PALS Megacode 2 Out-of-Hospital

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You are a healthcare provider working on an ALS ambulance. You are dispatched to the home of a 3-year-old female who has been experiencing trouble breathing. You are advised by dispatch that the mother reports the patient may have ingested glass cleaner, likely mistaking it for candy or a fruit drink, and that the patient’s breathing is worsening progressively. Your response time to the scene is 6 minutes. A rapid initial impression (ABCs) reveals the following:

Appearance: Awake, alert, anxious
Breathing: Increased work of breathing, tachypneic, grunting, intercostal retractions
Circulation: Skin is pink

1. What type and severity of respiratory emergency is occurring in the given scenario?*

Lung tissue disease leading to respiratory distress

Disordered control of breathing leading to respiratory failure

Lower airway obstruction leading to respiratory distress

Upper airway obstruction leading to respiratory distress

You have evaluated the patient and identified that they are experiencing respiratory distress caused by a lung tissue disease.

2. What are your initial actions?*

Establish IV access

Support the airway and provide humidified oxygen via NRB

Support the airway and provide oxygen via NC

Suction the airway

You have evaluated the patient and identified that they are experiencing respiratory distress caused by a lung tissue disease.

3. What are your initial actions?*

Support the airway and provide oxygen via NC

Establish IV access

Suction the airway

Support the airway and provide humidified oxygen via NRB

Your ALS partner is supporting the airway and has started providing regular oxygen via NRB. The patient is attached to a cardiac monitor and pulse oximeter. You conduct a rapid, hands-on primary assessment using the ABCDE approach which reveals the following:

Airway: Clear, maintainable
Breathing: RR 50/min, SpO2 84%, labored, grunting, coarse respirations, crackles
Circulation: HR 140/min, BP 110/59, normal CRT
Disability: Moving extremities x4, irritable
Exposure: Pink, afebrile, perioral erythema

4. A primary assessment reveals persistent respiratory distress. You are suspecting hydrocarbon poisoning via aspiration. What are your next actions?*

Continue providing humidified oxygen via NRB and repeat primary assessment

Prioritize the airway and prepare to intubate

Establish IV access and administer a nebulized bronchodilator

Establish IV access and administer corticosteroids

A primary assessment revealed low oxygen saturation, labored breathing, crackles bilaterally, and tachycardia.

5. Which of these findings is the primary indicator of impending respiratory failure?*

Crackles bilaterally

Labored breathing

Tachycardia

Low oxygen saturation

The patient has a low oxygen saturate despite being provided with supplemental oxygen. You have decided to implement additional measures to assist with respiratory support.

6. What are your next actions?*

Intubate with an ETT

Attempt non-invasive ventilation via BiPAP

Place an oropharyngeal airway and begin supported ventilation via BVM

Attempt non-invasive ventilation via CPAP

Your ALS partner prepares to intubate the patient. You conduct a rapid secondary assessment using the SAMPLE approach which reveals the following:

Signs/Symptoms: Identical to those noted in the primary assessment
Allergies: NKA, NKDA
Medications: none
Past medical history: Unremarkable, IUTD
Last meal 2 hours ago
Events: Approx. 20 minutes has gone by since the incident occurred

7. A secondary assessment reveals that there is a high risk of regurgitation of gastric contents, which currently contain hydrocarbon-based chemicals. If regurgitation occurs and these contents are aspirated into the lungs, chemical pneumonitis can occur. Based on these findings, what are your next actions?*

Apply cricoid pressure for 5-10 seconds after intubating

Intubate with a standard ETT and consider ET drug therapy

Intubate with a standard ETT

Intubate with a cuffed ETT and consider nasogastric tube placement

A paralytic is administered, and you perform an unremarkable ET intubation. The patient is now being mechanically ventilated. A nasogastric tube is placed. The patient is now being transported to the hospital.

8. What are your next actions?*

Provide mechanical ventilation and monitor

Consider ET drug therapy

Repeat primary assessment

Consider hyperventilation

A repeated primary assessment reveals an improvement in oxygenation from 84 to 97% and normal chest expansion with continuous mechanical ventilation. Coarse respirations and moist crackles are still present. Vitals are stable and the patient arrives at the hospital without any additional respiratory events.

9. What three diagnostic tests are likely to be performed on the patient in the emergency department?*

Arterial blood gas, complete blood count, complete metabolic panel

Complete metabolic panel, chest x-ray, arterial blood gas

Chest x-ray, arterial blood gas, central venous oxygen saturation

Central venous oxygen saturation, complete blood count, chest x-ray