Simman Station

Scenarios, Year 2
OSCE Revision
Author: Dr Jay Thompson
 SIMMAN STATIONS OSCE

Acute Pulmonary Oedema

● Airway – ​airway clear – introduce, are they talking, is there pinky frothy sputum
● Breathing –​ breathing, resp rate, pulse oximeter – if hypoxic, give O​2​ (high flow non-breath),
listen to chest, say you’d percuss, ABG and CXR. SIT UP and give oxygen (​PO).
● Circulation –​ blood pressure (could be hypertensive due to sympathetic surge e.g. compensated
or hypotensive due to decompensation) , pulse, ECG , large bore cannula for set of venous
bloods – FBC, U&Es, LFTS, BNP, troponin, CRP/ESR. ​GIVE DIURETICS (D furosemide slowly). Give
(N) GTN ​(as long as SBP > 90)
● Disability ​– very anxious/pain? CHECK GLUCOSE. Temperature. Check AVPU and give ​(M) + (A)
MORPHINE/metoclopramide​. Use morphine even if not in paid ​ ​ pulm. Venodilator ​
decreased preload so helps if decompensating
● Exposure – ​if not improving on current therapy check for underlying infective cause.

PODMAN = position, oxygen, diuretics, morphine, antiemetic, nitrates

Caused by heart failure =

● Daily weight to check for fluid retention
● DVT prophylaxis
● Repeat CXR
● Change oral frusemide (high dose frusemide gives tinnitus so do slowly) ​ ​ bumetanide
● ACEi + beta-blocker if heart failure
● Consider spironolactone
● Consider digoxin +warfarin if AF

Asthma
BUT FOR CHILDREN =
● Under 5s;
- SABA + ICS + leukotriene then refer (never give 4 drugs and ICS is 200 rather than 400)
● 5-12s;
- Exactly the same as adult except you only give ICS upto 400 in stage 2, then max 800 ICS in
stage 4 and never give 4​th​ drug
● REFER

Acute Asthma

● Airways – are they talking? Broken sentences? Listen for wheeze? Exhaustion? Tracheal
deviation
● Breathing – resp rate (increased), accessory muscles, o2 sats (reduced), quick resp exam – listen
(wheeze, silent chest), give high flow oxygen non-rebreath and sit up, ABG, CXR (​begin
treatments – salbutamol 5mg in 2 doses back to back + and ipratropium 0.5 nebs 6 hourly)
● Circulation – pulse, blood pressure if bp < 100 give IV fluid challenge of 20ml/kg, two large bore
cannula (​IV hydrocortisone 200mg or prednisolone po), ​ECG
● If still not controlled + ​magnesium sulfate 2g over 20mins
● If still not controlled + ​aminophylline IV ​5mg/kg over 20mins
● EXACERBATE CARE – invasive ventilation and send to ITU
● Check peak flow every 15-30 mins and SpO​2​ (keep > 92%)
● Salbumatol every 4hrs
● Check ABG if initial PaCO​2​ normal or increased
● D- AVPU, pain, temperature
● E – infection? Sputum culture, check potassium.
● Send home with 50mg prednisolone 5 days, give technique advice with inhalers etc
Only discharge when been on discharge meds for 24hours and stable, peak flow is more than 75%
predicted.
OSHITME = oxygen, salbutamol, hydrocortisone,ipratropium, theophylline, magnesium sulfate,
exacerbate care . (but magn comes before theophylline)
If salbutamol isn’t working after 10 puffs (over 30-60secs apart) call ambulance.
COPD

Muscarinic side effects = stops parasympathetics e.g. constipation, bradycardia

Acute COPD exacerbation

OSHITABC
Oxygen, salb, hydrocortisone,ipratropium, theophylline, antibiotics , bipap and chest physio

● Airway ​ - are they talking? Broken sentences?

