Tutorial OSCE : Tutorial OSCE May 22th , 2008 EM residents for 2008 National board exam.
OSCE : OSCE Combines of
X-ray , EKG, lab , slide interpretation
Perform procedure station.
Slide3 : Q1 : Read EKG . ANS : 3rd degree AV block .
Point : : Point : Have to differentiate from 2nd AV mobitz II , which most confuse when you’re hurry or get short strip.
Mostly 3rd AV block may be a little bit slower rate. And also can have many PVCs or many ectopic foci show up.
Be careful , Do not pay attention to the ‘Fancy ectopic foci’ more than the baseline rhythm.
Slide5 : Irregular QRS interval Regular QRS interval
Slide6 : Q2 : Read EKG . ANS : HypoK
Point : : Point : Key of HypoK = small T , then prominent U wave.
Impending QT prolongation
Slide8 : TU fusion
Slide9 : Q3 : Open mouth film ANS : Jefferson fracture
Slide10 :
Slide11 :
Point : : Point : Jefferson fracture = burst fracture of C1 ring.
Mechanism : Axial load
Further read in Tintinalli p.1706
Slide13 : Q4 : read CT ANS : Hyperdense MCA sign
Slide14 :
Slide15 : Another example Point : Large infarct so the pt usually present with alter mental status.
Slide16 : Q5 : Read X-ray ANS : Colles fracture
Point : : Point : In hurry , do not confuse with other distal radius fracture. Colles Fx
distal radial metaphysis fracture that is dorsally angulated and displaced proximally and dorsally .
The fracture line may also comminute and extend into the radioulnar or radiocarpal joint ("die-punch" fracture)
Slide18 : Smith Fx
"reverse Colles fracture," is a volar angulated fracture of the distal radius.
Hand is displaced palmar and produces a "garden-spade deformity .
AP film looks much like the Colles fracture
Slide19 : Barton Fx
dorsal or volar rim fractures of the distal radius
PA view often shows a comminuted fracture of the distal radial metaphysis.
lateral view reveals an intra-articular fracture of the volar or dorsal rim of the radius, which may be accompanied by carpal subluxation in the same direction
Further reading in Tintinalli. Volar Barton is more common.
Slide20 : Q6 :
6.1 Read Blood smear. 6.2 write the treatment ANS : P.falciparum rings in RBC
Point : : Point : Will give blood smear and microscope. You have to find it by yourself.
Don’t look what your friends left for you and believe without look through the slide. It’s easily to misunderstand because there’s no details come in the station.
Also ask about the treatment.
More about Malaria : More about Malaria
Slide23 : Q7 :Read Blood smear ANS : Microangiopathic hemolytic anemia
Slide24 : Microspherocyte Fragmented RBC Point : DDx.
renal disease
heart valve replacement
DIC
Vasculitis
malignant hypertension
postsplennectomy.
Further reading in Hemato book na.
Procedure section : Procedure section
Understand the rules. : Understand the rules. Most of the instructor in the OSCE station,
They’re looking in the checklist.
If you do speak in very details, and waste your time and finally cannot complete the list..
You’ll get LOW score.
This is what most of the procedure checklist looking for. : This is what most of the procedure checklist looking for.
Items for skill evaluation of the procedure (checklist) : Items for skill evaluation of the procedure (checklist) 1. Anatomy landmark and location
2. Indications and contraindications for this procedure
3.Use of sterile procedure and Universal Precautions
4. Technical ability
5. Appropriate documentation
6. Understanding of potential complications and their correction
Slide29 : Q8 : Perform central line insertion In station will give you a patient. Sit in Chair.
You have to explain in brief to the patient and achieve inform consent.
After that , the instructor will let you perform with the supine manikin.
Slide30 : Q8 : Perform central line insertion Have many devices on table for choices. Cavafix, Double lumen, Triple lumen.
You can choose Subclavian, IJ or femoral.
Be careful , don’t pick the 3-lumen kid set to use. ( there’s also in the table).
I suggest Cavafix : IJ : because you have only 5 min per station. To explain the insertion of guidewire take long long long time.
Follow the procedure-set-talk.
Slide31 : Procedure-set-talk.. Indication
Contraindication
Prepare yourself , your patient , your equipment
Yourself : Universal precaution !!!! Mask, glove , gawn (must speak out)
Your patient : inform consent.
Equipment preparation. ( speak and do along )
Perform and explain. ( have to practice lots because 5 min. is very short time. No time to think-must be spinal cord reaction. You may “shortness of breath” after every station.!!! )
Secure the procedure after finish. ( stap, plaster etc.)
Aftercare ( like take pt to CXR after central line)
Complication that must look for ( like pneumothorax etc.)
