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Emergency stations 2

14

Station 31: Medical emergencies the ABCDE approach


AIRWAY + oxygen
Consider: Suctioning
Airway manoeuvres
Airways adjuncts

BREATHING + sats
Inspection of chest
Respiratory rate
Trachea position
Expansion
Air entry
Colour
O2 sats

CIRCULATION + cannula
Peripheral pulses
Pulse
BP (consider postural) Urine output
Cannula insertion + blood tests
Capillary refill
Limb temperature

DISABILITY + blood sugar


Pupil response
Alert, voice, pain, unresponsive

Glasgow coma scale


Blood sugar

Obstructed
airway
EXPOSURE + temperature
Adequate exposure
Complete examination
Monitor temperature

Chin
lift

Oropharyngeal
airway

Nasopharyngeal
airway

N.B. In any unwell patient, initially


use a reservoir bag mask

Reservoir
bag mask

OSCEs at a Glance, Second Edition. Adrian Blundell and Richard Harrison. 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd. 41

Station 31a: Medical emergencies


Airway
Student info: You are the FY1 on a general surgical ward. The nurses
have asked you to urgently see a 65-year-old patient who was admitted
2 hours ago with acute cholecystitis. He is being given his first dose
of antibiotics and has now developed a rash, tongue and lip swelling
and wheeze. He is not on oxygen but does have a 20 gauge cannula
in his left hand which has the remainder of the antibiotic still attached
Examiner info: Initial observations show lip and tongue swelling,
stridor, respiratory rate (RR) 28, wheeze, saturations on room air
91%, heart rate (HR) 130, BP 85/50 mmHg and temperature 37.8C.
There is an erythematous rash developing all over the patients body
and particularly around the cannula site which still has antibiotic
attached to it. The observations can change depending on the action
of the student

Hints and tips


Follow the ABCDE protocol as discussed. The student may wish
to disconnect antibiotics immediately before commencing ABCDE
assessment.
Airway: compromised, use airway manoeuvres and airway adjuncts,
e.g. nasopharyngeal. Commence high flow oxygen via a reservoir
mask. Ask nurses to call anaesthetist for urgent airway support
Breathing: RR 28, sats 91% on room air, wheeze audible. Give 5 mg
salbutamol by nebuliser
Circulation: HR 130, cool peripheries, capillary return 3 seconds,
BP 85/50 mmHg. Disconnect antibiotic from cannula site if not already
done. Insert another large-bore cannula. Commence fluid resuscitation
(500 ml bolus stat). Give 200 mg hydrocortisone IV. Give 500 g
(0.5 ml) adrenaline 1 : 1000 IM. Give 10 mg chlorphenamine IV. Take
blood for routine tests
Disability: alert but very anxious, blood sugar level (BSL) 6
Exposure: erythematous rash developing all over the patients body,
particularly around the cannula site which had antibiotic attached to it
The diagnosis is anaphylactic shock due to antibiotic allergy.
This man needs resuscitation and stabilisation. He may also need
definitive airway management with endotracheal intubation.
Ix
FBC, clotting, U&E, LFT, Glc, group and
Bloods
save, ABG (assess oxygenation and
ventilation), ECG, CXR
Mx
Stop antibiotics, secure airway, O2, adrenaline,
Rx
steroids, nebulisers, antihistamine and IV fluids
Consider endotracheal intubation, IV access
Procedures
May respond quickly on the ward, but critical
Location
care setting if not
Regular observation
Monitoring
Anaesthetic and senior medical help
Specialists
Document clearly the allergy to the antibiotic in the patients notes
and drug charts. Discontinue current antibiotic prescription.
This type of scenario will evolve depending on the students actions.

