PALS Megacode Case Study 3 In-Hospital

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
- Obtain a detailed medical history
- Activate emergency response and begin lifesaving interventions
- 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?*
- Tamponade (cardiac)
- Hypoxia
- Hypoglycemia
- 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?*
- Lung tissue disease
- Upper airway obstruction
- Disordered control of breathing
- Lower 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?*
- Provide oxygen via NRB, continue CPR (five cycles), administer epinephrine IVP
- Continue CPR (five cycles), administer epinephrine IVP, support ventilation via BVM
- Attach a cardiac monitor, prepare to intubate, provide oxygen via NRB
- Continue CPR (five cycles), support ventilation via BVM, attach a cardiac monitor

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?*
- Deliver a single unsynchronized shock of 2 J/kg
- Administer epinephrine 0.1 mg/kg IVP
- Resume CPR (five cycles)
- 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
- 0.5 mg/kg
- 0.1 mg/kg
- 0.01 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?*
- Administer epinephrine 0.1 mg/kg IVP
- Deliver a single unsynchronized shock of 2 J/kg
- Prepare to intubate
- Provide humidified oxygen using BiPAP

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 2-3 seconds

PALS Megacode 3 In-Hospital