Slide32 : Procedure-set-talk. Ex.1: IJ cavafix Indication
To evaluate CVP
Contraindication
Pt. not co-operate , infection at site , suspected anatomical abnormal on the site ( have to change site) etc.
Prepare yourself , your patient , your equipment
Yourself : Universal precaution !!!! Mask, glove , gawn (must speak out)
Your patient : inform consent.
Equipment preparation. ( speak and do along ) : sterile set with suture, cavafix no.358, syringe 10cc-5cc , NSS to flush , EKG to monitor pt.
Slide33 : Procedure-set-talk. Ex.1: IJ cavafix (cont.) Perform and explain. ( have to practice lots because 5 min. is very short time. No time to think-must be spinal cord reaction. You may “shortness of breath” after every station.!!! )
Supine pt. with insert bed sheath into the interscapular area to set head down.
Position setting : turn face to left side. Identify anatomical land mark
Check breath sound before perform (as reference) and monitor EKG ( monitor arrhythmia when insert to Rt. Atrium)
Paint and sterile drape
Local anesthesia with xylocaine.
Needle guide tap at the tip of triangle. Point toward the ipsilateral nipple. At 45 degree up from skin.
Insert cavafix needle with sheath.
When achieve blood, decrease angle to 30 degree. And draw blood to confirm position.
Inserted sheath, remove needle, insert cavafix line. To about 15 cm. for IJ rt.
Remove the internal guide of cavafix. Secure and strap.
CXR
Slide34 : Procedure-set-talk. Ex.1: IJ cavafix (cont.) Secure the procedure after finish. ( stap, plaster etc.)
Aftercare ( like take pt to CXR after central line)
The proper position is : In SVC just above the carina, and paralel to SVC wall. (read further in procedure book)
Complication that must look for ( like pneumothorax etc.)
Pneumothorax
Hemothorax
Cardiac tamponade from guide cause wall rupture.
Etc.
Now can you see how “shortness of breath” develop in each OSCE station.
Slide35 : Q9 : Perform surgical airway Manikin supine
Choice allow for the needle or surgical cricothyroidotomy.
Further reading in procedure book.
Slide36 : Q10 : Perform intraosseous access Instructor will sit with patient’s parents.
You have to explain and inform consent.
Perform on chicken leg.
Further reading in procedure book. Available site : 1. proximal tibia – 2. distal tibia (malleolus) – 3. distal femur— 4. proximal humerus – 5. sternum (need special short needle)
Slide37 : Q11 : reduce the shoulder dislocation Read film
Perform with patient.
Sitting upright.
Any method you can choose.
Further reading in procedure book.
Slide38 : The shoulder dislocation 3 types
Anterior is most common
Posterior
Inferior
This film is anterior.
Slide39 : Types of anterior shoulder dislocation
Slide40 : Axillary nerve assesement
before and after perform the procedure
Sensation over deltoid area.
Slide41 : After finish reduction, repeat film and look for
Hill-Sachs
Bankart lesion Hill-Sachs Hill-Sachs
Hill-Sachs : Hill-Sachs An indentation or impaction fracture that is seen as an irregularity of the humeral head following anterior dislocation of the shoulder
Slide43 : A bony Bankart is a fracture of the anterior-inferior glenoid (front, lower portion of the glenoid). The presence of this fracture indicates that the labrum and ligaments in the front part of the shoulder are no longer attached to the glenoid
Slide44 : Q12 : ICD Read film
Diagnosis.
Speak to instructor.
** must explain finger explore to palpate lung parenchyma.
Have pic of ICD connection for choose.
Further reading in procedure book.
Slide45 :
Slide46 : Q13 : Prehosp Helmet removal Give victim in helmet ,prone on floor.
Also give 1 EMT to help.
After remove helmet, choose the correct size of collar and put in .
Further reading in procedure book.
Measurement the collar size. : Measurement the collar size. About angle of mandible
Types of helmet : Types of helmet Full face half face half face without front shield
Slide49 : Q14 : ACLS Give mannikin and team member
Let you act as team leader.
Mostly will be 2-step megacode. ( at first, pulse may present but weak ..then arrest later.
Ex. : Pulse VT but BP drop have to cardiovert then turn VF.
Slide50 : Tricks that can play with ACLS Refractory VF but can’t access IV line. So you can’t use cordarone.
Ans : Lidocaine in ETT
Mannikin have ETT already , and you forget to check
Ans : tube in stomach.
Unstable bradycardia you put pacemaker. But forget to take BP. Finally pt’ asystole. You don’t see asystole in monitor because you’re in pacing mode. So it’s look like sinus and you miss understand to PEA.
Ans : always get out of pace mode when assess patient’s rhythm.
Good luck to all of you, the 2nd generation Thai Emergency Physicians : Good luck to all of you, the 2nd generation Thai Emergency Physicians