Setup

Chief complaint: Cardiac arrest
Patient age: 4 years old
Weight: 14 kg

Recommended Supplies

• Manikin: Child, able to have IO placed , receive BMV, and be intubated
• Moulage: None
• Resources: PALS cards and/or weight-based tape (e.g., Broselow Tape)
• Manikin set up: IV line x 2 in place with drainage bags (IVs unavailable at start of case, learners must place IO)
• Equipment:
  • IV supplies
  • Intraosseous equipment including E-Z IO, needle, stabilizer, and connectors, saline flushes
  • Defibrillator and pads with snaps for simulator
  • Pediatric Airway Equipment:
    • Nonrebreather
    • End tidal CO2 monitor
    • Bag-valve mask with different size masks
    • Oxygen tubing
    • Suction
    • ET tubes
    • Stylet
    • Laryngoscope with blades
    • LMA (optional)
• Medications: Epinephrine, atropine, normal saline 1 L bag, normal saline flushes, lidocaine, amiodarone, D10 or D25, norepinephrine

Supporting Files

• Lab results
• POC labs/blood gas
• Glucose
• Chemistry
• Chest x-ray after intubation

Participants/Roles

• Participants/learners:
  • Team leader
  • Airway manager
  • Survey physician
  • CPR monitor
  • Medication preparer
  • Medication giver
  • Defibrillator
  • Chest compressor (2)
  • Family liaison/history taker
• Other:
  • Faculty or other embedded participants can play a nurse, respiratory therapist, or tech, if there are not enough learners to perform the above roles
  • Standardized patient (actor or faculty) to play patient’s parent

* Team roles may need to be adjusted in order to suit local practices and norms

Prerequisite Knowledge

• Faculty
  • PALS protocols
  • General knowledge of emergency medicine
  • Simulation implementation and debriefing experience

• Emergency medicine residents
  • Any stage of training
  • Completed PALS certification

Case Alternatives

• Initial intubation attempt may be declared a failure (even if tube is actually passed through cords) simulating a difficult airway requiring use of LMA.
• IO placement fails after first use or unsuccessful placement in proximal tibia so must consider other sites for IO placement.
• The patient may be hypoglycemic during PEA stage and will not respond to epinephrine until glucose is administered.
• The patient may be hypothermic (temp <33oC). The patient will not change from PEA to VF until the learner states 2 ways to rewarm the patient, through passive versus active techniques (warm fluids, warm blankets, Bair hugger, and bladder irrigation).
• The patient may develop unstable ventricular tachycardia with a pulse after defibrillation requiring synchronized cardioversion with at least 0.5 J/kg prior to return of normal sinus rhythm.

Milestones

PC1. Emergency Stabilization
PC2. Performance of Focused History & Physical Exam
PC3. Diagnostic Studies
PC5. Pharmacotherapy
PC7. Disposition
PC9. General Approach to Procedures (PC9)
PC10. Airway Management (PC10)
PC14. Other Diagnostic and Therapeutic Procedures
ICS2. Team Management

Resources

1. Donoghue A, Hsieh T, Nishiaski A, Myers S. Tracheal Intubation during Pediatric Cardiopulmonary Resuscitation: A Videography-Based Assessment
   in an Emergency Department Resuscitation Room. Resuscitation. 2016;99:38-43. PMID: 26703462
2. Mick MW, Williams RJ. Pediatric Cardiac Arrest Resuscitation. Emerg Med Clin North Am. 2020;38(4):819-839. PMDI: 32981620
3. Dallefeld S. A Summary of the PALS 2020 Updates. CriticalCareNow, 2021.
4. Highlights of the 2020 American Hearth Association Guidelines for CPR and ECC. AHA PALS Provider Manual, 2020.

Initial Evaluation

Start through identification of PEA

Critical Actions

• Team leader makes it clear he/she is the leader and assigns roles/tasks
• Gets history from EMS providers; no parent available initially
• Check for a pulse, recognize pulselessness, and continue CPR/BMV with effective chest compressions of correct depth and rate
• Place patient on continuous cardiac monitor
• Apply defibrillator pads (may not do this until patient is in VF)
• Obtains vascular access IV/IO
• Establishes appropriate weight of patient using length base tape
• Verbalizes recognition of PEA (no pulse, bradycardic rhythm on monitor)

Physical Exam

Instructor Notes: Changes and Case Branch Points

PEA Algorithm

Recognition of PEA through second dose of epinephrine

Critical Actions

• Follow PALS algorithm for the treatment of PEA
• Administers epinephrine within 5 minutes of patient arrivial (0.01 mg/kg followed by flush; CPR continued for 2 minutes before recheck of pulse and rhythm). Gives second dose 3-5 minutes after the first dose.
• Discuss a few reversible causes and treatment for them (hypothermia, hypoglycemia, acidosis, hyperkalemia)
• Verbalizes rhythm change to VF
• Parent given option to remain in room with patient with parent being updated by liaison/social work/etc.

