Setup

Chief complaint: Respiratory distress
Patient age: 10 years old
Weight: 20 kg

Recommended Supplies

• Manikin:Child-sized (5-8 year old) simulation manikin
• Moulage: None
• Resources: PALS cards and/or color-coded length-based resuscitation tape
• Manikin set up: IV lines x1 in place with drainage bag, neck piece with tracheostomy tube in place
• Equipment:
  • Pediatric airway cart:
    • Simple face-mask
    • Non-rebreather oxygen mask
    • Nasal cannula
    • Oxygen tubing
    • Suction equipment
    • Bag mask ventilation
    • Intubation equipment (cuffed ETT, Miller 1 blade, stylet, ET CO2 monitoring)
  • Tracheostomy tube and ties (4.0 trach)
    • Block the end of the trach to mimic a large plug. Super glue works well for this.
  • IV fluid bag, lines, pumps, poles, and angiocatheters
• Medications:
  • Code medications: Epinephrine, calcium gluconate, norepinephrine, D25W
  • Intubation medications: Succinylcholine, rocuronium, etomidate, ketamine, midazolam
  • Antibiotics: Ampicillin, ceftriaxone, azithromycin, vancomycin

Supporting Files

• Chest x-ray (AP and lateral): Multifocal pneumonia
• Point of care lab tests
• RUSH images: Collapsible and non-collapsible IVC

Participants/Roles

• Team leader
• Airway manager
• Survey physician
• Medication giver
• Family liaison
• Standardized patient (actor) to play patient’s parent

Faculty or nurse can play a nurse or tech, if there are not enough learners to perform the above roles.

Prerequisite Knowledge

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

• Emergency medicine residents
  • Any stage of training (preferably PGY-2 or greater for team lead)
  • Completed PALS certification
  • Bag mask ventilation
  • Rapid sequence induction (RSI)

Case Alternatives

• A pneumothorax may develop if there is aggressive bagging during resuscitation of the child.
• For more advanced learners, the hypotension and peripheral perfusion might not resolve until one or more vasoactive medications are administered (e.g., epinephrine, dopamine).
• The child can develop anaphylaxis to an antibiotic requiring appropriate therapy with IM epinephrine and a second-line antibiotic medication.

Virtual Resus Room

This simulation case can be run virtually using Google Slides and Zoom from the Virtual Resus Room (Peds Sepsis & Trach Change) page.

Milestones

PC1. Emergency Stabilization
PC2. Performance of Focused History & Physical Exam
PC3. Diagnostic Studies
PC7. Disposition
PC10. Airway Management
ICS1. Patient Centered Communication
ICS2. Team Management

Resources

1. Ambroggio L, Mangeot C, Murtagh Kuroski E, et al. AAP Guideline Adoption for Community-Acquired Pneumonia in the Outpatient Setting. Pediatrics. 2018;142:e20180331. PMID 30254038
2. Gopal P. Troubleshooting the crashing patient with a tracheostomy. Academic Life in Emergency Medicine. 2018.
3. Nickson C. Respiratory distress in tracheostomy patient. Life in the Fast Lane. 2019.
4. Weiss SL, Peters MJ, Alhazzani W, et al. Executive Summary: Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med. 2020 Feb;21(2):186-195.
5. Greenwood JC, Winters ME (2019). Tracheostomy Care. In Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care (7th ed., pp. 142- 159.e2). Elsevier.
6. Hess DR, Altobelli NP. Tracheostomy tubes. Respir Care. 2014;59(6):956-973. PMID 24891201
7. Horeczko T, Enriquez B, McGrath NE, Gausche-Hill M, Lewis RJ. The Pediatric Assessment Triangle: accuracy of its application by nurses in the triage of children. J Emerg Nurs. 2013; 39(2):182-189. PMID 22831826
8. White AC, Kher S, O’Connor HH. When to change a tracheostomy tube. Respir Care. 2010; 55(8):1069-1075. PMID 20667154

