Resuscitation OSCEs

Module 3

 

Part 1. Resuscitation OSCEs.

Introduction In the Emergency Department, the resuscitation room is probably the most stressful and daunting place. In the MRCEM Part C/OSCE exam, however, the resuscitation scenarios that you are faced with should be considered as straight forward opportunities to get more passes under your belt. The exam will present you with an Advanced Life Support (ALS) station, an Advanced Trauma Life Support (ATLS) Station and probably an Advanced Paediatric Life Support (APLS) station. Candidates sitting the MRCEM Part C/OSCE exam are expected to have successfully completed the mandatory resuscitation courses (ALS, APLS and ATLS), and in general the moulages presented in the exam will be no different to those experienced on these courses. As such, attending and completing ALS, APLS and ATLS courses is excellent revision and practice for the exam. Equivalent life support courses from other parts of the world also offer similar practice opportunities, but be sure to familiarise yourself with any differences between such courses and the official ALS, APLS and ATLS versions since this is one area where the candidate is required to stick rigidly to the UK Rescuscitation Council (ALS and APLS) and American College of Surgeons (ATLS) algorithms. The generic resuscitation OSCE. To be sure, resuscitation OSCEs tend to follow a predictable pattern and mark sheets reflect candidate performance in the following broad areas:

• Preparation • Initial assessment • Call the relevant resuscitation teams/allocate roles to team members • Initiate basic life support or perform an ABCDE assessment • Deliver immediately life-saving interventions as they are needed • Demonstrate knowledge of life support algorithms and drug doses • Advanced life support or further treatments guided by ABCDE assessment • Airway management – basic and advanced • Assessment of underlying causes • Knowledge and ability to perform further investigations and interventions to stabilise the patient • Post-resuscitation management • Structured handover/Safe disposal of the patient • Team management and leadership skills

There are very few if any resuscitation scenarios that can’t be broken down into these key areas, and candidates must have an understanding of how to approach each to gain all the available marks and not just regurgitate the relevant life support algorithm The candidate’s role Resuscitation scenarios will often require the candidate to participate initially as a resuscitation team member, perhaps performing the initial assessment and lifesaving interventions, so that the examiner can assess competence in simple but essential skills such as bag valve mask ventilation, safe defibrillation or performing a primary trauma survey. When sufficiently experienced help becomes available, however, you are then expected to step back to become the team leader, so that the examiner may now assess your leadership skills and potential.

ALS cardiopulmonary resuscitation scenarios The ALS cardiopulmonary resuscitation scenario is understandably seen in the exam year after year. Scenarios may begin at any point from the assessment of the sick patient with an ABCDE approach (see below) who then deteriorates to cardiac arrest, to joining an arrest midway through or even being asked to come to review the post resuscitation patient and organising safe transfer. The following breaks the typical ALS cardiopulmonary resuscitation scenario down into the following broad stages. Candidates must be able to perform each stage with full and detailed knowledge of the ALS guidelines, algorithms, drug doses and procedural skills. The stages may then be mixed and matched to the particular scenario presented in the station. Throughout, a solid knowledge of the latest (at the time of writing, 2015) ALS guidelines is required and these can be found on the Resuscitation Council website here https://www.resus.org.uk/. PREPARATION (IF TIME ALLOWS) • Put out a formal cardiac arrest call (2222) – it is better to have more help than none! • Choose a team leader (this will almost always be you the candidate) • Assign roles to the team members – airway, chest compressions, monitoring & defibrillation/drug • Prepare equipment – fluids, drugs, defibrillator machine and pads. INITIAL ASSESSMENT AND CONFIRMATION OF CARDIAC ARREST • ALWAYS reconfirm arrest yourself as team leader • Put out a cardiac arrest call (2222) if not already done • Attach monitor, confirm rhythm (shockable vs non-shockable). BASIC MANAGEMENT OF CARDIAC ARREST • 30:2 ratio of compressions to breaths • 100-120 compressions / minute • Depth of compressions 5-6cm. ADVANCED AIRWAY MANAGEMENT • Place an LMA (or ET tube if expertise present) • Confirm airway placement – end tidal CO2 and auscultation • Asynchronous chest compressions and ventilations once airway is placed • Attach CO2 monitoring (waveform capnography). ADVANCED DRUG MANAGEMENT • Obtain IV access • IO access (upper humerus) if IV access not gained within 2 attempts • Adrenaline immediately in PEA/asystole and then every 3-5 minutes (alternate cycles). DEFIBRILLATION • Place pads • Deliver a single shock (e.g. 200 joules biphasic) ensuring minimal time off chest (ideally less than 5 seconds). • Safe defibrillation technique is essential (this is where attendance on ALS courses and ALS simulation training is essential) • Resume CPR immediately after the shock and continue for 2 minutes • Adrenaline after the 3rd Shock and then alternate cycles • Amiodarone after the 3rd shock. ASSESSMENT AND TREATMENT OF REVERSIBLE CAUSES • Assess for cause during the first 2 minutes of CPR • 4 H’s – Hypoxia, Hypovolaemia, Hypothermia, Hypo/hyperkalaemia • 4 T’s – Tension pneumothorax, Thromboembolic event, Toxins, Tamponade

