First aid for a chemical eye injury — OSCE

Candidate instructions (8-minute station)

You are the paediatric registrar in the emergency department. A 6-year-old has just arrived after a dishwasher-tablet alkali powder burst into her right eye. The child is in pain and the eye is shut and watering; the parent briefly rinsed it under the tap at home. The parent is very anxious. [5]

Your tasks are: [5]

1. State and initiate the correct immediate action — copious irrigation, before any examination — and explain to the parent why it must come first. [5]
2. Reassure the parent that the most important treatment is the irrigation they helped start and that delay is the main enemy. [5]
3. Outline the irrigation protocol (fluid, duration, removing particles from under the lids, checking the pH) and the next steps including urgent ophthalmology. [5]
4. Give a clear safety-net and household-chemical-safety advice for the future. [8]

You are not expected to perform a slit-lamp examination before irrigation, to grade the burn before the eye is flushed, or to manage a suspected open globe in this station — the priority is to demonstrate and explain irrigation-first. [8]

Examiner prompt to the actor (parent)

"She was helping in the kitchen and the packet just burst — is her eye going to be okay? She is in so much pain and I can hardly look. I tipped water over it at home — was that the right thing? What are you going to do right now?" [5]

Marking domains

• Immediate correct action and its priority (4): initiates and explains that the child is irrigated immediately and copiously with saline or Ringer lactate, before any examination or pH check, because every minute of retained alkali destroys the limbal stem cells that resurface the cornea; names that the parent's tap-water rinse was correct first aid and that the volume and speed of irrigation matter most. [5]
• Reassurance that irrigation is the treatment that matters (2): reassures the parent that the single most important intervention is the irrigation they helped begin, that delay is the main enemy, and that the team will keep flushing until it is safe to examine; uses calm, plain language. [5]
• Protocol and next steps (2): outlines irrigating for at least 30 minutes, everting the lids and sweeping the fornices to remove any retained powder, then checking the tear-film pH and continuing until it reads neutral, followed by an eye examination to grade severity and urgent ophthalmology referral. [5] [4]
• Safety-net and prevention (2): advises that the outcome depends on the delay to irrigation and the severity seen once the eye can be examined; counsels on secure storage of household cleaning products and dishwasher tablets out of children's reach, and on returning immediately if vision, pain or redness worsen. [8]

Model answer — the explanatory script

"She's in the right place, and the most important thing we can do for her eye we are going to start right now — before anything else. The powder that hit her is an alkali, and alkali can damage the surface of the eye quickly, so the single best treatment is to flush it out with a lot of fluid, straight away. That is what we are doing now." [5]

"You did exactly the right thing tipping water over it at home — that was real first aid and it helped. What matters most is flushing the eye with plenty of fluid, fast, and that is what we are going to keep doing. I am going to put in a drop that numbs the eye so she can tolerate it, and we will run fluid over the eye for a good while. We will not do a detailed look at the eye until the flushing is well under way, because the flushing itself is the treatment — every minute we flush is protecting the surface of her eye." [5]

"Once we have flushed for a good stretch — at least half an hour — we will lift her lids and check that no powder is tucked underneath them, because a little fleck left under the lid keeps burning. Then we will test the fluid at the eye with a small paper strip to read the acidity, and keep flushing until that reading is back to normal. Only then will the eye doctor have a proper look to see how the surface is and what care it needs next. The eye doctor will be involved early, and depending on what we find, she may need drops to help healing and prevent infection." [5] [4]

"Her outcome depends most on how quickly we flush — which is why we started straight away — and on how much of the surface was affected, which we will see once we can examine her properly. For the future, please keep dishwasher tablets and all cleaning products high up and locked away out of her reach, because these injuries are common and preventable. Bring her straight back if the pain, redness or her vision get worse at any stage, even after we send you home. You did the right thing today by acting fast." [8]