A-E Station 6
Station 6
Take my breath away…
Candidate Instructions
Setting:
You are a foundation doctor on a night shift in ED. You are called to see a patient in resus who has presented with breathing difficulty.
Sophie-Jade Mason
Tasks:
1. Conduct an A-E examination on the patient addressing any issues as you progress.
2. State your preferred diagnosis to the examiner.
3. Outline any further management you would like to carry out to the examiner.
Simulated Patient Instructions
Briefing
Please act as the patient and reveal signs and results only as the candidate performs actions or requests tests.
Diagnosis: Anaphylaxis
You are Sophie-Jade Mason a 23 year old lady
You have started experiencing difficulty breathing.
Appearance and Behaviour
Conscious and able to converse in short sentences, but you should state that you feel as if your throat is closing up. Eyes - Opening spontaneously. Voice - orientated. Motor- Obey commands. (GCS 15/15).
If possible place a sheet over your legs and lower abdo - this will be hiding a rash on your legs in a real OSCE that the candidate would be expected to look for during their full examination within "E".
Start the Timer and Begin
Examiner Instruction
As the candidate enters please give them this handover (acting as the nurse on the ward)
“Doctor, this patient is having lots of trouble breathing, could you have a look?”
Intro
Airway
Assessment
Breathing
Assessment
Treatment
Cardio
Assessment
Treatment
Disability
Assessment
Exposure
Assessment
Examiner Instruction
At this point please direct the candidate to give their differential diagnosis and any further management plans.
Diagnosis & Further Management
Diagnosis
Further Managemnet
Summary
If nothing else, remember the 2 very important things in anaphylaxis management are adrenaline and IV fluids.
0.5 mg (ie half an ampoule) of 1:1000 adrenaline should be given IM if IV access isn’t available. Bear in mind this relies on the vasodilation that occurs in the muscles, so if an anaphylaxis patient has arrested and isn’t perfusing their muscle beds adequately IV would be route of choice if available.
Speak of arrest - their tendency to briskly dump their circulating volume (ie preload) into extravascular space (some studies have suggested approx 70% of circulating vol in the first 15 mins) is what pushes anaphylaxis patients towards PEA. So moral of the story fluids, fluids, fluids.
Honourable mention to a couple of trendy interventions that are always thrown around:
Steroids - these are the answer to many problems (big up dermatology), but sadly this is not one of them. Steroid administration is no longer in the guidelines.
Antihistamines as acute management - The reason ‘I’ comes after ‘B’ in the alphabet is (and feel free to correct me if I’m wrong) a minimal number of people have met their demise from itching vs not being able to breathe. Let us first sort the airway so the patient may live to itch another day.
Submit for Scoring
Tags | A-E | Shock | Anaphylaxis
Station Written by: Dr Ewa Kunysz
Peer Reviewed by: Dr Rhys Taylor
Summary - Dr Rishil Patel
Want to suggest an edit?
Comment below and we'll get right to it!