• DON’T just say “ I’m now going through the 4 H’s and 4 T’s” and expect the mark! Go through them in turn speaking out loud what you are thinking and doing to assess/treat each one: For example, “It’s possible hypovolaemia may have contributed to the arrest – can we run in 1L of normal saline STAT please” or “The patient was on renal dialysis so hyperkalaemia is a distinct possibility, can we give 10% calcium gluconate straight away please and follow it with ….”, or “I’m examining the patient’s legs for any sign of DVT suggestive of PE as the cause”, etc.

ONGOING CYCLES OF RESUSCITATION • Continue CPR for 2 minutes in each cycle • After 2 minutes, stop CPR perform a pulse check and check the rhythm on the monitor • If no pulse, perform defibrillation again with a single shock 200J biphasic if shockable rhythm (VF, pulseless VT) then resume CPR for 2 minutes. Resume CPR without defibrillation where a non-shockable rhythm (PEA or asytole) is present. • Adrenaline on alternate cycles. RETURN OF SPONTANEOUS CIRCULATION (ROSC) • If a pulse is present, do not resume CPR • Obtain the patient’s blood pressure • Check for and treat further rhythm abnormalities (VT, SVT or bradycardia) • Then, once the patient is in sinus rhythm and has a recordable blood pressure move on to post-resuscitation care POST-RESUSCITATION CARE • Ensure full monitoring with ECG, oxygen saturations, and CO2 waveform capnography (gives the earliest indication of deterioration) • Obtain blood pressure and request the ECG, arterial blood gas and mobile chest X-ray • Review possible causes and continue/instigate treatments, “Should this patient go to for primary PCI?” • Ensure secure airway and place on ventilator • Instigate targeted temperature management (NOT therapeutic cooling) • Structured handover to the ITU team • Clear documentation of resuscitation • Audit form for resuscitation officers • Explanation of events to family and further management planned • If resuscitation was unsuccessful, indicate you would speak to the family to break the bad news and consider the possibility of organ donation. Possible ALS OSCEs There will be the classics – VF, pulseless VT and PEA cardiac arrest – but also cardiac arrest with a twist, or what the ALS manual describes as ‘cardiac arrest under special circumstances’. These latter require the candidate to have a slightly more in-depth knowledge of the ALS manual and to do a bit more than just follow the plain vanilla ALS cardiopulmonary resuscitation algorithm. Examples include:

• ‘P’ wave asytole • Hypothermic cardiac arrest • Hyperthermic cardiac arrest/Drowning • Cardiac arrest in late pregnancy • Cardiac arrest secondary to calcium channel blocker or beta-blocker overdose • Cardiac arrest due to tricyclic antidepressant (TCA) overdose • Cardiac arrest following acute deterioration of the seriously unwell or peri-arrest patient. Management of the above special circumstances are given in the ALS manual and should be known for the exam.

The seriously unwell/peri-arrest adult. Although in theory, the number of possible OSCEs based around unwell and/or peri-arrest adults is endless, in reality only a small number of scenarios are tested in MRCEM PartC/OSCE stations and they all require a structured ABCDE approach: • Call for experienced help. If cardiac or respiratory arrest is imminent, put out a cardiac arrest call. • Maintain the airway. Jaw thrust or head tilt/chin lift. Use adjuncts as required and call for anaesthetic help if needed • Give Oxygen • Assess breathing and place on oxygen saturation monitoring. Assist breathing if required with bag-valve ventilation • Assess circulation. Obtain IV access and send blood for FBC, U&E and clotting. Request a blood gas. Support the circulation with IV fluid (1L 0.9% saline STAT) as required • Attach the monitor and assess the cardiac rhythm • Check D (calculate the GCS and measure blood glucose) and E (expose to look for rash of anaphylaxis or meningococcal septicaemia) • Consider the likely cause of serious/life threatening illness • Then instigate the appropriate peri-arrest algorithm or treatment protocol, for example (in brief):

