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OSCE > OSCE Management > Flashcards

OSCE Management Flashcards

1
Q

Management Glaucoma

A

Spe:
-Acetazolamide 500 mg. Decreased production
-Pilocarpine 2% Q5min for 1 hr. Increase outflow.
-Timolol 0.5% 1 drop ever 30-60 min. Redcues production and increases outflow. CI: reactive airway disease/bradycardia or heart block.
-Latanoprost 0.05% daily. Increases outflow.
Sup:
-Analgesia
-Antiemetic
-Sit 45 deg
Cons/Dispos:
- Urgent opthal inpt, laser iridotomy

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2
Q

Intubation - standard

A 
Resus, full physiological monitoring incl CO2 
Indication for intubation
Team roles, closed loop comm
Prep 
- Pt positioning: ear-sternal notch
- Preoxygentation: NRBM 15L
- pred difficulty? 
Equipment: SOAPME
- med: ketamine 1.5mg/kg and roc 1.5mg/kg
Verbalise plan: A/B/C/D

CMAC size 4
Bougie, size 7.5/8 ETT

Confirm ETT position - CO2, ausc, CXR
NGT
Sedation / analgesia

Ongoing care

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3
Q

Intubation - head injury, modifications

A

C-spine in line immobilisation
Add fentanyl 1mcg/kg to blunt ICP rise
VL - partial view cords

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4
Q

Intubation - facial trauma, modifications

A 
Fiberoptic in OT after topical LA
C-spine immobilisation 
VL - risk occlusion by blood, macintosh blade for DL view 
Double suction 
Assistant for direct pressure 
double scrub for Surg Airway
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5
Q

Intubation - laryngotracheal trauma, modifications

A 
C-spine immobilisation 
Small ETT 
Gentle insertion 
Double scrub surg airway 
Avoid PPV - tracheal transection

Awake tracheostomy
Sevo gas induction in OT

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6
Q

Management of CICO situation

A

Declare emergency, call for help
Vortex model, 2 best attempts
- ETT: C/D blade, bougie/stylet, optimal position
- LMA
- BVM, 2 handed, PEEP
Surgical cricothyroidotomy, scalpel bougie tube.

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7
Q

Management of post-intubation hypoxia

A

Attention of team - hypoxia
Increase FiO2
Tube position - depth, kinked
Ventilate by hand, assess bronchospasm - pneumothorax, anaphylaxis
CVS status - BP, HR (loss CO)
Ventilator settings, sedation, paralysis
Breath stacking

Dislodged / disconnected ETT, obstruction, pneumothorax, equipment, stacking breaths

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8
Q

Management of anaphylaxis

A

Declare anaphylaxis, team roles, closed loop comm. full monitoring, resus.
IM adrenaline 10 mcg/kg to 500mcg (0.01 mls 1:1000)
Repeated in 2 min if no change
High flow O2
Reassure patient, consider DDx: asthma, other cause of shock
IV adrenaline infusion 0.1 mcg/kg/min, peripheral IVC large vein
IV fluid bolus 20 mls/kg
Insertion arterial line if ongoing

IV hydrocortisone 100 mg

Refractory

  • salbutamol 10mg nebulised
  • magnesium sulfate 10 mmol/IV
  • Glucagon if on b-blockers
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9
Q

Procedural sedation

A 
Risk assessment 
- age, comorbidities, weight 
- procedure type 
- fasting 
Prep: intubation equip, O2, capnography

IV ketamine 1mg/kg then 0.5 mg/kg top up, propofol 1mg/kg then 0.5mg/kg top up
- dose reduce if elderly

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10
Q

Management of local anaesthetic toxicity

A 
Resuscitation team, team roles, full monitoring, defib pads 
O2 - NRBM 
Seizure - midazolam 0.15mg/kg IV 
ACLS in arrest 
Lipid emulsion 20%
- 1.5 mls/kg IV over 1 min, repeat Q5 min x2 
- infusion 15 mls/kg/hr for 30-60 min
- to 12 mls/kg total

Documentation, M&M
Team debrief / support
Open disclosure

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11
Q

Describe MTP management

A

Declare critical bleeding
Large bore IV access, RIC / MAC / IO
- PRBC : FFP : Platelets, initially 1:1:1 ratio
- Identify source & control
- Reverse anticoagulation (Idaruzimab, PCC)
- Target BP of __

TXA 1g 
Target 
- warming - temp > 36 
- normal pH
Calcium gluconate aim Ca > 1.1 
Cryoprecipitate to aim fibrinogen > 1.0 
Tailored resuscitation to viscoelastometry findings 
Consultation with haematology & definitive care team and ICU
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12
Q

Management of traumatic head injury

A
  • Airway control
  • Cerebral perfusion pressure - neuroprotective
  • Avoid further bleeding
  • Seizure control
  • Definitive care

Airway: inline immobilisation, fentanyl, VL
CPP: Aim SBP 110, transfusion if bleeding / IVT / noradrenaline
Rebleeding: reverse coagulopathy, SBP 110-160, hypertension with hydralazine, sedation/analgesia, head up, loose ties.
Rx seizure with midazolam, levetiracetam
TF to neurosurg centre

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13
Q

Management of occupational needlstick injury

A 
First aid 
Source: HIV, HepC, HepBsAg
Recipient: HIV, HepC, HepBsAg, Anti-HepBsAb
Counselling: sex, pregnancy, blood
Tetanus 
PEP if high risk source 
Represent if symptoms of seroconversion 
Follow up with ID
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14
Q

Management of sexual exposure to HIV

A 
Risk assessment: source risk, fluid, method of transmission, volume / STI 
First aid 
Tetanus prophylaxis 
Source / Exposed: HIV, HCV, HBsAg / Anti-HBsAg
PEP 
Safe sex, no pregnancy, blood donation
Symptoms of seroconversion 
Follow up with ID
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15
Q

Management of primary pneumothorax

A

BTS - interpleural distance at level of hilum

< 2 cm, no symptoms - DC and FU D1 and W1 until resolution
>2 cm or symptomatic - Aspirate. D1 / W1 FU (option of conservative)
> 2cm, failed aspiration (>3L aspirated, > 2 cm at 4 hrs, breathless) - ICC

*large conservative: CXR 4 hrs, SpO2 > 92%, comfortable walking.