Physical Exam

Instructor Notes: Changes and Case Branch Points

Ventricular Fibrillation Algorithm

Start of ventricular fibrillation through two rounds of defibrillation

Critical Actions

• Continue to support airway with BMV and continue CPR at 15:2 compression-ventilation ratio (unless patient was intubated)
• Defibrillator pads should be placed, if not already done previously
• Intubation should not be attempted at this point as it should be recognized that immediate defibrillation should be attempted
• Follow PALS algorithms for VF and defibrillation at 2-10 J/kg
• Resume CPR immediately after shock delivered
• Recognize return of NSR

Physical Exam

Instructor Notes: Changes and Case Branch Points

Case Conclusion

RoSC and NSR identified through signout to admitting team or facility

Critical Actions

• Recognize return of spontaneous circulation and stabilize the patient (treat hypotension, keep normothermic, treat hypoglycemia)
• Titrate oxygen to keep oxygen saturation 94-99%
• Ask for blood gas, electrolytes, and calcium, if not already done
• Update family
• Plan disposition as admission versus transfer

Physical Exam

Instructor Notes: Changes and Case Branch Points

Demonstrate early evaluation of a critically ill patient (application)

Learners should approach a critically ill patient in a standardized fashion. Always check for responsiveness. If unresponsive, check for a pulse. If no pulse, start CPR and proceed to airway, breathing, and circulation. Interventions such as airway repositioning/adjuncts/ intubation should be considered if poor air movement or difficulty with BMV. After A, B, and C have been addressed, the patient should be evaluated for disability and exposed for a thorough head to toe exam. In pediatrics, people often say that D also stands for “don’t forget the dextrose” as a blood glucose level should be checked in any child with altered mental status. In this case, the learner is stopped at C and must treat the circulation problems before they can go on to D and E, but still should consider dextrose as a reversible cause. Once ROSC is achieved disability and exposure should be completed to look for any other injuries that may have occurred.

Recognize PEA and ventricular fibrillation (knowledge)

It is important to not only look at the monitor but to also feel for a pulse. If the monitor is only checked the learner might think the patient has symptomatic bradycardia and if they only feel for a pulse then they might assume asystole. For VF the learner must be familiar with what VF looks like and understand there is no pulse with VF as the heart only quivers.

Apply the appropriate PALS algorithms for PEA and ventricular fibrillation (application)

During debriefing it is good to walk through verbally the algorithms for both of these rhythms. This is a good time to review what good CPR is:

• Child: Rate of 100-120 with chest compression of 1/3 of AP diameter or about 2 inches (5 cm)
• Infant: About 1.5 inches (4 cm) in an infant

Allow complete recoil and rotate compressors frequently. Minimize interruptions to <10 sec.

PEA

1. Continue CPR and BMV (discussed in next objective)
2. Obtain IV/IO access
3. Consider advanced airway
4. Epinephrine 0.01 mg/kg per dose (0.1 mg/mL concentration) given every 3-5 minutes IV/IO, followed by NS flush. May give epinephrine 0.1 mg/kg (1 mg/mL concentration) down the ET tube if no access is obtained.
5. CPR continued throughout and stopped for <10 secs to check for a pulse and resumed immediately if pulse not felt
6. Pulse check / rhythm check 2 minutes after epinephrine given
7. Repeat epinephrine if still in PEA
8. Consider and treat reversible causes: Hypovolemia, hypoxia, hydrogen ion (acidosis), hypoglycemia, hypo or hyperkalemia, hypothermia, tension pneumothorax, tamponade, toxins, pulmonary or coronary thrombosis (PALS 2016)

Ventricular fibrillation

1. Place defibrillator pads if not already on the patient
2. Continue CPR and BMV
3. Do intubate patient before giving shock. Best to try and get out of VF as soon as possible.
4. Shock patient with 2-4 J/kg followed be immediate compressions
5. Continue CPR for 2 minutes before rhythm check.
6. If still in VF, shock again at 4-6 J/kg followed by immediate compressions.
7. Give epinephrine 0.01 mg/kg every 3-5 minutes.
8. If after second shock and still no change in rhythm, consider an advanced airway
9. Continue increasing J/kg with subsequent defibrillations, but no more than 10 J/kg
10. May consider amiodarone 5 mg/kg or lidocaine 1mg/kg after epinephrine given.
11. Also consider reversible causes if not done above.

