Mock Codes

Objectives

• Review mock code scenarios that occur in pediatrics.

• Stress and optimize ABCs in resuscitation as they relate to the case-specific circumstances.

Code 1: “Lifeless in Crib”

• Healthy term infant put down for nap in crib after feeding at 9:00 am.

• Child checked at 10:30 am, found to be very pale and apneic and not arousable.

• 9-1-1 called. Mouth-to-mouth resuscitation started by mother.

• EMS arrives: Bag-mask ventilation started. Patient is pulseless. Chest compressions started.

ECG Shows Asystole

Should the patient be defibrillated?

Should the patient be intubated in the field?

How should vascular access be established?

Drug protocol?

Defib indicated in pulseless VF/VT, not asystole.

Available data say no. Other considerations.

IV or IO

Epinephrine 0.1 mL/kg 1:1000 TT or 1:10,000 IV/IO every 3 to 5 min. Consider higher dose.

Arrival in EDPatient is intubated. TT tube size?

Expected ETCO2 wave form to confirm intubation?

How can chest compressions and ventilations be monitored and optimized?

3.5 or 4.0 TT

Might show poor wave form if pulmonary perfusion is poor, in which case, cannot be used to confirm trach intubation.

Auscultate, chest movement, ETCO2. Check pulse, BP, optimize pulse ox perfusion and oxygenation.

Other ConsiderationsGlucose check?Prognosis?Duration of resuscitation attempt?

Reversible causes of pulseless arrest?

Poor

H’s, T’s: Hypoxemia, hypovolemia, hypothermia, hyponatremia, hyperkalemia, hypoglycemia, tamponade, tension pneumothorax, toxic ingestion, thromboembolism

110 mg%

Available data suggest about 30 minutes.

Case Outcome

• Poor prognosis• Resuscitation not likely to be

successful if spontaneous circulation does not return within 30 min and reversible causes are not present.

• Medical examiner and organ donation official require notification.

• Discussion of death with family in ED.

Code 2: “Toxic, Febrile, Stridorous”

• 3-year-old boy, awake, ill appearing, leaning forward, noisy breathing, drooling

• Recent immigrant. No primary care, no immunizations.

What diagnosis should be suspected?

• Vital signs:Epiglottitis

HR 110, RR 20, BP 100/70, T 40°C, O2 sat 88% on room air, 95% on humidified oxygen

While Calling for Help. . .• He collapses and arrests. • Apneic, pulse present • Rescue breathing should be initiated.Will it be possible to ventilate him with bag-

mask ventilation (BMV)?

Why did he arrest? Is his airway completely closed?

Yes, so strategy to optimally deliver BMV should be considered.

He is septic and has been breathing through a tiny straw. Respiratory fatigue. His airway likely still has a narrow opening.

Optimizing BMV (1 of 2)

How can BMV in this patient be optimized?• Consider the following:• One-person or two-person method?

• Supine positioning? Supine positioning will worsen his airway obstruction. Recall that he arrived in a “tripoding” position (leaning forward). BMV in the tripod or prone position would be better.

Two-man method to optimize mask seal and ventilation effort

EE

TT

CC

MouthMouthUprightUpright

Epiglottitis x-rayEpiglottis (E), Vocal cords (C), Trachea (T)

He prefers to lean forward because this moves the epiglottis off his airway opening.

EECC

TT

Leaning forwardLeaning forward

MouthMouth

When supine, epiglottis falls onto airway opening, worsening airway obstruction.

EECC TT

MouthMouth

Prone (face down)Prone (face down)

EE

CC TT

MouthMouth

Supine (face up)Supine (face up)

When prone, epiglottis falls anteriorly off airway opening, improving airway access.

Optimizing BMV (2 of 2)

• Begin BMV with patient upright, leaning forward, or prone.

• This optimizes airway opening.• Two-person method required.• His oxygenation improves, and he begins to

wake up.Can endotracheal intubation be attempted?

Yes, but patient is now awake and will require RSI in supine position. It is probably better to wait until help arrives.

Case Outcome

• Epiglottitis with respiratory arrest due to airway obstruction.

• Intubation is difficult.• BMV is possible.• Optimize body positioning (upright/forward

or prone) to facilitate BMV.• If not, intubation attempt is required.• If “cannot ventilate/cannot intubate,” attempt

emergency surgical airway.

Code 3: “V-Tach in the Dialysis Unit”

• 10-year-old boy in dialysis unit.• Long history of renal failure and poor

compliance with hemodialysis• He collapses in dialysis unit before dialysis

is started and is noted to be apneic and pulseless.