Initial Presentation

Start of evaluation through trach replacement

Critical Actions

• Team leader assigns tasks
• Obtain relevant history from parent
• Perform primary survey and identify serious conditions
• Provide supplemental oxygen and basic airway maneuvers
• Perform BMV through tracheostomy
• Suction tracheostomy tube
• Replace tracheostomy tube
• Place patient on continuous cardiac monitor
• Establish vascular access
• Obtain point-of-care rapid glucose level
• Discuss progress and plan of care with the parent (and involve them in shared decision-making)

Physical Exam

Instructor Notes: Changes and Case Branch Points

Management of Septic Shock

Trach change completed through fluid resuscitation and antibiotics

Critical Actions

• Recognize and provide prompt management for shock and pneumonia with IV fluids and antibiotics
• Discuss progress and develop plan of care with the parent (and involve them in decision-making)
• OPTIONAL: Perform RUSH POCUS exam if unable to determine the cause of hypotension

Physical Exam

Instructor Notes: Changes and Case Branch Points

Case Conclusion

Completion of fluid resuscitation/antibiotics through agreement for transfer to pediatric ICU

Critical Actions

• Plan for transfer to pediatric ICU (sign out patient to accepting facility/ service)
• Ensure family is updated on plan of care and explain why tracheostomy tube was not functioning

NOTE: The patient should have received appropriate airway management and antibiotics by this final stage.

Physical Exam

Describe the signs/symptoms of septic shock in a pediatric patient (application)

Septic shock: Shock is a condition where the body’s ability to provide oxygen to the tissues is not adequate to the needs of the tissues. Septic shock is a complex pathophysiological state of distributive shock when shock is due to the inflammatory response to a systemic infection.

Shock can be recognized as:

• Compensated: Initially the body will compensate for the inadequate oxygen delivery by increasing heart rate and peripheral vasoconstriction. Children often have greater physiologic reserve than adults and can stay in compensated shock for longer.
  • Symptoms include increased capillary refill time, tachycardia, a new flow murmur, diaphoresis, and fatigue.
• Uncompensated: At this point the body is no longer able to compensate through increased heart rate and decreased peripheral perfusion. At this point the blood pressure begins to drop. In children this is usually a sign of impending cardiovascular decompensation.
  • Symptoms include decreased blood pressure, altered mental status, and cardiac arrest.

Demonstrate early evaluation of a critically ill, medically complex pediatric patient (application)

In general, the evaluation of a medically complex child does not greatly differ from that of a previously healthy child as both populations require quick assessment of ABC’s with emphasis on overall clinical status.

Pediatric assessment triangle:

• Appearance (Mental status): Note abnormal tone, level of arousal, and changes in speech/cry
• Work of Breathing: Note presence of abnormal breath sounds, retractions, nasal flaring, grunting, apnea etc.
• Circulation to Skin: Note presence of pallor, delayed capillary refill, mottling, cyanosis etc.

Primary survey:

• Airway: Does the patient have a patent airway?
• Breathing: Auscultate for bilateral breath sounds
• Circulation: Assess for presence/absence of pulses and degree of peripheral perfusion
• Disability: Report Glasgow Coma Scale, examine pupils • Exposure: Allow for adequate visualization of the patient

However, the evaluation of the medically complex, technology- dependent child may require special vigilance compared to the previously healthy such as:

• Baseline status: What might be considered abnormal for a previously healthy child may be a baseline attribute of a more medically complex child (e.g., in this case, the patient is nonverbal and therefore the Glasgow Coma Score does not appropriately quantify the change in this patient’s mental status). Caregivers are the best resource for this information. Trust them!
• Medical equipment: To provide effective care for a medically complex child, providers should be familiar with the equipment they present with. This can range from common equipment such as a gastrostomy tube to more complex machinery, such as vagal nerve stimulators and baclofen pumps.

