Explaining the ASCIA action plan and demonstrating the autoinjector — OSCE

Candidate instructions (8-minute station)

You are the paediatric registrar in the discharge bay of the emergency department. A 6-year-old child weighing 19 kg is ready to go home after an anaphylactic reaction to peanut, treated with intramuscular adrenaline. The child has never had an adrenaline autoinjector prescribed before. The child's mother and the child's class teacher (who is present to learn the school plan) are in the room. [10]

Your tasks are: [10]

1. Explain the green ASCIA Allergic Reaction Plan and the red ASCIA Anaphylaxis Action Plan, and the single decision that takes a carer from green to red. [10]
2. Demonstrate correct adrenaline autoinjector technique on a trainer device, to the mother and the teacher, and have them practise. [9]
3. Explain the lie-flat positioning, the five-minute repeat rule, and why every community device use means ambulance and hospital observation. [12]
4. Agree the school plan with the teacher — where the device is stored, who is trained, and how the response is rehearsed. [10]

You are not expected to manage the reaction itself — that is done. You are building the prevention package the family and school will carry home. [10]

Examiner prompt to the actor (mother)

"She's only had this once — surely it won't happen again? And the injection looks so complicated, what if I do it wrong and hurt her, or give it when I didn't need to? Can't the school just call an ambulance? And she's grown so much this year — does the dose stay the same?" [3]

Marking domains

• Frame and explanation of the two plans (3): explains the green plan for mild skin reactions (antihistamine, watch for escalation) and the red plan for anaphylaxis (adrenaline now); names the escalation triggers clearly — any airway or breathing problem, collapse or pallor, or skin plus another body system in a rapid reaction; frames the colour-coded plan as removing the need to diagnose under stress. [1] [10]
• Device technique (3): demonstrates on the trainer device — cap off, orange end to the outer middle third of the thigh, push until it clicks, hold three seconds, massage, can go through clothing; has the mother and the teacher each practise; confirms the 19 kg child needs the 0.15 mg junior device and flags the weight-band transition at 20 kg. [9]
• Positioning, repeat and observation (2): explains lying the child flat with legs raised (never standing or walking), the second dose after five minutes if no response, and that every device use means ambulance and hospital observation for the biphasic reaction. [12] [3]
• School plan and communication (2): agrees with the teacher where the device is stored (accessible, not locked away), who is trained, and how the response is rehearsed; addresses the mother's anxiety about doing it wrong with the 'adrenaline is safer than withholding' reassurance; checks understanding. [10]

Model answer — the explanatory script

"Thank you both for coming in. I'm glad she's well now — what happened at the party was anaphylaxis, a severe allergic reaction, and the adrenaline she was given is what brought her back. My job today is to make sure that if this ever happens again, wherever she is, the people around her can do exactly what saved her today. So I'm going to give you two pieces of paper and show you a device, and I'd like you both to have a go." [10]

"The two pieces of paper are her action plans. The green one is for a mild reaction — say a few hives or a slightly swollen lip. On the green plan you stay with her, you can give an antihistamine if you have one, and you watch her closely. The red one is the anaphylaxis plan — and that's the one that says use the device. The red plan starts the moment she has any trouble breathing, any swelling of her tongue or throat, she goes pale or floppy, or she has a reaction that's spreading fast across more than one part of her body. The whole point of the two colours is that you don't have to diagnose her — you just read the colour. If it's a red feature, you use the device." [1]

"Let me show you the device. This is a trainer — it has no needle and no medicine, it's just for practising. The real one works the same way. First, you take the cap off. Then you hold it in a fist — blue to the sky, orange to the thigh. The orange end is the one with the needle. You place the orange end against the outer part of her thigh, here, the middle third, and you push firmly until it clicks, and you hold it there for three seconds — one, two, three — then take it off and rub the spot. You can do it through her clothes, you don't need to undress her. I'd like you both to have a go now on the trainer." [9]

"A few things people always worry about. You won't hurt her — the needle is tiny and goes into the muscle of the thigh, and the dose is set by her weight. At nineteen kilograms she's on the junior device, 0.15 milligrams, and that's correct for her now. The one thing to remember is that the moment she reaches twenty kilograms — and she'll get there soon, children grow — she needs to move up to the next device, 0.3 milligrams, because the junior dose won't be enough. I'll weigh her at every visit, and I'll give you a note for when to change. And if you're ever unsure whether to use it — use it. Adrenaline is much safer than not giving it. The worst that happens from an unnecessary dose is she feels a bit shaky for a minute. The worst that happens from withholding it when she needs it doesn't bear thinking about." [9]

"When you use the device, three things happen in order. First, you lie her flat — legs up if you can. Do not let her stand up or walk around, because standing can cause a dangerous drop in her blood pressure. Second, you give the device. Third, you call the ambulance and tell them it's anaphylaxis — that word gets the right response. If she's no better after five minutes, you give the second device — that's why I'm giving you two, one for home and one for school. And every single time the device is used, she goes to hospital in the ambulance, even if she looks completely better, because the reaction can come back a few hours later and the hospital watch is what catches that." [12] [3]

"For school — and I'm glad you're here — I'll give you a copy of the red plan and a device to keep at school. We need a named staff member trained — your school's ASCIA anaphylaxis training covers this — and the device needs to be somewhere accessible, not locked in a cupboard. We'll rehearse the response so everyone knows their part. On the dose question — yes, she'll move up to the 0.3 milligram device at twenty kilograms, and I'll flag that at her review." [10]

"So you're going home today with two plans, two devices, a trainer to practise with, and a review appointment. You both know what the red signs are, you've both used the trainer, and you know the three steps — lie flat, device, ambulance. Does that make sense, and what questions do you have?" [10]