● Breathing ​– resp rate, o2 sats, resp exam – listen (emphysema, course crackles, bronchial
breathing e.g. infective, reduced breath sounds), auscultate, trach deviation, chest expansion,
reduced cricosternal? ABG, CXR? 24% venturi mask aiming for 88-92%, aim for PaO​2​ > 8. Give
Salbutamol 5mg (backtoback) every 4hrs, Ipratropium 0.5mg every 6hrs
● Circulation – ​pulse, bp, ecg, get IV access – give ​Hydrocortisone IV 200mg ,​ bloods – FBC, U&Es,
LFTS, give ​theophylline
● Consider Bipap if not better
● D – ​glucose, AVPU, pain? Infection – sputum culture, check K (from salbutamol), GIVE
ANTIBIOTICS (doxycycline 200mg loading then 100mg po od for 5 days)​, check urine output –
CO​2​ retention. CURB65
● Chest physio
● Invasive ventilation if didn’t work

Acute PE

● Airway – are they talking, quick history,

● Breathing – tachypnoeic, resp rate, O2 sats – 100% via non-rebreath if hypoxic, resp exam –
listen, percuss etc ​SITUP. ​, ABG (+ CXR), cyanosis
● Circulation – pulse, bp, ECG, cardiac exam, large bore cannula, bloods = d-dimer, FBC, UES, LFTS,
glucose, BNP, troponin, clotting and INR
● D - AVPU, if in pain – morphine + metaclopramide
● E – everything else, WELLS SCORE consider treatment from this (high probability >4 = CTPA, Low
prob = D-dimer, if D-dimer positive = CTPA, if negative = not PE)
● If massive PE (haemodynamically unstable) = ​thrombolyse (alteplase 50mg bolus) or surgical
embolectomy/interventional.
● If not ​LMWH ​e.g. enoxaparin 1.5mg/kg/24hr SC
● If BP is low (<90) give fluids (colloid), if its >90 then start ​warfarin ​and confirm diagnosis.
● Call consultant
● Ongoing = TEDS in hospital
● If DVT give graduation compression stockings for 2 years and continue LMWH until INR>2
(atleast 5 days)
● Target INR = 2-3 with warfarin
● Duration;
- 3 months for reversible cause
- 6 months for unknown cause
- Indefinite if ongoing cause
Pneumothorax

ICD = intrapleural chest drain

Acute STEMI

● Airway​ – check their talking, ask quick history i.e. any cardiac/lung problems?
● Breathing ​–resp rate, o2 sats, resp exam, chest expansion, if hypoxic high flow oxygen aim for
94-98%, ABG + CXR
● Circulation ​– cardiac exam, large bore cannula IV – bloods; FBC, glucose, LFTS, UES, troponin,
d-dimer, clotting, BNP & ANP, lipids, blood pressure (remember if cardiac history/peripheral
oedema give 250ml saline instead of 500 if BP < 90/60. ECG monitoring 12 lead, pulse. If ECG
shows STEMI – ​give Aspirin and Clopidogrel 300mg loading dose, then 75mg daily, atenolol
5mg IV + GTN 2 puffs (​a
● D – ​AVPU, pain, sepsis i.e. endocarditis (​give morphine/metoclopramide​)
● E –​ frothy sputum, LVF, peripheral oedema – consider diuretics, urgent referral for ​PCI + start
Glycoprotein2b3a inhibitor e.g. Tirofiban
● Within 24hrs ​– start ACEi i.e. Lisinopril 2.5mg, Betablocker i.e. atenolol 5mg IV
● Give LMWH e.g. enoxaparin IV then subcut – ​until fully mobile or 3 months if large anterior
● Discharge meds;
- Statin
- Betablocker
 - Aspirin (lifelong at 75mg)
- Clopidogrel (75mg for 1 year)
- ACEi
- Cardiac rehab
- Lifestyle advice i.e. smoking/diet
DABS = dual antiplatelet, ACEi, betablocker and statin

● GIVE ​CABG ​if tri-vessel blockage or if ​Left mainstem​ or if ​failed angioplasty etc.

If NSTEMI

EXACTLY THE SAME

d- ​Do grace score = CV risk If high; give GP2b3a inhibitor and PCI . If low risk = may discharge after
12hrs if negative trop.
● Outpatient = angiography, perfusion scan, stress echo
● DABS
● If signs of LVF consider diuretics, if right consider fluids.
● If hypotensive be careful with GTN.

