosis or pallor. Normal symmetrical chest movements, Normal respiratory effort & rate at…bpm, JVP is….”
2- FEEL: for:
1. Airflow.
2. Tracheal shift. (if collar on don’t remove it. If sand bags, do it.)
3. Chest wall for crepitus.
4. Flail segments & sucking chest wounds.
5. Subcutaneous emphysema.
 “Mr/Ms…, I’m going to uncover and feel your neck and chest, Okay.”
 “Any pain?”
To the examiner “There is no tracheal shift, crepitus, flail segments, sucking wounds or subcutaneous emphysema.”
3- LISTEN: Â Â Â Â Â 1. Sounds of obstruction (Stridor) & Air escaping.
2. Breath sound & symmetry of air entry. Both sides: apex, lower, & sides.
3. Heart sounds. If muffled with high JVP: Temponade: pericardiocenthesis.
 “Mr/Ms…, I’m going to listen your chest.”
To the examiner “Breath sounds are normal, symmetrical, no stridor, normal heart sounds / ….   diminished air entry on the left…..”
4- Assess Respiratory Function:

   Ventilation modalities:

Circulation:
1. Ask for Vital signs:

To the examiner/nurse “What are his/her vitals, please?”
Carefully listen to what the examiner says and comment: e.g. “Normal/ so, he has fever/tachycardia/ tachypnea….”.

- Blood pressure: If conscious mobile patient, take it on:
“Mr/Ms.., I’m going to check your blood pressure in both your arms then your leg, (if no collar) and I’ll recheck your arm while sitting/standing for a minute?.”
Note: Usually the examiner will stop you and give you the results, but start doing it until he/she stops you.
Measure BP in unconscious yourself on one arm.

To the examiner “Blood pressure is …. mmHg lying and …. mmHg standing. No postural hypotension, No significant upper/lower extremities difference. (aortic dissection)”

To the nurse “Put him on cardiac monitor & pulse oxymeter. Repeat vitals every (5-15) minutes & inform me.”

2. IV lines & Investigations:

To the nurse
1) “I want 2 wide pore gauge 14-16 IV lines established, please.
2) Start Normal Saline/ Ringer Lactate, one liter on each at 125-1000 ml/h each (choose).
3) Take a blood sample and send for:
- Blood group, Rh & cross-match,
- CBC, Lytes, (ABGs, CK-MB, Tropinin) if respiratory/ cardiac case
- Liver function test (ALT, AST, ALP, & amylase),
- Renal function tests (BUN, Cr),
- Coagulation profile (INR/PTT),
- Rapid bedside Blood sugar,
- Toxicology screen (if indicated).
4)Â Also send for:Â 12- lead ECG, CXR, Head CT (if comatose),
C-Spine & pelvic X-rays (if trauma)”
5)Â Foley’s catheter / Nasogastric tube (if needed).
“Mr/Ms .., I’ll put a bee tube inside in order to monitor your urine output, okay..?”
Note: If blood seen from meatus: NO FOLEY’S (? Urethral injury)

Assess Respiratory Function:
Change to assisted ventilation or ETT if needed.
 If BP low:

 If Comatose:

3. Rule out shock:

Go to Detailed Secondary Survey

FFFÂ Go to management below.

Management of hemorrhagic shock:

1 - Ask for vitals again: “What are his/her vitals, please?”
Carefully listen to what the examiner says and comment: e.g. “Normal/ so, he has fever/tachycardia/ tachypnea….”.
2 - Secure airway and O2: Already done but check the mask and O2 level.
3 - Control bleeding by:
Find out them at the ebook ” A Step By Step Guide To Mastering The OSCEs”
4 - Replace lost blood:
5 - Vasopressors:
- Not during bleeding.
- Used if hypotension persists despite appropriate volume administration. Also for septic and anaphylactic shocks.

* If Patient is stable now: Proceed to Disability.
If not: Repeat ABC until becomes stable.

Then you have to go into D, E and then detailed survey.

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2) Today’s OSCE Exam preparation tips:

We also asked you to prepare steps for every emergency management of common emergencies like:
** IF Diabetic Emergencies:

To the nurse “Run the Normal Saline at 1000cc/h each;
Give 5 (-10) IU Insulin IV bolus, then another 5 (-10)/h by IV infusion”
“When Blood glucose reaches 15 mMol/L change the fluid to two third 5% dextrose water (D5W) and one third Normal Saline. Then add 20 mEq/L KCL to the fluid.”
“Send for urine glucose and ketones.”