Identify the signs/symptoms of impending respiratory failure in a medically complex pediatric patient (application)

Respiratory failure is a condition where the body’s respiratory system is not able to meet the rest of the body’s demands for oxygenation and/or ventilation (elimination of carbon dioxide). Signs of respiratory distress in a medically complex patient are often similar to those of otherwise healthy children (e.g. tachypnea, nasal flaring, retractions, grunting), but depending on the patient’s medical history, signs of respiratory distress may be different. For example, a patient with hypotonia might not be able to sit up and tripod or even generate the muscular effort that produces retractions despite being significantly hypoxic.

Construct and implement initial medical management of septic shock in a medically complex pediatric patient (application)

In 2020, the Surviving Sepsis group released revisions to the updated guidelines for the management of pediatric septic shock.(Weiss et al. Intensive Care Med 2020). The guidelines are worth reviewing in detail but below is a modified summary:

• Early recognition of sepsis is essential to improve outcomes
• When sepsis is recognized (minute zero):
  • Place the child on supplemental O2 (non-rebreather mask or high flow nasal cannula)
  • Establish IV/IO access x2 as quickly as possible. If traditional IV access is difficult (>2 attempts or trying for >90 seconds), consider an ultrasound-guided IV or IO access, whichever is quickly possible. IO access is appropriate even in awake patients in septic shock.
• Within 60 minutes:
  • Fluids
    • Administer 20 mL/kg balance/buffered crystalloids (e.g., LR), up to 60 mL/kg.
    • After each bolus, reassess vital signs and capillary refill.
    • Goals include an improvement in heart rate, capillary refill time <2 seconds, and normalization of blood pressure.
    • Keep in mind that a medically complex child may not have the same baseline vital signs expected for age. Previous records and caregivers can be helpful to establish each patient’s baseline vital signs.
    • Reassess for crackles/rales and/or hepatomegaly. Stop fluids if any of these signs develop.
    • Correct hypoglycemia if present (a point of care test can be helpful to get results back more rapidly).
  • Antimicrobial Therapy
    • Administer broad spectrum antibiotics:
      • Ceftriaxone 50-75 mg/kg to a max of 2,000 mg.
        • Do not use in patients <4 weeks of age. In this population, ampicillin + gentamicin or ampicillin + cefotaxime are appropriate. Dosing may change with the infant’s gestational and post-natal age.
        • Some centers prefer cefepime over ceftriaxone in medically complex patients with septic shock.
      • Vancomycin 15-20 mg/kg
    • Obtain blood cultures
      • Blood cultures should ideally be obtained prior to administration of antibiotics; however, obtaining sterile access for a culture should not delay IV fluids administration.
• If hemodynamic goals are not met after 40-60 mL/kg of fluids initiate vasopressors
  • It is ok to initiate vasopressors peripherally but convert to centrally when possible. (Note: Intraosseous access is considered central access.)
  • Options are epinephrine or norepinephrine at 0.05 mcg/kg/min and titrate to response
• Often medically complex children are at risk for adrenal insufficiency (chronic steroid use, panhypopituitarism, etc.). Consider a hydrocortisone stress dose if initiating vasopressors. The initial dose is 50 mg/m².
  • Rough estimate: infants 25 mg, children 50-100 mg

Demonstrate airway management of a sick child using appropriate
adjuncts and BMV (application)

In general, children have higher oxygen demand for body weight than adults. This means children may require a higher frequency of bagging, but a common mistake in acute situations is to hyperventilate due to too rapid a rate of bagging the patient. End- tidal carbon dioxide (EtCO2) monitoring attached to the bag can help identify the appropriate rate of bagging.

The size of the bag used for ventilation should be appropriate for the size of the child.