• If bradycardic and compromised, give atropine followed by external cardiac pacing • If tachycardic and compromised, perform DC cardioversion • If anaphylaxis is likely, give IM adrenaline, repeated as required, IV fluids, IV steroids and IV antihistamines • If life threatening asthma is likely, give continuous nebulised B2 agonist, ipratropium nebulisers, IV steroids and IV magnesium sulphate. Get anaesthetic help early. • If massive PE is likely, thrombolyse with alteplase 50mg IV bolus

• If the patient arrests despite your best efforts (they commonly do in OSCEs) put out a cardiac arrest call and start down the ALS cardiac arrest algorithm (above). Possible ALS OSCE involving seriously unwell/peri-arrest adult patients:

• The seriously unwell/peri-arrest patient requiring A to E assessment • Tachyarrhythmia (AF, SVT, VT) • Bradyarrhythmia (complete heart block) • Status epilepticus • Status asthmaticus • Anaphylaxis • The toxic patient: tricyclic antidepresssant overdose, opiate overdose, beta-blocker and calcium antagonist overdose to name a few.

APLS Cardiopulmonary resuscitation scenarios Candidates are likely to have had the least hands on experience with paediatric resuscitation cases, even though many candidates will have worked in paediatrics by the time they come to sit the MRCEM Part C/OSCE exam. Thus, attending an APLS course or participated in paediatric simulation training sessions is essential preparation for paediatric resuscitation both in the OSCE and the ED!. More than adult resuscitation, paediatric resuscitation scenarios have the added pressures of distraught relatives, performing calculations and remembering drug doses, as well as the ever-present consideration of non-accidental injury (NAI). Despite these added pressures, it is important to stay focused (both in the OSCE and real life) and remember that there is a basic structure, along with well-defined algorithms, to follow for any seriously unwell or arrested child that is the subject of an OSCE, or that may be brought into the ED. Generic approach to paediatric cardiac arrest PREPARATION • Always put out a paediatric arrest call – it is better to have more help than is needed and send them away than vice versa • Choose a team leader who will assign roles (this will more often than not be you the candidate) • Assign a doctor +/- a nurse to be with family members to elicit information and provide information and support • Preparation of equipment – airway equipment, fluids, drugs, and defibrillator machine with age appropriate pads etc. CALCULATIONS – ‘WETFLAG’ These must be known of by heart as candidates will be required to write them up on a whiteboard in the OSCE either in preparation for, or as part of, the resuscitation of any sick or injured child.

W – Weight: 0 – 1 yr (0.5 x age in months) + 4
  1 – 5 yrs (2 x age in years) + 8
  6 -12 yrs (3 x age in years) + 7
E – Energy:   4 Joules/Kg
T– Tube ETT- Internal Diam (age /4 + 4)cm
  Length (oro) (age /2 +12)cm
  Length (naso) (age /2+ 15)cm
F – Fluids Medical/cardiac arrest 20 ml/kg
  Trauma and DKA 10 ml/kg
L – Lorazepam   0.1 ml/Kg IV/ IO
A – Adrenaline   0.1 ml/kg of 1/10,000 solution
G – Glucose   2ml/kg of 10% dextrose

