OSCE Management Flashcards
Management Glaucoma
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
Intubation - standard
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
Intubation - head injury, modifications
C-spine in line immobilisation
Add fentanyl 1mcg/kg to blunt ICP rise
VL - partial view cords
Intubation - facial trauma, modifications
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
Intubation - laryngotracheal trauma, modifications
C-spine immobilisation Small ETT Gentle insertion Double scrub surg airway Avoid PPV - tracheal transection
Awake tracheostomy
Sevo gas induction in OT
Management of CICO situation
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.
Management of post-intubation hypoxia
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
Management of anaphylaxis
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
Procedural sedation
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
Management of local anaesthetic toxicity
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
Describe MTP management
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
Management of traumatic head injury
- 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
Management of occupational needlstick injury
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
Management of sexual exposure to HIV
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
Management of primary pneumothorax
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.
Management of secondary pneumothorax
<1 cm no symptoms, admit, O2, observe
1-2 cm no symptoms, aspiration. < 1 cm - O2, failure = ICC
> 2 cm or breathless - ICC
Management of necrotising fasciitis
Surgical debridement Antibiotics -Meropenem 1g (20mg/kg) Q8H -Vancomycin 25-30 mg/kg IV -Clindamycin 600 mg (15 mg/kg) IV Q8H Haemodynamic support
management of neonatal resuscitation
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
Management of toxic alcohol poisoning
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
Ventilation in asthma
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
Principles of management of Access Block
Principles
- collaborate with team (NIC)
- gather information
- establish priorities
- delegation (have oversight)
- escalate - admin, inpatients, stakeholders, ambulance
- support staff
Specific actions for management of access block
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
Management of disaster
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
Management of Infant with SVT
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
Management AMI
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
Management TdP
CPR
IV magnesium 2g / 1-2 min
DC cardioversion
Overdrive pacing
Management aortic dissection
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
Management of AAA
Resus, monitoring, IV x2 O2 SBP target 90 MTP Definitive: open repair / endovascular
Management of Critical Asthma
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
