Pediatric Advanced Life Support - PALS Core Testing Case Scenario 5: Asystole (Infant;Arrest)*

Scenario Lead-in

Prehospital: You have been dispatched to a house where a 6 month old infant had had

respiratory distress; she is now unresponsive.

ED: An ambulance is en route to the emergency department with a 6 month old infant who was found unresponsive in her crib; CPR is ongoing

General Inpatient Unit: You are called as a member of the rapid response team to see a 6 month old who was admitted with respiratory distress, but she has now become limp and unresponsive.

ICU: You are called to see a 6 month old who became progressively limp and unresponsive. The infant was admitted with respiratory distress with the remainder of the emergency department workup unremarkable.

Vital Signs:

Heart Rate CPR in progress

Blood Pressure CPR in progress

Respiratory Rate Bag-mask ventilation (CPR)

SpO2 Not obtainable

Temperature Deferred

Weight 7 kg

Age 6 months

Scenario Overview and Learning Objectives

Scenario Overview: This scenario focuses on the identification and management of cardiac arrest and a “nonshockable” rhythm. Emphasis is placed on immediate delivery of high-quality CPR and early administration of epinephrine. The student should identify potential reversible causes of asystole (H’s and T’s); respiratory distress and failure may have cause hypoxia and acidosis in the scenario, the instructor may (if time allows) discuss important elements of post-cardiac arrest care, including titration of inspired oxygen concentration to maintain Spo2 of 94%-99%; targeted temperature management (especially avoidance or aggressive treatment of fever); hemodynamic support; support of airway, ventilation, and perfusion; and support or neurologic and other end-organ function.

Scenario Specific Objectives

Identifies cardiac arrest with a nonshockable rhythm; in this scenario, the infant has asystole

Describes correct dose and rationale for epinephrine administration

Summarizes potentially reversible causes of asystole; during the scenario the student considers possible reversible causes of cardia arrest (recalled by conditions beginning with H’s and T’s); in the infant respiratory distress may have produced hypoxia and acidosis

Discuss principles of post-cardiac arrest care; for this scenario, these include titration of inspired oxygen concentration as tolerated; targeted temperature management (especially prevention of fever); hemodynamic support; support of airway; oxygenation, and ventilation; and support neurologic and other end-organ function

Evaluate - Initial Impression (Pediatric Assessment Triangle)

Appearance: Extremities appear to be limp; no spontaneous movement and visible reaction to noise

Breathing: No spontaneous breathing

Circulation: Cyanotic/pale extremities and lips; severe mottling

Identify:

Immediate intervention needed

Intervene:

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

Check for response (no response), and perform simultaneous check for breathing (none) while checking brachial pulse (none)

Immediately begin high-quality CPR

Evaluate - Primary Assessment

No response to tap and shout

No breathing

No pulse

Weight 7 kg using color-coded length-based resuscitation tape

Identify

Cardiopulmonary arrest

Intervene:

Use a CPR feedback device to guide CPR delivery

When defibrillator arrives, apply pads/leads and turn on monitor

Identify rhythm (asystole); immediately resume high-quality CPR, rotating compressors and checking rhythm every 2 minutes

Obtain vascular access (intravenous [IV]/intraosseous [IO])

Give epinephrine 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL concentration) IV/IO during chest compressions. Follow with saline flush. Repeat every 3-5 minutes during cardiac arrest.

Apply pulse oximeter (per local protocol, may be deferred until return of spontaneous circulation [ROSC])

Evaluate - Secondary Assessment

Deferred Except to Identify Reversible Causes

SAMPLE (deferred until ROSC or only to extent needed to evaluate reversible causes, ie, the H’s and T’s; do not interrupt resuscitation)

Signs and symptoms: History as reported in scenario lead-in

Allergies: None

Medications: None

Past medical history: None

Last meal: 4 hours ago

Events (onset): As specified in scenario lead-in

Physical examination:

(deferred until ROSC or only to extent needed to evaluate reversible causes)

Vital signs after ROSC following high-quality CPR and 2 doses of epinephrine:

Sinus rhythm; heart rate 170/min; respiratory rate 20/min (with bag-mask ventilation); Spo2 99%; blood pressure 73/42 mm Hg; temperature 36 C (96.8 F)

If no epinephrine is delivered or CPR quality is poor, asystole continues

Identify

Cardiopulmonary arrest

Asystole

ROSC

Intervene

Continue high quality CPR

Reassess rhythm and rotate compressors every 2 minutes; minimize interruption in chest compressions, limiting any pause to less than 10 seconds

Consider potentially reversible causes of asystole (H’s and T’s)

Consider endotracheal intubation, especially if unable to provide adequate ventilation with bag-mask and advanced care provider is available

After ROSC

Apply pulse oximeter (if not already applied), Titrate inspired oxygen concentration to maintain Spo2 of 94%-99%

Provide targeted temperature management, including prevention or rapid treatment of fever

Titrate vasoactive drugs to maintain blood pressure in normal range.

Support airway, oxygenation, and ventilation.

Support of neurologic and other end organ function

Evaluate - Diagnostic Assessments

Perform Throughout the Evaluation of the Patient as Appropriate

Lab data

(as appropriate)

Blood glucose 96 mg/dL (after ROSC)

Arterial/venous blood gas, electrolytes, calcium, magnesium

Imaging after ROSC

Chest x-ray after ROSC: Normal heart and lung fields.

Identify/Intervene

Blood work and chest x-ray are not available during scenario