• Infants and small children can use a 450 mL bag
• Older children may benefit from a 1,000 mL bag

A useful mnemonic for pediatric airway management with bag mask ventilation comes from the Textbook of Neonatal Resuscitation (Weiner & Zaichkin, 2016): MR SOPA

• M: Mask adjustment. Attempt to obtain a full seal around the mouth and nose. This may require changing the size of the mask to better suit the patient. One size does not fit all!
• R: Reposition airway. Given the more prominent occiput in children relative to adults, a shoulder roll can be more effective than a neck roll. Try to place the patient in a “sniffing” position with the chin and nose tilted up. This can be accomplished with a head tilt-jaw thrust maneuver.
• S: Suction. Respiratory infection is a common cause for pediatric respiratory distress and providing suction can remove secretions that are obstructing the airway.
• O: Open mouth. Similarly, the nose may be obstructed despite suctioning and opening the mouth can be an effective way of improving gas exchange. In an obtunded patient with no gag reflex, this may be accomplished with an oropharyngeal airway.
• P: Pressure increase. Particularly in medically complex children, lung compliance may be decreased due to chronic lung disease or frequent pulmonary infections. Higher peak inspiratory pressures may be needed to adequately ventilate and oxygenate. However, caution should be taken to avoid barotrauma and a pneumothorax.
• A: Alternate airway. If the above steps are not effective in addressing the child’s respiratory distress then progression to more advanced airways are indicated. Besides endotracheal intubation, consider a properly sized laryngeal mask airway.

Propose a plan to troubleshoot a tracheostomy device (evaluation)

If the patient is in respiratory distress, consider that the patient may not have a stable airway. This may be due to obstruction, dislodgement, or the creation of a false passage.

• Obstruction may be due to mucus/secretions, blood or granulation tissue. Sometimes these obstructions may create a one-way valve allowing for inspiration but not expiration. Suctioning may not be sufficient to clear the obstruction.
• Dislodgement (accidental decannulation) may occur during patient movement, trach manipulation, or connecting/ disconnecting the trach from a ventilator.
• A false passage may be created during a difficult trach change that places the internal end of the tube into the soft tissues and not into the trachea. If this is recognized a stable airway must be established immediately.

In general, if a tracheostomy is more than 7 days old and the patient is in respiratory distress and there is concern that the tracheostomy tube is the source, the tracheostomy tube should be exchanged. If the tracheostomy tube exchange is unsuccessful or does not lead to improvement in the patient’s respiratory distress, consider alternate etiologies of respiratory distress such as pneumonia and pneumothorax.

• If the tracheostomy tube is still believed to be the problem, then you can attempt to provide bag-mask ventilation orally; making sure to occlude the tracheostomy stoma.
• If this is not adequate then consider intubating either through the stoma or orally.
  • If intubating orally, be sure to pass the cuff past the tracheostomy stoma.
  • If intubating through the stoma then use the same size cuffed endotracheal tube as the patient’s tracheostomy tube.

Demonstrate tracheostomy tube replacement (application)

If a tracheostomy is less than 7 days old, there is a high risk for complications and tracheostomy tube exchange in the Emergency Department should only rarely be considered appropriate.

The steps for a tracheostomy tube exchange:

• Before beginning, gather appropriately sized airway supplies including 2-3 tracheostomy tubes with the patient’s current tube size and 1-2 smaller tubes in case of difficulty.
• Check equipment for lack of defects and ensure the cuff inflates properly.
• Preoxygenate the patient for at least one minute with 100% FiO2.
• Deflate the old tube’s cuff and remove the tube.
• Place the new tube (with solid obturator in place) into the stoma.
• Once in place, remove the obturator, insert the hollow inner cannula, and inflate the cuff.
• Check placement with end tidal CO2 monitoring.

Demonstrate focused history taking from a caregiver (application)

In acute settings, a useful mnemonic for taking a focused but appropriate history is AMPLE.

