Pediatric Advanced Life Support - PALS Core Testing Case Scenario 14:Cardiogenic Shock (Infant; Cardiomyopathy)

Scenario Lead-in

Prehospital: You have been dispatched to transport a 4 month old female infant with a 48 hour history of respiratory distress.

ED: You are asked to assess and manage a 4 month old female infant who has increased work of breathing with substernal and intercostal retractions, a breathless cry, and wheezing. She has a 3 day history of respiratory distress and increased lethargy. The infant was seen by her pediatrician 2 days ago for wheezing and respiratory distress and was given steroids and nebulizer treatments with improvement.

General Inpatient Unit: You are called to assess a 4 month old female infant who has been admitted to the ward with a 24 hour history of increased work of breathing and increased oxygen requirement.

ICU: You are called to the bedside of a 4 month old female infant who has been admitted to the intensive care unit with a 24 hour history of increased respiratory distress. Sha has crackles and wheezing and an increased oxygen requirement. He occasional cry sounds “breathless”. The infant now appears mottled and lethargic. Her intravenous access is no longer functioning.

Heart Rate 180/min

Blood Pressure 60/33 mm Hg

Respiratory Rate 60/min

SpO2 89% on room air

Temperature 35.7 C (96.2 F)

Weight 7 kg

Age 4 months

Scenario Overview and Learning Objectives

Scenario Overview: Emphasis should be on identification of treatment hypotensive cardiogenic shock. Priorities include immediate establishment of intravenous (IV) access and careful administration of a small bolus of isotonic crystalloid over 10-20 minutes, with careful reassessment of cardiorespiratory function during and after the fluid bolus. The provider should recognize the development of signs of worsening heart failure during administration of the fluid bolus and stop fluid bolus administration. The infant requires inotropic therapy to improve cardiac and systemic perfusion. The infant requires inotropic therapy to improve cardiac function and vasoactive drug therapy to improve blood pressure and systemic perfusion. The infant may need additional support with continuous positive airway pressure (CPAP), noninvasive bilevel positive-pressure ventilation, or other positive-pressure ventilation support to improve oxygenation. Expert consultation from pediatric cardiologist and further diagnostic studies (including echocardiography) are needed.

Scenario-Specific Objectives

Differentiates compensated vs hypotensive shock; in this scenario, the child is hypotensive, so has hypotensive shock.

Differentiates the sign and symptoms of cardiogenic shock from other types of shock; in this scenario, the combination of signs of hypotensive shock with signs of heart failure (labored breathing, crackles, and hepatomegaly) and evidence of decreased perfusion (mottling, cyanosis, lethargy) point to likely cardiogenic shock

Provide correct interventions for cardiogenic shock; in this scenario, these interventions include establishment of cardiac monitoring and pulse oximetry, carful bolus administration of isotonic crystalloids, careful reassessment during and after each fluid bolus, and initiation and titration of inotropic/vasoactive drugs

Describes correct volume and duration of bolus fluid administration of cardiogenic shock and describes possible negative effects of excessive bolus fluid administration; in this scenario, signs of intolerance of bolus fluid administration include worsening of signs of heart failure with no improvement in shock signs.

Evaluate - Initial Impression (Pediatric Assessment Triangle)

Appearance: Lethargic; minimal reaction to noises in room

Breathing: Labored breathing with moderate to severe intercostal and subcostal retractions

Circulation: Pale; significant mottling with peripheral cyanosis noted

Identify:

Immediate intervention needed

Intervene:

Activate emergency response system, if appropriate.

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

Breathing: Respiratory rate about 60/min; mild intercostal retractions; nasal flaring and intermittent grunting; Spo2 89% on room air, 100% with 100% oxygen

Circulation: Heart rate 180/min; central pulses present (not strong) and peripheral pulses weak and thread; capillary refill about 4 seconds; cool, mottled hands and feet; blood pressure 60/30 mm Hg

Disability: Lethargic; responds to painful stimuli

Exposure: Temperature 35.7 C (96.2 F) weight 7 kg

Identify

Respiratory distress

Hypotensive shock, probably cardiogenic

Sinus tachycardia

Intervene

Obtain vascular (IV/intraosseous (IO) access

Administer a fluid bolus of 5-10 mL/kg of isotonic crystalloid IV/IO over 10-20 minutes

Perform careful and frequent reassessment during and after fluid bolus. Stop fluid bolus if respiratory distress worsens of rales or hepatomegaly develop/worsen

Check glucose using point of care (POC) testing

Evaluate - Secondary Assessment

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

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

Signs and symptoms: Increased work of breathing and lethargy

Allergies: No known allergies

Medications: None

Past medical history: No past medical history of illness

Last meal: Poor intake for the last 12 hours

Events: (onset): 24 hours of increased respiratory distress and difficulty breathing, no improvement with steroids or nebulizer treatments.

Physical examination:

Repeat vital signs after oxygen and first fluid bolus: Heart rate 180/ min; respiratory rate 75/ min; Spo2 89% while receiving 100% oxygen by nonrebreather face mask; blood pressure 56/30 mm Hg

Head, eyes, ears, nose and throat/neck; Mucous membranes slightly dry

Heart and lungs; Rapid rate; systolic murmur now detected; crackles and retractions worsening

Abdomen: Liver edge palpable at 3 cm below costal margin; nondistended abdomen; hypoactive bowels sounds

Extremities: Cold upper and lower extremities; mottles; weak peripheral pulses

Back: Normal

Neurologic: Lethargic; pupils 4 mm, equal, reactive

Identify

Cardiogenic shock

Hypotensive shock

Worsening respiratory distress after fluid bolus

Possible respiratory failure

Intervene

Stop bolus fluid administration (signs of heart failure worsening)

Begin appropriate inotropic/vasoactive support if hypotension and assess response

Assess response to oxygen administration

Identify persistent hypoxemia despite oxygen administration

-Administer CPAP or noninvasive bilevel positive-pressure ventilations or other support if hypoxemia and respiratory distress and continue

Obtain 12 lead electrocardiogram (ECG)

Obtain a pediatric cardiology consultation and an echocardiogram, if available

Arrange for transfer to the intensive care unit (ICU) for closer monitoring, if infant is not already in ICU

Evaluate – Diagnostic Assessments

Perform Throughout the Evaluation of the Patient as Appropriate

Lab data

Arterial blood gas (after initiation of CPAP of positive-pressure ventilation): pH 7.25; Pco2 20 mm Hg; PO2 170 mm Hg; lactate 4.9 mmol/L

Glucose (POS testing) 80 mg/dL (4.4 mmol/L)

Pending: Electrolytes, blood urea nitrogen/creatinine, calcium, complete blood count with differential, prothrombin time/international normalized ratio/partial thromboplastin time

Cultures: Blood, urine

Imaging

Chest x-ray: Cardiomegaly; increased pulmonary vascular markings

Identify/Intervene

Blood glucose concentration should be checked as soon as reasonably possible in all critically ill infants and children. Hypoglycemia should be treated immediately.

Arterial blood gas confirms metabolic acidosis associated with inadequate cardiac output.

Chest x-ray shows cardiomegaly and pulmonary edema consistent with heart failure/cardiogenic shock.

Obtain echocardiogram when available.