  CONFIRMATION OF ARREST • ALWAYS reconfirm arrest yourself as team leader • Open the airway • Give 5 rescue breaths • Assess for spontaneous breathing and for a pulse (10 seconds) • Confirm rhythm on monitor – PEA or VF/pulseless VT (it is rarely a shockable rhythm in paediatrics unless there is an underlying cardiac condition) BASIC MANAGEMENT • Open the airway. Head tilt/chin lift to the neutral position in the infant, the ‘sniffing’ position in the child. Use adjuncts as required (be sure to size them appropriately before use • 15:2 ratio of compressions to ventilation breaths • Encircling compression technique for babies, heel of one hand for infants and two hands for bigger children as deemed appropriate by torso size • 100-120 compressions/minute • Depth of compressions – 1/3 depth of the chest wall ADVANCED AIRWAY MANAGEMENT • Placement of LMA or ET tube by expert only is recommended • Confirmation of airway placement – end tidal CO2 and auscultation • Continuous asynchronous chest compressions and once airway is placed • Ventlate at a rate of 10-12/min. • Monitor ventilation with waveform capnography ADVANCED DRUG MANAGEMENT • Attempt IV access. • IO access (proximal tibia) if IV access is not immediately obtained • Adrenaline (10mcg/kg or 0.1ml/kg of 1 in 10,000 solution IV/IO) immediately in PEA/asystole and then 3-5 minutes (alternate cycles) DEFIBRILLATION • Place pads. Pads should be appropriately sized (8-12 cm for children and 4.5cm for infants). Position below right clavicle and on the left in the mid-axillary line for older children; front and back of chest for infants and small children. • Deliver a single shock (4 J/Kg) with minimal time off the chest (ideally less than 5 seconds) • Safe defibrillation technique is essential (this is where attendance on APLS courses and APLS simulation training is essential) • Resume CPR for 2 mins immediately after the shock. • Adrenaline (10mcg/kg IV/IO) after the 3rd Shock and then alternate cycles • Amiodarone (5mg/kg IV/IO) after the third shock ASSESSMENT AND TREATMENT OF REVERSIBLE CAUSES • Assess for cause during the first two minutes of CPR

• The spectrum of causes of paediatric cardiac arrest is different than that in adults. Common causes in children are airway obstruction, respiratory illness and sepsis; also consider accidental toxin ingestion and NAI. In the neonate, congenital cardiac disease may be the cause.

• Talk through the 4 Hs – Hypoxia, Hypovolaemia, Hypothermia, Hypo/hyperkalaemia and 4Ts – Tension pneumothorax, Thromboembolic event, Toxins, Tamponade, but focus on what you can do to treat the more likely causes – ensure a patent airway and adequate ventilation, give fluid boluses (20ml/kg 0.9% saline IV/IO) to treat hypovolaemia, and look for any treatable injuries suggestive of NAI.

ONGOING CYCLES OF RESUSCITATION • Continue CPR for 2 minutes • After 2 minutes stop CPR and check the rhythm on the monitor and perform a pulse check. • If no pulse, perform defibrillation again with a single shock 4J/kg if shockable rythm (VF, pulseless VT) then resume CPR for 2 minutes. Resume CPR without defibrillation if a non-shockable rhythm (PEA or asytole) is present. • Adrenaline on alternate cycles. RETURN OF SPONTANEOUS CIRCULATION (ROSC) • If a pulse is present, do not resume CPR • Perform an ABCDE assessment. • Check for and treat further rhythm abnormalities (VT, SVT or bradycardia) • Then, once the patient is in sinus rhythm and has stable circulation move on to post-resuscitation care POST RESUSCITATION CARE • Ensure full monitoring with ECG, oxygen saturations and CO2 waveform capnography (gives earliest indication deterioration) • Obtain blood pressure if and ECG if appropriate, capillary blood gas and mobile chest X-ray • Review possible causes and continue/instigate treatments • Secure the airway if not already done and optimise oxygenation • Handover to the PICU team • Clear documentation of resuscitation • Audit form for resuscitation officers • Explanation of events to family and further management planned • If unsuccessful ensure a second healthcare professional present to sit with family • This is often a case of SIDS (sudden infant death in the infant) and needs stringent work up by the duty paediatric team • Named doctor for child safeguarding and deaths must be informed • ED consultant (if not present) must be informed of all child deaths in department • Offer to contact religious minister if family wish it Possible APLS Cases.

• BLS • Chocking • Advanced Paeditric Life Support for the arrested chld or neonate. • Hypothermic cardaic arrest/the drowned child • IO cannulation

The seriously ill child APLS scenarios may present the candidate with a seriously ill child who progresses into full cardiac arrest, for example, a septic child, fitting child or case of paediatric anaphylaxis. This offers the examiner the opportunity to assess your A-E assessment of a seriously ill child and then also to observe your cardiopulmonary resuscitation skills. Other scenarios will just focus on the seriously ill child but expect more in the way of management and perhaps introduce added pressures of an anxious relative or guardian. Whatever the circumstance, an A – E approach is required and the mark sheet will reflect this. Done properly, a thorough A – E assessment will identify any life-threatening emergencies that require immediate action and will also lead to the likely cause of the child’s underlying illness, which can then be managed along standard lines. Therefore, you MUST be able to perform a structured, thorough assessment of the airway, breathing, and circulation of a sick child. Practice the actions, maneuvers, and tasks required for this until they are second nature. Practice talking through your A – E assessment out loud for the examiners benefit, “I’m just going to open the airway with head tilt and chin lift to the neutral position and assess the breathing by looking for ..”. Then just don’t forget D and E – disability and exposure! In addition to knowing the WETFLAG calculations, a knowledge of normal and abnormal vital signs in children is required when assessing the seriosly ill child. Normal values for vital signs in children.