• CPR and BMV are in progress.• Initial rhythm shows ventricular tachycardia.

Pulseless V-Tach• Pulseless arrest algorithmShould the patient be given drugs or electricity

first?Should the patient be defibrillated or

cardioverted?How many joules?What reversible cause of pulseless arrest is

possible in this patient?

Defibrillated2 J/kg, then 2-4 J/kg, 4 J/kg

Hyperkalemia. Rhythm often resembles VT.

Defib x3 first

Hyperkalemia• No improvement after 1 round of epinephrine

and defibrillation x4.What drug most rapidly reverses dysrhythmia

due to hyperkalemia?What other measures can be taken to lower

potassium levels in this patient and in non-dialysis patients?

What other conditions predispose to hyperkalemia?

NaBicarbonate, albuterol, insulin/glucose, furosemide, Kayexalate, dialysis

Calcium

CAH, adrenal crisis, K overdose

Case Progression

• He is given IV calcium chloride. • This immediately converts him to sinus

rhythm with good blood pressure. • Serum potassium is 7.5 mEq/L.• He is given IV sodium bicarbonate.• A wide-complex rhythm recurs, and he is

given IV calcium, which restores him to sinus rhythm.

• He is given an albuterol aerosol treatment.• Hemodialysis is started immediately.

Case Outcome

• Hyperkalemic dysrhythmia• Calcium converts rhythm to sinus and

restores perfusion rapidly, but only temporarily.

• Other measures must be taken to reduce serum potassium level.

• Patients at risk for severe hyperkalemia include those with CAH (infants) and adrenal crisis, renal failure patients, and those ingesting excess potassium.

Code 4: “Inpatient Respiratory Arrest”

• Healthy term infant presents to primary care physician’s office with complaint of lethargy and poor feeding.

• Infant is transferred to ED for possible sepsis.

• Sepsis workup (blood, urine, CSF, chest x-ray) is done, and all results are normal thus far.

• Ampicillin and gentamicin are started empirically.

Case Progression (1 of 2)

• CODE BLUE is called when monitor alarms sound and a nurse finds him to be apneic and limp.

• Monitor shows a sinus bradycardia.• Pulse is palpable.Are any drugs indicated at this time?

No. ABCs are first priority.A: Airway is open.B: No respiratory effort, BMV indicated.

Case Progression (2 of 2)

• BMV is started.• Heart rate normalizes.• O2 sat is 100% with BMV.• There is no respiratory effort or spontaneous

movement. BP is normal.Any drugs indicated at this time?What is the next intervention?

No.Intubation

using RSI. He is noted to have no muscle tone, so a muscle relaxant is not necessary.

Case Outcome

• Infant botulism: Initial presentation with afebrile lethargy and poor feeding.

• Presentation is mistaken as sepsis. Antibiotics are ordered.

• Gentamicin is a weak neuromuscular blocking agent.

• In conjunction with partial neuromuscular blockade from early infant botulism, gentamicin is sufficient to result in apnea and respiratory arrest.

Code 5:“Foreign Body Aspiration”

• 2-year-old arrives in your office for a well child check. While playing with her sister’s marbles, she puts one in her mouth and begins to choke.

• Her frantic mother gets your attention. • Child is breathing, but she is in severe

distress with loud short bursts of stridor.• Receptionist calls 9-1-1.

Obstructed Airway AlgorithmIs it appropriate to perform abdominal thrusts,

back blows, or chest compressions?

Is this more optimally done with the patient supine, leaning forward, prone, or upside down?

Any role for laryngoscopy or use of Magill forceps?

Five abdominal thrusts are indicated. Other choices are indicated in infants.

Can be done upright or supine. Other positions are difficult but have advantages.

After the above.

Case Progression

• She begins to turn blue.• After fourth abdominal thrust, her stridor

becomes louder and her color improves.• She then coughs, spits out the marble, and

her breathing normalizes.

Case OutcomeCan a marble fit into the trachea of a 2-year-

old?Where could the marble go, and how does it

obstruct the airway?

• Airway obstruction algorithm:– Abdominal thrusts for children – Back blows, chest compressions for infants– Laryngoscopy

No

1) Esophagus – compress trachea2) Larynx – block vocal cords

Code 6: “Cardiac Arrest”

• Paramedics call on radio informing you that they are transporting 34-week pregnant woman who is passing a large amount of blood vaginally while in transport.

• Premature male infant just delivered.• Apgar score is 0 (pulseless, apneic, pale).• BMV and chest compressions are in

progress.• ETA is 3 min.