Acute bradycardias

● Treat underlying cause e.g. exclude MI etc

● Give atropine 0.6-1.2mg
● External pacing

Narrow complex tachycardia (SVT = sinus tachy, atrial fib, atrial flutter, AVNRT or AVRT)

● Airway – check talking, quick history

● Breathing – o2 sats, resp rate, quick resp exam, if hypoxic give high flow oxygen, ABG, CXR
● Circulation – pulse, BP, 12 lead ECG continuous, large bore cannula – Bloods = FBC, UEs, LFTs,
troponin, BNP, ddimer, clotting, cardiac exam. If pulse regular and high and narrow complex =
vagal manoeuvres, if failed = adenosine 6mg IV bolus then 12mg, then 12mg.​ If adverse signs
e.g. BP<90, HF, decreased consciousness or HR>200 = ​sedate and cardiovert electrically, if that
fails then amiodarone 300mg ​20-60mins, then ​900mg over 24hrs.
● IF IRREGULAR TREAT AS AF
● If no adverse signs ​ ​ choose from amiodarone (same as above), digoxin 500ug over 30mins,
verapamil, atenolol.
● D – AVPU, pain etc
● E – heart failure, underlying cause etc.

Acute Atrial fibrillation (<48hrs)

● Same process as above, until management – ensure irregularly irregular

● Control rate with beta-blocker e.g. metoprolol or digoxin
● 1) If adverse signs ​ ​ DC cardiovert then amiodarone
● 2) If no adverse signs and <48hrs onset ​ ​ rate control = betablocker (if contraindicated try
rate-controlling CCB e.g. verapamil NOT BOTH) or digoxin (3​rd​ line = amiodarone). Consider
 cardioversion chemically first line = flecaininde, 2​nd​ line = amiodarone 300mg over 20-60mins,
then 900mg over 24hrs.
(use amiodarone if structural heart disease over flecainide as it is more effective)
● D – cha2ds2v, hasbled
● If 1 and male consider anticoagulation
● If 1 and female no anticoagulation
● If 2 or above anticoagulated

If paroxysmal = self-limiting and less than 7days, anticoagulate with Chads… Treat with rate control
b-blocker, flecainide (pill-in-pocket)
If permanent (i.e. cardioversion all attempts failed), rate control b-blocker + anticoagulated
according.

Broad complex tachycardias (VT,VF, SVT with BBB)

ABCD- management
● Pulse? If no ​ ​ defibrillation.
● If yes;
● Adverse signs e.g. HF, bp<90, chest pain, decreased consciousness, HR>150? If yes ​ ​ ​sedate and
cardiovert
● If no ​ ​ correct electrolyte problems (i.e. K​+​ or Mg​2+​)
● Then assess rhythm ​ ​ amiodarone cardioversion
● If failed ​ ​ DC synchronised cardioversion

Cardiogenic shock

Causes;
● MI, hyperkalaemia, endocarditis, aortic dissection, rhythm disturbance, tamponade (MIHEART)
or Tension pneumothorax or massive PE
● Airways – are they talking? Brief history? PMH of any of above.
● Breathing – resp rate, ABG, CXR, O​2​ sats ​ ​ give oxygen 15/L 94-98%, resp exam., tracheal
deviation, ensure not tension pneumothorax!
● Circulation – Bp, ecg, pulse, bloods – fbc, ues, lfts, clotting, d-dimer, troponin, bnp/anp, two
large bore cannula IV, cardiac exam. ​If arrhythmia – correct and follow other pathway. If
electrolyte disturbance, correct. Correct acid-base abnormality. ​Give
morphine/metoclopramide.
● D - avpu, pain Echo, consider ct thorax, urine output