Age of child (years) under 1 1-2 2-5 5-12
Respiratory rate 30-40 25-35 25-30 20-25
Heartrate 110-160 100-150 95-140 80-120
Systolic blood pressure 80-90 85-95 85-100 90-110

  A generic approach to the seriously ill child is as follows: • Call for experienced help. If cardiac or respiratory arrest is imminent put out a paediatric cardiac arrest call. • Assess then maintain the airway with head tilt/chin lift (neutral position infants and ‘sniffing’ position children) and use airway adjuncts if required. Call for anaesthetic help early if drowsy or airway compromised. • Give high flow oxygen • Assess breathing and place on oxygen saturation monitoring. Assist the breathing if respiratory effort is poor with bag-valve ventilation • Assess the circulation and obtain IV/IO access. Treat shock with fluid boluses (20ml/kg 0.9% saline in most cases, 10ml/kg for DKA or trauma) • Reassess after every intervention • Send blood samples and ask for a capillary blood gas • Attach the monitor and assess the cardiac rhythm • Instigate the appropriate peri-arrest algorithm or treatment protocol depending on likely cause of illness, for example (in brief):

• If SVT and shock, attempt vagal manoeuvres, give adenosine 100mcg/kg repeated at 200mcg/kg if no response. Synchronised DC cardioversion if unsuccessful (1J/kg first attempt, 2J/kg second attempt). Then expert help. • If VT and shock, synchronised DC cardioversion (1 J/kg first attempt, 2 J/kg second attempt). Amiodarone (5mg/kg IV over 30mins) and expert help if unsuccessful • Bradycardia is almost always a pre-terminal event in a sick child with respiratory or circulatory compromise. Treat hypoxia and shock first by optimising oxygenation and ventilation and give fluid boluses (20ml/kg 0.9% saline) up to three times. Atropine if there has been vagal stimulation prior to the bradycardia. Adrenaline 10mcg/kg bolus if everything else is unsuccessful. • If anaphylaxis is likely, give IM adrenaline (150mcg or 0.15ml 1 in 1000 for 6 months – 6yrs; 300mcg or 0.3ml of 1 in 1000 for 6-12yrs), IV fluid bolus, steroids and anti-histamines • If sepsis is likely, treat shock by optimising oxygenation, IV fluid boluses (20ml/kg 0.9% saline) repeated up to 3 times and give cefotaxime 50mg/kg IV.

• ALWAYS check D (AVPU and blood sugar) and E (for signs of meningococcal rash and injury/NAI) in all sick children

• If the sick child arrests despite your best efforts (they may in the OSCE) then put out a paediatric cardiac arrest call and begin down the APLS cardiac arrest algorithm.

Communicating with anxious parent/guardian. Understandably, in most cases, a sick child will be accompanied by anxious and distraught family members. In the OSCE, look at this not as an added complication to the scenario but as a great opportunity to gain marks for your communications skills.

• Keep the parent/guardian close at the bedside (NEVER send them away)

• tell the examiner you would allocate a nurse to the parent/guardian to support them

• Elicit information from them about what has happened, ask them about past medical history, medications and allergies. This is a great way to keep them usefully occupied, as well as gain valuable information that will help your resuscitation

• Explain everything you are doing to their child as you go along and why you are doing it. “Jimmy isn’t breathing very well at the moment so I’m going to give him some oxygen, it won’t hurt him and it will make him more comfortable”, “We are going to need to give him some fluid into his veins so I need to put in a drip, He’ll only feel a tiny prick and then we can give him the treatments he needs” etc.

• Display patience and empathy no-matter how irritating and distracting to the resuscitation you feel the parent/guardian is being

• Don’t use false reassurance. Don’t tell them that everything will be alright – it may not be! Be honest, “Jimmy has a bad infection that has made him very sick. We are going to do everything we can to help him get better but he is going to need a lot of treatment now and over the next few days in hospital.”

