Written OSCE Practice

Question 1

Case Study One: You’ve been called to a 76 year old female, Mrs Goggins, who has been found collapsed in her house by her son. She complained during a telephone call of feeling dizzy and really sick; her son immediately came round and found Mrs Goggins collapsed in a chair. His mother has never been like this before and it’s really worrying. Usually his mother is sprightly and can do her own shopping, recently her angina has started to play-up, with more frequent exacerbations that have really limited her mobility. Last year she went to the hospital with a ‘heart scare’ but the Doctors never really found a cause.

Your crewmate has obtained the following observations:
Respiratory Rate 10 min1; Pulse Rate 40 min1 & irregular; oxygen saturations 91% (air); temperature 36.4°C; Blood Glucose 8.2 mmol. ECG showed - the rate is 40bpm, irregular

• the rhythm is Type II AV Block (2:1)
• the PR interval is normal and consistent in the conducted beats
• the P-P interval is regular
• the Q-Q interval is irregular
• one heart beat is dropped with every two P waves (hence 2:1 patte rn)
• there is an underlying RBBB characterised by abnormal RSR complexes in V3 and III, however unknown if this is a new showing for this patient
• the cause of syncope is likely to be due to the type II AV block with transition to complete heart block/ 3rd degree heart block likely (due to patient’s vital signs)

Answer 1

• Diagnosis: NSTEMI with Type II AV block
• Primary differential: PE with S1Q3T3 pattern
• Other differentials: unstable angina, TIA, stroke, heart failure, pulmonary oedema
  2. Management

Ensure no injury from fall, rule out cervical spine injury

Airway
- Ensure airway is patent, remove obstructions
Breathing
- Auscultate chest, ensure equal air entry with no additional sounds. If expiratory wheeze present, administer 5mg salbutamol via nebuliser on 15l o2
- If chest clear administer 15l o2 via non-rebreathe mask as per sats and titrate to targeted sats of 95-100%
- Due to bradypnoe, have BVM ready incase patient goes into respiratory arrest

       Circulation -	Obtain IV access and administer atropine initial dose of 500mcg (due to symptomatic bradycardia), administer 250ml fluid challenge as a bolus (assuming patient is hypotensive due to other obs although not stated (classic) ) Disability -	Obtain full GCS, check PEARL Expose -	Check for rash, top to toe examination, rule out long bone and pelvic injury

RE-ASSESS ABCDE

       -Extrication via scoop onto stretcher to keep patient flat due to being unstable
      - administer aspirin 300g PO as per MI protocol, not GTN due to hypotension and no              -            pain at time of assessment
       - monitor en route, administer second dose of atropine if indicated pre alert to nearest ED for ?NSTEMI with an episode of syncope with bradycardia

3. Alternative causes for bradycardia
   - MI
   - Myocarditis
   - Heart failure
   - PE
   - hypothyroidism