Demonstrate airway management of a sick child including synchronized bag mask ventilation and intubation (application)

Learners should recognize that adequate bag-valve mask ventilation is critical in the care of a patient. Good air entry should be evaluated and if poor chest rise then the patient should be repositioned, air way opened, oral/nasal airways considered. If continues with poor air entry with BMV, advanced airways should be considered. Being prepared for a difficult airway in any critical patient is important. Have a plan, such as calling for back-up (anesthesia, more experienced physician, respiratory therapist) and having rescue equipment at bedside (video laryngoscopy, LMA, and cricothyrotomy kit).

When performing BMV, the compression to ventilation ratio should be 15:2 when there are 2 or more providers (30:2 when only 1 provider). Once the patient is intubated, it is not necessary to do the 15:2 ratio but the patient should not be bagged too fast. A rate of 1 breath every 8-10 seconds and each breath should be given over 1 sec. Continue to watch for visible chest rise. If BMV is too rapid and too much air is insufflated, the abdominal distention can occur and make BMV more difficult.

The learners should be able to choose appropriate size equipment for this child and should recognize that this child should have a cuffed ET tube placed. Once an advanced airway is in place, the learner should use capnography or capnometry to confirm and monitor ET tube placement. When a patient is in VF, defibrillation should be prioritized over intubation.

Demonstrate intraosseous placement (application)

Intraosseous lines should be placed in critically ill children when IV access cannot be obtained quickly (no more than 2 attempts at peripheral IV or no access within the first 60 seconds of a resuscitation).

The learner should be able to voice or show during the case the different sites that intraosseous lines can be placed. For children less than 6 years of age, placement in the proximal/distal tibia and distal femur are preferred over the humerus.

• Proximal tibia
• Distal tibia
• Distal femur
• Proximal humerus

Use the EZ IO drill and drill the needle until it is secure in the bone.

Be careful not go through the posterior aspect of the bone, especially in young infants. Make sure that your hand, which is holding the limb is NOT directly behind where you are drilling.

Needle selection is weight-based. The pink EZ-IO is most commonly used in pediatrics because it’s good for 3-39 kg. The blue needle is adult size (or ≥ 40 kg).

What can be infused?

• Anything that you would put through an IV can go through an IO. In some ways it’s better because you do not have to worry about extravasation of potentially harmful medications (CaCl or epinephrine drips) like you do with a peripheral IV. However, you must always keep a solution infusing, or the IO will become clogged.

What labs can be sent from an IO?

• You can do most labs, except for the CBC which will inaccurate because it will be from the marrow and not circulation.

If the patient is awake or alert, what can you do for the pain?

• The infusion of IV fluids and other products or medications through the IO can be painful. If you inject 2-5 mL of 2% preservative and epinephrine-free lidocaine into the bone through the IO, this will reduce the pain from the infusions (2-5 mL infants/children, 5-10 mL for adults).

Resources demonstrating IO placement:

• EZ-IO IO Access [PDF]
• Video [YouTube]

Discussion points for common errors:

• Did the team recognize the need and get the IO in a timely fashion? Many people will wait too long before they place an IO. It really should happen within the first minute if there is no access.
• Did they pick the right location? If so, this is a good opportunity to discuss alternative sites for IO placement and what are the contraindications for IO placement:
  • Fracture in the selected bone
  • Overlying infection in the soft tissue
  • Previous orthopedic surgery (pins, etc.) in that bone
• Where was the holder’s second hand? Was it safe or could they have injured themselves if they went through the bone?
• Did they use aseptic technique? They should clean the overlying tissue with betadine or similar agent prior to drilling the bone.
• How did they secure the IO? Inside the IO kit, there are “locks” or securing sites that can be fitted over the IO and hold them in place. Did they use it? If not, important to discuss because they can come out or be knocked out in an emergency.
• Tip: If you are using the “old” or handheld IO’s, you can take a needle driver from a suture kit, clamp it to the exposed part of the needle and then tape that to the child’s leg using cloth or wide strips of tape.

