Pediatric Mock Resuscitation Scenario #1* *(Critical Actions are in Bold) Brief Presenting History Two-month-old infant in father's

arms with a chief complaint of lethargy, fever, and poor feeding. Initial Vital Signs P 180 BP 50/20 RR60. If asked. 39.0oC, No weight done Initial Physical Examination General appearance- Pale, gray, mottled, decreased tone. If asked. Eyes closed, responds to painful stimuli with weak cry. Airway: Breathing: Circulation Sugar: Patent. Breath sounds full and clear symmetrically without wheezing, but increased rate Heart tones remarkable for tachycardia only, Capillary ref ill time 4 to 5 seconds, pulses weak. Bed Side Sugar

Pupils equal and reactive, anterior fontanel flat, no retinal hemorrhages. Abdomen nondistended, bowel sounds hypoactive, soft without mass. Rectal tone normal, stool heme negative No external signs of trauma Further History Given on Request Child with symptoms of URI past two days. Fever to touch this AM. Failed to wake for feeding as expected. Parents unable to arouse him. Refuses to take the breast. No history of ingestion or Trauma. Exclusively breast-fed. No urine output for more than 12hr. Full term, normal spontaneous vaginal delivery, uncomplicated pregnancy, labor, and delivery. No medications. Expected Interventions 100% oxygen by face mask (Learner may indicate need for elective intubation in critically ill child at risk for deterioration) Monitors (CR and pulse oximeter) CR shows Sinus Tach, Pulse Ox does not pick up due to poor perfusion Obtain estimated weight by Broselow card (Wt = 4kg) IV access attempts (Unable to obtain X3 attempts or 90 sec. (Learner should indicate need for IO, Learner should demonstrate proper technique as covered in Skill Demonstration, Intra-osseous needle placement) Normal saline 20 ml/kg bolus, Reassess perfusion. (Learner should recognize signs of poor perfusion and make clinical diagnosis of decompensated shock) Laboratory tests: Rapid glucose, ABG, CBC, blood culture, electrolytes, glucose, UA/UC. Antibiotics: Ceftriaxone 100 mg/kg IO and Ampicillin 100 mg/kg I0. Reassessment after Bolus Pulse decreases to 170, BP up to 60/40 Initial Laboratory Findings Rapid glucose = 180, ABG (if obtained) = pH 7.02, PCO2 45, PO2 160. (If Learner gets this ABG, they should indicate need semi-emergent intubation) (Alternatively, give Learner a better ABG so that they do not immediately intubate, and proceed to option 2) (Learner should indicate need for 2nd Fluid bolus)

Progression Option 1: Infant shows signs of increasing fatigue with decreasing RR, decreased responsiveness, worsening perfusion. (Learner should indicate need for semi-emergent endotracheal intubation) Option 2: (My favorite) Infant shows initial signs of improving with IVF boluses, but then vomits and obstructs Airway (Learner should go back to Airway (Suction, Positioning, Oxygen)) In either option, infant now becomes apneic and develops asystole on monitor prior to completing preparations for intubation Expected Interventions Bag-Valve-Mask with 100% O2 Chest Compressions at 5.1 ratio (Learners should demonstrate proper technique as covered in Skill Demonstration, Bag-Valve-Mask with Chest Compressions) Intubation (Learners should demonstrate proper technique as covered in Skill Demonstration, Endotracheal Intubation) Unable to visualize cords secondary to secretions - necessitating further suctioning No. 1.0 Miller blade, 3.5 ETT Cricoid pressure Place NG tube and End-tidal C02 monitor Confirm ETT position (Learner should utilize Broselow Card for selecting equipment and drug doses as covered in Skill Demonstration, Use of Broselow Tape) Epinephrine 1:10,000, 0.1 ml/kg IO/IV, or epinephrine 1-.1000, 0.1 ml/kg ETT First dose unsuccessful second dose epinephrine 1:10000, 0.1 ml/kg IO/IV Progression Patient develops sinus bradycardia on monitor with palpable pulses atropine 0.02mg/kg IV minimum dose O.1mg Patient develpes normal sinus with improving perfusion (Learner should demonstrate proper management of Asystole and Bradycardia as covered in lecture and Reading) Teaching Points Recognize -the presentation of septic shock Septic shock is a syndrome of inadequate end organ perfusion requiring oxygen, intravascular fluid resuscitation, and antibiotics. Symptoms of shock evident in this patient include history of decreased activity, poor oral intake, and decreased urine output. Signs of shock are tachycardia, poor perfusion with cyanosis, prolonged capillary refill time and mottled skin, and altered mental status. Hypotension as displayed by low blood pressure is a late finding of shock in pediatrics and is indicative of impending cardiovascular collapse. Initial management of Septic Shock with poor perfusion. Isotonic crystalloid solution is administered initially as an IV bolus, 20 ml/kg, over a short period (<l5 minutes). If reassessment of the patient's condition reveals persistent poor perfusion, the 20 ml/kg bolus is repeated and then followed by colloid (i.e., 5% albumin as a 20 ml/kg bolus). Patients with shock refractory to fluid resuscitation require inotropic support in the form of a continuous IV infusion of dopamine 10 to 20 mcg/kg/min or epinephrine 0.1 to 1 mcg/kg/min. Review critical actions as covered in lecture, reading, demonstrations If necessary, review material and repeat demonstrations of skills before preceding to next scenario.

