PALS Megacode 1 In-Hospital Hurry, don’t let time run out! Sorry, time is up! 0 Hours 0 mins 0 secs Step 1 of 8 12% 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?* Disordered control of breathing leading to respiratory failure Lung tissue disease leading to respiratory failure Lower airway obstruction leading to respiratory distress Upper airway obstruction leading to respiratory distress 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?* Attempt non-invasive ventilation via BiPAP Support the airway and provide oxygen via NRB Establish IV access Administer PO corticosteroids 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?* No drugs are indicated at this time Establish IV access Administer nebulized epinephrine 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?* Provide non-invasive ventilatory support via BVM Attempt non-invasive ventilation via BiPAP Administer a second dose of nebulized epinephrine Administer nebulized albuterol 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?* Continue non-invasive ventilatory support via BVM Intubate the patient using an ETT Seek expert consultation Administer nebulized epinephrine 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 Intubate the patient using an ETT Increase the ventilation rate with the BVM 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?* Oropharyngeal airway Laryngeal mask airway Cricothyroidotomy Tracheostomy
