PALS Megacode Scenario 2

You are taking care of patients in the emergency room when the triage nurse from the admissions area calls out for some help with a patient. When you approach the triage room, you make your “initial impression of the child” to begin the systematic approach algorithm. You observe a school aged female child leaning forward in the tripod position and note the following for your initial impression:

Initial impression of patient:
Appearance: Alert but focused on breathing; unable to speak because of resp. difficulty
Breathing: Tachypnea and significant work of breathing; accessory muscle use; loud audible wheezing
Color: Skin is pale

The mother states that the child has a history of mild asthma, but her albuterol inhaler has not been helping for the past 12 hours.
Based upon your assessment, how would you classify the severity of the child’s asthma exacerbation?

Based upon your initial impression how would you classify this respiratory problem?

After the initial at the door impression and identification of severe respiratory distress what would be your first priority?

As you attach the patient to a monitor and pulse oximeter, you request the nurse to initiate oxygen therapy.

Which is the appropriate choice of oxygen supplementation for the patient at this time?

The nurse has applied 100% humidified oxygen by non-rebreathing mask. The cardiac monitor and continuous pulse oximetry are on the patient.

You perform the Primary Assessment and these are your findings:

Female
10-year-old

Vital Signs: HR 130; RR 45; O2 Sat 85% prior to o2 admin.; BP 105/75

Focused Primary Assessment:
Airway: The airway is patent, moderate retractions and accessory muscle use.
Breathing: Respiratory rate is 45, and breathing is shallow and labored. O2 sat is 85%. Audible wheezing and crackles and on auscultation.
Circulation: Heart rate is 140; capillary refill remains less than 2 sec.
Disability: Patient moves all extremities, Irritable and anxious
Exposure: Skin pale

What should be initiated at this time? (choose the best answer)

Continuous albuterol + ipratropium nebulizer treatments are being given. At this time, a peripheral IV is inserted per your request.
What IV medication would be appropriate for the treatment of the patient’s current condition?

Humidified oxygen via non-rebreather mask has been on the patient for 5 minutes, and she is being given albuterol + ipratropium by continuous nebulizer.

You reevaluate per the systematic approach algorithm.

Vital Signs: HR 140; RR 40; O2 Sat 92%; BP 110/48

Repeat Focused Primary Assessment:
Airway: The airway remains patent, wheezing and crackles slightly improved with continued retractions.
Breathing: Respiratory rate is 40, and breathing remains labored with accessory muscle use . O2 sat is 92% with 100% oxygen by non-rebreathing mask. Continued wheezes on auscultation.
Circulation: Heart rate is 140; capillary refill remains less than 2 sec.; IV is intact and saline locked
Disability: Patient moves all extremities, remains irritable, with anxiety
Exposure: Pale skin

Based upon the reassessment above what is your next intervention?

You initiate BIPAP with an FIO2 of 60%. As you continue on with the Systematic Approach Algorithm, the “Evaluate” phase of the algorithm also calls for diagnostic assessments. For this scenario, what are the two most important diagnostic assessments to perform while you continue to treat the patient’s severe asthma?

BIPAP with age appropriate settings has been on the patient for 5 minutes, and she is started on her 3rd albuterol + ipratropium by continuous nebulizer treatment.

You reevaluate per the systematic approach algorithm.

Vital Signs: HR 130; RR 30; O2 Sat 96%; BP 102/45

Repeat Focused Primary Assessment:
Airway: The airway remains patent, wheezing and retractions improved, and there are fewer crackles on auscultation.
Breathing: Respiratory rate is 30, and breathing is now less labored with minimal accessory muscle use. O2 sat is 96% with Bipap and Fio2 set at 60%.
Circulation: Heart rate is 130; capillary refill remains less than 2 sec.; IV is intact and saline locked
Disability: Patient moves all extremities, remains irritable, with anxiety
Exposure: Pale skin

Based upon the reassessment above what would you do at this time?

The patient’s condition is stabilizing and your are preparing for the patient to be transferred to the pediatric ICU for continued observation. While you are waiting for the transfer what other IV medication can be given to the patient?

Great Job! The patient is continuing to stabilize and will soon be transferred to a higher level of care.
Last question. Which of the following could be indications that intubation of the patient would be necessary? (Choose all correct answers)