Pediatric Advanced Life Support - PALS Core Testing Case Scenario 2: ‎Hypovolemic Shock Hypovolemic Shock (Infant: Nonaccidental Trauma With Increased Intracranial Pressure)

Pediatric Advanced Life Support - PALS Core Testing Case Scenario 2: Hypovolemic Shock (Infant: Nonaccidental Trauma With Increased Intracranial Pressure)

Scenario Lead-in

Prehospital: You have been dispatched to transport a 6 moth old with altered level of consciousness. The infant was picked up from day care earlier today and reportedly slept during the car ride home. Her father reports that he was unable to get the infant to eat dinner. She lies lifeless in father’s arms.

ED: Emergency Medical Services providers arrive with a 6 month old with altered level of consciousnedd. The infant was reportedly picked up from day care and slept during the car ride home. Her fater reports that he was unable to get her to eat dinner. The infant lies listless in her father's arms. The emergency medical services providers were unable to establish peripheral intravenous access.

General Inpatient Unit: As a member of the rapid response team, you respond to a 6 month old infant with altered level of consciousness who was admitted directly from her physician's office. The father reported that he picked up the infant from day care and she slept during the car ride home. The father reports that he was unable to get the infant to eat dinner. The infant lies listless in the crib. The ward team has been unable to establish peripheral intravenous access.

ICU: You are ased to assess and manage a 6 month old infant with altered level of consciousness. The infant was picked up from day care by her father, who reports that the infant slept during the car ride home. The father reports that he was unable to get the infant to eat dinner. The infant lies listless in the crib. The infant's peripheral intravenous access has infiltrated.

Vital Signs:

Heart Rate 160

Blood Pressure 84/30

Respiratory Rate 10-18/min

SpO2 93% on Room Air

Temperature 37.0 C (98.6F)

Weight 8.6 kg Age 6 months

Scenario Overview and Learning Objectives

Scenario Overview: Emphasis should be on identification compensated hypovolemic shock. Priorities include immediate establishment of intravenous (IV)/ intraosseous (IO) access and administration of fluid bolus of isotonic crystalloid, repeated as needed during and after each fluid bolus. Glucose concentration should be checked with point-of-car (POC) testing. This infant’s shock is complicated by sign of increased intracranial pressure, probably associated with intracranial injury. Providers must recognize the need for expert consultation and further diagnostic studies.

Scenario Specific Objectives

Recognize signs of compensated and hypotensive shock: this scenario illustrates intracranial pressure (key indicators include decreased level of consciousness, tachycardia, cool and mottled skin, delayed capillary refill, and hypotension)

Summarizes signs and symptoms of hypovolemic shock: key indicators in this case include signs of shock with signs of trauma.

Demonstrates correct interventions for hypovolemic shock; this case requires administration of oxygen, administration of an isotonic fluid bolus with careful reassessment during and after the fluid bolus with careful reassessment during and after the fluid bolus, and consulting someone with surgical expertise (eg, pediatric or neurosurgeon)

Summarizes how to evaluate systemic end organ perfusion; indirect indicators appropriate for this include skin temperature/color, level of consciousness, and urine output.

Evaluate - Initial Impression (Pediatric Assessment Triangle)

Appearance:

Lethargic:

Breathing: Irregular and shallow breaths

Circulation: Pale, with significant mottling in extremities.

Identify:

Immediate intervention needed

Intervene:

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

Breathing: Respiratory rate 10-18/min and irregular; mild subcostal and intercostal retraction; SpO2 93% on room air, increases to 95% with 100 % oxygen with bag-mask ventilation; lungs clear to auscultation.

Circulation: Heart rate 160/min; pale; central pulses fair, peripheral pulses weak; capillary refill about 4 seconds; mottled arms and legs; cool and dusky hands and feet; blood pressure 84/30 mm Hg

Disability: Lethargic, responds to pain; pupils have sluggish reaction to light

Exposure: Rectal temperature 37.0 C (98.6 F) weight 8.6 kg

Identify:

Respiratory failure. Compensated shock. Sinus tachycardia. Possible increased intracranial pressure.

Intervene:

Obtain vascular access (IV/IO)

Administer a fluid bolus of 20mLkg of isotonic crystalloid rapidly IV/IO;

Assess perfusion and monitor cardiorespiratory status closely during and immediately after each fluid bolus.

Stop fluid bolus if signs of heart failure develop (eg, increased respiratory distress or development of rales or hepatomegaly).

Check (POC) glucose concentration and treat hpoglycemia, if needed.

Assess response to oxygen administration.

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: Lethargy, irregular breathing

Allergies: None known

Medications: None

Past medical history: Term newborn

Last meal: 6 hours ago

Events (onset): Patient was reportedly “normal self” before being dropped off at day care. Day care told dad that the infant took second nap before being picked up. Infant has demonstrated increasing lethargy, decreased work of breathing, and irregular rate.

Repeat vital signs after oxygen and fluids: Heart rate 140/min; respiratory rate 30/min bag-mask ventilation; Sp02 95% during bag-mask ventilation with 100% oxygen; blood pressure 80/50 mm Hg

Head, eyes, ears, nose, throat/neck: Bruising to ears.

Heart and lungs: Rapid rate, no extra heart sounds or murmurs; lungs sound clear

Abdomen: No palpable liver edge; nondistended; nontender; hypoactive bowel sounds

Extremities: Normal skin turgor

Back: Normal

Neurologic: Lethargic; pupils 4mm, equal, sluggish reaction to light

Identify

Compensated hypovolemic shock. Respiratory failure with disordered control of breathing (decreased level of consciousness). Possible intracranial injury with increased intracranial pressure.

Intervene

Repeat bolus of 20 mL/kg of isotonic crystalloid IV/intraosseous (IO) push; repeat if needed for persistent shock symptoms.

Perform careful and frequent cardiorespiratory assessment during and after each fluid bolus.

Stop fluid bolus if signs of heart failure develop (increased respiratory distress or development of rales or hepatomegaly).

Identify possible signs of increased intracranial injury.

Obtain expert consultation (eg, for trauma surgeon, pediatric surgeon, or neurosurgeon)

Arrange for transfer to the intensive care unit (ICU) for closer monitoring if child is already in the ICU.

Evaluate - Diagnostic Assessments

Perform Throughout the Evaluation of the Patient as Appropriate

Lab data

Capillary gas: pH 7.20, PCO2 55 mm Hg, PO2 34mm Hg base excess-9, hemoglobin 10 g/dl

Glucose (POC) Testing 80 mg/dl (10.3 mmol/L

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

Cultures: Blood, urine

Imaging: Computed tomography (CT/magnetic resonance imaging (MRI)/ultrasound stat

Chest x-ray: Small heart, clear ling fields

Head CT/MRI

Identify/Intervene

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

Mixed respiratory and metabolic acidosis should improve with support of ventilation and oxygenation and treatment of possible hypovolemic shock.

Additional studies will be needed to evaluate the cause of poorly reactive pupils and bruising to the ears (eg, CT scan/MRI)