• Most of all, DON’T ignore the anxious parent/guardian. In the stress of the moment, it is all too easy to either forget about them or ignore them while you concentrate on the resuscitation. A good chunk of the marks in the station will be for communication skills which mean that a perfect resuscitation alone may not get you a pass! Possible APLS scenarios involving the seriously ill or peri-arrest child.

• Peri arrest arrhythmia algorithms • Stridor / airway assessment • Sepsis • Severe dehydration • IO cannulation • Anaphylaxis • Status epilepticus • Status asthmaticus

Detail of the paediatric peri-arrest algorithms and of protocols for treating the seriously unwell child are given in the APLS manual. In addition, most UK Emergency Departments have easily accessible protocols and guidance on treating unwell children.

The approach to the injured patient – ATLS. There will be at least one trauma station in every MRCEM PartC/OSCE exam. This may involve an adult trauma or an injured child – or commonly one of each! ATLS and APLS certification and study of the respective course manuals are, therefore, pre-requisite for understanding the correct approach to trauma in adults and children alike. ATLS scenarios follow a very similar structured template as for both the ALS and APLS scenarios and the examiner will be keen to see you demonstrate your assessment skills as a team member, as well as your leadership skills when the scenario allows you to step back and take the role of team leader. The station will usually present the candidate with a manikin, pre-prepared with mock injuries, an assistant (usually a staff nurse or junior doctor) and relevant equipment (cervical collars, blocks, IV fluids thoracostomy tubes etc.). In the trauma moulage, you are likely to have to perform interventions. These may be quite varied, for example, cervical collar sizing and application, needle decompression of a tension pneumothorax or applying a pelvic binder. Demonstrating cricothyroidotomy or even talking through how and when to perform a thoracostomy are within bounds. The relevant procedures are described in the ATLS and APLS manuals and demonstrated in the videos in this and the procedures page of the online course. It is also useful to be aware of the way in which trauma care is structured in the UK. In most regions, there is a major trauma centre (MTC) which accepts major trauma of all descriptions by land and air. The MTC will usually be a tertiary centre hospital with all major trauma and surgical specialties on site and/or readily accessible (orthopaedics, general surgery, cardiothoracic surgery, vascular surgery, neurosurgery etc.). In the surrounding region, there will also be Trauma Units, whose role is to accept less severely injured patients by ambulance treat them as required and refer them on to an MTC if specialist care is needed. This is often referred to as the ‘hub and spoke’ model. In general, the backdrop to MRCEM ATLS scenarios will be a trauma unit, where large numbers of specialists aren’t immediately available and the candidate is reasonably expected to manage the trauma as leader of a smaller team. Note that the use of Focused Assessment using Sonography in Trauma (FAST) is now well established as an adjunct to the trauma primary survey and as such candidates must be able to set up, describe and perform the classic four region FAST scan as well as interpret the resulting images. The structured approach to trauma is invariant:

• Preparation • Primary survey (A – E) with life-saving interventions • Adjuncts to the primary survey • Secondary survey with treatments • Disposal

Most OSCEs focus on the preparation and primary survey, include a single lifesaving intervention to stabilizes the patient followed by adjuncts and disposal. Let’s look at those stages in turn: PREPARATION • Always put out an early call for the adult or paediatric trauma team • Choose a team leader who will assign roles (this will almost always be you the candidate) • Important: give universal precautions (gloves, gown and eye protection) to all team members • Prepare equipment and put out massive transfusion call if the pre-alert meets local criteria PRIMARY SURVEY (A – E ASSESMENT) WITH LIFE-SAVING INTERVENTIONS Airway

• Protect C-spine then assess and maintain the airway (it is YOUR role in the OSCE to secure the c spine – remember that ATLS walk – until it is 3 point immobilized with correctly sized collar and blocks or another pair of hands takes over) • Be alert to recognize the presence or potential for traumatic airway obstruction and the need to establish a patent airway

Breathing

• Assess breathing, give oxygen and attach to saturations and ECG monitoring. • Recognise and treat life-threatening chest injuries (e.g. tension pneumothorax) • Recognise severe respiratory distress and the need for ventilatory support

