Pediatric Advanced Life Support - PALS Core Testing Case Scenario 13:Obstructive shock (Child; Hypotensive; Tension Pneumothorax)

Scenario Lead-in

Prehospital: You are on scene with an 8 year old boy. He was intubated with an oral tracheal tube because of depressed mental status, and the he suddenly deteriorated and is being manually ventilated by another care provider. An intravenous catheter is in place.

ED: An 8 year old boy is being transported by emergency medical services. He has been intubated with an oral tracheal tube for decreased level of consciousness (a Glasgow Coma Scale Score of 4). He suddenly deteriorated and is being manually ventilated through the endotracheal tube. A intravenous catheter is in place.

General Inpatient Unit: You are called to the room of an 8 year old boy who is intubated by the rapid response team pneumonia and hypoxemia. An oral tracheal tube was placed. As the team was preparing to transport him to the intensive care unit, the child suddenly deteriorated and is being manually ventilated through the endotracheal tube. An intravenous catheter is in place.

ICU: You are called to the room of an 8 year old boy who is intubated and mechanically ventilated. He has suddenly deteriorated and is being manually ventilated through the endotracheal tube. An intravenous catheter is in place.

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Heart Rate 140/min

Blood Pressure 80/54 mm Hg

Respiratory Rate Manual ventilation

SpO2 68% on 100% oxygen

Temperature 37.2 C (99.0 F)

Weight 20 kg

Age 8 years

Scenario Overview and Learning Objectives

Scenario Overview: Emphasis is placed on immediate recognition of respiratory failure and signs of obstructive shock. The provider should use the DOPE (Displacement of the tube, Obstruction of the tube, Pneumothorax, Equipment failure) mnemonic to quickly identify a tension pneumothorax as the cause and then must perform immediate needle decompression followed by chest tube insertion. Emphasize the importance of performing the needle decompression before obtaining a chest x-ray.

Scenario-Specific Objectives

Recognizes compensated vs hypotensive shock; this case illustrates hypotensive shock (key indicators in this case include hypotension, tachycardia, and decreased level of consciousness)

Summarizes signs and symptoms of obstructive shock; key indicators in this case include signs of shock combined with evidence of tension pneumothorax

Summarizes the elements of the DOPE mnemonic for an intubated patient with sudden deterioration; in this scenario, displacement of tube, obstruction of tube, and equipment failure should be ruled our before needle decompression.

Demonstrates correct interventions for tension pneumothorax; in this scenario, interventions include needle decompression, a chest x-ray and chest tube insertion

Discusses conditions under which fluid bolus administration would be appropriate for treatment of obstructive shock; although fluid resuscitation is not needed in this scenario, bolus fluid administration may be helpful for cardiac tamponade, until pericardiocentesis can be performed and in massive pulmonary embolus

Evaluate - Initial Impression (Pediatric Assessment Triangle)

Appearance: No spontaneous movement; flaccid extremities; no visible reaction to noise

Breathing: Orally intubated; poor chest wall movement with manual ventilation using a resuscitation bag

Circulation: Pale skin; dusky mucous membranes

Identify:

Immediate intervention needed

Intervene:

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

Continue manual ventilation with 100% oxygen.

Apply cardiac monitor.

Apply pulse oximeter.

Evaluate - Primary Assessment

Focused on Assessment Needed to Restore Patent Airway, Oxygenation, Ventilation, and Perfusion

Airway: Orally intubated with a 6.0 cuffed endotracheal tube (ETT); secured at 18 cm at the lip

Breathing: Manuallyventilated; asymmetric chest rise, absent breath sounds on the right; increasing inspiratory pressure needed to produce chest expansion; Spo2 68% despite receiving 100% inspired oxygen. As student evaluates using DOPE mnemonic, provide the following responses to student queries and actions:

-Displacement: Depth of insertion unchanged; breath sounds present on left; exhaled CO2 still detectable

-Obstruction: Normal breath sounds on left; if ETT is withdrawn slightly to detect and treat possible left main stem intubation, there is no change in the breath sounds, chest rise, or resistance to manual ventilation

-Pneumothorax (consistent with current clinical picture)

-Equipment failure; Ruled out by switching to manual ventilation with bag

Circulation: Heart rate 140/min; weak pulses; capillary refill 5 seconds; blood pressure 80/54 mm Hg

Disability: Unconscious; pupils equal and reactive to light

Exposure: Temperature 37.2 C (99.0 F)

Weight: 20 kg

Identify:

Respiratory failure and hypotensive shock

Probable tension pneumothorax and obstructive shock

Intervene:

Analyze rhythm (sinus tachycardia).

Assess response to oxygen and manual ventilation (no change)

Check waveform capnography (if applicable)

Rule out endotracheal tube displacement and obstruction and equipment failure

Perform need decompression on right side (inserting an 18-to-20 gauge over the needle catheter over the top of the child’s third rib, second intercostal space in the midclavicular line)

Obtain chest x-ray and insert chest tube

Evaluate - Secondary Assessment

Identify Reversible Causes, but Defer Remainder of Secondary Assessment Until Effective Ventilation Established (After Needle Thoracostomy)

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

Signs and symptoms: Orally intubated for respiratory failure; sudden deterioration

Allergies: None

Medications: None

Past medical history: None

Last meal: Nothing by mouth

Events (onset): Sudden deterioration in intubated patient

Physical examination:

Repeat vital signs after oxygen: Heart rate 175/min; manual ventilation at 24 breaths/min

-If needle decompression performed: Spo2 85% and rising; blood pressure increases to 110/65 mm Hg; capillary refill 3 seconds

-If needle decompression not performed: Spo2 58% and falling; blood pressure becomes undetectable and cardiac arrest develops; capillary refill extremely prolonged

Head, eyes, ears, nose, throat/neck:

-If needle decompression performed: Normal

-If needle decompression not performed: Jugular vein distention

Heart and lungs:

-If needle decompression is performed: Breath sounds equal bilaterally and there is decreased resistance to manual ventilation

-If needle decompression not performed: Breath sounds absent on right

Abdomen: Normal

Extremities:

-If needle decompression performed: 2+ central and peripheral pulses, capillary refill 3 seconds

-If need decompression not performed: No palpable pulses, capillary refill extremely prolonged

Back: Normal

Neurologic: Unconscious

If sedation and/or cardioversion undertaken without expert consultation

Vital signs: heart rate 218/min; wide complex tachycardia persists; blood pressure 64/35 mm Hg; development of signs of heart failure and poor perfusion

Identify

Respiratory failure

Hypotensive obstructive shock (corrects when need decompression performed; if need decompression is not performed, pulseless arrest develops)

Tension pneumothorax

Intervene

Reassess cardiorespiratory function (particularly ventilation and perfusion); immediate improvement should be noted following needle decompression

Verify that intravenous catheter remains patent.

Check glucose with point of care (POC) testing

Arrange for transfer to intensive care unit (ICU) (if child is not already in ICU) for closer monitoring and treatment of underlying conditions

Evaluate - Diagnostic Assessments

Perform Throughout the Evaluation of the Patient as Appropriate

Lab data

Pending: Arterial blood gas or venous blood gas

Imaging

Chest radiograph (should not delay intervention until chest x-ray performed)

Identify/Intervene

Laboratory diagnostic testing is deferred until treatment of the tension pneumothorax

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

Note: Needle decompression is performed before obtaining chest x-ray (ie, the chest x-ray should follow needle decompression but can precede chest tube insertion)