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?*
- Obtain a detailed medical history
- Continue the evaluate-identify-intervene sequence
- Activate emergency response and begin lifesaving interventions
- Secure the airway

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
- Hydrogen ion (acidosis)
- Hypoxia
- Tamponade (cardiac)

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
- Lower airway obstruction
- Lung tissue disease
- 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?*
- Attach a cardiac monitor, prepare to intubate, provide oxygen via NRB
- Continue CPR (five cycles), support ventilation via BVM, attach a cardiac monitor
- 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?*
- Deliver a single unsynchronized shock of 2 J/kg
- Secure an advanced airway
- Resume CPR (five cycles)
- Administer epinephrine 0.1 mg/kg IVP

CPR is resumed for another five cycles. During the first cycle of CPR, you administer epinephrine IV.
6. What is the correct dose?*
- 0.01 mg/kg
- 0.1 mg/kg
- 0.5 mg/kg
- 0.05 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
- Prepare to intubate
- Provide humidified oxygen using BiPAP
- Deliver a single unsynchronized shock of 2 J/kg

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
- 2 breaths every 30 compressions
- 1 breath every 6 seconds
- 1 breath every 2-3 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
- Palpate for a peripheral pulse
- Stop mechanical ventilation
- Palpate for a central 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 pulse check
- Resume CPR (five cycles)
- Perform a rhythm check
- Deliver a single unsynchronized shock of 2 J/kg

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?*
- Hypotension
- Hypothermia
- Delayed CRT
- Tachycardia

You have decided to start post-cardiac arrest care by addressing the patients’ hypotensive state.
12. What are your next actions?*
- Seek expert consultation
- Administer an NS 15 ml/kg fluid bolus
- Administer an NS 20 ml/kg fluid bolus
- Administer an NS 12 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
- Monitor and observe within the ward
- Transfer to a higher level of care for close observation
- Extubate the patient and assess for spontaneous respirations

PALS Megacode 3 In-Hospital