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16
Q

Management of secondary pneumothorax

A

<1 cm no symptoms, admit, O2, observe
1-2 cm no symptoms, aspiration. < 1 cm - O2, failure = ICC
> 2 cm or breathless - ICC

17
Q

Management of necrotising fasciitis

A 
Surgical debridement 
Antibiotics
-Meropenem 1g (20mg/kg) Q8H
-Vancomycin 25-30 mg/kg IV 
-Clindamycin 600 mg (15 mg/kg) IV Q8H
Haemodynamic support
18
Q

management of neonatal resuscitation

A 
Resuscitaire, timer, call paeds 
Dry and stimulate 
IPPV, PEEP 5, PIP <30
1 min - HR < 100, reduce leaks, check position, O2 
Still HR < 60 --> 100% O2, CPR, IV access 
Adrenaline 0.1 mls/kg 1:10,000
Intubation
IV fluid bolus 20 mls/kg 
BSL, naloxone
19
Q

Management of toxic alcohol poisoning

A 
Intubation, sodium bicarb prior 
IV benzos for seziures 
Sodium bicarb if pH < 7.3
Haemodialysis 
Ethanol 8mls/kg IV 10% ethanol, then 1-2 mls/kg/hr, target 0.1-0.15 g/dL
OR Fomepizole 15mg/kg IV

EG: Hypocalcaemia only rx if refractory seizures / long QT
Methanol: IV folinic acid

20
Q

Ventilation in asthma

A

Principle

  • oxygenation
  • permissive hypercapnoea, pH > 7.1
  • avoid dynamic hyperinflation

SIMV, Vol control
6 mls / kg
Large ETT
Long expiratory time, Low RR, ie 6 bpm, IE of I:5 or more, short inspiratory time
PEEP zero / 5 (< autoPEEP)
Aim P Plat < 30, increase high pressure alarm (reflects large airway bronchospastic pressure)
Sedation / paralysis

21
Q

Principles of management of Access Block

A

Principles

  • collaborate with team (NIC)
  • gather information
  • establish priorities
  • delegation (have oversight)
  • escalate - admin, inpatients, stakeholders, ambulance
  • support staff
22
Q

Specific actions for management of access block

A

Principles: collaborate, gather information, prioritize, delegate and maintain oversight, escalate and support staff.

Clear cubicles - ward/ICU, DC lounge, SSOU - private, HITH
- RV for discharge (ED / inpt) 
Allocate resources - senior dec making
Escalate - Bed Manager, ED Exec 
Liase with Amb - ? bypass
23
Q

Management of disaster

A

Ext emergency activation code

Space - clear, allocate areas
Personelle - retain, support, roster, brief, form teams
Equipement - specific
Drugs - specific
Organisation - Exec, director, media, security.

Post- debrief, restock

24
Q

Management of Infant with SVT

A

Unstable (hypotensive, poor perfusion, ACS)
- DC cardioversion, 1 J/kg, sync
- sedation, diazepam IV
Stable
- ice pack 30 sec face, gag
- IV adenosine, 0.1 mg/kg then 0.2 then 0.3 mg/kg
12 lead post reversion

25
Q

Management AMI

A

Monitoring incl defib
O2 for SpO2 92-96%
Dual Antiplatelet: Aspirin 300 mg PO, clopidogrel 300 mg
Analgesia: IV opioid / GTN infusion
Reperfusion therapy
- PCI if available within 1-2 hrs
- Fibrinolysis, tenecteplase 1000 IU/kg to 10,000. IV bolus.
Anticoagulation: IV heparin 5000 units if PCI or enoxaparin 30mg IV if fibrinolysis
Nitrates: IV infusion GTN

Anticipate complications: APO, arrhythmia
CCU
Family / documentation

26
Q

Management TdP

A

CPR
IV magnesium 2g / 1-2 min
DC cardioversion
Overdrive pacing

27
Q

Management aortic dissection

A

Analgesia - IV morphine
Control HR - IV metoprolol 1-2 mg/2 min, every 3-5 min, to HR 60-80
Control BP - GTN 10 mcg/min, inc by 5 mcg/min to SBP 100-120
Definitive care
- A: surgical repair
- B: ICU, aggressive BP therapy. medical or endovascular mx.

Goals of care
Family / documentation

28
Q

Management of AAA

A 
Resus, monitoring, IV x2 
O2 
SBP target 90
MTP 
Definitive: open repair / endovascular
29
Q

Management of Critical Asthma

A

O2 sat 94-98%
Continuous nebulised salbutamol
Nebulised ipratropium 500 mcg
Hydrocortisone IV 4mg/kg to 100 mg
Magnesium IV 0.2 mmol/kg to 10 mmol over 20 min
Aminophylline 10 mg/kg IV to 500 mg over 60 min

Adrenaline 10 mcg/kg IM
VV ECMO

Anticipate hypokalaemia & treat

OSCE (3 decks)

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