Pediatric Advanced Life Support - PALS Core Testing Case Scenario 12:Pulseless Arrest, Pulseless Ventricular Tachycardia (Infant; Arrest)

Scenario Lead-in

Prehospital: You are dispatched to a home where a6 month old suddenly became gray and apneic. Babysitter called 91-1-1 and initiated CPR.

ED: An ambulance is en route with a 6 month old infant who suddenly became limp and gray. CPR is in progress.

General Inpatient Unit: You are called as a member of the rapid response team to see a 6 month old who suddenly became limp and gray. The infant was admitted for observation following period of apnea. CPR is in progress.

ICU: You are called to see a 6 month old who suddenly became limp and gray. Patient was admitted following a period of apnea. CPR in progress.

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Heart Rate CPR in progress

Blood Pressure CPR in progress

Respiratory Rate Bag mask ventilation (CPR)

SpO2 Not obtainable

Temperature Deferred

Weight 8 kg

Age 6 months

Scenario Overview and Learning Objectives

Scenario Overview: This scenario focuses on the identification and management of cardiac arrest and a “shockable” rhythm. Emphasis is placed on immediate delivery of high quality CPR and integration of shock delivery while minimizing interruptions in CPR. One shock followed by CPR, and then (when pulseless ventricular tachycardia VT persists) a second shock followed by CPR + antiarrhythmic (amiodarone or lidocaine) are administered before return of spontaneous circulation (ROSC). Identification of potential causes (H’s T’s) should be discussed during debriefing.

Insertion of advanced airway and post-ROSC care are beyond the scope of this scenario. Post-RISC care us addressed with asystole scenario.

Scenario-Specific Objectives

Identifies cardiac arrest with shockable rhythm; in this scenario, the infant has pulseless VT

Demonstrates safe shock delivery with appropriate dose and minimal interruption of chest compressions; the correct initial dose is 2J/kg, second shock is 4 J/kg , and subsequent doses are at least 4 J/kg (maximum 10 J/kg or adult dose for the defibrillator)

Describes correct dose and rationale for epinephrine administration

Uses appropriate antiarrhythmic in ventricular fibrillation (VF)/pulseless VT; the 2015 AHA Guidelines Update for CPR and ECC noted that either amiodarone or lidocaine is equally acceptable

Identifies reversible causes of persistent pulseless VT; during the debriefing, the student should be asked to recall possible reversible causes of cardiac arrest (recalled by conditions beginning with H’s and T’s)

Evaluate - Initial Impression (Pediatric Assessment Triangle)

Appearance: Extremities appear to be limp; no spontaneous movement and no visible reaction to noise

Breathing: No spontaneous breathing

Circulation: Cyanotic/pale extremities and lips; overall gray color

Identify:

Immediate intervention needed

Intervene:

Activate emergency response system. Emergency medical services request additional assistance if needed.

Check for response (no response) and perform simultaneous check for breathing (none) and brachial pulse (none)

Immediately begin high quality CPR.

Evaluate - Primary Assessment

Should verify airway, breathing, and circulation support

Monitor reveals pulseless VT

Weight 8 kg per color coded length based resuscitation tape

Identify:

Cardiopulmonary arrest

Pulseless VR cardiac arrest

Intervene:

Use a CPR feedback device, if available, to guide CPR delivery

When defibrillator arrives, apply pads/lead and turn on monitor.

Identify rhythm (pulseless VT, shockable).

Attempt defibrillation with 2 J/kg as soon as possible

Resume high quality CPR immediately after shock delivery.

Obtain vascular access (intravenous IV/intraosseous IO)

Apply pulse oximeter (per local protocol, may be deferred until return of spontaneous circulation (ROSC)

Evaluate - Secondary Assessment

Deferred Except to Identify Reversible Causes

SAMPLE history (deferred until ROSC or only to extent needed to evaluate reversible causes, ie, H’s and T’s; do not interrupt resuscitation)

Signs and symptoms: Infant suddenly became limp; no precursors

Allergies: None

Medications: None

Past medical history: None

Last meal: 1 hour ago

Events: (onset): As specified in scenario lead in

Physical examination:

(deferred until ROSC or only to extent needed to evaluate reversible causes)

Vital signs after ROSC following high quality CPR, a total of 3 shocks delivered, 1 dose of epinephrine, and 1 dose of antiarrhythmic (amiodarone or lidocaine): Sinus rhythm; heart rate 140/min; respiratory rate 30/min (bag mask ventilation); Spo2 100%; blood pressure 84/50 mm Hg; temperature 36.4 C (97.5 F)

If no shock is delivered, pulseless VT continues

Identify

Cardiopulmonary arrest

Pulseless wide complex tachycardia, pulseless TV

Intervene

Continue high quality CPR; reassess rhythm every 2 minutes

If a shockable rhythm persists at a second rhythm check, give second shock of 4 J/kg, followed by immediate CPR.

Prepare epinephrine 0.01 mg/kg (0.1 mL/kg, followed by immediate CPR)

Prepare epinephrine 0.01 mg/kg (0.1 mL/kg of 0.1 ng/ml concentration) IV/IO and administer during chest compressions

-Repeat every 3-5 minutes during cardiac arrest

If shockable rhythm persists at third rhythm check, deliver shock, resume CPR, and prepare and administer antiarrhythmic drug for persistent VF/ pulseless VT during chest compressions.

-Administer amiodarone 5 mg/kg IV/IO bolus (maximum single dose 300 mg) or lidocaine 1 mg/kg IV/IO

-Any subsequent shocks should be at dose of 4 J/kg or higher (maximum 10 J/kg or standard adult dose for that defibrillator).

-Consider endotracheal intubation, especially if unable to provide adequate ventilation with bag mask device and advanced care provider is available.

Evaluate - Diagnostic Assessments

Perform Throughout the Evaluation of the Patient as Appropriate

Lab data (as appropriate)

Blood glucose 112 mg/dL (6.2 mmol/L) (after ROSC)

Arterial/venous blood gas, electrolytes, calcium, magnesium

Imaging

Chest x-ray (after ROSC): Normal heart and lungs fields

Identify/Intervene

Blood work and chest x-ray are not available during the scenario