Acute limb ischaemia

● Airways – talking, quick history – pain on walking etc

● Breathing – resp rate, ABG, CXR, o2 sats – check limbs separately. Give oxygen if hypoxic –
non-rebreath high flow.
● Circulation – pulses! Ecg – correct AF, bp, ABPI! Give IV fluids if BP low (watch out for cardiac
disease), Cardiac exam, bloods – fbc, clotting, u&es, lfts, d-dimer, HbA1c, lipids, glucose,
creatinine kinase. ​Give unfractionated heparin IV (unfractionated has a higher affinity to
coagulation factors than LMW)
● D – avpu, give ​morphine/metoclopramide if pain. NIL BY MOUTH.​ Co-amoxiclav if signs of
infection.
● Duplex Doppler – if complete occlusion ​ ​ embolectomy or bypass or thrombolysis
● If not completely occluded ​ ​ angiogram to guide any distal bypass.
● (If thrombosis – takes hours/days = thrombolysis or bypass) (If embolus – sudden onset =
embolectomy + warfarin)
● POST SURGERY – use heparin IV, then warfarin to leave on.
● Manage CV risk lifestyle factors

Abdominal aortic aneurysm rupture

● High flow O​2

● 2 large bore cannulae in each arm, fluid if shocked but keep SBP < 100
● Give blood desperate
● Call vascular surgeon

Thoracic aortic dissection

● BETA BLOCKER – labetalol, esmolol. Keep BP 100-110

● Type A – open repair
● Type B – conservative initially (surgery if persistent pain or complications)

Immediate transfusion reactions

Stroke
● Airway – non-responsive? Dysphasia? Aspiration? Vomit in mouth? Consider Naso-gastric tube
or invasive ventilation. Quick
● Breathing – resp rate, O2 sats, ABG, if hypoxic ​ ​ oxygen.
● Circulation – pulse (resuscitate), ecg (check for AF and treat), BP control, cardiac exam, bloods –
fbc, INR, clotting, D-dimer, LFTs, U&Es, glucose via 2 large bore cannulae.
● D - urgent CT head, AVPU, NIHSS score, echo, angiography
● Consider thrombolysis! Check contraindications.
● Rule out haemorrhagic – ​give aspirin 300mg for 2 weeks then switch to clopidogrel 75mg
indefinitely. (INR 2-3). Use warfarin if due to AF or cardioembolic. Start after 2 weeks.
● DVT prophylaxis
● Start statin after 48hrs
● Carotid Doppler. If > 70% then carotid endartectomy
● SALT assessment within 24hrs
● Arrange dietician, salt, stroke rehab nurse, ot, specialist nurse
● CV RISK FACTOR MODIFICATION

TIA

● Same as stroke - aspirin 300mg after CT, swap to clopidogrel after 2 weeks. If uncertain CT head.
● ABCD​2​ (age > 75 (1), blood pressure >140/90 (1), clinical signs = hemiparesis/sensory (2), speech
disturbance (1), diabetes (1), duration = over 60mins (2), <60mins (1)
● if over 4 = high probability, refer to TIA clinic within 24hrs.
● If under 4 = low probability, refer within 1 week.
● Carotid dopper + angiography
● Carotid endartectomy within 2 weeks.
● ECG 24hr tape

Anaphylaxis

● Airway – swollen tongue? Consider intubation if resp. obstruction, elevate the feet.
Swelling/urticarial? hoarseness, stridor? Brief history – stings/eaten/allergies. ​Give adrenaline
0.5mg IM (repeat every 5 mins) if needed – guided by cardiorespiratory.
● Breathing – resp exam, ABG, O2 sats, CXR, wheeze? Laryngeal obstruction? Resp rate high?
Cyanosis? Fatigue. Oedema? Give 100% O​2​. ​Salbutamol Nebs 5mg if wheeze + 0.5mg
ipratropium.
● Circulation – pulse, ECG, tachycardic, cardio exam, BP – hypotensive – give 500ml fluid IV. Pale,
clammy, faintness, drowsy, coma. Get IV access. Bloods – fbc, u/es, lfts, blood for mast cell
tryptase. ​Give chlorphenomine 10mg IV, Hydrocortisone 200mg IV.
● D – AVPU, pain, 2​nd​ deteroriation
● Discharge = teach adrenaline self-injection technique with epipen, advise wearing of medic alert
bracelet, advise recognition and avoidance of triggers, Skin prick tests may help ID antigens,
RAST – blood test for IGE specific antibodies.

CHAOS – chlorphenamine, hydrocortisone, adrenaline, oxygen, salbutamol (+ipratropium)