OSCE scenario: Drug Overdose
Instructions to Candidate
OSCE Scenario: Drug Overdose
Setting:
The participants are the candidate, and a junior registrar and nurse. There is a bed
with a patient who was is drowsy and confused.
Potential maximum tablets that are missing are written on the whiteboard:
100x40mg propranolol
100x10mg propranolol
28x20mg Escitalopram
Unknown quantity of alcohol
The candidate has received instructions that are outside the room that they are in a
busy ED in the northern suburbs and have been called by a junior registrar to assist
with a patient. They are to assume clinical leader role and respond to the more junior
doctor as appropriate.
OSCE scenario: Drug Overdose
Instructions to Candidate
INSTRUCTIONS to Candidate:
You are working in a busy emergency department in the northern suburbs, with a junior
registrar. A 21 year-old woman is brought in with a drug overdose of propranolol, alcohol and
escitalopram. The registrar has commenced seeing the patient in the Resuscitation Room, and
you have been called in by her for assistance.
You are required to:

briefly assess the clinical situation

describe your risk assessment to staff and explain your rationale for drug
treatment

assume clinical leadership and

continue appropriate therapy for this patient as guided by the scenario.
You may assume that all drugs are available in the Resuscitation Room. Non invasive
ventilation is not available to you. You need to provide detailed instructions to the nurse and
registrar, including drug doses and administration routes. You will have two staff members:
Marie, an ED registrar and Kris an experienced nurse. They will follow your instructions but
will not initiate any treatment unless requested. They may alert you to major changes in the
patient’s clinical status.
You will be assessed on:

Management of the patient’s clinical situation

Appropriate clinical decision making and prioritization

Leadership and teamwork

Communication with the patient and team members
Note: you will NOT be assessed on procedural skills, such as advanced airway
management.
Fellowship Examination OSCE
SUBJECT AND CURRICULUM REFERENCE
Toxicology
Leadership and Management
Medical Expertise
CLINICAL SCENARIO STEM
You are working in a busy emergency department in the northern suburbs, with a junior
registrar. A 21 year-old woman is brought in with a drug overdose of propranolol, alcohol and
escitalopram. The registrar has commenced seeing the patient in the Resuscitation Room, and
you have been called in by her for assistance.
Potential maximum tablets that are missing are written on the whiteboard:
100x40mg propranolol
100x10mg propranolol
28x20mg Escitalopram
Unknown quantity of alcohol
INSTRUCTIONS
Candidate:
You are required to describe the risk assessment to the staff and commence therapy
for this patient with a propranolol overdose. You may assume that all drugs and
equipment usually available in a Resuscitation Room are available. You will need to
provide detailed instructions to the nurse and registrar including drug dose and
administration route.
You will have a patient (actor) and two staff members; an emergency department
registrar and an emergency department nurse who will assist by carrying out your
instructions but will not initiate any treatment unless requested. They may alert you to
major changes in the patient’s clinical status.
Role player – ED nurse:
You are an experienced ED nurse and will follow instructions as given by the
candidate promptly and efficiently. You are able to note any significant changes to the
clinical status of the patient. You are not to initiate therapy without being asked, nor
prompt regarding patient management. You are able to seek clarification if any
instruction is unclear. If asked to administer a drug you will need to be provided with
the dose and route of administration. If asked to ventilate or connect to a ventilator
you will expect to be provided with clear instruction, and can prompt the candidate if
required.
Role player – ED registrar:
You will follow instructions as given by the candidate. You are able to note any
significant changes to the clinical status of the patient. You are not to initiate therapy
without being asked, nor prompt regarding management. You are able to seek
clarification if any instruction is unclear. If asked to administer a drug you will need
to be provided with the dose and route of administration. If asked to ventilate or
connect to a ventilator you will expect to be provided with clear instruction, and can
prompt the candidate if required.
Examiner:
The candidate should efficiently describe the risk assessment to the staff members
and then immediately proceed with resuscitation.
The candidate should assume the team leader role, and communicate with and utilise
team members appropriately.
The candidate should commence reasonable therapy for a significant propranolol
overdose including intravenous drugs with doses and prepare for intubation and
ventilation as required.
Once intubated, the candidate should think of the need for an insulin/dextrose infusion
to aid in stabilisation of haemodynamics.
Assessment criteria
 Accurately identify severe propranolol overdose
 Manage drug therapy for propranolol overdose appropriately.
 Identify need for intubation and proceed to intubation using
appropriate drugs for RSI.
 Intubation technique.
 Appropriate post intubation checks and ventilation goals in a patient
with propranolol overdose
Marie:
I don’t know what happened. She was ok when she was first brought in. She could
walk with assistance but in the last half an hour she has become more drowsy. She’s
taken an overdose. She is bradycardic but her BP is ok.
First set of Vitals: P60, BP 110/70, Sats 96% RA
First GCS of patient:
Eyes open spontaneously
4
Verbal groaning
2
Motor localises to pain
5
*Patient vomits*

Candidate must make a prompt assessment of the patient including GCS and
risk assessment of the overdose

Candidate has to explain to staff the situation ie reason for the drop in GCS
and bradycardia

Candidate should initiate IV access, 02, blood tests including FBP, U&E (K),
BSL, paracetamol, ECG and IV hydration
Kris:
I’ve just done an ECG can you please sign it.

Candidate must explain the ECG appearance to the junior doctor
If not Marie to prompt: Why do you think she dropped her GCS? Why is she
bradycardic? Is the ECG normal?
Kris:
Do you want me to give charcoal?

Candidate expected to delay charcoal in case of further drop in GCS and
potential aspiration
Blood pressure drops to 89 systolic, pulse remains at 60 and GCS drops to 3/15. Kris
to inform doctor of this deterioration if unnoticed.

Candidate to prepare for intubation of the patient (now dummy) and promptly
initiate treatment (hyperventilation, sodium bicarbonate). Candidate to specify
induction drugs if any to nurse and ventilator settings.

Candidate must simultaneously initiate measures to raise blood pressure ie
fluids and vasopressors/inotropes. Then must consider insulin/dextrose
infusion

Candidate expected to explain rationale for using Insulin/dextrose and how it
will be administered
If not Kris to prompt: How do you want me to give the insulin, what kind of insulin?
If not Marie to prompt: Why are you using an insulin infusion? If candidate does not
mention insulin Marie to mention that she’s heard of using insulin in propranolol
overdose.
Medical Expertise

Focused clarification of history and examination
o
Correctly identifies relevance of bradycardia
o
Correctly gives GCS score
o
Identifies and explains the diagnosis of significant propranolol overdose to
staff and has a plan should the patient deteriorate which would include
intubation, hyperventilation, sodium bicarbonate and insulin/dextrose
infusion


ECG
o
Identifies sinus bradycardia
o
Identifies PR prolongation
o
Looks for QRS widening
Identification and appropriate justification of appropriate investigations
o
IV access, 02, IVH
o
Bloods: FBP, U&E, BSL, paracetamol, VBG
o

Asks for an ECG
Development of appropriate management plan
o
Intubation
o
Hyperventilation and sodium bicarbonate
o
Insulin/Dextrose
o
May consider atropine or isoprenaline infusion for bradycardia
o
May consider charcoal after the patient is intubated
o
Contacts ICU team for admission
o
Considers calling toxicology specialist for advice