Three Minutes ETA• In the 3 minutes available, think ABC.Airway preparations?

Breathing preparations?

Circulation preparations?

2.5 or 3.0 TT, airway equipment, suction

Manual resuscitator, mask, oxygen, oximeter

Vascular access (UVC, IO), crystalloid, packed RBCs (now), alternative volume expander; overhead warmer, external warming devices

Arrival (1 of 2)

A: Intubated with 3.0 TT. B: Good chest rise. Color is pale. Pulse

oximeter not reading. C: ECG monitor shows sinus bradycardia,

but patient is pale and pulseless.Electrical activity without pulsation or perfusion

is called?What is the likely cause in this case?

H’s and T’s. In this case, likely due to hypovolemia.

PEA (formerly called EMD)

Arrival (2 of 2)

• Blood loss suspected. Immediate vascular access required.

• UVC or IO? The fastest and easiest route should be used, but this depends on your personal skill level. Neonatologists prefer UVC. Peripheral IV or IO is acceptable. If an IO is attempted, consider using a smaller needle such as a spinal needle.

Vascular Access Obtained• Crystalloid bolus NS 20 mL/kg• Some color improvement.• Albumin bolus is given.• ECG shows bradycardia; patient is still

pulseless without chest compressions. Routine neonatal protocol crossmatch will take 40 min. Will you request blood now or wait 40 min? He is in severe hemorrhagic shock. Request blood now. Death likely if transfusion is delayed.

Uncrossmatched Blood

• He is given 20 mL/kg of uncrossmatched packed RBCs (type O negative).

• His heart rate and color immediately improve.

• Blood given to neonates is usually irradiated as well. If irradiated blood is not immediately available, nonirradiated blood might be the only alternative.

• Obtaining blood takes time. As soon as you think you need it, start process of getting it.

Code 7:“Found at Bottom of Pool”

• While at grandparents’ home, child was left to play on his own briefly.

• Grandfather began looking for him 5 min later.

• Another 5 min later, child found at bottom of pool.

• Grandfather dives in, and grandmother calls 9-1-1. It is a cold evening. Air temp is 40°F (4°C), and pool heater was turned off.

Case Progression (1 of 5)

• Child pulled from the pool, described as cold, limp, and lifeless. No respirations or pulse noted. Grandfather begins CPR.

• Paramedics arrive and start BMV and chest compressions.

• ECG shows ventricular fibrillation. Should patient be defibrillated?

Should patient be given epinephrine?Yes, but it is unlikely to succeed.

Yes, but it is unlikely to succeed in hypothermic patients.

Case Progression (2 of 5)

• Rewarming is necessary. • Passive rewarming: Warm blankets, radiant warmers,

hot packs• What are some possibilities for active core rewarming?

1) Intubation and ventilation with warm humidified oxygen.

2) Warm IV fluids (special pump/tubing required to do this well)

3) Gastric lavage with warm saline4) Surgical methods: Peritoneal lavage, thoracotomy

irrigation, ECMO (40° to 44°C)

Case Progression (3 of 5)

• Patient is intubated. Chest compressions continue.

• Rectal temp noted to be 28°C.How fast should patient be rewarmed?

What lab tests should be ordered during rewarming period?

1° -2°C per hour

Glucose 95 mg%,Na 129, K 3.8, Cl 100, Bicarb 14

Case Progression (4 of 5)

• Ventricular fibrillation persists.At what temperature should defibrillation be

attempted again?

In pulseless arrest VF algorithm, what is the ratio of defibrillation shocks to epinephrine doses?

It can be attempted earlier but is unlikely to succeed if core temp is less than 30°C.

Shock x3, then two options: 1) Epi-shock-epi-shock, repeat.2) Epi-shock-shock-shock, repeat.

Case Progression (5 of 5)

• He is successfully defibrillated on fourth attempt.

• Sinus rhythm results in a good blood pressure.

• Pulseless electrical activity (PEA) with hypothermia.

• Rewarming continues, and patient does well.

Code 8:“Sudden Deterioration in ICU”

• CODE BLUE is called in ICU at 2:00am.• Respiratory therapist is performing bag

ventilation on a 15-month-old, and the nurse is performing chest compressions.

• He was admitted to ICU from ED 6 hours earlier with bilateral pneumonia and hypoxia. He worsened rapidly, requiring intubation.

• Postintubation chest x-ray shows large bilateral pleural effusions.

Case Progression (1 of 4)

• Auscultation reveals poor aeration bilaterally. Breath sounds might be louder on left.

