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PALS Case Study
» In Hospital Case Study 4
PALS Megacode 4 In-Hospital
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You are a healthcare provider working in a pediatric intensive care unit. You are called to the bedside of a 5-month-old female infant with copious amounts of purulent nasal secretions and increased lethargy after being admitted two days ago for bronchiolitis. Cardiac monitoring, IV maintenance fluids, and supplemental oxygen at 4 L/min via NC are being provided. The infant is receiving nebulized albuterol treatments every 4 hrs with no change in condition; the last treatment was 2 hrs ago. A recent chest x-ray revealed extensive pulmonary hyperinflation with no infiltrates or consolidation. You enter the room and conduct a rapid initial impression (ABCs) which reveals the following:
Appearance:
Irritable
Breathing:
Tachypneic, increased effort, wheezing
Circulation:
Pink
1. ALS algorithms allow healthcare providers to systematically evaluate and subsequently treat critically ill patients. What is the name of the primary algorithm used in PALS?
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Management of Respiratory Emergencies
Recognition of Respiratory Problems
Pediatric Cardiac Arrest
Systematic Approach
The initial impression is the first step of the PALS Systematic Approach algorithm and provides a rapid visual and auditory observation of the patient.
2. What is the purpose of this observation?
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Determine if stat diagnostic tests are needed
Recognize possible environmental hazards
Identify if a life-threatening problem is present
Intervene with approach actions to treat the problem
3. What is the type and severity of the respiratory emergency occurring in the given scenario?
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Lung tissue diseases leading to respiratory distress
Disordered control of breathing leading to respiratory failure
Upper airway obstruction leading to respiratory distress
Lower airway obstruction leading to respiratory distress
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 ยฐC), no rashes, no trauma
4. A primary assessment reveals persistent respiratory distress. What are your initial actions?
*
Suction the nose and provide oxygen via NRB
Respiratory failure is imminent; secure an advanced airway without delay
Suction the nose and place an advanced airway
Administer nebulized albuterol, suction nose, and place an advanced airway
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.
5. What are your next actions?
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Administer nebulized racemic epinephrine
Prepare for ET intubation
Start CPR
Administer a higher dose of nebulized albuterol
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.
6. What are your next actions?
*
Continue providing supported ventilation via BVM
Administer 20 ml/kg IV fluid bolus
Administer additional bronchodilators
Intubate immediately and begin providing mechanical ventilation
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.
7. What are your next actions?
*
Monitor for hypotension
Obtain a complete metabolic panel
Obtain an arterial blood gas
Obtain a peripheral venous blood gas
The infant has been provided with mechanical ventilation for several minutes. A repeated primary assessment reveals a continued improvement in oxygenation and further stabilization.
8. If there was a sudden deterioration in the infantโs condition shortly after intubating, what reasons would you consider in explaining the sudden change in status?
*
Obstruction of the ETT or shock
Displacement of the ETT or pneumothorax
Shock of equipment failure
Pneumothorax or myocardial infarction
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