Pediatric Advanced Life Support - PALS Core Testing Case Scenario 4: Upper Airway Obstruction (Child; moderate to Severe)

Scenario Lead-in

Prehospital: You are responding to a 9-1-1 call for a 1 year old with breathing difficulty. ED: A 1-year old girl is brought in by first responders from her home after mother called 9-1-1 because the child was having difficulty breathing.

General Inpatient Unit: You are called to the room of a 1-year old girl who is being admitted from the emergency department for respiratory distress and croup-like symptoms. ICU: You are called to the room of a 1-year old girl who is being admitted from the emergency department for respiratory distress and croup-like symptoms.

Vital Signs:

Heart Rate 154/min

Blood Pressure 75/43 mm Hg

Respiratory Rate 64/min

SpO2 84% on Room Air

Temperature 36.3 C (97.4F) Weight 10 kg Age 1 years

Scenario Overview and Learning Objectives

Scenario Overview

Emphasis in the scenario is on rapid recognition and management of respiratory distress associated with significant upper airway obstruction. The child’s lethargy, signs of increased respiratory effort, and stridor at rest all indicate the need to remove the child from the parents, position the child to open the airway and suction the nares, administer nebulized epinephrine and dexamethasone, and prepare for more-advanced care, including early consultation. Discussion during debriefing addressed estimation on endotracheal tube size.

Scenario-Specific Objectives

Identifies the signs and symptoms of significant upper airway obstruction; in this scenario, they include significant tachypnea and increased work of breathing, inspiratory stridor, fair chest movement, and decreased level of consciousness.

Recognizes that removing the child from the parent’s arms is indicated for this child; in this scenario, the child is lethargic with only fair chest rise and mild cyanosis

Performs correct interventions for a significant upper airway obstruction; in this scenario, these include positioning to open airway, suctioning of nares, oxygen administration, nebulized epinephrine (may be repeated), administration of dexamethasone, and preparation for respiratory support

Identifies the need to obtain the expert consultation to be available for insertion of advanced airway

Evaluate - Initial Impression (Pediatric Assessment Triangle)

Appearance: Being held by parent; appears lethargic, not moving much

Breathing: Tachypneic with increased work of breathing; high-pitched inspiratory stridor;

only fair chest rise noted

Circulation: Mild cyanosis of lips

Identify:

Immediate intervention needed

Intervene: Activate the emergency response system. Emergency medical services requests additional assistance if needed. Place patient on bed and reposition to open airway using head tilt-chin lift. Administer 100%oxygen by nonrebreather face mask. Apply cardiac monitor. Apply pulse oximeter

Evaluate - Primary Assessment

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

Airway: Patent; no oral obstruction

Breathing: High-pitched, faint, inspiratory stridor; respiratory rate 64/min; moderate, suprasternal, intercostal, and subcostal retractions; Spo2 84% before oxygen administration, then 95% after provision of 100% inspired oxygen; nasal flaring present with copious secretions; improved chest rise with repositioning; transmitted upper airway sounds with overall poor air entry

Circulation: Heart rate 154/min; mild cyanosis of lips before oxygen administration (lips now pink); warm skin centrally and peripherally; strong central and peripheral pulses; capillary refill 3 seconds; blood pressure 75/43 mm Hg

Disability: Lethargic, but withdraws and whimpers to tactile stimulation; anterior fontanel soft and flat

Exposure: Temperature 36.3 C (97.4 F)

Weight: 10 kg

Identify:

Respiratory distress of failure Upper airway obstruction

Intervene:

Continue positioning/oxygen administration. Suction nares. Administer nebulized epinephrine.

Contact expert help to be available. If child fails to improve or deteriorates further and to develop plan of care.

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: Awoke yesterday with fever, barking, and seal-like cough; seemed to improve yesterday, but worse overnight

Allergies: None known

Medications: Acetaminophen for fever given by mother 2 hours ago

Past medical history: Otitis media at 10 and 11 months

Last meal: 8 hours ago; refused bottle and breakfast this morning

Events (onset): Symptoms worse at night; increased work of breathing and more lethargic this morning

Physical examination

Repeat vital signs after oxygen and racemic epinephrine: Heart rate 161/min; respiratory rate 56/min; Spo2 99% on supplementary oxygen; blood pressure 77/48 mm Hg

Head, eyes, ears, nose, throat/neck: Nasal flaring persists; less nasal secretions; airway remains with support and positioning; moist mucous membranes.

Heart and lungs: Lungs clear; transmitted upper airway sounds (less pronounced); suprasternal, intercostal, and subcostal retractions improved; improved bilateral chest rise; stridor is louder

Abdomen: Normal

Extremities: Normal

Back: Normal

Neurologic: Becoming more alert

Identify

Respiratory distress Upper airway obstruction

Intervene

Evaluate response to nebulized epinephrine. Repeat nebulized epinephrine and reassess response.

Providers may consider use of heliox, but it can’t be used if the child requires a high concentration of inspired oxygen.

Check glucose using point-of-care testing

Administer oral/intravenous/intramuscular corticosteroids (eg, dexamethasone); administer oral corticosteroids if child is sufficiently alert.

Be prepared to provide initial advanced care, such as immediate bag-mask ventilation, if the child’s condition fails to improve or deteriorates further.

Arrange for the child to have careful, close observation as severe symptoms may recur, requiring transfer to the intensive care unit (ICU) (if the child is not already in ICU)

Evaluate - Diagnostic Assessments

Perform Throughout the Evaluation of the Patient as Appropriate

Lab data

Glucose 72 mg/dL (4.2 mmol/L)

Consider complete blood count and electrolytes

Imaging

Lateral soft-tissue neck radiographs may be considered but are generally not necessary

Identify/Intervene

Laboratory test are generally not appropriate during immediate management (initially providers should minimize stimulation until child’s airway obstruction and work of breathing are more stable).

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

-This child has not been eating well, so it will be important to check the glucose. Hypoglycemia should be treated immediately.

Lateral neck radiographs may be considered to identify causes of upper airway obstruction that may not respond to initial interventions