• Allergies
• Medications. This may be a long list in a medically complex child. Sometimes caregivers have a list or an app on their phones that list medications. It may be necessary to delegate a member of the medical team to obtain a full medication list from a caregiver. Often caregivers record medication doses in milliliters rather than milligrams. Most medications have standard concentrations from which doses can be calculated.
• Past medical history. Asking about immunizations and birth history can often be very helpful. In a medically complex patient be sure to ask about prior surgeries and device placement as well as common comorbidities such as seizures, chronic lung disease, and metabolic disorders.
• Last food/drink intake. Medically complex children may be fed orally, through a gastrostomy tube, or a gastro-jejunostomy tube. Be sure to ask open-ended questions about any intake rather than asking about meals.
• Events leading to presentation. Ask about changes from the patient’s baseline over the past few days with pointed questions attempting to identify critical neurologic, cardiac, and respiratory pathologies.

Explain diagnosis and management to caregivers (synthesis)

While the caregivers of a medically complex child may seem very knowledgeable and savvy (and may use advanced medical terminology), it is important in an acute setting to continue to use simple, patient-centered language. Caregivers are often very anxious and they may require repetition to fully understand what you are trying to convey, particularly if it is bad news. If time allows, using a teach-back method allows you to make sure that the caregiver understands what you are trying to communicate and allows for misunderstandings to be addressed.

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.

File 1: Chest X-Ray

Chest X-ray: AP View

Chest X-ray – Lateral View

File 2: Laboratory Results

File 3: RUSH Images

File 3A

File 3b

Download Case 13 supporting files

Notes:

• File 1: Chest X-ray Interpretation – The CXR shows a multifocal pneumonia. Images courtesy of the Division of Diagnostic Imaging and Radiology, Children’s National Hospital, Washington, DC
• File 3a. RUSH image before fluid resuscitation showing a collapsible IVC
• File 3b. RUSH image after fluid resuscitation showing a non-collapsible IVC

For the embedded participant playing the patient’s parent

Case Background Information

Your son has multiple medical problems due to being born prematurely, including a breathing tube in his neck (tracheostomy). Your son has been sick for about a week and is getting worse now with worse trouble breathing. So, you came to the hospital for him to be evaluated. He hasn’t been this sick in a year but when he looked like he does today it meant he had to be hospitalized.

Who are the Learners?

Emergency medicine interns: They are in their first year of specialty training and may have experience in gathering information from patients and families but are less familiar with medical treatments and procedures.

Emergency medicine residents: They are in their second to fourth year of specialty training and are growing more comfortable with gathering information, developing a plan and then performing medical treatments and procedures.

Standardized Patient Information

• Narrative: He’s been sick for about a week. After four days the cough wasn’t getting better and his fevers got worse so we took him to his regular doctor. She started him on some antibiotics. Last night he was coughing a lot and the night nurse suctioned the trach several times and ended up replacing the tube. Since I started taking care of him we haven’t been able to get his sats above 85% so I wanted him checked.
• Motivation: You are worried that your son may have to be hospitalized again. This usually means a long hospital stay, sometimes in the intensive care unit and this is frightening.
• Demeanor: Initially you are concerned that his breathing is very fast and that his oxygen number “saturation” is much lower than normal. Over time (especially if you do not feel that you have been kept informed about what is going on), it is ok to become more anxious. He has not been this sick for a long time and his physicians were talking about taking out his trach so this illness is clearly a setback.
• Communication Guidelines: While it is ok to ask questions, please DO NOT interrupt the learners when they are thinking out loud as one of their objectives is to verbalize their thoughts. Another goal of the session is to have the learners learn how to talk to families so please do not become so upset/obstructive that the learners feel justified having you removed from the room.

