You are a healthcare provider working on an ALS ambulance. You are dispatched to the home of an 11-year-old male who has been experiencing increased respiratory effort. You are advised that the patient has a history of asthma and recurrent pulmonary infections. They are currently on ciclesonide INH twice daily and albuterol INH as needed. Albuterol x2 was used 20 minutes ago with no signs of improvement. Your response time to the scene is 3 minutes. Upon arrival, you observe the patient sitting at the house entrance, leaning forward in the tripod position. Both parents are present. A rapid initial impression (ABCs) reveals the following:

Appearance: Alert but unable to speak, focused on breathing
Breathing: Increased effort, accessory muscle use, wheezing
Circulation: Pale skin

1. The information provided by dispatch combined with an initial impression reveal that the patient is experiencing an acute asthmatic exacerbation. How would you classify the intensity of the exacerbation?*

Mild

Moderate

A secondary assessment is needed to classify the degree to severity

Severe

2. What type and severity of respiratory emergency is occurring in the given scenario?*

Upper airway obstruction leading to respiratory failure

Lower airway obstruction leading to respiratory distress

Lung tissue disease leading to respiratory failure

Disordered control of breathing leading to respiratory distress

You instruct your ALS partner to support the airway and begin providing oxygen while you evaluate the patient.

3. What is the most appropriate oxygenation therapy option in the given scenario?*

Humidified oxygen via NC

Humidified oxygen using BiPAP

Regular oxygen via NC

Regular oxygen via NRB

Your ALS partner is supporting the airway and has started providing regular oxygen via NRB. The patient is attached to a cardiac monitor and pulse oximeter. You conduct a rapid, hands-on primary assessment using the ABCDE approach which reveals the following:

Airway: Patent, moderate retractions, accessory muscle use
Breathing: RR 47/min SpO2 85%, labored, prolonged expirations, wheezing
Circulation: HR 135/min, BP 110/78, normal CRT
Disability: Moving extremities x4, irritable
Exposure: Pale, afebrile, no rashes

4. A primary assessment reveals persistent respiratory distress. Oxygen is being provided via NRB with no improvement. What are your next actions?*

Establish IV access

Administer nebulized epinephrine

Administer nebulized albuterol + ipratropium

Consider non-invasive ventilatory support with PEEP

Nebulized albuterol + ipratropium is administered with no improvement. Peripheral IV access is established.

5. What are your next actions?*

Administer IV terbutaline

Administer IV corticosteroids

Consider non-invasive ventilatory support with PEEP

Administer nebulized epinephrine

IV corticosteroids are administered, and oxygen via NRB is continued with a second nebulizer treatment of albuterol + ipratropium. A repeated primary assessment reveals persistent subcostal retractions, accessory muscle use, labored breathing, and audible wheezing. The patient remains pale and irritable. Oxygenation improves from 85% to 91%. IV access is maintained.

6. What are your next actions?*

Sedate and intubate

Continue providing oxygen via NRB

Attempt non-invasive ventilation via BiPAP

Administer IV terbutaline

You have attempted non-invasive ventilation via BiPAP for five minutes followed by a third nebulized treatment of albuterol + ipratropium. During the treatment, a repeated primary assessment shows an improvement in subcostal retractions, accessory muscle use, labored breathing, and wheezing. The patient remains pale and irritable. Vitals improve to HR 125, BP 101/46, RR 35. Oxygenation improves from 91% to 95%. The patient is now being transported to the hospital.

7. What are your next actions?*

Administer IV terbutaline

Continue BiPAP and titrate FiO2 to maintain SpO2 > 94%

Sedate and intubate

Continue providing oxygen via NRB

You continue BiPAP and titrate FiO2 to maintain an SpO2 above the hypoxia threshold of 94%. Continued stabilization is observed. You have already administered systemic corticosteroids.

8. What other IV drugs can be given to encourage continued improvement?*

Epinephrine

Calcium

Magnesium sulfate

Dimenhydrinate

You consider administering IV magnesium sulfate during transport.

9. What administration protocol would you use in the given scenario?*

1.2 mg IVP

IV magnesium sulfate is not indicated in asthma

25-50 mg/kg IV infusion over 10-20 minutes

25-75 mg/kg IV infusion over 15-30 minutes

Magnesium sulfate 25-75 mg/kg IV infusion is started during transport and continued improvement is noted. The patient is transported to the hospital without any additional respiratory deteriorations.

10. During the call, which of the following criteria would have been clinical indications to consider ET intubation?*

Inadequate air movement, fever >39.1 °C, decreased LOC

Decreased LOC, delayed capillary refill, SpO2 <94%

Decreased LOC, inadequate air movement, SpO2 <94%

Fever >39.1 °C, decreased LOC, SpO2 <94%

PALS Megacode 5 Out-of-Hospital

Hurry, don’t let time run out!

You instruct your ALS partner to support the airway and begin providing oxygen while you evaluate the patient.

Your ALS partner is supporting the airway and has started providing regular oxygen via NRB. The patient is attached to a cardiac monitor and pulse oximeter. You conduct a rapid, hands-on primary assessment using the ABCDE approach which reveals the following:

Nebulized albuterol + ipratropium is administered with no improvement. Peripheral IV access is established.

You continue BiPAP and titrate FiO2 to maintain an SpO2 above the hypoxia threshold of 94%. Continued stabilization is observed. You have already administered systemic corticosteroids.

You consider administering IV magnesium sulfate during transport.

Magnesium sulfate 25-75 mg/kg IV infusion is started during transport and continued improvement is noted. The patient is transported to the hospital without any additional respiratory deteriorations.

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