Construct and implement initial medical management after ROSC (application)

When the patient returns to NSR, the learner should recognize ROSC. Once ROSC has occurred the learner should do the following:

1. Optimize ventilation and oxygenation. Titrate FiO2 to maintain oxygen saturation 94-99%.
2. If no advanced airway was placed prior,consider placing now.
3. Assess for shock. Treat contributing factors and give 20 mL/kg of isotonic crystalloid (may consider 10 mL/kg if suspect poor cardiac function). Consider the need for pressor support if shock is refractory to fluid resuscitation.
4. Assess blood gas, serum electrolytes, glucose, calcium, if not already done so previously
5. Monitor for and treat hypoglycemia.
6. Keep the patient normothermic, avoiding hyperthermia.
7. Treat any agitation and seizures.

Demonstrate focused history taking from a caregiver (application)

The initial history will come from EMS. The learner should take the few seconds to listen to what the EMS personnel have to report. When the mother arrives, a person should be assigned to get a history from her. It should be focused on what occurred when the patient drowned, such as any possible trauma, how long the patient might have been submersed, any other medical conditions that might make resuscitation more difficult, or medical problems that may have led him to drown. Medications and allergies should be inquired about, just like for all patients.

Explain diagnosis and management to caregivers (synthesis)

If personnel are available, one member of the team may stay with the family to gather history and explain interventions. Family members should be given the option of staying in the room and watching the resuscitation or stepping out of the room. Information should be relayed to the family using layperson’s terms. The rationale for invasive interventions such as IV placement/IO placement, CPR, BMV, defibrillation, and intubation should be explained preceding or at the time of occurrence, when possible.

Demonstrate teamwork and closed loop communication (application)

Teams may use different frameworks to improve team dynamics and communication. Below are a few definitions that may be helpful to discuss, adapted from the AHRQ TeamSTEPPS Pocket Guide.

• Brief: Short session prior to start of encounter to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies
• Huddle: Ad hoc team discussion to re-establish Situation Awareness; designed to reinforce plans already in place and assess the need to adjust the plan
• Callout: A strategy used to communicate critical information during an emergent event. Helps the team prepare for vital next steps in patient care. (Example: Leader- “Airway status?”; Surveying provider- “Airway clear”; Leader- “Breath sounds?”; Surveying provider- “Breath sounds decreased on right”)
• Check-back: A closed-loop communication strategy that requires a verification of information ensuring that information conveyed by the sender is understood by the receiver as intended. The sender initiates the message; the receiver accepts it and restates the message. In return, the sender verifies that the re-statement of the original message is correct or amends if not. (Example: Leader- “Give diphenhydramine 25 mg IV push”; Med Prep- “Diphenhydramine 25 mg IV push”; Leader- “That’s correct”)
• SBAR: A framework for team members to structure information when communicating to one another.
  • S = Situation (What is going on with the patient?)
  • B = Background (What is the clinical background or context?)
  • A = Assessment (What do I think the problem is?)
  • R = Recommendation (What would I do to correct it?)
• Situation monitoring: The process of continually scanning and assessing a situation to gain and maintain an understanding of what is going on around you.
• Situation awareness: The state of “knowing what’s going on around you.”
• Shared mental model: Result of each team member maintaining situation awareness and ensures that all team members are “on the same page.” An organizing knowledge structure of relevant facts and relationships about a task or situation that are commonly held by team members.
• STEP: A tool for monitoring situations during complex situations. A systematic method to review Status of patient, Team members’ performance and status, Environment, and Progress towards goal.
• Cross-monitoring: A harm error reduction strategy that involves 1. Monitoring actions of other team members 2. Providing a safety net within the team. 3. Ensuring that mistakes or oversights are caught quickly and easily. 4. “Watching each other’s back.”
• CUS: Signal phrases that denote “I am Concerned,” “I am Uncomfortable,” and “This is a Safety Issue.” When spoken, all team members should understand clearly not only the issue but also the magnitude of the issue.

Chest X-ray

Download Case 11 supporting files

Notes:

• Chest x-ray interpretation: Post intubation film showing right upper lobe atelectasis and pulmonary edema bilaterally. Image from Dr. Rebekah Burns.

