PALS Megacode 1 In-Hospital

You are a resident physician working in a pediatric emergency department. An 18-month-old male is seen in triage for a barking cough and abnormal breathing. The mother reports a four-day history of moderately high fever, progressive coughing fits, nasal congestion, purulent rhinorrhea, and decreased PO intake. The child was brought to the hospital because the mother is concerned with “weird breathing noises” that started an hour ago. You enter the room and conduct a rapid initial impression (ABCs) which reveals the following:

• Appearance: Alert, irritable
• Breathing: Increased effort, accessory muscle use, paradoxical respirations, nasal flaring, inspiratory stridor, nasal congestion
• Circulation: Skin is pale

You have evaluated the patient and identified that they are experiencing severe respiratory distress caused by an upper airway obstruction.

An RN is supporting the airway and has started providing oxygen via NRB. You conduct a rapid, hands-on primary assessment using the ABCDE approach which reveals the following:

• Airway: Patent, severe retractions, accessory muscle use, nasal flaring
• Breathing: RR 70/min, SpO2 81%, labored, prolonged expirations, inspiratory stridor
• Circulation: HR 192/min, BP 110/78, strong peripheral pulses bilaterally, normal CRT
• Disability: Moving extremities x4, irritable
• Exposure: Febrile (38.7 °C), pale, dry lips, no rashes

Nebulized epinephrine is administered, and the patient continues being provided with oxygen via NRB. Peripheral IV access is established, and corticosteroids are administered. A repeated primary assessment reveals an oxygenation change from 81 to 92% but otherwise no change in condition.

Non-invasive ventilatory support via BVM is provided. A repeated primary assessment reveals an oxygenation change from 92 to 95%, decreased nasal flaring, and more controlled respirations.

Non-invasive ventilatory support via BVM is continued. A repeated primary assessment reveals an oxygenation change from 95 to 90%, no nasal flaring, no retractions, no accessory muscle use, decreased inspiratory stridor, no extremity movement, lethargy, and the requirement of full ventilatory assistance with inadequate respiratory effort. HR is declining, and central and peripheral pulses are weakening upon palpation.

A paralytic is administered, and you perform an unremarkable ET intubation. The patient is now being mechanically ventilated. A nasogastric tube is placed. A repeated primary assessment reveals an oxygenation change from 90 to 98%. The lungs are CTA bilaterally, strong peripheral and central pulses are palpable bilaterally, and vital signs are reflecting rapid improvements in respiratory status.