PALS Megacode Case Study 8 In-Hospital

You are a pediatrician working in an urgent care facility. A 9-month-old female is seen in triage with a two-day history of moderate fever, projectile emesis, liquid stools, and poor PO intake. The nurse calls you into the room. A rapid initial impression (ABCs) reveals the following:
- Appearance: Awake, weak, crying intermittently
- Breathing: Increased effort, rapid
- Circulation: Pale, mottled
1. A rapid initial impression helps you establish that the patient is responsive, and that emergency intervention is not indicated at this time. You prepare to further evaluate the patient. What are your initial actions?*
- Provide oxygen via NRB, attach a cardiac monitor, attach a pulse oximeter
- Provide oxygen via NRB, establish IV access, start CPR
- Perform a pulse check, establish IV access, attach a pulse oximeter
- Perform a pulse check, start CPR, attach a cardiac monitor

You have identified that the patient is experiencing compensated hypovolemic shock. Two unsuccessful attempts are made at establishing peripheral IV access. The patient continues receiving supplemental oxygen via NRB, and vitals reflect further deterioration.
2. A primary assessment reveals a drop in blood flow through the circulatory system suggesting that the patient is experiencing shock. What is the most likely cause of the given scenario?*
- Obstructive shock
- Hypovolemic shock
- Cardiogenic shock
- Septic shock

An RN has started providing supplemental oxygen via NRB. 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, open
- Breathing: RR 55/min, SpO2 99%, ineffective, lungs CTA bilaterally
- Circulation: HR 195/min, BP 75/40, delayed CRT (4 secs), weak peripheral pulse
- Disability: Conscious
- Exposure: Pale, cool, mottled, febrile (39.1 °C)
3. What are your next actions?*
- Administer nebulized albuterol
- Establish IO access
- Administer nebulized epinephrine
- Place a nasogastric tube for fluid administration

Intraosseous access has been established.
4. What are your next actions?*
- Administer an NS 10 ml/kg fluid bolus over 5-10 min
- Administer an NS 20-30 ml/kg fluid bolus over 15-20 min
- Administer an NS 20 ml/kg fluid bolus over 5-20 min
- Administer an NS 20 ml/kg fluid bolus over 15-20 min

An NS 20 ml/kg fluid bolus is being administered over 5-20 min.
5. During the treatment, what should be monitored as a component of shock management?*
- Potassium
- Calcium
- Glucose
- Magnesium

An NS 20 ml/kg fluid bolus is administered over 5-20 min and glucose levels are low. A repeated primary assessment reveals HR 190/min, RR 50/min, SpO2 98%, BP 70/34, CRT 4 sec, and weak peripheral pulses bilaterally.
6. What are your next actions?*
- Obtain a peripheral venous blood gas
- Begin mechanical ventilation via BVM
- Prepare to intubate
- Administer a second NS 20 ml/kg fluid bolus over 5-20 min

A second NS 20 ml/kg fluid bolus is administered over 5-20 min and glucose levels are normalized. A repeated primary assessment reveals HR 170/min, RR 51/min, SpO2 98%, BP 80/40, CRT 3 sec, and slightly stronger peripheral pulses bilaterally.
7. What are your next actions?*
- Administer albumin
- Begin mechanical ventilation via BVM
- Obtain a peripheral venous blood gas
- Administer a third NS 20 ml/kg fluid bolus over 5-20 min

A second NS 20 ml/kg fluid bolus is administered over 5-20 min and a repeated primary assessment reveals HR 155/min, RR 40/min, SpO2 98%, BP 90/45, CRT 2 sec, and normal peripheral pulses bilaterally.
8. If the patient had failed to improve after three NS fluid boluses, what would that have indicated?*
- Hypovolemic shock may not be the appropriate diagnosis
- Fluid replacement needs to be modified
- Ongoing fluid loss is occurring; consider internal processes
- All the above

PALS Megacode 8 In-Hospital