Pediatric Advanced Life Support - PALS Core Testing Case Scenario 6: Pulseless Electrical Activity (Child; Arrest)

Scenario Lead-in

Prehospital: You are dispatched to a house where a 3 year old child is now unresponsive. Prescription pill, including his grandmother’s oral hypoglycemic agent, are scattered throughout the child’s room.

ED: An ambulance is en route to the emergency department with a 3 year old child who was found nonresponsive in his bed. Prescription pills, including his grandmother’s oral hypoglycemic agent, were scattered throughout the child’s room.

General Inpatient Unit: You are called as a member of the rapid response team to see a 3 year old who was admitted with lethargy; he now has become limp and unresponsive. Emergency medical services had found prescription pills, including his grandmother’s oral hypoglycemic agent, scattered throughout the child’s room.

ICU: You are called to see a 3 year old who was admitted with lethargy; he now has become progressively limp an unresponsive. Emergency medical services found prescription pills, including his grandmother’s oral hypoglycemic agent, scattered throughout the child’s room.

Vital Signs:

Heart rate: CPR in progress

Blood pressure: CPR in progress

Respiratory rate: 100% bag-mask ventilation (CPR)

Spo2: Not obtainable

Weight: 17 kg

Age: 3 years

Scenario Overview and Learning Objectives

Scenario Overview: The scenario focuses on the identification and management of the child with 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 causes of pulseless electrical activity (PEA) (H’s and T’s). The child had significant hypoglycemia that must be corrected, and other drug toxicities may be present (the team must identify the drugs collected by emergency medical services (EMS) providers). Although not required for successful completion of 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 of neurologic and other end organ function.

Scenario -Specific Objectives

Identifies cardiac arrest with nonshockable rhythm; in this scenario, the child had PEA

Describes correct dose and rationale for epinephrine administration

Summarizes potentially reversible causes of PEA; during the scenario, the student/provider considers possible reversible causes of cardiac arrest (recalled by conditions beginning with the H’s and T’s); in this child, significant hypoglycemia and possible other toxic drugs have contributed to the arrest.

Discuss principles of post-cardiac arrest care; 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 of neurologic and other end organ function.

Evaluate - Initial Impression (Pediatric Assessment Triangle)

Appearance: Appears to be limp; no spontaneous movement and no 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 for carotid pulse (none)

Immediately begin high quality CPR

Evaluate - Primary Assessment

Deferred to provide Immediate Basic Life Support

No response to tap or shout

No breathing

No pulse

Weight 17 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 (PEA); 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

Identify Reversible Causes, but Defer Remainder of Secondary Assessment Until After Stabilization of Airway, Oxygenation, and Ventilation

SAMPLE history (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 known

Medications: None

Past medical history: None

Last meal: 5 hours ago

Events (onset): As specified in scenario lead in

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

Blood glucose 35mg/dL (1.9 mmol/L); all other H’s and T’s within normal limits

Vital signs after ROSC following high quality CPR and 2 doses of epinephrine: Sinus rhythm; heart rate 172/min; respiratory rate 20/min (with bag mask ventilation and 100% oxygen);

Spo2 98% bag mask; blood pressure 90/60 mm Hg; temperature 36 C (96.8 F)

IF no epinephrine is delivered, CPR quality is poor, or hypoglycemia is nor corrected, PEA continues and deteriorates to asystole.

Identify

Cardiopulmonary arrest

PEA

ROSC

Intervene

Continue high-quality CPR

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

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

Check glucose concentration with point of care (POC) testing Give IV dextrose as soon as hypoglycemia is identified

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

After ROSC

Apply pulse oximeter (if not already applied). Titrate inspired oxygen 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 neurologic and other end organ function.

Repeat serum glucose and search for other possible causes of cardiac arrest.

Evaluate - Diagnostic Assessments

Perform Throughout the Evaluation of the Patient as Appropriate

Lab data (as appropriate)

Blood glucose 108 mg/dL (6.0 mmol/L) after glucose administration and ROSC

Arterial/venous blood gas, electrolytes, calcium magnesium

Imaging after ROSC

Chest x-ray (after ROSC) Normal heart and lung functions

Identify/Intervene

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