SCE - Improving care in ED



1. Lead examiner ………….…………………….….

2. Co-examiner …………..……………………….

Candidate Number:

SCENARIO

It is 2030 hours on a weeknight. You are the duty consultant in a tertiary level emergency department. The department currently has all cubicles occupied except for two which are unmonitored. Ambulance control rings to notify you that an ambulance is en route to your department with a 54 year old man with an acute anterior myocardial infarct. Estimated time of arrival is 5 minutes. All five of your resuscitation cubicles are occupied by the following patients;

Cubicle 1. A 75 yo lady with unstable angina, awaiting a bed in the cardiology unit.

Cubicle 2. A 50 yo man with resolved chest pain and a normal ECG, who has just arrived and is yet to be assessed.

Cubicle 3. A 3 yo girl with croup. Now stable 30 minutes after nebulised adrenaline.

Cubicle 4. A 22 yo man being monitored 2 hours following an overdose of TAD and benzodiazepines.

Cubicle 5. A 17 yo man with a closed head injury who is about to be intubated by your registrar because his GCS has fallen to 9/15.

Question 1: Outline your preparations to receive the new patient. (included in stem)

|Expected Response |Details & Comments |Score |

|Liaise with charge nurse |Discuss patients in resuscitation area, those awaiting inpatient bed | |

|Move one or more patients from resuscitation |3 yo croup | |

|area |try and expedite transfer of 75 yo lady to cardiology bed | |

|Gather resources |Team | |

|Ensure ongoing care to patients |Direct patient in cubicle 2 to be seen | |

| |Oversee management of RSI in cubicle 5 | |

|Prepare for patient arrival | | |

|Notify cardiology team |? for acute angioplasty | |

|Other |Consider ambulance bypass or pre-bypass | |

| | | |

Question 2: The patient arrives. 12-lead ECG demonstrates an acute anterior STEMI, with R on T features. DISCUSS the role of antiarrhythmic agents in this patient.

|Expected Response |Details & Comments |Score |

|High risk of ventricular arrhythmia |Stabilise myocardium vs drug toxicity | |

| |May avoid agents if angioplasty imminent | |

|No drugs |Pros: avoids adverse effects, cheaper, quicker | |

| |Cons: risk of malignant arrhythmia | |

|Beta blockers |Pros: potent antiarrhythmic, slows rate, reduces myocardial O2 consumption, IV | |

| |doses may be titrated | |

| |Cons: hypotension, CCF, bronchospasm, peripheral vasospasm | |

|Lignocaine |Pros: familiarity, reduces AP duration, infusion, short acting, safe | |

| |Cons: potential CNS toxicity | |

|Amiodarone |Pros: broad spectrum, safe profile in acute setting | |

| |Cons: slow onset of action, needs 24 hour infusion after bolus | |

|Sotalol |Pros: bolus only, no infusion | |

| |Cons: adverse effects as with Beta blockers, increases AP duration, efficacy | |

| |inferior to amiodarone and ? lignocaine | |

|Mg / K |Pros: reduce AP duration, indicated if levels low | |

| |Cons: slow infusion | |

|Other | | |

Question 3: The patient is taken to the cardiac catheter lab for acute angioplasty. Soon after, the cardiology registrar rings to say that as a result they cannot accept the 75 yo lady with unstable angina. Outline your options.

|Expected Response |Details & Comments |Score |

|Explore cardiology bed further |Explore reasons for their refusal, can staffing be increased to open bed, can a | |

| |patient be transferred to the ward | |

|liaison |Bed manager, cardiologist | |

|Remain in ED |If resources permit, prefer not to increase 12 hour stay | |

|Transfer |Eg private, public | |

|Unmonitored bed |If stable after time, no pain, no ECG or enzyme rise | |

|Short stay unit / observation ward |+/- monitor | |

|Discharge |Depending on case, if low risk, adequate observation period, follow up, consent | |

Question 4: Following your negotiations the patient is accepted to a cardiology bed. You check cubicle 5 where the registrar has successfully intubated the 17 yo boy and confirmed ETT placement with an ET CO2 trace. He is concerned that the patients oxygen saturation is 90% despite 100% oxygen. Outline your response.

|Expected Response |Details & Comments |Score |

|Bag and mask ventilation |100 % oxygen | |

|Check oxygen supply | | |

|Confirm hypoxia |Check patient, check ETT, check SpO2, ABG, CXR | |

|Optimise ventilation |Increase PEEP, increase I:E ratio | |

|Ensure adequate sedation, paralysis | | |

|Seek and treat reversible patient causes |Pneumothorax, pulmonary oedema, hypotension, aspiration, bronchospasm | |

|Other | | |

Question 5: The patient is stable. The charge nurse requests your approval to go on ambulance bypass as there is only one free cubicle and long waiting times for triage category 4 and 5. What measures would you consider to avoid bypass?

|Expected Response |Details & Comments |Score |

|Liaise with charge nurse |Update on patient status | |

|Supervise patient care |Advise on assessment and management decisions | |

|Delegate staff to attend patients |eg fast track, | |

|Liaise with inpatient beds |Hasten transfer of patients awaiting bed | |

|Clear a resuscitation cubicle |If possible | |

|Admit patients to short stay unit if possible | | |

|Seek back up |Oncall staff if indicated | |

|Bypass may be appropriate | | |

Comments:

Total Mark:

SCENARIO

It is 2030 hours on a weeknight. You are the duty consultant in a tertiary level emergency department. The department currently has all cubicles occupied except for two which are unmonitored. Ambulance control rings to notify you that an ambulance is en route to your department with a 54 year old man with an acute anterior myocardial infarct. Estimated time of arrival is 5 minutes. All five of your resuscitation cubicles are occupied by the following patients:

Cubicle 1. A 75 yo lady with unstable angina, awaiting a bed in the cardiology unit.

Cubicle 2. A 50 yo man with resolved chest pain and a normal ECG, who has just arrived and is yet to be assessed.

Cubicle 3. A 3 yo girl with croup. Now stable 30 minutes after nebulised adrenaline.

Cubicle 4. A 22 yo man being monitored 2 hours following an overdose of TAD and benzodiazepines.

Cubicle 5. A 17 yo man with a closed head injury who is about to be intubated by your registrar because his GCS has fallen to 9/15.

Question 1: Outline your preparations to receive the new patient.

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