You are a pediatric intensivist at a major metropolitan hospital. You have been paged STAT to a hospital room to evaluate a 4-month-old male for respiratory distress who was admitted yesterday for acute interstitial pneumonitis. You enter the room and conduct a rapid initial impression (ABCs) which reveals the following:

Appearance: Unresponsive
Breathing: Decreased respiratory effort
Circulation: Skin is pale

1. A rapid initial impression reveals that the child is unresponsive. What are your initial actions?*

Secure the airway

Activate emergency response and begin lifesaving interventions

Obtain a detailed medical history

Continue the evaluate-identify-intervene sequence

The patient is unresponsive, and you have activated the Code Team. Two-rescuer CPR (five cycles) is being performed by a pair of nurses, while three other healthcare providers enter the room with a crash cart. During the first round of compressions, a more detailed medical history is obtained which reveals a three-day history of high fever, worsening productive cough, decreased PO intake, and only one wet diaper in the last 24 hours. The patient has been receiving maintenance fluids and ceftriaxone intravenously since admission, coupled with oxygen via NC at 3 L/min. Unremarkable PMHx, IUTD.

2. Which of the following H’s and T’s is the most likely cause of the arrest?*

Hypoglycemia

Tamponade (cardiac)

Hypoxia

Hydrogen ion (acidosis)

You have identified that the most likely cause of the arrest is hypoxia caused by respiratory failure secondary to acute interstitial pneumonitis.

3. What type of respiratory emergency is occurring in the given scenario?*

Disordered control of breathing

Lung tissue disease

Lower airway obstruction

Upper airway obstruction

You have an entire Code Team and an ALS-equipped crash cart at your disposal.

4. Which of the following combinations of actions have highest priority in the given scenario?*

Continue CPR (five cycles), support ventilation via BVM, attach a cardiac monitor

Attach a cardiac monitor, prepare to intubate, provide oxygen via NRB

Continue CPR (five cycles), administer epinephrine IVP, support ventilation via BVM

Provide oxygen via NRB, continue CPR (five cycles), administer epinephrine IVP

Five cycles of CPR are performed, ventilatory support via BVM is provided, and a cardiac monitor is attached to the patient. Following five rounds of compressions, a rhythm check reveals pulseless electrical activity. SpO2 levels are declining to dangerously hypoxic levels.

5. What are your next actions?*

Administer epinephrine 0.1 mg/kg IVP

Resume CPR (five cycles)

Deliver a single unsynchronized shock of 2 J/kg

Secure an advanced airway

CPR is resumed for another five cycles. During the first cycle of CPR, you administer epinephrine IV.

6. What is the correct dose?*

0.05 mg/kg

0.01 mg/kg

0.1 mg/kg

0.5 mg/kg

Epinephrine 0.01 mg/kg IV is administered, and CPR is resumed (five cycles). SpO2 levels continue to decline.

7. What are your next actions?*

Deliver a single unsynchronized shock of 2 J/kg

Administer epinephrine 0.1 mg/kg IVP

Provide humidified oxygen using BiPAP

Prepare to intubate

You perform an unremarkable ET intubation and suction the ETT to clear secretions from the airway. A rhythm check reveals unchanged pulseless electrical activity. CPR is resumed (five cycles) and the patient is now being mechanically ventilated.

8. What is the rate of respirations for the mechanically ventilated patient in the given scenario?*

1 breath every 15 compressions

1 breath every 2-3 seconds

2 breaths every 30 compressions

1 breath every 6 seconds

CPR is resumed for five cycles. A rhythm check reveals sinus rhythm.

9. What are your next actions?*

Deliver a single unsynchronized shock of 2 J/kg

Stop mechanical ventilation

Palpate for a central pulse

Palpate for a peripheral pulse

You are unable to palpate for a central pulse. CPR is resumed for another five cycles and epinephrine is administered.

10. Following five cycles of compressions, what are your next actions?*

Perform a rhythm check

Resume CPR (five cycles)

Deliver a single unsynchronized shock of 2 J/kg

Perform a pulse check

A rhythm check reveals an organized rhythm, and a central pulse is now palpable. Return of spontaneous circulation is achieved, but the patient remains unconscious. What are your next actions?

Airway: Open, ETT, mechanically ventilated
Breathing: RR 10/min, SpO2 97%, coarse rales and crackles bilaterally
Circulation: HR 110/min, BP 65/30, delayed CRT (3-4 secs)
Disability: Unconscious
Exposure: Pale, cool

11. Your primary assessment reveals that the patient is hypotensive, hypothermic, and tachycardic with a delayed CRT of 3-4 secs. Which of these findings has the highest degree of priority for attention in the post-cardiac arrest phase?*

Tachycardia

Delayed CRT

Hypothermia

Hypotension

You have decided to start post-cardiac arrest care by addressing the patients’ hypotensive state.

12. What are your next actions?*

Administer an NS 20 ml/kg fluid bolus

Administer an NS 12 ml/kg fluid bolus

Seek expert consultation

Administer an NS 15 ml/kg fluid bolus

ou have started the patient on an NS 20 ml/kg fluid bolus. A repeated primary assessment reveals that the patient is stabilizing, and BP is gradually increasing. You order a full diagnostic workup, including a chest x-ray, arterial blood gas, and complete blood count.

13. What are your next actions?*

Repeat a second NS 20 ml/kg fluid bolus

Extubate the patient and assess for spontaneous respirations

Monitor and observe within the ward

Transfer to a higher level of care for close observation

PALS Megacode 3 In-Hospital

Hurry, don’t let time run out!

You have identified that the most likely cause of the arrest is hypoxia caused by respiratory failure secondary to acute interstitial pneumonitis.

You have an entire Code Team and an ALS-equipped crash cart at your disposal.

Five cycles of CPR are performed, ventilatory support via BVM is provided, and a cardiac monitor is attached to the patient. Following five rounds of compressions, a rhythm check reveals pulseless electrical activity. SpO2 levels are declining to dangerously hypoxic levels.

CPR is resumed for another five cycles. During the first cycle of CPR, you administer epinephrine IV.

Epinephrine 0.01 mg/kg IV is administered, and CPR is resumed (five cycles). SpO2 levels continue to decline.

You perform an unremarkable ET intubation and suction the ETT to clear secretions from the airway. A rhythm check reveals unchanged pulseless electrical activity. CPR is resumed (five cycles) and the patient is now being mechanically ventilated.

CPR is resumed for five cycles. A rhythm check reveals sinus rhythm.

You are unable to palpate for a central pulse. CPR is resumed for another five cycles and epinephrine is administered.

A rhythm check reveals an organized rhythm, and a central pulse is now palpable. Return of spontaneous circulation is achieved, but the patient remains unconscious. What are your next actions?

You have decided to start post-cardiac arrest care by addressing the patients’ hypotensive state.

ou have started the patient on an NS 20 ml/kg fluid bolus. A repeated primary assessment reveals that the patient is stabilizing, and BP is gradually increasing. You order a full diagnostic workup, including a chest x-ray, arterial blood gas, and complete blood count.

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