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?”): “His breathing has gotten worse over the past few hours, and I can’t get his oxygen saturation above 85%.”
• AGE: 10 years old
• ADDITIONAL HISTORY: “He’s been sick for about a week. After 4 days, the cough wasn’t getting better and his fever got worse so we took him to his regular doctor. She started him on some antibiotics. Last night he was coughing a lot, and the night nurse suctioned the trach several times and ended up replacing the tube. Since I started taking care of him, we haven’t been able to get his saturation above 85% so I wanted him checked.”
• PAST MEDICAL HISTORY: Born premature at 24 weeks, chronic lung disease, intellectual disability, cerebral palsy, seizure disorder, admitted to the hospital for pneumonia x3 in his life, last admitted 1 year ago. The trach was weaned off of home oxygen 6 months ago, and he is not on a ventilator. He has a G-tube for feeding at night.P rior to this episode he had been doing well and his physicians were discussing having the tracheostomy removed.
• SOCIAL HISTORY: Lives at home with both parents and a younger brother (brother has a mild cold that started a week ago).
• FAMILY HISTORY: Father with asthma
• PAST SURGICAL HISTORY: Tracheostomy placement when he was a baby, G-tube placement around the same time
• MEDICATIONS: Baclofen, oxcarbazepine, azithromycin for the past 4 days (started by primary care doctor). The full medication list is with the other parent who is arriving by car “soon”.
• ALLERGIES: No known drug allergies
• IMMUNIZATIONS: Up-to-date
• FEEDINGS: 2 cans of Pediasure overnight by the G-tube. These feedings have been going normally while he’s been sick.
• BIRTH HISTORY: Born at 24 weeks premature. Prolonged NICU stay. The main complications of his prematurity are cerebral palsy and chronic lung disease.

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 could say without being asked:

• “The doctors said he was getting better. Why is he so sick today?”

Things you might say triggered by events in the scenario:

The learners enter the room to find a medically complex child in respiratory distress. They immediately place the child on bedside monitors and recognize that the patient is hypoxic and hypotensive with altered mental status. Supplemental oxygen is provided over the trach and IV access is established to start a fluid bolus. After completing a physical examination and obtaining an appropriate history, the providers note that the child’s respiratory status has not improved with supplemental oxygen (or BMV through the tracheostomy tube) and the trach should be investigated. The trach cannot be suctioned due to an obstructive plug and it must be changed. Once the trach is changed the patient’s respiratory status improves. At this point it should be recognized that the patient is still in septic shock. RUSH POCUS (if performed) at this point identifies a collapsible IVC consistent with hypovolemia. Appropriate management requires additional IV fluid boluses and antibiotics. Repeat POCUS (if performed) reveals non-collapsible IVC. The family should be updated throughout the course of this scenario. Once the patient has been stabilized, arrangements must be made for transfer to a facility with a pediatric intensive care unit. The chest x-ray (if ordered) reveals a multi-lobar pneumonia.

Anticipated Management Mistakes

1. Not keeping the family updated: One of the goals of this case is to have learners balance direct patient care with keeping the family of the patient aware of the plan. We find it helpful to have the parent(s) become increasingly vocal, though not reaching the level of disruption where having the parent removed from the room becomes reasonable.
2. Trach is repeatedly suctioned/lack of recognition of trach plug: Sometimes learners get stuck on suctioning the trach as the solution and will repeatedly insert the suction catheter despite the end of the trach being blocked. You can cue them by saying that they are not getting anything out when they suction.
3. Attempting to intubate from above: Some groups of learners decide to intubate from above rather than change the trach. If attempts are made to intubate, the parents are instructed to object and point out that the patient’s ENT specialist said he would be a difficult airway. If the learners persist and attempt to intubate without removing the trach, continue to keep the patient in respiratory distress (they will likely notice the trach tube obstructing their attempts to pass the ETT). If the trach is removed and the tube is placed past the stoma then progress the case like the trach was successfully changed.
4. Failure to recognize septic shock: At times, once the respiratory distress was addressed with a trach change, some learners feel like the case is over and do not recognize the persistently poor vital signs signifying underlying septic shock. If this is the case it may be helpful to continue to increase the heart rate and decrease the blood pressure until shock is recognized and treated.
5. Lack of disposition plan: If the learners stabilize the patient but do not have a disposition plan (e.g., transfer to a facility with a pediatric ICU), the parents have been prompted to ask where they are going next.