Pediatric Advanced Life Support - PALS Practice Case Scenario 1: Hypovolemic Shock (Child; Uncompensated Shock)

Practice Case Scenario 1

Hypovolemic Shock (Child; Uncompensated Shock)

Scenario Lead-in

Prehospital: You are dispatched to transport a 12 year old with abdominal injuries caused by flipping over bicycle handlebars. Mother reports that this happened 4 hours ago. There was no loss of consciousness and the child was wearing a helmet. You observe the patient in obvious discomfort, and he says he has worsening abdominal pain. There are no indications of spinal injury.

ED: Parents arrive with their 12 year old with abdominal injuries caused by flipping over bicycle handlebars. Mother reports this happen about 4 hours ago. There was no loss of consciousness and the child was wearing a helmet. Patient appears in obvious discomfort, and he says he has worsening abdominal pain. Spinal injury has been ruled out.

General Inpatient Unit: As a member of the rapid response team, you respond to a 12 year old admitted with abdominal injuries caused by flipping over bicycle handlebars. History and physical exam are consistent with no loss of consciousness at scene, and patient was wearing a helmet. Patient is in obvious discomfort, and he says he has worsening abdominal pain. Spinal injury has been ruled out.

ICU: You are called to the bedside of a 12 year old who has been admitted to the intensive care unit with abdominal injuries caused by flipping over bicycle handlebars. History and physical are consistent with no loss of consciousness at the scene and patient was wearing a helmet. Patient is in obvious discomfort, and he says he ahs worsening abdominal pain. Spinal injury has been ruled out.

Vital Signs:

Heart Rate 130/min

Blood Pressure 110/50 mm Hg

Respiratory Rate 30/min

SpO2 92% on room air

Temperature 37.5 C (99.5 F)

Weight 49 kg

Age 12 years

Scenario Overview and Learning Objectives

Scenario Overview: Emphasis should be placed on identification of compensated traumatic hypovolemic shock progressing to hypotensive shock despite bolus fluid administration. Priorities include immediate establishment of intravenous (IV) intraosseous (IO) access and administration of fluid bolus. Glucose concentration should be checked with point of care (POC) testing. When this child’s shock does not respond to 2-3 fluid boluses of isotonic crystalloid, bolus administration of packed red blood cell is indicated. Providers must recognize the need for expert consultation (eg, pediatric trauma surgeon) and further diagnostic studies.

Scenario Specific Objectives

Recognizes initial compensated shock and hypotensive shock;

This scenario begins with a child in compensated shock who progresses to hypotensive shock despite bolus fluid administration.

Summarizes signs and symptoms of hypovolemic shock; key indicators in this scenario include abdominal trauma, tachycardia, mottled skin, weak pulses and decreased level of consciousness.

Demonstrates correct interventions for hypovolemic shock; this patient requires oxygen administration, administration of one or more boluses of isotonic crystalloid with careful reassessment during and after each fluid bolus, administration of packed red blood cells, and surgical consult.

Summarizes how to evaluate systemic (end-organ) perfusion; indicators appropriate for this scenario include skin temperature/color, level of consciousness, and urine output

Evaluate - Initial Impression (Pediatric Assessment Triangle)

Appearance: Awake, in obvious discomfort

Breathing: Increased work of breathing, mild tachypnea

Circulation: Pale, with mottled hands and feet

Identify:

Immediate intervention needed

Intervene:

Activate emergency response system. Administer 100% oxygen by nonrebreathing mask

Evaluate - Primary Assessment

Airway: Clear

Breathing: Respiratory rate about 30/min; mild subcostal and intercostal retractions; mild nasal flaring; Spo2 92% on room air, increases to 95% with 100% oxygen administered via nonrebreathing mask; lungs clear to auscultation.

Circulation: Heart rate 130/min; central pulses weak, peripheral pulses barely felt; capillary refill about 4 second; cool and mottled hands and feet; blood pressure 110/50 mm Hg

Remainder of Primary Assessment performed if airway, ventilation, and perfusion are adequately supported

Disability: Alert

Exposure: Rectal temperature 37.5 C (99.5 F) weight 46 kg

Identify:

Respiratory distress Compensated shock Sinus tachycardia

Intervene:

Obtain vascular access (IV/IO); send blood sample for stat type and cross match

Administer a fluid bolus 20 mL/kg of isotonic crystalloid; repeat boluses rapidly IV/IO; assess perfusion; and monitor cardiorespiratory status closely during and immediately after each fluid bolus

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

Check POC glucose concentration and treat hypoglycemia if needed

Assess response to oxygen

Evaluate - Secondary Assessment

Identify Reversible Causes but Defer Remainder of Secondary Assessment Until After Initial Shock Therapy

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

Signs and symptoms: Mechanism of injury, abdominal pain, distended abdomen

Allergies: None known

Medications: Albuterol inhaler

Past medical history: Mild asthma

Last meal: 6 hours ago

Events: (onset): Thrown for bicycle, abdomen caught on handlebars 4 hours ago; initial pain, now worse; increased work of breathing

Physical examination:

Repeat vital signs after oxygen and 2 boluses of 20 mL/kg fluids: Heart rate 90-100/min; respiratory rate 15/min; Spo2 96% with 100% oxygen via nonrebreathing mask; blood pressure 90/50 mm Hg; capillary refill 4 seconds

Head, eyes, ears, nose and throat/neck: Mucous membranes moist

Heart and lungs: No extra heart sounds or murmurs

Abdomen: Distended, tender; hypoactive bowel sounds

Extremities: Superficial abrasion; central pulses readily palpable, weak peripheral pulses; capillary refill 4 seconds

Back: Normal

Neurologic: Responds appropriately to questions, but clearly in pain; pupils 4 mm, equal, briskly reactive to light

Identify

Hypotensive shock (likely hypovolemia related to blood loss)

Intervene

Repeat bolus of 20 mL/kg of isotonic crystalloid IV/IO push; repeat boluses need for persistent shock symptoms

Perform careful and frequent cardiorespiratory assessment during and after each fluid bolus.

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

Consider administration of 10 mL/kg of packed red blood cells if signs of shock and hemodynamic instability persist despite 2-3 boluses of isotonic crystalloids

Arrange for transfer to surgery if patient cannot achieve hemodynamic stability

Obtain expert consultation (eg, from trauma surgeon or pediatric surgeon); additional diagnostic studies will be necessary

Arrange transfer to intensive care unit (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 7.30, Pco2 25 mm Hg, PO2 mm Hg, Hemoglobin 7 g/dL

Glucose (POC) 135 mg/dL (7.5 mmol/L)

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

Imaging

Chest x-ray: Small heart, clear lung fields

Abdominal computed tomography: Moderate liver laceration

Identify/Intervene

A blood glucose level should be performed as soon as reasonably possible in all critically ill children. Hypoglycemia should be treated immediately.

Child is anemic as the result of blood loss and isotonic crystalloid therapy.

Metabolic acidosis with respiratory compensation. The metabolic acidosis should correct if the child’s abdominal injury had stabilized and effective shock resuscitation is provided.

Additional studies will be needed to evaluate abdominal injury.