Circulation

• Assess the circulation for signs of hypovolemic shock. Obtain the blood pressure. • Obtain 2 large bore IV access. Send blood for FBC, U&E, clotting and crossmatch. • Consider the potential causes of the shock – remember the 4 regions of hidden blood loss are in the chest, abdomen, pelvis and long bones along with the visible evidence of loss -‘1,2,3,4 and on the floor’. Be able to roughly estimate the amount of blood loss using the ATLS classification table for hypovolaemic shock. • Put out a massive transfusion call if hypovolaemic shock is present and be able to describe to the examiner what blood products this should bring. • Treat hypovolaemic shock with IV fluids initially, then as soon as available, switch to blood products. • Give tranexamic acid 1g IV • Understand the significance of and be able to recognise responders vs non-responders to initial fluid resuscitation • FAST is an adjunct to the assessment of circulation during primary survey and should be used at this stage if signs of shock/suspected internal blood loss are present. • Consider other interventions to limit blood loss such as pelvic binder or splinting long bone fractures.

Disability

• The candidate must be able to recognise serious head injury and take steps necessary to prevent any secondary brain injury. The decision to know when to intubate and ventilate the patient with a fluctuating GCS is not just by strict GCS cut offs, but by an ability to sense and gauge likely progression of injury • Don’t ever forget hypoglycaemia (DEFG) • Consider giving analgesia as well at this stage

Exposure

• Expose the whole patient and do a sweep for other injuries. Make sure the examiner sees you examine the long bones for fractures and the perineal area/urethral meatus for bruising and bleeding respectively • If the patient is stable consider log-roll • Think about hypothermia and take appropriate steps to prevent it

ADJUNCTS TO THE PRIMARY SURVEY • ATLS dictates that the primary survey is followed by plain film trauma series x rays (lateral C-spine, chest and pelvis). Perform a FAST scan at this stage as well if not already done. Make sure to review and act on the results of these investigations • State to the examiner what further imaging you would do, e.g. CT scan of chest, abdomen and pelvis, and the rational for doing them. • Be sure, though, not to delay lifesaving surgery where obviously required for unnecessary imaging – the ‘golden hour’ principle should always be aimed for. DISPOSAL • The OSCE may end with a stable patient going for CT scan, an unstable patient going to the operating room, or with handover to the full trauma team that only now arrives. Preparing the patient for transfer to a tertiary trauma centre is also a possibility. • Disposal can often cause dilemmas to the ED team, with many cases causing contention amongst the specialty teams. The MCEM OSCE may well test your ability to refer on the patient and escalate to your seniors if you are met with obstruction from the specialty team • Ensure that you have packaged patients appropriately for transfer (to CT, OR or wards) • This should mean that all ‘relevant’ investigations have been undertaken, notes are completed and that most importantly the patient has been continually reassessed and is safe for transfer

• Finally, don’t forget communication. Even in the ATLS scenario there may be a relative or parent/guardian who must be kept informed of events and outcomes.

Possible ATLS scenarios

• Head injury (varying severities) • Spinal fracture • Tension pneumothorax • Pneumothorax • Haemothorax • Flail chest • Lung contusions • Liver laceration • Splenic laceration • Open book pelvic fracture • Long bone fractures • Polytrauma • Minor injuries only • Trauma in late pregnancy

The ATLS and APLS manual together cover the basic management of the above injuries in both adults and children and the MRCEM OSCE candidate would be wise to study these manuals and be familiar with their content.

Part 2. Leadership skills.

Introduction Resuscitation OSCEs are unique among the MRCEM part C/OSCE exam stations, in that they offer the opportunity to demonstrate leadership skills. Although you may need to begin the station by acting as a team member and initiating the assessment and early management, at the first available opportunity you should step back and allow your team members to take over hands on roles while you co-ordinate the resuscitation as team leader. Other OSCEs may start with a minute to prepare before the patient arrives, and this is your clue to assume team leadership role from the outset. How to demonstrate leadership skills (1) CLEARLY TAKE ON THE ROLE OF TEAM LEADER This must be explicit, not quietly assumed by default. During the preparation stage:

• Introduce yourself to the team members • Clearly, take on the role of team leader in a confident voice so the examiner and other team members can hear you • Allocate roles to the other team members. Don’t just tell them what to do, briefly ask each one about their grade and experience then allocate an appropriate role and check they are alright with it. For example, “…and are you ALS trained?”, “No”, “OK but have you attended cardiac arrests before and done chest compressions?”, “Yes, I can do that. “, “Great, can I ask you to start chest compressions as soon as the patient arrives”. • Ensure your team’s safety – ask them to put on universal precautions • Brief them on as much as you know so far, “Are we all ready? OK, so we have a 27yr old male coming in from a road traffic accident with injuries to the head and chest…”

If you start the resuscitation alone:

• Introduce yourself to team members as they arrive, asking them their grade and experience • Assign them appropriate roles which should release you to step back and lead from then on.

