Pediatric Advanced Life Support - PALS Core Testing Case Scenario 1: Hypovolemic Shock (Child)‎

Pediatric Advanced Life Support - PALS Core Testing Case Scenario 1: Hypovolemic Shock (Child)

Scenario Lead-in

 Prehospital: You have been dispated to transport a five year old with a three day history of fever and diarrhea.   She has been increasingly lethargic in the last two hours. 

 ED: You are asked to assess and manage a five year old with a three day history of fever and diarrhea. She has   been increasingly lethargic in the last two hours.

 General Inpatient Unit: You are called to assess a five year old who has been admitted to the ward with a three   day history of fever and diarrhea. She has been increasingly lethargic in the last hour and has had sever ongoing   diarrhea. Her intravenous access is no longer functioning. ICU: You are called to the bedside of a five year old   who has been admitted to the intensive care unit with a three day history of fever and diarrhea. She has been         increasingly lethargic in the last two hours and has had severe ongoing diarrhea. Her intravenous access is no   longer functioning.

Vital Signs:

Heart Rate 140 

Blood Pressure 100/80 

Respiratory Rate 36/min 

SpO2 92% on Room Air 

Temperature 38.0 C (100.4F) 

Weight 21 kg 

Age 5 years

Scenario Overview and Learning Objectives

Scenario Overview: Emphasis in this scenario should be an identification of compensates hypovolemic shock. Priorities include oxygen, immediate establishment of intravenous (IV) access, and administration of fluid bolus of isotonic crystalloid, repeated as needed to treat shock signs. Reassessment of cardoprespiratory status is needed during and after each fluid bolus. Glucose concentration should be checked early in this lethargic child.

Scenario Specific Objectives

Recognize signs of compensated and hypotensive shock: this case illustrates compensated hypovolemic shock (key indicatiors include anxiety, tachypnea without abnormal labor, tachycardia, cool and mottled skin, delayed capillary refill and normotention).

Summarizes signs and symptoms of hypovolemis shock: in this scenario, the child has a 3 day history of diarrhea and fever, signs of shock, and poor skin turgor

Demonstrates correct interventions for hypovolemic shock; the most important interventions in this scenario include oxygen administration, administration of one or more boluses of isotonic crystalloid solution and careful reassessment during and after each fluid bolus.

Summarizes how to evaluate systemic )end=organ) perfusion; indirect indicatiors of end-organ perfusion include skin temperature/color, level of consciousness, and urine output.

Evaluate - Initial Impression (Pediatric Assessment Triangle)

  Appearance: Anxious, restless                                                                                                                          Breathing: Fast rate, increased respiratory effort                                                                                          Circulation: Pale, dry, and significant mottling, especially in hands and feet

Identify:

Immediate intervention needed

Intervene: Activate the emergency response system. Emergency medical services requests additional assistance if needed. Administer 100% oxygen by nonrebreathing face mask. Apply cardiac monitor Apply pulse oximeter

Evaluate - Primary Assessment

Focused on Assessment Needed to Support Airway, Oxygenation, Ventilation, and Perfusion

Airway: Patent; no audible abnormal airway sounds (no stridor, no audible wheezing)

Breathing/ Ventilation: Respiratory rate about 36/min; minimal intercostal retractions; SpO2 92% on room air, increases to 100% with 100% oxygen; lungs clear on auscultation

Circulation/Perfusion: Central pulses fair, peripheral pulses weak; heart rate 140/min; blood pressure 100/80 mm Hg; capillary refill about 4 seconds; cool, mottled hands and feet

Remainder of Primary Assessment performed if airway, ventilation and perfusion are adequately supported

Disability: Poor skin turgor

Exposure: Temperatur 38.0 C (100.4 F)

Weight: 21 kg

Identify:

Compensated shock, Sinus Tachycardia

Intervene:

Obtain vascular access (child has compensates shock, so initial attempt should focus on IV access).

Administer a fluid bolus of 20mLkg of isotonic crystalloid rapidly via IV.

Assess perfusion and monitor cardiorespiratory status closely during and immediately after each fluid bolus.

Stop fluid bolus if signs of heart failure develop (eg, increased respiratory distress or development of rales or hepatomegaly).

Check pont-of-care (POC) glucose concentration and treat hpoglycemia, if needed.

Assess response to oxygen administration.

Evaluate - Secondary Assessment

Identify Reversible Causes, but Defer Remainder of Secondary Assessment Until After Initial Shock Therapy

SAMPLE history 9only to extent needed to evaluate reversible causes)

Signs and symptoms: Diarrhea for 3 days

Allergies: None known

Medications: Methylphenidate

Past medical history: Attention-deficit/hperactivity disorder

Last meal: No oral intake for 24 hours

Events (onset): 3 day history of low grade fever and diarrhea; noted to be increasingly lethargic in the last 2 hours

Physical examination:

Repeat vital signs after oxygen and one bolus of 20mL/kg fluids: Heart rate 94/min, respiratory rate 30/min; SpO2 98% with 100% oxygen by nonrebreating face mask; blood pressure 90/50 mm Hg

Head, eyes, ears, nose, throat/neck: Mucous membranes dry; neck supple

Heart and lungs: Normal rate, no extra heart sounds or murmurs; lungs sound clear; capillary refill down to 3-4 seconds

Abdomen: No palpable liver edge; nondistended; nontender; diminished bowel sounds

Extremities: Cool hands and feet: weak peripheral pulses: capillary refill 3-4 seconds

Back: Normal

Neurologic: Lethargic; pupils 4mm, equal, reactive

Identify

Compensated hypovolemic shock

Intervene

Repeat bolus of 2o mL/kg of isotonic crystalloid IV/intraosseous (IO) push; repeat if needed to treat persistent shock symptoms.

Perform careful and frequent cardiorespiratory assessment during and after each fluid bolus/

Stop fluid bolus if signs of heart failure develop (increased respiratory distress or development of rales or hepatomegaly).

Arrange for transfer to the intensive care unit (ICU) (unless child is already in the ICU).

Evaluate - Diagnostic Assessments

Perform Throughout the Evaluation of the Patient as Appropriate

Lab data

Arterial blood gas: pH 7.18, PCO2 24 mm Hg, HCO3 13 Meq/L, PO2 74 mm Hg

Glucose (POC) Testing: 70 mg/dl (3.3 mmol/L

Pending: Electrolytes, blood urea nitrogen/creatinine, serum urea, bicarbonate level, serum lactate

Cultures: Blood, urine

Temperature: 38.0C (100.4F)

Imaging

Chest x-ray: Small heart, clear lung fields

Identify/Intervene

A blood flucose concentration should be checked as soon as reasonably possible in all critically ill children, particularly neonates and infants. Hypoglycenia should be treated immediately.

Metabolic acidosis should correct with effective treatment of shock.