Station 31b: Medical emergencies


Breathing
Student info: You are the FY1 on the medical admissions ward. You
go to clerk a 25-year-old asthmatic woman who has been admitted by
her GP with worsening breathlessness. When you enter the room you
find her to be extremely breathless and unable to complete sentences.
She is not on oxygen and has not been cannulated
42 Introduction Emergency stations 2

Examiner info: Initial observations show RR 30, wheeze, saturations


on room air 90%, HR 115, BP 120/78 mmHg and temperature 36C.
There is reduced air entry to both lungs and marked wheeze. She is tiring.
The observations can change depending on the action of the student

Hints and tips


Follow the ABCDE protocol as discussed.
Airway: patent. Commence high flow oxygen via a reservoir mask
Breathing: RR 30, sats 90% on room air, reduced air entry to both
lungs, wheeze audible, normal resonance. Give 5 mg salbutamol and
500 g ipratropium through oxygen driven nebuliser. Unable to do
peak flow
Circulation: HR 115, capillary return normal, BP 120/78 mmHg.
Insert a cannula. Give 200 mg hydrocortisone IV. Take blood for
routine tests
Disability: alert but getting tired, BSL 5
Exposure: decreased chest wall movements
The diagnosis is life-threatening asthma.
This woman needs urgent treatment and stabilisation with increased
airway support in an intensive care unit, especially as hypoxic and
tiring and may have normal/raised PCO2 levels.
Ix
FBC, clotting, U&E, LFT, Glc, group and
Bloods
save, ABG (assess oxygenation and
ventilation), ECG, CXR (evidence of infection
or pneumothorax)
Mx
Oxygenate, steroids, continuous beta-agonist
Rx
nebulisers, regular ipratropium nebulisers,
consider magnesium sulphate and
aminophylline
IV access, endotracheal intubation in lifeProcedures
threatening cases
Will need to be in a critical care setting
Location
Continuous monitoring
Monitoring
Senior medical help, urgent critical care and
Specialists
anaesthetic review
This type of scenario will evolve depending on the students actions.

Station 31c: Medical emergencies


Circulation
Student info: You are the FY1 on the gastro team and the nurses have
asked you to see a patient on your ward urgently. He was admitted
overnight with melaena on a background of alcoholic liver disease.
On admission he was clinically stable and he is awaiting a gastroscopy. He has passed more melaena and is not looking well. He is not
on oxygen but does have a 20 gauge cannula in his left hand
Examiner info: Initial observations are patent airway, RR 24, clear
lungs, saturations on room air 92%, HR 120, BP 80/50 mmHg, temperature 36C. On exposure the patient has had a large amount of
melaena. The observations can change depending on the action of the
student

Hints and tips


Follow the ABCDE protocol as discussed.
Airway: patent, commence high flow oxygen via a reservoir mask
Breathing: RR 24, sats 92% on room air, chest clear
Circulation: HR 120, cool peripheries, capillary return 4 seconds,
BP 80/50 mmHg. Insert two large-bore cannulae. Commence fluid
resuscitation (500 ml IV normal saline stat). Take blood for routine
tests and cross-match 4 units
Disability: alert, BSL 5

Exposure: large amount of melaena, signs of chronic liver disease


(palmar erythema, proximal muscle wasting, gynaecomastia, spider naevi)
The diagnosis is most likely an upper GI bleed due to oesophageal
varices.
This man needs resuscitation and stabilisation before transferring
for endoscopy.
Ix
FBC, clotting, U&E, LFT, Glc, cross-match 4
Bloods
units, ABG (assess metabolic state), ECG
Mx
O2, IV fluids, blood transfusion, consider
Rx
terlipressin, consider IV antibiotics, correct
clotting abnormalities, consider vitamin K
Consider urinary catheter and central line. If
Procedures
needed, SengstakenBlakemore tube by specialist
Gastro ward or critical care if necessary
Location
Regular observation, central venous pressure
Monitoring
(CVP), strict fluid balance, regular blood tests,
oesophagogastroduodenscopy (OGD)
Senior medical help
Specialists
Inform on-call gastro doctor and arrange gastroscopy.
This type of scenario will evolve depending on the students actions.

