You are taking care of patients in the emergency room when a 6 year old boy is brought in by his mother and quickly triaged.

You make your "initial impression of the child" to begin the systematic approach algorithm:

Initial impression of patient:
Appearance: Alert; Does not speak because of resp. difficulty; Very focused on breathing
Breathing: Tachypnea and significant work of breathing; accessory muscle use; loud audible wheezing
Color: Skin is pale and cool

The mother states that the whole family has been sick with a URI. She also states that the child was given 2 puffs of albutetol X 7 over the past 8 hours before coming to the hospital. The child has a history of two in hospital admissions for asthma in the past year, but never required intubation.

Based upon your initial impression, how would you classify the severity of the child's asthma exacerbation?

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

As you continue with the systematic approach algorithm, after the initial at the door impression and identification of severe respiratory distress and compromise what would be your first priority? Choose all that apply.

At this time, you have a respiratory therapist and an RN on hand to help with the care of this patient. As you initiate your primary assessment, what intervention(s) should you delegate to the respiratory therapist given the child's condition? Choose all that apply.

While the RT initiates the 100% oxygen by NRB mask, continuous albuterol nebulizer treatments, and cont. pulse oximetry, the RN attaches the child to a monitor and starts and IV.

You finish your Primary Assessment and these are your findings:

Male
6-year-old

Vital Signs: Temp 100.2 (37.9 C); HR 130; RR 40; O2 Sat 87% prior to o2 admin.; BP 105/75

Focused Primary Assessment:
Airway: The airway is patent, Severe retractions and accessory muscle use.
Breathing: Respiratory rate is 40, and breathing is labored. O2 sat is 87%. Audible wheezing and crackles and on auscultation.
Circulation: Heart rate is 130; capillary refill remains less than 2 sec.; strong pulses
Disability: Patient moves all extremities, Irritable and anxious
Exposure: Skin pale and cool; mottled lower extremities

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

100% oxygen by NRB mask and continuous albuterol nebulizer treatments have been on for 10 minutes. You now perform your re-evaluation per the systematic approach algorithm.

Reassessment findings:

HR 140; RR 40; O2 Sat 88% on 100% oxygen NRB; BP 100/60

Focused Primary Reassessment:

Airway: The airway is patent, Severe retractions and accessory muscle use.

Breathing: Respiratory rate is 40, and breathing is more shallow and remains labored. O2 sat is 88%. Audible wheezing and crackles and on auscultation.

Circulation: Heart rate is 130; capillary refill remains less than 2 sec.; strong pulses
Disability: Patient is more lethargic and less responsive
Exposure: Skin remains pale and cool with mottled lower extremities

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

Prior to intubation, the patient is positioned to ensure an open airway with good visualization down the airway. The RT provides pre-oxygenation with 100% oxygen by bag valve mask and the nurse gives the patient ketamine for sedation and succinylcholine as a paralyzingly agent.

You then intubate the patient by inserting a 5.0 cuffed ET tube. After insertion, the cuff is inflated and the patient is placed on mechanical ventilation.

After intubation what interventions should be carried out to ensure proper placement of the ET Tube? (Choose all correct answers)

The placement of the ET tube is completed without complication and proper placement is confirmed initially by ETCO2 waveform capnography, auscultation and by chest x-ray.

The patient remains fully sedated and has good chest rise and fall.
5 minutes after the intubation, you begin your reassessment per the systematic approach algorithm.

Reassessment findings:

HR 120; RR 25; Oxygen Sat 100% with FIO2 of 70% on Ventilator; BP 105/67

Focused Primary Reassessment:
Airway: ET Tube in place and patent, slight tight lung compliance felt when using bag valve mask.
Breathing: Respiratory rate is 25 on ventilator, and O2 sat is 100%. Wheezing on auscultation.
Circulation: Heart rate is 120; capillary refill remains less than 2 sec.; strong pulses
Disability: Patient is sedated.
Exposure: Skin more pink and warm to touch.
Choose the interventions that would be appropriate at this time. (Choose all that apply)

The nurse has placed a nasogastric tube and applied suction to decompress the stomach. Respiratory therapy also obtained an ABG which shows that the patient has significant respiratory acidosis.

Your next step is to transfer the patient to the PICU.

You transport the patient by gurney and you are accompanied by the nurse and RT (respiratory therapy). RT is maintaining oxygenation and ventilation by manual ventilations with a bag valve device attached to the ET tube with 100% humidified oxygen.

During the transport, the ETCO2 monitor and oxygen saturation monitor begin to alarm. The ETCO2 waveform flattens and the reading shows 0. The oxygen saturation is alarming and the reading is 85%

What is the most likely cause of this change in ETCO2 and oxygen saturation?

The ET tube is quickly determined to be displaced. Given the situation of being in the process of transporting the patient to the PICU, what is the best choice for the correct intervention?

The ET tube is removed. Airway is now being maintained with the two person bag-mask ventilation technique. Oxygen saturation is back up to 95%.

Transport to the PICU is completed, you begin your reassessment per the systematic approach algorithm after arrival.

Reassessment findings:

HR 120; Oxygen Sat 93%% with BVM device; BP 105/67

Focused Primary Reassessment:
Airway: Airway is open with continued slight tight lung compliance felt when giving ventilations.
Breathing: Respiratory rate controlled with manual ventilations, and O2 sat is 93%. Wheezing on auscultation.
Circulation: Heart rate is 120; capillary refill remains less than 2 sec.; strong pulses
Disability: Patient is sedated.
Exposure: Skin remains pink and warm to touch.
Choose the best intervention for the patient at this time.

Congratulations! The patient has been successfully reintuabated and the PICU team has assumed care of the patient.
If there is a sudden deterioration in this patient's respiratory condition even though the ET tube is in place, not obstructed, and there is no equipment failure what should you suspect?