You are a healthcare provider working on an ALS ambulance. You are dispatched to the home of a 14-year-old female who has experienced a perceived syncopal episode. Your response time to the scene is 6 minutes. Upon arrival, you notice that the front door of the house is open. You approach the door and announce your department. You hear an adult calling out for help. You enter the home and find the 7-year-old child lying supine on the living room floor. The adult identifies themselves as their mother, and reports that her child collapsed suddenly and that they’re unable to wake them up. A rapid initial impression (ABCs) reveals the following:

Appearance: Unconscious, unresponsive
Breathing: Inadequate breathing, decreased respiratory effort
Circulation: Peripheral cyanosis

1. A rapid initial impression reveals that the child is unresponsive. What are your initial actions?*

Establish IV access and push fluids

Perform a head tilt-chin lift to open a patent airway

Conduct a primary assessment

Attach a cardiac monitor and perform a rhythm check

You perform a head tilt-chin lift to open a patent airway and secure it using an oropharyngeal airway.

2. What are your next actions?*

Attach a cardiac monitor and obtain an ECG

Provide ventilatory support with supplemental oxygen via BVM

Conduct a primary assessment

Establish IV access and push fluids

Your ALS partner has started providing ventilatory support with supplemental oxygen via BVM The patient is attached to a cardiac monitor and pulse oximeter. Peripheral IV access is established. You conduct a rapid, hands-on primary assessment using the ABCDE approach which reveals the following:

Airway: Patent, not maintainable voluntarily
Breathing: RR 47/min, SpO2 90%, ineffective
Circulation: HR 65/min, BP 90/50, normal CRT
Disability: Unresponsive, constricted pupils bilaterally
Exposure: Pale, afebrile, peripheral cyanosis

3. What type and severity of respiratory emergency is occurring in the given scenario?*

Upper airway obstruction leading to respiratory distress

Lung tissue disease leading to respiratory failure

Lower airway obstruction leading to respiratory failure

Disordered control of breathing leading to respiratory distress

You have identified that the patient is experiencing respiratory distress resulting from disordered control of breathing.

4. Which of the following combinations of clinical conditions can lead to disordered control of breathing?*

Pulmonary edema, drug overdose/poisoning, foreign body obstruction

Bronchiolitis, pulmonary edema, asthma

Increased intracranial pressure, drug overdose/poisoning, seizures

Croup, bronchiolitis, pneumonia

You conduct a rapid secondary assessment using the SAMPLE approach which reveals that the mother keeps prescription morphine in the house. You ask the mother to confirm if the pill bottle is in a secure place. They check their purse and discover that the bottle is empty. You are now suspecting that the respiratory distress is being induced by an opioid overdose.

5. What are your next actions?*

Administer naloxone

Administer a fluid bolus of 20 ml/kg

Transport the patient to the hospital

Intubate the patient using an ETT

You decide to administer naloxone (Narcan) as it is likely to rapidly reverse the opioid-induced respiratory depression the patient is experiencing with an effect that will be almost immediate.

6. What initial dose of naloxone should you administer?*

0.1 mg/kg IVP

0.5 mg/kg IVP

0.01 mg/kg IVP

0.05 mg/kg IVP

You administer naloxone 0.01 mg/kg IVP with no change in condition. You decide to administer a second dose of naloxone.

7. What dose of naloxone should you administer?*

0.01 mg/kg IVP

0.05 mg/kg IVP

0.1 mg/kg IVP

0.5 mg/kg IVP

A second dose of naloxone is administered and reveals a near immediate improvement. The patient regains consciousness and begins moving their extremities. They are trying to speak but have an advanced airway in place.

8. What are your next actions?*

Remove the oropharyngeal airway

Administer a third dose of naloxone

Prepare for transport

Repeat a primary assessment

The advanced airway is removed, and the child is breathing spontaneously. Ventilator support via BVM is stopped, and the patient is placed on an NRB at oxygen flow of 15 L/min. A repeated primary assessment reveals that the patient is stabilizing. You advise the hospital and prepare the patient for transport.

9. If IV access was not available, which of the following routes of administration could have been used for alternative naloxone delivery?*

Intranasal

Intramuscular

Intraosseous

All the above

PALS Megacode 7 Out-of-Hospital

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