OSCE – Simulation

1.  Critical Asthma  (Double)

Subject and Curriculum Reference

Resuscitation

Airway

  • Oxygen delivery systems
  • Bag mask ventilation
  • Intubation and rapid sequence induction
  • Confirming ET position
  • Capnography
  • Ventilation

Anaesthetics

  • General Anaesthetic techniques
    • IV induction and maintenance agents
    • Muscle relaxants

Respiratory Medicine

  • Asthma

Expand

Clinical Scenario Stem

A 21 year old female, Marie Clarke is brought in by ambulance to your urban emergency department at 2pm on a Thursday afternoon with severe shortness of breath. She has a known history of severe asthma and was intubated and admitted to the Intensive Care Unit earlier this year.

You are called to the resuscitation bay just as she is being transferred onto the bed from the ambulance trolley.

In the next room you will be asked to lead and participate in managing this scenario as a simulation. A mannequin will represent your patient. Your resuscitation team consists of 2 nursing staff, one of which is able to assist with airway procedures and a middle-grade registrar who is not airway competent. All in your team are competent but will need direction.

The simulation will proceed for 20 minutes.

There will be no interaction with the examiners in the room.

 

Simulation Instructions

Participants

  • Nurse 1 – Airway trained nurse
  • Nurse 2 – Generally trained emergency nurse
  • Middle-grade registrar not airway competent
  • Have badges

Patient

  • 21 year old female, Marie Clarke
  • Known brittle asthmatic
  • Multiple admissions for severe asthma
  • Intubated and admitted to ICU earlier this year for asthma
  • Weight 60kg

Overview of course of simulation

  • Presents with critical asthma
  • Initial critical asthma treatment tried but unsuccessful
  • Patient tires
  • Non-invasive machine unavailable
  • Pushed to intubate
  • Patient intubated and ventilated
  • Post-intubation becomes hypotensive due to dehydration
  • Once fluid loaded will stabilise
  • If patient deterioration not recognised then will initially loose consciousness and if still not intubated then will go into respiratory arrest

Equipment

Full non-invasive monitoring

Intubatable mannequin

Airway

  • Oxygen masks/delivery systems ranging from nasal prongs to non-rebreather
  • Suction
  • ETT various sizes
  • LMA various sizes
  • Laryngoscopes
  • Bougie
  • Capnography
  • ETT ties
  • Ventilator
  • Nebulisers
  • Adaptor to apply MDI into ventilator circuit

Circulation

  • IVs various sizes
  • Fluids

All drugs available

 

Initial set-up

  • Mannequin on bed lying down
  • No monitoring on
  • No O2 on
  • Equipment placed on table near patient

 

Initial Information from ambulance handover (to be given to candidate by Nurse 1)

  • Patient
    • 21 year old female
    • Marie Clarke
  • History of presenting complaint:
    • 2 days of upper respiratory tract symptoms (sneezing, sore throat, runny nose)
    • Woke this morning with shortness of breath
    • Felt very wheezy and coughing
    • Taking 12 puffs of Ventolin through spacer every 4 hours initially but every 20 minutes in last 2 hours
    • Took 50 mg of Prednisolone this morning
    • Progressively more short of breath
    • History of severe asthma since childhood
    • Multiple admissions
    • 3 ICU admissions
    • Last admission 4 months ago ? intubated in ICU for 2 days
    • Is on a preventer that she is taking ? fluticasone/salmeterol combination
  • Ambulance interventions
    • On arrival severe respiratory distress
    • Widespread wheeze chest exam
    • Sitting forward, tripod position, marked work of breathing with use of accessory muscles
    • O2 sats 91% RA
    • RR 26 bpm, HR 122 bpm, BP 134/85
    • Put on continuous nebulised salbutamol and given ipratropium nebuliser as well
    • O2 sats came up to 95% RA, HR up to 126 bpm, BP 130/82
    • RR continued to be 26 bpm and no ease in work of breathing
    • Only 5 min ambulance ride from hospital
    • No IV access

 Expected initial instructions to team

  • Establishing team & roles
  • Apply high flow O2
  • Attach monitoring
  • Sit patient up
  • Assessment
    • Obs
    • Resp exam

 Initial obs & exam

  • O2 sats 85% if RA, 92% on 15 L NRB, 90% on nebuliser
  • RR 26 bpm
  • HR 128 bpm, BP 134/85, temp 36.5°C, sinus tachycardia
  • LOC 15/15
  • Talking in words only
  • Tripod position
  • Marked use of accessory muscles (SCMs, intercostal and subcostal recession)
  • Decreased air entry throughout but can hear widespread wheeze, long expiratory phase
  • No initial blood gas available until get IV access