If you enter an ongoing resuscitation:

• Introduce yourself to the team members and either ask whether there is a team leader already, or just state “I’m probably the most experienced here, do you mind if I take over as team leader?”, “Great, now what have we done so far?” • Then move the resuscitation to the next stage by giving appropriate instructions

(2) MANAGE YOUR TEAM EFFECTIVELY Most candidates forget they have team members, try to do everything themselves and end up demonstrating scant leadership. Don’t be one of them! Instead:

• Stand back from hands-on roles other members can perform • Give clear instructions to team members • Keep team members occupied and moving between tasks. For example, once three point immobilisation of the cervical spine is in place, move the team member responsible for manual inline stabilisation to another task, perhaps putting out a massive transfusion call, after that to helping apply a pelvic binder and so on. Each time checking they are competent and comfortable performing each new task

(3) BE THE POINT OF CONTACT BETWEEN THE TEAM AND THE REST

• This means that you are pro-active in interacting with the patient if required, relatives if present and with other specialties as needed. This allows the team members to focus on their role in the resuscitation. Not so you – the team leader is expected to multi-task! • Make sure you are the one that gives a clear structured handover at the end of the OSCE • Do the tough stuff, e.g. volunteer to break bad news to parents and relatives when necessary

(4) ICING ON THE CAKE By now, you may have demonstrated enough leadership to gain the leadership marks on the scoresheet, but why stop there. Go for those global marks as well!

• Address your team members as individuals by name! This sounds so much better and you should have obtained their name during initial introductions. Compare “Lesley, could you give another adrenaline please. Thank you”, to “You, can you give adrenaline now” • Avoid rattling off whole lists of instructions and tasks, all of which obviously can’t be completed simultaneously. It is very tempting to do this as the candidate feels they are scoring many points quickly but it is poor leadership. Focus on what is important next and give no more that two or three instructions at a time, allowing time for them to be completed (it will be quick in an OSCE) before issuing more. • Be courteous, considerate and supportive to your team throughout. “Are you OK doing chest compressions still, do you want to swap around?” • Invite input from the team and involve them in decision making. “..well, I’ve been through all the possible causes I can think of, does anyone else have any other ideas?” • Thank your team at the end of the resuscitation • Suggest a team debrief

Summary Overall you are aiming to control the scenario, rather than let it control you. You may be paddling furiously below the water, but try to appear calm, relaxed and confident above the surface.

Part 3. Example resuscitation OSCE videos

Part 4. Improving your resuscitation/moulage skills.

Resuscitation skills can be learnt but must be practiced. First, make sure you know the ALS, APLS and ATLS guidelines including algorithms and drug doses. Ensure you know the peri-arest algorithms and accepted treatment protocols for serious illness in adults and children. Then practice them! Seek out opportunities to be on the various resuscitation teams during all your rotations. Once you have obtained the relevant life support certification, ask supervisors and seniors if you can team lead under supervision. Get into the resuscitation room as much as you can during your ED rotation and learn how to treat serious illness from the experienced staff there. Think about the list of skills you may need in the OSCE then learn and practice them. Help with log rolls even if it is not your patient, put out the word that you want to learn next time a chest drain is required. Practice your A-E assessment on every young child you see. Another way to learn and practice resuscitation skills is in simulation sessions. Attend any and all simulation sessions organised by the resuscitation officers or by departments. Get together with colleagues and request simulation teaching from your consultants. Attend simulation courses. Candidates at the time they take the MRCEM Part C/OSCE exam vary greatly in their trauma experience. Some have little to none, either due to lack of exposure in a hospital that doesn’t accept trauma or, conversely due to working in a trauma centre where the average trauma is attended by so many eager trainees and tertiary specialists that they struggle to be involved. Others are quite used to participating in trauma teams in peripheral trauma units, where cover is thinner and their hands-on input is essential to the team. Either way, with the advent of 24 hour senior cover, experience in trauma team-leading is unlikely to fall into your lap. Be pushy with your seniors and ask if you can lead the trauma team – under supervision of course – and make sure you are the first to volunteer as team leader at trauma simulation sessions.

Please note that these videos are copyright protected and are produced and owned by Bromley Emergency Training & Research Ltd. They are for private study only and may not be distributed in any form.