Pediatric Advanced Life Support - PALS Core Testing Case Scenario 16: Bradycardia (Child; Seizure)

Scenario Lead-in

Prehospital: You are dispatched to the home of an 8 year old child who was having generalized seizure and received rectal diazepam; he now has decreased respiratory effort.

ED: Paramedics arrive with an 8 year old child who was having a generalized seizure and received rectal diazepam; he now has decreased respiratory effort.

General Inpatient Unit: You are a member of the rapid response team called to evaluate an 8 year old who had a generalized seizure on the floor and received intravenous lorazepam; he now has decreased respiratory effort.

ICU: You are asked to evaluate an 8 year old who just had a seizure and received intravenous lorazepam; he now had decreased respiratory effort.

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Heart Rate 45/min

Blood Pressure 85/54 mm Hg

Respiratory Rate 6/min

SpO2 62% before bag mask ventilation with oxygen

Temperature 39.3 C (102.7 F)

Weight 27 kg

Age 8 years

Scenario Overview and Learning Objectives

Scenario Overview: Emphasis should be placed on identification treatment of hypoxic bradycardia associated with disordered control of breathing/respiratory depression and upper airway obstruction. Priorities include immediate establishment of a patent airway an effective bag mask ventilation with 100% oxygen. Provider may need to reopen airway and reattempt bag mask ventilation before it produces effective chest rise. Chest compressions are nor required because the heart rate, oxygenation, and perfusion rise quickly once effective bag mask ventilation is provided. If the spontaneous ventilation, providers should prepare for advanced airway insertion. The student should describe how to estimate the child’s endotracheal tube size. Discussion of flumazenil as a receptor antagonist is beyond the scope of the scenario and the drug is contraindicated for the patient (it can lower seizure threshold).

Scenario-Specific Objectives

Demonstrates support of oxygenation and ventilation in a patient with hypoxic bradycardia

Recognizes indications for CPR in bradycardia patient; in this scenario, compressions are not needed because the child’s heart rate and oxygenation quickly improve once effective bag mask ventilation with oxygen provided

Sates 3 causes of bradycardia; these include hypoxia (most common), vagal stimulation, heart block, and drug overdose.

Describes appropriate indications for the dose and epinephrine for bradycardia

Evaluate - Initial Impression (Pediatric Assessment Triangle)

Appearance: No visible reaction to noise

Breathing: Very slow respiratory rate

Circulation: Pale; lips slightly dusky

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 (still very slow) and carotid pulse (slow pulse detected)

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: Snoring respirations

Breathing: Spontaneous respiratory rate 6/min; Spo2 62% on room air; initially bag mask ventilation with 100% oxygen produces no chest rise and poor air entry bilaterally; if provider reopens airway and reattempts bag mask ventilation, significant improvement in ease of ventilation and chest rise is apparent, and Spo2 rises rapidly

Circulation: Initial heart rate 45/min (sinus bradycardia); weak peripheral pulses; 2+ central pulses; capillary refill 3-4 seconds; blood pressure 85/54 mm Hg; heart rate increases to 95/min with effective bag mask ventilation with 100% oxygen

Disability: Unresponsive

Exposure: Temperature 39.3 C (102.7 F) weight 27 kg; no rashes

Identify:

Respiratory failure due to upper airway obstruction and disordered control or breathing

Sinus bradycardia (rate 45/min increases to 95/min with bag mask ventilation)

Decreased level of consciousness

Intervene:

Insert oral airway

Reopen airway, reposition face mask, ensure adequate seal to face, and provide bag mask ventilation that produces chest rise.

Assess heart rate response to ventilation and oxygen administration to determine the need for additional intervention.

Obtain vascular access (intravenous IV/intraosseous IO)

Evaluate - Secondary Assessment

Identify Reversible Causes, but Defer Remainder of Secondary Assessment Until Heart Rate 60/min or Greater With Adequate Perfusion

SAMPLE

Signs and symptoms: Had generalized tonic clonic seizure and received benzodiazepine as noted

Allergies: None

Medications: Levetiracetam

Past medical history: Known seizure disorder; last seizure was 6 months ago

Last meal: Ate normally 2 hours ago

Events: (onset): Upper respiratory infection symptoms for 2 days; generalized tonic-clonic seizure lasting 12 minutes; seizures activity stopped 5 minutes before team’s arrival

Physical examination:

Repeat vital signs after effective bag mask ventilation: Heart rate increases to 95/min; Spo2 95% with bag mask ventilation at a rate of 16-20/min with 100% oxygen; blood pressure 95/54 mm Hg

Head, eyes, ears, nose and throat/neck: Continues to be ventilated with bag mask device with oropharyngeal airway in place; pupils 3 mm, equal, and reactive to light

Heart and lungs: No murmur; good air with positive pressure ventilation;

2+ central and peripheral pulses; capillary refill 3 seconds

Abdomen: Soft; no organomegaly

Extremities: Unremarkable

Back: Unremarkable

Neurologic: Remains unresponsive to painful stimulation; pupils 3 mm, equal, and reactive to light

Point of care (POC) glucose (see below)

Identify

Altered level of consciousness Sinus rhythm with correction of bradycardia Respiratory failure due to upper airway obstruction and disordered control of breathing

Intervene

Continue bag mask ventilation as needed. If Spo2 is greater than 94% and perfusion is improving with bag mask ventilation, do the following:

-Wean supplementary oxygen as tolerated.

-Evaluate spontaneous respiratory effort and provide assisted ventilation to support spontaneous respiratory efforts.

-Remove oral airway if child begins to respond at all or develops cough or gag reflex.

-Stop bag mask ventilation if child’s spontaneous ventilation effort becomes adequate.

If child does not recover effective spontaneous ventilation and airway protective mechanisms, consider placement of advanced airway. Obtain expert consultation.

Check POC glucose concentration

Evaluate - Diagnostic Assessments

Perform Throughout the Evaluation of the Patient as Appropriate

Lab data (as appropriate)

Blood glucose 107 mg/dL

A blood gas (arterial, venous, or capillary) not indicated in the immediate management of this child

Imaging

Head computed tomography if there is a history or physical findings to suggest trauma

Identify/Intervene

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

Laboratory studies (other than POC glucose testing) are deferred until effective airway, oxygenation, ventilation, and heart/rate perfusion are established.