PALS Megacode 4 In-Hospital

The initial impression is the first step of the PALS Systematic Approach algorithm and provides a rapid visual and auditory observation of the patient.

An initial impression tells you that the infant is in acute respiratory distress. A rapid, hands-on primary assessment using the ABCDE approach reveals the following:

• Airway: Maintainable, but worsening
• Breathing: RR 81/min, SpO2 85%, labored, retractions, nasal flaring, wheezing
• Circulation: HR 196/min, BP 90/60, normal CRT, pink skin
• Disability: Moving extremities x4, not interactive
• Exposure: Subfebrile (37.6 °C), no rashes, no trauma

You have suctioned the nose and are providing oxygen via NRB. A repeated primary assessment reveals HR 188/min, RR 73, SpO2 94%, BP 95/45, and CRT 2 sec. The patient remains irritable and lethargic while showing continued signs of labored breathing, moderate retractions, and decreased air movement.

Nebulized racemic epinephrine has been administered and you begin non-invasive ventilatory support via BVM. A repeated primary assessment reveals HR 205/min, RR 48, SpO2 90%, BP 80/45, and CRT 2 sec. Hypoxia is becoming a concern.

The patient is successfully intubated, and mechanical ventilation is provided. Confirmation of correct ETT placement is confirmed using waveform capnography. Auscultation reveals good air movement bilaterally and an improvement in vital signs is noted.

The infant has been provided with mechanical ventilation for several minutes. A repeated primary assessment reveals a continued improvement in oxygenation and further stabilization.