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PALS Case Study
» In Hospital Case Study 1
PALS Megacode 1 In-Hospital
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You are a resident physician working in a pediatric emergency department. An 18-month-old male is seen in triage for a barking cough and abnormal breathing. The mother reports a four-day history of moderately high fever, progressive coughing fits, nasal congestion, purulent rhinorrhea, and decreased PO intake. The child was brought to the hospital because the mother is concerned with “weird breathing noises” that started an hour ago. You enter the room and conduct a rapid initial impression (ABCs) which reveals the following:
Appearance:
Alert, irritable
Breathing:
Increased effort, accessory muscle use, paradoxical respirations, nasal flaring, inspiratory stridor, nasal congestion
Circulation:
Skin is pale
1. What type and severity of respiratory emergency is occurring in the given scenario?
*
Lower airway obstruction leading to respiratory distress
Upper airway obstruction leading to respiratory distress
Disordered control of breathing leading to respiratory failure
Lung tissue disease leading to respiratory failure
You are a resident physician working in a pediatric emergency department. An 18-month-old male is seen in triage for a barking cough and abnormal breathing. The mother reports a four-day history of moderately high fever, progressive coughing fits, nasal congestion, purulent rhinorrhea, and decreased PO intake. The child was brought to the hospital because the mother is concerned with “weird breathing noises” that started an hour ago. You enter the room and conduct a rapid initial impression (ABCs) which reveals the following:
Appearance:
Alert, irritable
Breathing:
Increased effort, accessory muscle use, paradoxical respirations, nasal flaring, inspiratory stridor, nasal congestion
Circulation:
Skin is pale
2. What severity of respiratory distress is occurring in the given scenario?
*
Moderate respiratory distress
Mild respiratory distress
Severe respiratory distress
Impending respiratory failure
You have evaluated the patient and identified that they are experiencing severe respiratory distress caused by an upper airway obstruction.
3. What are your initial actions?
*
Support the airway and provide oxygen via NRB
Attempt non-invasive ventilation via BiPAP
Administer PO corticosteroids
Establish IV access
An RN is supporting the airway and has started providing oxygen via NRB. You conduct a rapid, hands-on primary assessment using the ABCDE approach which reveals the following:
Airway:
Patent, severe retractions, accessory muscle use, nasal flaring
Breathing:
RR 70/min, SpO2 81%, labored, prolonged expirations, inspiratory stridor
Circulation:
HR 192/min, BP 110/78, strong peripheral pulses bilaterally, normal CRT
Disability:
Moving extremities x4, irritable
Exposure:
Febrile (38.7 °C), pale, dry lips, no rashes
4. A primary assessment reveals persistent respiratory distress. You are suspecting laryngotracheobronchitis (croup). What are your next actions?
*
Establish IV access
Administer nebulized epinephrine
No drugs are indicated at this time
Administer acetaminophen PO
Nebulized epinephrine is administered, and the patient continues being provided with oxygen via NRB. Peripheral IV access is established, and corticosteroids are administered. A repeated primary assessment reveals an oxygenation change from 81 to 92% but otherwise no change in condition.
5. What are your next actions?
*
Attempt non-invasive ventilation via BiPAP
Administer nebulized albuterol
Provide non-invasive ventilatory support via BVM
Administer a second dose of nebulized epinephrine
Non-invasive ventilatory support via BVM is provided. A repeated primary assessment reveals an oxygenation change from 92 to 95%, decreased nasal flaring, and more controlled respirations.
6. What are your next actions?
*
Seek expert consultation
Intubate the patient using an ETT
Administer nebulized epinephrine
Continue non-invasive ventilatory support via BVM
Non-invasive ventilatory support via BVM is continued. A repeated primary assessment reveals an oxygenation change from 95 to 90%, no nasal flaring, no retractions, no accessory muscle use, decreased inspiratory stridor, no extremity movement, lethargy, and the requirement of full ventilatory assistance with inadequate respiratory effort. HR is declining, and central and peripheral pulses are weakening upon palpation.
7. What are your next actions?
*
Attempt non-invasive ventilation via BiPAP
Increase the ventilation rate with the BVM
Intubate the patient using an ETT
Administer nebulized epinephrine
A paralytic is administered, and you perform an unremarkable ET intubation. The patient is now being mechanically ventilated. A nasogastric tube is placed. A repeated primary assessment reveals an oxygenation change from 90 to 98%. The lungs are CTA bilaterally, strong peripheral and central pulses are palpable bilaterally, and vital signs are reflecting rapid improvements in respiratory status.
8. If swelling in the airway would have interfered with performing a successful ET intubation, what other options would you have considered?
*
Cricothyroidotomy
Laryngeal mask airway
Oropharyngeal airway
Tracheostomy
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