Station 31d: Medical emergencies


Disability
Student info: You are reviewing one of your patients in a bay on the
medical assessment ward when you notice a middle-aged woman in
the bed opposite starts to have a seizure. You call the nurse over and
start to assess the patient. You do not know this patient but the nurse
tells you she has been admitted with a urinary tract infection (UTI),
and had all her normal medications that morning
Examiner info: Initial observations are: teeth and mouth clenched
shut with non patent airway, RR 12 and erratic, clear chest, sats on
room air 94%, HR 110, BP 135/85 mmHg, temperature 36.5C, BM2.1.
The patient is having a tonic clonic seizure. The patient is on multiple
oral hypoglycaemic medications and was admitted with a UTI. The
observations can change depending on the action of the student

Hints and tips


Follow the ABCDE protocol.
Airway: teeth and mouth are clenched shut. Use airway manoeuvres
and adjuncts to secure airway. Apply high flow oxygen using a reservoir mask
Breathing: RR is 12 and erratic, chest is clear, sats are 94% on air
Circulation: HR 110 and BP 135/85 mmHg, capillary refill normal.
Insert large-bore cannula. Start IV infusion. Take blood for routine tests
Disability: tonic clonic seizure, BSL 2.1, pupils equal and reactive.
Give IV glucose bolus (75 ml 20% glucose or 150 ml 10% glucose
(25 ml 50% glucose concentration is viscous, making it more irritant
and more difficult to administer and rarely used now). If IV access
cannot be established, 1 mg glucagon should be given IM or SC. If
patient continues to seize despite correction of blood glucose give 4 mg
lorazepam IV (or 10 mg diazepam IV if lorazepam not available)
Exposure: tonic clonic seizure activity, incontinent of urine, nil else
The most likely diagnosis is seizure from hypoglycaemia.
Ix
FBC, U&E, lab glucose, ABG (metabolic
Bloods
disturbance), ECG
CT head if any evidence of head injury or
Imaging
primary neurological disorder. CXR if
infection or aspiration suspected
Blood cultures, urine and sputum if infection
Micro
suspected

Mx

Rx

Location
Monitoring
Specialists

Oxygen, secure airway, IV glucose (once the


patient regains consciousness, oral glucose
should be administered), benzodiazepine IV if
seizure prolonged. Review medications and
stop any hypoglycaemic agents (remember the
half-life of some agents can be quite
prolonged, risking further hypoglycaemia)
Consider transfer to critical care setting
Regular observation
Senior medical review, consider critical care if
seizure prolonged or if neurological depression
is making airway vulnerable

Station 31e: Medical emergencies


Exposure
Student info: You have been asked by the nurses to review a man on
the orthopaedic ward. He is 84 and underwent repair of a right fractured neck of femur 3 days ago. He has been quite well during the day
but the nurses are now worried about him as he seems confused and
is not feeling well. They have asked you to attend urgently
Examiner info: Initial observations are: patent airway,RR 25, clear
chest, sats on room air 96%, HR 120, BP 90/50 mmHg, temperature
38C. The patient has developed a wound infection the hip operation
site is erythematous and there are pus soaked bandages. The observations can change depending on the action of the student

Hints and tips


Follow the ABCDE protocol as discussed.
Airway: patent but the patient is unwell so apply high flow oxygen
using a reservoir mask
Breathing: RR 25, chest is clear, sats are 96% on air
Circulation: tachycardic (HR 120) and hypotensive (BP
90/50 mmHg), capillary refill 2 seconds. Insert large-bore cannula.
Commence fluid resuscitation (500 ml normal saline IV stat). Take
blood for routine tests
Disability: alert although confused, BSL 4.2, pupils equal
Exposure: the wound site is erythematous and the dressing are pus
soaked
The most likely diagnosis is sepsis from a wound infection.
Ix
FBC, U&E, CRP, ABG (metabolic
Bloods
disturbance), ECG
X-ray of hip, may want CXR looking for other
Imaging
source of infection
Blood cultures, wound exudate, urine and
Micro
sputum if other infection source suspected
Mx Rx
Oxygen, IV fluids, IV antibiotics,
thromboembolic prophylaxis, analgesia, clean
wound and redress after surgeons have
reviewed it
Consider transfer to critical care setting
Location
Regular observation, strict fluid balance
Monitoring
Senior medical and orthopaedic review
Specialists
During any scenario that requires an ABCDE assessment, act on
abnormal findings appropriately and then reassess the response to your
interventions. If the patient deteriorates at any time then return to the
airway. Following this initial assessment it will be necessary to use a
logical approach to determine the diagnosis (see Chapter 2). State to
the examiners that you would review the patients hospital notes, drug
chart and observations.
Emergency stations 2 Introduction 43