You are a healthcare provider working on an ALS ambulance. You are dispatched to the home of an 11-year-old boy who according to dispatch is febrile, lethargic, and diaphoretic. Your response time to the scene is 4 minutes. Upon arrival, the father rushes you into the home where you find the mother tending to the child in their bedroom. A rapid initial impression (ABCs) reveals the following:

Appearance: Toxic, weak, lethargic
Breathing: Increased respiratory effort, rapid, labored
Circulation: Flushing

1. An initial impression tells you that the child is responsive, but in respiratory distress. As your ALS partner begins opening the jump bag, you notice that the child’s left forearm is wrapped in first-aid gauze. Upon inquiry, the father explains that the child fell yesterday evening while playing at the park and that a piece of glass punctured his arm. The father further reports that the child appeared fine after the event, but started complaining of localized pain a few hours ago, followed by a high fever and general malaise. What differential should you be considering in the given scenario?*

Distributive shock

Metabolic acidosis

Compartment syndrome

Respiratory failure

You are considering that the child may be experiencing distributive shock secondary to a systemic inflammatory response caused by a foreign body. You instruct your ALS partner to start providing supplemental oxygen via NRB and support the airway as needed. The patient is attached to a cardiac monitor and pulse oximeter. You conduct a rapid, hands-on primary assessment using the ABCDE approach which reveals the following:

Airway: Patent, maintainable
Breathing: RR 31/min, SpO2 97%, shallow, labored, lungs CTA bilaterally
Circulation: HR 152/min, BP 105/60, normal CRT, bounding carotid pulse
Disability: Irritable, anxious
Exposure: Flushed, febrile (40.7 °C); left forearm is erythematous, tender, warm to touch, swollen; puncture site appears infected, seropurulent drainage, strong odour

2.A primary assessment reveals an infected trauma site, signs of inadequate tissue perfusion, but a BP within normal range. What is the appropriate shock classification?*

Compensated shock

Decompensated shock

Irreversible shock

Hypotensive shock

The patient is receiving supplemental oxygen via NRB while you continue the evaluate-identify-intervene sequence of the systematic approach.

3. What are your next actions?*

Consider ET intubation

Administer acetaminophen PO

Place an NPA

Establish IV access

Peripheral IV access is established, and your partner prepares for transport.

4. What are your next actions?*

Repeat a primary assessment

Heparin lock the IV for transport

Administer acetaminophen PO

Administer an NS fluid bolus

Broad-spectrum IV antibiotics are administered. According to sepsis protocol, an NS fluid bolus is also started within 15 minutes of shock recognition.

5. What is the correct dosing for the NS fluid bolus administration?*

15 ml/kg

20 ml/kg

10 ml/kg

25 ml/kg

Broad-spectrum IV antibiotics and an NS 20 ml/kg fluid bolus are being administered. You and your partner move the patient to the ambulance and prepare for transport to the hospital that is 10 minutes away. As the patient is loaded into the ambulance, they begin convulsing, breathing becomes inadequate, and perioral cyanosis is noted.

6. What secondary problem is occurring in the given scenario?*

Upper airway obstruction

Lower airway obstruction

Lung tissue disease Disordered control

Disordered control of breathing

The seizure lasts for approximately 45 seconds, during which time priority is placed on maintaining an open airway and providing adequate ventilation. You transport the patient to the emergency department without any additional events. A pediatric intensivist is waiting in the resuscitation room. They conduct a repeated primary assessment which reveals:

Airway: Open
Breathing: RR 36/min, SpO2 97%, shallow, labored, lungs CTA bilaterally
Circulation: HR 138/min, BP 105/55, normal CRT, bounding carotid pulse
Disability: Listless, but responds to verbal commands
Exposure: Flushed, febrile (40.9 °C); left forearm is erythematous, tender, warm to touch, swollen; puncture site appears infected, seropurulent drainage, strong odour

7. You are the pediatric intensivist who took over the case. Paramedics relay to you that they maintained oxygenation via NRB, established IV access, and started an NS 20 ml/kg fluid bolus x1. What are your next actions?*

Administer broad-spectrum IV antibiotics

Start an arterial line

Administer acetaminophen SUPP

Intubate the patient

Broad-spectrum IV antibiotics are administered. A repeated primary assessment reveals persisting signs of compensated shock.

8. What are your next actions?*

Administer acetaminophen SUPP

Start an arterial line

Administer a second NS 20 ml/kg fluid bolus

Intubate the patient

A second NS 20 ml/kg fluid bolus is administered. A repeated primary assessment reveals persisting signs of compensated shock. You start a third NS 20 ml/kg fluid bolus but anticipate that the patient is in refractory shock.

9. What vasoactive drug should you consider administering?*

Norepinephrine

Nifedipine

Epinephrine

Verapamil

IV norepinephrine is administered, and a third NS 20 ml/kg fluid bolus is completed. A repeated primary assessment reveals significant improvements and gradual stabilizing.

10. What are your next actions?*

Request a neurology consult

Replace NRB with a NC at 4 L/min of oxygen

Administer a second dose of broad-spectrum IV antibiotics

Transfer to a higher level of care for further observation

PALS Megacode 6 Out-of-Hospital

Hurry, don’t let time run out!