Pediatric Advanced Life Support - PALS Core Testing Case Scenario 7: Lung Tissue (Parenchymal) Disease (Infant)

Scenario Lead-in

Prehospital: You respond to a 6 month old in respiratory distress.

ED: Emergency medical services providers arrive with a 6 month old boy brought from home with respiratory distress.

General Inpatient Unit: You are called to the room of a 6 month old boy being directly admitted for respiratory distress.

PICU: You are called to the room of a 6 month old boy just admitted to the intensive care unit for respiratory distress

.

Heart Rate 160/min

Blood Pressure 90/60 mm Hg

Respiratory Rate 80/min

SpO2 82% on Room Air

Temperature 39.2 C (102.5 F)

Weight 6 kg

Age 6 months

Scenario Overview and Learning Objectives

Scenario Overview: Emphasis in this scenario is on rapid recognition of respiratory failure associated with lung tissue (parenchymal) disease. Recognition of signs of respiratory failure (including significant respiratory effort, hypoxemia despite high flow supplementary oxygen, decreased level of consciousness, and cyanosis) should prompt immediate initiation of appropriate therapy, starting with administration of 100% oxygen and bag mask ventilation. The provider sure quickly consult a provider with advanced expertise when the infant fails to improve. This infant need intubation and mechanical ventilation by an expert in the care of children with respiratory failure. Pediatric intensive care unit (PICU) care is required. During debriefing, the method to estimate endotracheal tube size (cuffed and uncuffed) is discussed. Although not required for successful completion of the scenario, the possible use continuous positive airway pressure (CPAP) of noninvasive ventilation can be addressed with emphasis that such therapy must be provided in appropriate settings where continuous monitoring is provided and intubation equipment and appropriate provider expertise are readily available.

Scenario-Specific Objectives

Distinguishes between respiratory distress and respiratory failure; in this scenario, the infant’s clinical signs are consistent with respiratory failure

Identifies signs and symptoms of lung tissue disease in a pediatric patient; in this scenario, the signs of lung tissue disease include tachypnea, increased respiratory effort, grunting, crackles (rales) tachycardia, and hypoxemia despite oxygen administration.

Implements corrective interventions for lung disease; in this scenario, those interventions include administration of a high concentration of oxygen, appropriate monitoring, reassessing the infant, and advancing to more support of oxygenation and ventilation when the infant fails to improve

Recalls the common causes of lung disease; common causes include pneumonia and aspiration

Evaluate - Initial Impression (Pediatric Assessment Triangle)

Appearance: Lethargic

Breathing: Shallow, rapid respirations; grunting

Circulation: Pale skin; cyanosis

Identify:

Immediate intervention needed

Intervene:

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 but noisy; grunting

Breathing: Shallow, rapid respirations; mild intercostal and subcostal retractions; bilateral crackles; no stridor or wheezing; expiratory phase in not prolonged; respiratory rate 80/min; Spo2 82% on room air and increased to 88% on 100% oxygen via a nonrebreathing face mask

Circulation: Heart rate 160/min; pale skin; cyanosis; strong central and peripheral pulses; capillary refill 2 seconds; blood pressure 90/60 mm Hg

Disability: Lethargic; arousable by voice

Exposure: Temperature 39.2 C (102.5 F)

Weight: 6 kg

Identify:

Respiratory failure Lung tissue disease

Intervene:

Asses response to oxygen Provide bag-mask ventilation with 100% oxygen

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: Sudden onset of respiratory distress after an episode of vomiting; no previous cold symptoms or cough

Allergies: None known

Medications: Metoclopramide

Past medical history: None

Last meal: 2 hours ago

Events (onset): Previously well other than history of severe gastroesophageal reflux

Physical examination:

Repeat vital signs after bag mask ventilation with 100% oxygen; respiratory rate 24/min; heart rate 160/min; Spo2 96% with bag mask ventilation; blood pressure 100/70 mm Hg

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

Heart and lungs: Diminished breath sounds; bilateral diffuse crepitations

Abdomen: Normal

Extremities: Normal

Back: Normal

Neurologic: Lethargic; becoming less responsive and more difficult to arouse

Identify

Respiratory distress Lung tissue disease

Intervene

Continue bag mask ventilation

Contact a more advanced provider with appropriate expertise. -Note: If the child’s level of consciousness improves and continuous monitoring is provided, critical care providers may consider use of non-invasive ventilation support (CPAP of noninvasive positive-pressure ventilation) if there is equipment and appropriate expertise for rapid intubation immediately available.

Obtain vascular access

Obtain arterial/venous blood gas

Check glucose with point of care (POS) testing

Prepare equipment and skilled personal for endotracheal intubation using a cuffed tracheal tube

Arrange transfer of the child to an intensive care unit (ICU) (unless the child is already in the ICU)

Consider specific interventions for lung tissue disease (eg, antibiotics for suspected pneumonia)

Evaluate - Diagnostic Assessments

Perform Throughout the Evaluation of the Patient as Appropriate

Lab data

Glucose (POC testing) 136 mg/dL (7.5 mmol/L)

Complete blood count, blood culture, arterial/venous blood gas pending

Imaging

Chest x-ray

Identify/Intervene

Laboratory tests generally are not appropriate during the first 5-10 minutes when attempting to stabilize a hypoxemic child with severe respiratory distress/respiratory failure.

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

Chest x-ray shows diffuse bilateral airspace disease.