 Initial expected management actions

  • A &B
    • Continuous nebulised salbutamol with high flow O2
    • reassurance
  • C
    • Ensure IV access x 2
    • Fluid load
  • D
    • Watch for deterioration of LOC
  • Asthma management
    • Corticosteroid
      • Hydrocortisone 100-250mg IV
      • Methylprednisolone 1mg/kg IV
    • IV Magnesium sulphate
      • 2g over 20 mins
    • IV salbutamol
      • 5mcg/kg/min 1 hour then 1-2 mcg/kg/hr
    • Could ask for aminophylline
      • 5 mg/kg load over 20 min (unless on maintenance) then 0.5-0.7 mg/kg/hr
    • IV Ketamine infusion
      • 5-2 mg/kg/hr
    • Anticholinergic
      • Ipratropium 500 mcg q 6 hour nebulised
    • May ask for adrenaline
      • 3-0.5 mg SC
      • 5 mg nebulised
      • IV 1-20 mcg/min
    • May ask for NIV/BiPAP/CPAP
      • Not available
    • VBG 1 available (takes 3 mins)
      • pH 7.24
      • PaO2 92 mmHg
      • PaCO2 44 mmHg
      • HCO3 28 mmol/L
      • BSL 5.8 mmol/L
    • Preparation for deterioration
      • Intubating equipment
      • Intubating drugs
      • plan

 Deterioration 1 – Deterioration in LOC

  • Obs for first 7 minutes as initially set
  • Then deteriorates:
    • Will need to be alerted to this by nurse 1
    • RR falls to 10 bpm
    • HR 126 bpm sinus tachycardia
    • BP 136/88
    • O2 sats fall to 85% on high flow Ox
    • LOC reduced to E2V2M5 9/15
    • Very drowsy
    • Blood gas not available

Expected response

  • Recognition of deterioration esp. in LOC and tiring
  • Reassessment ABCD approach
  • Preparation for intubation/ventilation
    • Equipment
    • Drugs
    • Good IV access & fluids
    • Operator (candidate themselves)
    • Airway nurse
    • capnography
    • Ventilator
  • Intubation
    • Drugs
      • Ketamine 2mg/kg IV
      • Suxamethonium 1-1.5 mg/kg IV
    • Laryngoscope, ETT, bougie if wants
    • Cricoid may/may not be applied
    • Gets intubation first go
    • Check tube placement
      • Capnography – good trace
      • Listens – equal both sides
      • O2 sats come up to 96%
    • Ventilation
      • May do BMV only with long expiratory phase
      • Need to ask ventilator settings
        • TV 8ml/kg 480 ml (500ml)
        • RR 10 bpm
        • I:E 1:4 or 1:5
        • Inspiratory flow rate 80-100 L/min
        • PEEP 0
        • Permissive hypercapnia (pH > 7.1)
        • Check plateau pressure
      • Ongoing sedation
        • Needs good sedation

 

Deterioration 2 – drop in BP after intubation

  • Initial obs after intubation
    • BP 85/48
    • HR 122 bpm
    • O2 sats 96%
    • Sinus tachycardia

 

Expected response

  • Reassessment
    • A B C D approach
    • Check for pneumothorax
      • Exam
      • Ask for X-ray or US
    • Give 500-1000 ml fluid bolus as push
    • Blood gas not available

 

Patient stabilises after fluid bolus

  • HR 92 bpm, BP 126/78, O2 sats 96%
  • Gas not yet available

 

Further deterioration if candidate does not respond as expected

  • Initial asthma management
    • If does not institute critical asthma Mx (continuous salbutamol nebs, IV meds, O2)
    • Faster deterioration in LOC & forced to tube
  • Deterioration of LOC
    • If does not recognise or move to intubation
      • HR, O2 sats, RR, BP start to fall
      • Eventually arrests
    • If does not recognise drop in BP and/or does not give fluids
      • Further fall BP
      • Then HR falls

 

Score Sheet

Not met Partly met Fully met
Initial introduction

  • Introduces self
  • Establishes who team members are
  • Assigns roles
Initial handover

  • Listens
  • Checks information
Initial management steps

  • Applies O2
  • Monitoring
  • Sits patient up
Initial assessment

  • Rapid and focused
  • Asks for obs
  • Work of breathing
    • ? patient talking
    • Accessory muscles
    • Patient position
  • Examines chest
Initial critical asthma management

  • Continuous nebulised salbutamol
  • IV access
  • Fluid load
  • Ongoing reassessment
  • Further drugs
    • Steroids considered
    • IV bronchodilator considered
    • NIC considered
Deterioration in LOC expected management

  • Recognises deterioration
  • Repeats structured assessment
  • Intubation
    • Preparation
    • Voices plan to airway nurse including back-up plan
    • Drugs
      • Induction
      • Muscle relaxant
    • Intubation technique
    • Check tube placement
  • Ventilation
    • Obstructive strategy settings
    • Permissive hypercapnia
Hypotension after intubation

  • ABCD reassessment (structured)
  • Considers pneumothorax
  • Gives fluid load
Gathers information dynamically as situation evolves
Develops clear management plans
Team lead

  • Clear instructions
  • Keeps team informed
  • Uses team appropriately throughout
Logical structured manner
Needs 8/10 to pass

  • Listens to initial handover
  • Initial critical asthma care appropriate
  • Recognition of deterioration of LOC and move to intubation
  • Prepares for intubation
  • Intubation technique safe
  • Ventilation strategy appropriate for asthma patient
  • Recognition of deterioration of BP after intubation
  • Looks for pneumothorax and gives IV fluids
  • Clear communication
  • Structured approach

 

Author: J Haire  

Leave a Reply

Your email address will not be published. Required fields are marked *