​Pediatric Advanced Life Support - PALS Core Testing Case Scenario 8: Distributive Shock (Adolescent; Septic Shock)

Pediatric Advanced Life Support - PALS Core Testing Case Scenario 8: Distributive Shock (Adolescent; Septic Shock)

Scenario Lead-in

Prehospital: You are dispatched to transport a 12 year old girl with a 24 hour history of high fever and lethargy. She has become progressively more confused in the last hour.

ED: Parents arrive with their 12 year old girl who has a 24 hour history of high fever and lethargy. She has become progressively more confused in the last hour.

General Inpatient Unit: You have just received a 12 year old girl directly admitted to the ward from her physician’s office. She has a 24 hour history of high fever and lethargy. She has become progressively more confused in the last hour. You are unable to establish intravenous access.

ICU: You are called to the bedside of a 12 year old girl who has been admitted to the intensive care unit with a history of high fever and lethargy. She has become progressively more confused in the last hour. The intravenous access placed at the time of admission has infiltrated.

Vital Signs:

Heart Rate 130/min

Blood Pressure 80/30 mm Hg

Respiratory Rate 35 min

SpO2 93% on room air

Temperature 39.0 C (102.2 F)

Weight 41 kg

Age 12 years

Scenario Overview and Learning Objectives

Scenario Overview:

Emphasis should be on identification of hypotensive distributive/septic shock. Priorities include immediate establishment of intravenous (IV)/intraosseous (IO) access and administration of fluid bolus(es) if isotonic crystalloid with careful reassessment of cardiorespiratory function during and after each fluid bolus. The provider should be able to discuss the importance of detection of signs of heart failure and need to stop bolus fluid administration if such signs develop. Within the first hour of identification of signs of septic shock, providers must give bolus fluid therapy, administer antibiotics, and initiate vasoactive drug therapy (if shock persists despite bolus fluids).The provider should also make plans to transfer chile to appropriate setting (unless child is already in the intensive care unit (ICU)

Scenario Specific Objectives

Recognizes hypotensive vs compensated shock; in this scenario, the child has hypotensive shock

Recognizes need for early/rapid intervention with bolus administration of isotonic crystalloids and vasoactive drug therapy within the first hour if shock signs/symptoms persist despite bolus fluid administration

Recognizes the need for carful and frequent cardiorespiratory reassessment durn and after each fluid bolus; The provider looks for signs of heart failure (increased respiratory distress or development of rales or hepatomegaly) and the need to stop bolus fluid administration if signs of heart failure develop

Recognizes need for early/rapid administration of antibiotics (during the first hour after identification of shock symptoms)

Evaluate - Initial Impression (Pediatric Assessment Triangle)

Appearance: Lethargic; irritable’ mumbling

Breathing: Increased rate, but no distress

Circulation: Pale and mottled

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: Clear

Breathing: Respiratory rate about 35/min; Spo2 93% on room air, increased to 97% with administration of 100% oxygen; lungs clear to auscultation

Circulation: Heart rate 130/min; central pulses good, peripheral pulses bounding; flash capillary refill (less than 1 second); warm, but mottled hands and feet; blood pressure 80/30 mm Hg

Disability: Lethargic; mumbling; confused

Exposure: Rectal temperature 39.0 C (102.2 F); petechial-purpuric rash over extremities and torso; weight 41 kg

Identify

Hypotensive shock (likely septic shock) Sinus tachycardia

Intervene:

Obtain vascular access (IV/IO)

Administer a 20 mL/kg bolus of isotonic crystalloid IV/IO

-Reassess during and after fluid bolus

-Stop fluid bolus if signs of heart failure develop (eg, development of respiratory distress rales or hepatomegaly)

Administer antibiotics (if not already done) within first hour of recognition of shock. If possible, obtain blood culture before antibiotic administration, but don’t delay antibiotic administration.

Check point of care (POC) glucose and treat hypoglycemia if needed

Evaluate - Secondary Assessment

Identify Reversible Causes, but Defer Remainder of Secondary Assessment Until Hypotension Corrected

SAMPLE history (only to extent needed to evaluate reversible causes)

Signs and symptoms: Fever and lethargy for 24 hours

Allergies: None Known

Medications: None

Past medical history: Previously well

Last meal: No oral intake for 6 hours

Events (onset): 24 hour history of fever and increasing lethargy; noted to be confused in last 2 hours

Physical examination:

Repeat vital signs after oxygen and fluids; Heart rate 122/min; respiratory rate 35/min; Spo2 100% with 100% inspired oxygen; blood pressure 84/32 mm Hg

Head, eyes, ears, nose and throat/neck: Mucous membranes slightly dry; neck supple

Heart and lungs: Rapid rate; no extra heart sounds or murmurs; lungs sound clear\

Abdomen: No palpable liver edge; nondistended; nontender; normal bowel sounds;

Extremities: Warm hands and feet; mottled; bounding periphearal pulses

Back: Normal

Neurologic: Lethargic; pupils 4 mmm equal, reactive

Extremities: Warm hands and feet

Identify

Hypotensive distributive/septic shock

Intervene

If signs of shock persist, repeat fluid bolus of 20 mL/kg of isotonic crystalloid IV/IO as needed. Reassess during and after each fluid bolus.

-Stop fluid bolus if signs of heart failure develop (eg, development of respiratory distress, rales or hepatomegaly).

Begin vasoactive drug therapy within first hour of the recognition of shock if systemic perfusion fails to improve after bolus fluid therapy.

-Consider administration of epinephrine infusion (or dopamine, if epinephrine is not available)

Ensure that bolus fluid therapy, administration of antibiotics, and initiation of vasoactive therapy (if shock is fluid refractory)are all accomplished within the first hour after the identification of signs of septic shock.

Assess response to oxygen administration.

Arrange transfer to ICU for closer monitoring if child is not already in ICU

Evaluate - Diagnostic Assessments

Perform Throughout the Evaluation of the Patient as Appropriate

Lab data

Capillary gas: pH 7.16; Pco2 20 mm Hg; PO2 20mm Hg; base deficit/excess -10; lactate 5.0 mmol/L; hemoglobin 11 g/dL

Glucose (POC) 185 mg/dL (10.3 mmol/L)

Pending: Electrolytes, blood urea nitrogen/creatinine, calcium, complete blood count with differential, prothrombin time/international normalized ratio/partial thromboplastin time

Cultures: Blood, urine

Imaging

Chest x-ray: Small heart, clear lung fields

Identify/Intervene

The blood glucose concentration should be checked with POC testing whenever the infant or child is critically ill. Hypoglycemia should be treated immediately.

Metabolic acidosis with partial respiratory compensation should correct if shock resuscitation is effective