Pediatric Advanced Life Support - PALS Core Testing Case Scenario 3: Lower Airway Obstruction (Child; More Severely Ill)

Scenario Lead-in

Prehospital: You are responding to a 911 call for a 10 year old with breathing difficulty.

ED: A 10-yea-old girl is brought in by first responders from her home after her mother called 9-1-1 saying that her daughter had difficulty breathing.

General Inpatient Unit: You are called to the room of a 10-year- old girl who is being admitted from the emergency department for respiratory distress.

PICU: You are called to the room of a 10-year- old girl being admitted from the emergency department for respiratory distress

Vital Signs:

Heart Rate 140/min

Blood Pressure 106/68 mm Hg

Respiratory Rate 40/min

SpO2 86% on Room Air

Temperature Afebrile

Weight 35 kg Age 10 years

Scenario Overview and Learning Objectives

Scenario Overview: Emphasis in this scenario is on rapid identification and management of respiratory distress/potential respiratory failure caused by lower airway obstruction/asthma. The provider must quickly recognize signs of distress (severe tachypnea and hypoxemia on room air) and provide initial therapy, including administration of 100% oxygen, nebulized albuterol, ipratropium and oral corticosteroids. Continuous nebulized albuterol may also be needed. Early consultation with an expert in the care of children with status asthmaticus is required because this child has a history of status asthmaticus requiring multiple intensive care unit (ICU) admissions. The child improves, so acceleration of care is not required. During the debriefing the student is asked the indications for endotracheal intubation.

Scenario-Specific Objectives

Recognize signs of respiratory distress caused by lower airway obstruction: in this scenario, they include increased respiratory rate and effort, prolonged expiratory time, and wheezing.

Performs correct initial interventions for lower airway obstruction; in this scenario, they include administration of oxygen, nebulized albuterol, and ipratropium bromide and corticosteroids.

Discuss importance of obtaining expert consultation if child with asthma has a history of ICU admissions and/or fails to respond to initial interventions.

Evaluate - Initial Impression (Pediatric Assessment Triangle)

Appearance: Anxious; moderate distress; sitting upright.

Breathing: Increased work of breathing; retractions

Circulation: Pale skin

Identify:

Immediate intervention needed

Intervene:

Activate the emergency response system. Emergency medical services requests additional assistance if needed. 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: Unobstructed; no abnormal breath sounds are audible

Breathing/ Ventilation: Moderate suprasternal and intercostal retractions; prolonged expiratory time; expiratory wheezes in the lower lobes’ respiratory rate 40/min; Spo2 86% on room air’ just before 100% oxygen administration.

Circulation/Perfusion: Heart rate 140/min; pale skin; strong radial pulse; capillary refill 2 seconds; blood pressure 106/68 mm Hg.

Disability: Awake; speaks in 2-to-3 word sentences

Exposure: Afebrile; no rashes

Weight: 35 kg

Identify:

Respiratory distress, possible respiratory failure. Lower airway obstruction

Intervene:

Allow child to maintain position of comfort Assess response to oxygen Administer nebulized albuterol and nebulized ipratropium Administer oral corticosteroids

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: Cough; respiratory distress

Allergies: None known

Medications: Inhaler that has not been refilled for several weeks

Past medical history: Known asthmatic, poorly controlled due to poor compliance of medical care; 3 ICU admissions for respiratory failure; family members smoke in the house.

Last meal: 3 hours ago

Events (onset): Cold symptoms for the last 3 day; increased cough and distress for the past 24 hours

Physical examination:

Repeat vital signs after oxygen and fluids: Heart rate 140/min, respiratory rate 32/min; SpO2 94% when receiving 100% oxygen via nonrebreathing face mask; blood pressure 112/71 mm Hg

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

Heart and lungs: Wheezing on expiration in lower lobes; poor air movement; persistent moderate suprasternal and intercostal retractions

Abdomen: Normal

Extremities: Normal

Back: Normal

Neurologic: Anxious; no other abnormalities; now speaking 3-to-4 word sentences

Identify

Respiratory distress Lower airway obstruction

Intervene

Assess response to albuterol and ipratropium. If wheezing and aeration are not improved, consider provision of continuous nebulized albuterol. Obtain vascular access. Check glucose with point-of- care (POC) testing. Consider obtaining expert consultation regarding the management of pediatric status asthmaticus. If no improvement in signs of lower airway obstruction despite continuous albuterol and administration of ipratropium bromide, consider additional interventions (eg, magnesium sulfate) and diagnostic testing (arterial blood gas, chest x-ray), and consult and expert in the management of pediatric status asthmaticus (if not already done). Arrange for transfer of child to the ICU (if child is not already in the ICU) so that child may receive additional monitoring and therapy. If child’s condition does improve, be prepared to titrate inspired oxygen concentration, as tolerated, to keep Spo2 94% or greater.

Evaluate - Diagnostic Assessments

Perform Throughout the Evaluation of the Patient as Appropriate

Lab data

Glucose (POC testing) 126 mg/dl (7.0 mmol/L)

Identify/Intervene

Although laboratory tests are generally not appropriate during the immediate management, a blood glucose concentration should be checked as soon as reasonably possible in all critically ill infants and children. Hypoglycemia should be treated immediately.

Additional testing (eg, chest x-ray) may be performed if child demonstrates any additional respiratory signs or symptoms.