For the embedded participant playing the patient’s parent or guardian

Case Background Information

A 4-year-old boy was found down in a pool by his mom. It is unknown how long he’s been unconscious. Mom gets him out of the pool, calls 911, and initiates chest compressions. On arrival, EMS finds the patient to be in asystole. They continue chest compression and administer BMV, but are unable to obtain IV access. On arrival to the ED, the patient is being bagged and receiving chest compressions.

Who are the Learners?

Emergency Medicine interns

• May have experience in obtaining a history from family
• Some may have PALS certification others may not be familiar with medical treatments and procedures

Emergency Medicine junior residents (PGY-1/PGY-2)

• Should have experience in obtaining access on patient and able to place an IO line

Emergency Medicine senior residents (PGY-3/PGY-4, or PGY-2 in a 3-year training program)

• Should have experience in running the code, following PALS algorithm, being team leader, and airway management

Standardized Patient Information

You find your 4-year old son unconscious in the pool, face down, and scream to tell people to call 911. You initiate CPR. EMS arrives and takes your son. You show up at the ED a few minutes after your son has arrived.

You are worried about your son dying. You look anxious as you arrive into the ED. You start asking a lot of questions: How is my son? What are they doing? Is he going to be okay?

Patient Information

(Please remember not to offer any of this information, but when asked please respond while remaining in character.)

• CHIEF COMPLAINT (your response to open-ended questions such as “what’s going on?” or “what can we do for you? Or “what happened?”): Drowning, cardiac arrest
• AGE: 4 years old
• ADDITIONAL HISTORY: Your son was at a pool party. You were talking to another mom, when you noticed your son was not around. Someone screamed from afar and said that a child was in the pool. You run towards the pool and find your son face down in the pool, unconscious.
• PAST MEDICAL HISTORY: Had frequent ear infections first 2 years of life
• SOCIAL HISTORY: Lives with mom, dad, 2-month-old sister. Loves dogs. Goes to preschool.
• FAMILY HISTORY: Unremarkable
• PAST SURGICAL HISTORY: PETs placed at 2 years of age
• MEDICATIONS: None
• ALLERGIES: No known drug allergies
• IMMUNIZATIONS: Up-to-date
• BIRTH HISTORY: Healthy baby, born full term via vaginal delivery. No ICU stay.

Potential Dialogue

IMPORTANT: Do not offer unsolicited information. Please allow the learners to ask questions. Do not offer information unless they ask you.

Things you might say without being asked:

• “What is going on? Is my son alive? Is he breathing? What am I going to do?”

The learners enter the room to find a patient that is unconscious, pulseless, with EMS actively bagging the patient and doing CPR. The learners recognize that the patient is in PEA and continue chest compressions. IV/IO access is attempted. The IV attempts fail, but the IO is successful. Learners may or may not attempt intubation at this point. PALS algorithm is used for treatment of PEA, and after 2 rounds of epinephrine and high quality CPR, the patient goes into VF. At this moment, learners recognize that CPR needs to be continued and prepare to defibrillate the patient. The patient is defibrillated 1 or 2 times at 2-4 J/kg, then 4-6 J/kg, and then 6-10 J/kg before ROSC is achieved. The patient has mild hypothermia and hypotension after ROSC is achieved. The hypothermia severity is mild, and warm fluids/ warm blankets can be used. Hypotension should be treated with fluids, and pressors should be considered, if fluids are inadequate. The learners ensure that the family understands the patient’s medical course and answers questions. The learners admit or transfer the patient to a Pediatric ICU.

Anticipated Management Mistakes

1. Failure to check for a pulse on initial presentation and see the heart rate on the monitor as 30-40, thereby thinking the patient has symptomatic bradycardia instead of PEA. In this scenario, if this happens, the nurse will prompt the leader by asking if there is a pulse.
2. Intubation of the patient when VF is recognized. In this case, if this occurs, the nurse or RT will state that they thought it was best to defibrillate as quickly as possible when a patient has VF or pulseless ventricular tachycardia. The facilitators, during debriefing, can discuss the risk/benefit of intubation during arrhythmic events and can point out there were signs of adequate bagging with good chest rise, equal breath sounds, and good oxygen saturation levels.
3. Not resuming immediate CPR after defibrillation: In this case if this happens, the patient will most likely not achieve ROSC. Real time guidance can be offered by the facilitator.
4. Difficulty using defibrillator: Many hospitals are switching to new defibrillators, and we found that many of the learners are not comfortable using the new equipment. If this is found, a tutorial may be necessary to teach the use of defibrillators.