Pediatric Advanced Life Support - PALS Core Testing Case Scenario 15: Disordered Control of Breathing Disease (Infant)

Pediatric Advanced Life Support - PALS Core Testing Case Scenario 15: Disordered Control of Breathing Disease (Infant)

Scenario Lead-in

Prehospital: You respond to a 9-1-1 call for a 6 month old having a seizure.

ED: Emergency medical services arrives with a 6 month old boy brought from his home after his mother called 9-1-1 because her child had a seizure

General Inpatient Unit: You are called to the room of a 6 month old boy who is being admitted after having a seizure

Heart Rate 146/min

Blood Pressure 88/56 mm Hg

Respiratory Rate 12/min

SpO2 80% on room air

Temperature 39.7 C (103.5 F)

Weight 7 kg

Age 6 months

Scenario Overview and Learning Objectives

Scenario Overview: Emphasis of this scenario is on recognition and immediate management of an infant with respiratory failure and disordered control of breathing (inadequate respiratory rate and effort and decreased level of consciousness after seizure that likely complicates an episode of meningitis). This infant requires immediate opening of the airway and bag mask ventilation with 100% oxygen. During debriefing, discuss indications for intubation in this patient and methods to estimate appropriate cuffed and uncuffed endotracheal tube sizes.

Scenario-Specific Objectives

Identifies respiratory distress vs respiratory failure; in this scenario, respiratory failure is present

Summarizes signs of disordered control of breathing; in this scenario, the infant demonstrated inadequate spontaneous respiratory effort with very slow and shallow breaths, although they were regular

Recalls causes of disordered control of breathing; cues to the instructor: common causes include drugs, increased intracranial pressure, and seizures

Discusses correct interventions for disordered control of breathing; in this scenario, interventions include opening the airway and bag mask ventilation with 100% oxygen

Evaluate - Initial Impression (Pediatric Assessment Triangle)

Appearance: Lethargic; eyes closed; no visible reaction to his mother’s voice or noises in environment

Breathing: Very slow respiratory rate with minimal chest rise

Circulation: Pink skin

Identify:

Immediate intervention needed

Intervene:

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

Position the infant to open airway

Begin bag mask ventilation with 100% oxygen

Apply cardiac monitor

Apply pulse oximeter

Evaluate - Primary Assessment

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

Airway: Paradoxical movement of chest and abdomen when breathing, relieved when airway opened

Breathing: Spontaneous respiratory rate 12/min; shallow and regular; Spo2 80% on room air and 99% with bag mask ventilation with 100% oxygen at a rate of 30/min

Circulation: Heart rate 146/min; dusky (before bag mask ventilation with 100% oxygen); strong central and peripheral pulses; capillary refill 2 seconds; blood pressure 88/56 mm Hg

Disability: Lethargic; responsive to painful stimuli

Exposure: Temperature 39.7 C (103.5 F) weight 7 kg

Identify:

Respiratory failure (inadequate respiratory rate effort)

Intervene:

Verify chest rise with bag mask ventilation and monitor response to bag mask ventilation with oxygen

Continue bag mask ventilation with 100% oxygen and monitor for increase in infant’s spontaneous respiratory effort-match ventilation with infant’s effort if possible

Consider insertion of oropharyngeal airway if infant is unresponsive with no cough or gag reflex

Establish vascular access (intravenous)

Treat fever with antipyretic

Evaluate - Secondary Assessment

Identify Reversible Causes, but Defer Remainder of Secondary Assessment until After Stabilization of Airway, Oxygenation, and Ventilation

SAMPLE history

Signs and symptoms: Fever, irritable for the last 3 days

Allergies: None known

Medications: Acetaminophen given by mother 2 hours ago

Past medical history: None-no history of previous seizure disorder

Last meal: Ate 3 hours ago

Events: (onset): Abrupt onset of tonic-clonic seizure lasting approximately 5 minutes

Physical examination:

Repeat vital signs with assisted ventilation with 100% oxygen: Respiratory rate 30/min with bag mask ventilation now assisting the infant’s spontaneous respiratory effort; heart rate 136/min; Spo2 99% with inspired oxygen concentration of 100%; blood pressure 94/58 mm Hg.

Head, eyes, ears, nose, and throat/neck: Airway; pupils 3 mm bilateral and reactive; tense anterior fontanelle

Heart and lungs: Clear breath sounds; good chest rise with assisted ventilation; rate and depth of spontaneous breaths increasing

Abdomen: Normal

Extremities: No edema; no rash

Back: Normal

Neurologic: Level of consciousness unchanged; moves all 4 extremities with painful stimulus both in non-purposeful fashion

Identify

Respiratory failure (inadequate respiratory rate and depth)

Disordered control of breathing

Intervene

Closely monitor infant’s level of consciousness, spontaneous respiratory effort, and airway protective mechanisms (ability to cough to protect airway). Remove oral airway if responsiveness improves or cough or gag reflex returns.

If infant’s spontaneous respiratory effort improves, provide bag mask ventilation that assists the infant’s respiratory effort.

A patient will continue to be bradypneic with reduced level of consciousness, continue bag mask ventilation with 100% oxygen, and obtain expert consultation to plan for advanced airway insertion and support of ventilation.

Check glucose using point of care testing.

Arrange for transfer to higher level of care for evaluation, observation, and care.

Evaluate - Diagnostic Assessments

Perform Throughout the Evaluation of the Patient as Appropriate

Lab data

Glucose (bedside) 166 mg/dL (9.2 mmol/L)

Electrolytes; blood urea nitrogen/creatinine; complete blood count with differential; blood culture

Imaging

Chest x-ray ordered

Identify/Intervene

A blood glucose concentration should be checked as soon as reasonably possible in all critically ill infants and children. This infant had a seizure and still has decreased level of consciousness, so it will be important to check the glucose.

It is not always possible to obtain an arterial blood gas.