Recognize respiratory distress and impending respiratory failure.

Signs and symptoms of respiratory distress are varied, depending primarily on the patient's age and stage in the evolution of respiratory failure. Older children may complain of shortness of breath, chest pain, or air hunger that a preverbal child would be unable to communicate and might manifest only as "fussiness." The infant younger than 4 months of age is an obligate nose breather. Upper respiratory infections may therefore cause significant compromise. Attention should be given to the degree of tachypnea (the initial mechanism for preserving minute ventilation), adequacy of tidal volume (by observing
chest rise or abdominal excursion), and presence of bilateral breath sounds (assessing symmetry and air movement), nasal flaring, retractions (subcostal, intercostal, supraclavicular), accessory use of neck muscles, head bobbing, and changes in inspiratory/expiratory ratio. Progression from respiratory distress to respiratory failure may be evident because of clinical findings of decreased or absent breath sounds, severe retractions, use of accessory muscles, cyanosis (excluding patients with cyanotic congenital heart disease), poor muscle tone, grunting, weak cough or gag, and eventual depression of mental status and response to pain. Physiologic findings consistent with respiratory failure include PaO2 less than 60 mm Hg in 60% oxygen (excluding patients with cyanotic heart disease), Paco2 greater than 60 mm Hg and rising, vital capacity less than 15 ml/kg, and maximum inspiratory force (pressure) greater than -20 cm H20. The diagnosis of respiratory failure is based primarily on clinical parameters, and radiographs or laboratory studies should not delay a decision to secure an airway or assist ventilations.

Pediatric Mock Resuscitation Scenario #2* *(Critical Actions are in Bold) Brief Presenting History A 2-week-old male with 48 hour history of poor feeding, increased work of breathing, and irritability Initial Vital Signs If asked: 36.9oC, pulse oximetry 97% in room air. HR = To Fast to Count (Do not give HR until asked) Initial Physical Examination General appearance: pale, irritable, but alert. Mild mottling . Airway: Parent. Breathing: Clear breath sounds with no retractions. Circulation: Tachycardic, normal S1 and S2, no murmur, pulses strong, capillary refill time 2-3sec. Sugar If Obtained, will be normal No evidence of trauma. No hepatosplenomegaly No peripheral edema. Further History Given on Request NSVD no complications during pregnancy or delivery No medications, NKDA. Family history negative. Expected Interventions 100% 02 Monitors (CR, oximeter ) CR Monitor shows narrow complex tachycardia > 220 (SVT) Monitor blood pressure and perfusion BP = 90/60 IV access (I usually allow Learners to obtain PIV if they correctly performed IO insertion in initial scenario) 20cc/kg NS/LR bolus (Confirms SVT in that there is no variation in HR with bolus) 12-Lead electrocardiogram Progression After fluid bolus, there is no change in heart rate. Pulses strong. The 12-lead EKG reveals very regular narrow-complex tachycardia at 245 beats per minute Expected Interventions First-line therapy, without drugs. Increase vagal tone maneuvers. Cover face with bag of ice to evoke "diving reflex." Valsalva maneuver (Knee to Chest). Unsuccessful, Infant maintains good perfusion (at this point) Progression Adenosine 0.05 mg/kg IV unsuccessful Adenosine 0.1, 0.2 mg/kg IV unsuccessful