• ECG shows sinus bradycardia (30 bpm).• O2 sat is 40%.• No palpable pulse, BP not measurable.• Chest radiograph has just been taken.Should you wait for it or act now?

You must act now. Patient is likely to die before chest radiograph returns.

Case Progression (2 of 4)

What diagnosis should be suspected?

What procedure should you do immediately, and what side should you start on?

What result are you anticipating?Aspiration of air with noticeable improvement in patient’s cardiopulmonary status

Needle thoracentesis of the right side

Tension pneumothorax

Case Progression (3 of 4)

• From right thoracentesis, no air is aspirated, and the patient’s status is worsening.

What should be done now?Needle thoracentesis of left side.This results in rush of air and rapid rise in patient’s heart rate and oxygenation. BP improves, and chest compressions are discontinued.Active continuous aspiration through thoracentesis needle is continued.

Case Progression (4 of 4)

• Chest x-ray reveals tension pneumothorax on left with large pleural effusion on right.

What procedures should be done now?Tube thoracostomy (chest tube) should be done on left first to stabilize tension pneumothorax.Large amount of thick, purulent fluid drains through tube upon insertion. Tube thoracostomy is then performed on right side and also drains pus.

Other ConsiderationsList some other causes of sudden deterioration

while on a ventilator. Extubation, esophageal intubation, right mainstem intubation, plugged tracheal tube, oxygen mishap (no oxygen in line), ventilator malfunction, air embolus, pneumopericardium

Case Outcome

• Tension pneumothorax• Staph pneumonia • Bilateral empyema. Cultures from pleural

effusion exudate grow S aureus. • Staph pneumonia typically progresses

rapidly to bilateral empyema, respiratory failure, and pneumothorax. Prophylactic tube thoracostomies are sometimes recommended.

Code 9: “Faints in Office”

• Healthy 15-year-old boy has had three episodes of fainting at basketball practice during past month.

• He faints in office waiting room a few minutes after arrival. Mother cannot arouse him and cries for help.

• He is pale, apneic, and pulseless. You start CPR, and a nurse calls 9-1-1.

Case Progression (1 of 2)

• Nurse gets AED from office next door. Can AEDs be used in teenagers?

Which teenagers are likely to develop VF or VT and benefit from an AED? Patients with history of syncope with exercise are at risk for VF/VT. They should not exert themselves until cleared by a cardiologist.

Yes, AEDs are approved for use in children 8 years and older. Special pediatric AEDs can be used in children <8 and >1 year.

Case Progression (2 of 2)

• Apply pads according to picture.• Turn AED on.• “Analyzing rhythm.”• “Shock recommended.”• “Stand clear.”• Push shock button.• “Check pulse.”• Pulse present; patient begins to arouse.• EMS arrives; sinus rhythm noted.

Case Outcome

• Patient transported to hospital and admitted to ICU.

• Cardiologist evaluation determines patient has hypertrophic cardiomyopathy.

• Patient placed on antidysrhythmia agents.

Code 10: “Apneic Bradycardic”

• 25-year-old woman gives birth precipitously upon arrival in ED.

• Infant is covered with meconium and is limp without respiratory effort.

Should infant be mask ventilated or intubated for tracheal suctioning? Suction mouth and nose quickly, then proceed to intubate infant and suction trachea. If a meconium aspirator is not available, apply moderate suction to a 3.0 TT and withdraw it while suctioning.

Case Progression (1 of 3)

• Following tracheal suctioning and suctioning of mouth and nose, infant is still apneic and bradycardic.

What is your next action?

Infant is also bradycardic. Should he be given epinephrine or atropine? No. In most instances, bradycardia is due to hypoxia. Chest compressions should precede drugs.

ABCs. Open airway. Since infant is apneic, begin BMV with oxygen.

Case Progression (2 of 3)

• What conditions in the newly born would be made worse by bag-mask ventilation?Congenital diaphragmatic hernia is a major condition that would be worsened by BMV. Excessive BMV can also worsen pneumothorax, or force excessive air into stomach and bowel, resulting in restriction on diaphragm.

Case Progression (3 of 3)

• Infant’s color improves rapidly; HR is now above 100.

• Still has poor muscle tone and little spontaneous movement.

• When BMV is stopped, infant does not have a good respiratory effort and is not crying.

What are some possible causes?Maternal opiates – infant respiratory depression, birth asphyxia, brain malformation or hemorrhage

Case Outcome

• Maternal opiate use is suspected. • Naloxone is administered IMm and the

infant’s tone and respiratory effort soon improve.