(Learner should NOT elect to cardiovert patient until infant develops signs of poor perfusion)

Patient gradually becomes more dyspneic and diaphoretic, with decreased responsiveness. (Learner should Reassess ABCs) Capillary refill time is now 4 seconds, BP now unattainable Expected Interventions Synchronized cardioversion, 0.5 J/kg Unsuccessful (Optimally, learner should prepare for intubation prior to cardioversion, my experience is that most residents dont do this unless you hint at it) Synchronized cardioversion, 1 J/kg Patient developes Ventricular Fibrillation, stops breathing and looses pulse (Learner should show knowledge of indication for synchronized Cardioversion in SVT with evidence of poor perfusion as covered in Assigned reading. I usually tell the residents that they need to know their SVT, Vfib, and VT algorithms prior to the day of the code) Expected Interventions Bag-Valve-Mask Ventilation with chest compressions while readying defibrillator (Use correct technique as covered in Skills Demonstrations) Unsynchronized Defibrillation, 2J/kg Unsuccessful (Learner should demonstrate knowledge of treatment of Vfib as covered in Assigned reading) Unsynchronized Defibrillation, 4J/kg Unsuccessful Unsynchronized cardioversion, 4J/kg Unsuccessful Endotracheal Intubation (3.5 ETT, 1.0 Miller Blade, suction) (Learner should demonstrate correct technique as covered in Skills Demonstrations) Epinephrine by IV 1:10000 0.1 cc/kg Repeat Unsynchronized Defibrillation, 4 J/kg Successful *Note- Cardioversion and Defibrillation Procedural Skills should be reviewed prior to this scenario if correct performance of skill is to be a critical action. If not covered as a skill demonstration, the Learner should still know the indications since it is covered in their reading. I usually demonstrate Cardioversion and Defibrillation prior to starting the scenarios, so that the residents can be expected to demonstrate the skill. Teaching Points Distinguish supraventricular tachycardia (SVT) from sinus tachycardia. Supraventricular tachycardia is a reentrant type of tachycardia. In reentrant tachycardia the onset and cessation are abrupt and the rate is highly regular. Unlike sinus tachycardia, SVT is not responsive to analgesia or sedation, volume resuscitation, or control of fever. An EKG reveals a regular, narrow-complex tachycardia, typically greater than 240 beats per minute. Manage SVT without hemodynamic compromise Many reentrant tachycardias can be managed with maneuvers to increase vagal tone. For some children who have infrequent episodes, the Valsalva maneuver can be used at home. A bag of ice placed on the face will convert the rhythm in some children, especially infants. Use of ocular compression should be discouraged in the pediatric population because of possible retinal injury. Adenosine is an effective treatment for SVT in many cases. The dose is 0.05 mg/kg IV, which is doubled to 0.1 mg/kg if not initially effective. A third dose of 0.2 mg/kg may be administered and repeated for resistant SVT. Adenosine is an extremely volatile drug that must be given by rapid intravenous push followed immediately by a saline f lush to be effective. If effective, adenosine will block conduction at the AV node and may (only transiently) cause profound but asymptomatic bradycardia. In hemodynamically stable infants with SVT unresponsive to adenosine, Pediatric Cardiology should be consulted prior to any further intervention. Recognize situations in which aggressive management of SVT is indicated. At any point if the patient becomes hypotensive, or develops compromised perfusion, synchronized cardioversion should be administered according to protocol. Cardioversion is an invasive procedure and has risks for precipitating decompensation (as in this case). Residents should be taught to anticipate possible adverse outcomes to their therapies and prepare for them.

Discuss treatment of VFib and pulseless Vtach Review PALS algorithms as covered in reading. Review the procedure of cardioversion and defibrillation if necessary. Point out differences in PALS and ACLS protocol (Airway control concurrent with Defibrillation)