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?
efib indicated in pulseless VF/VT, not as
Should the patient be intubated in the field?
Available data say no. Other consideratio
How should vascular access be established?
IV or IO
Drug protocol?
Epinephrine 0.1 mL/kg 1:1000 TT
or 1:10,000 IV/IO every 3 to 5
min. Consider higher dose.
 Arrival in ED
Patient is intubated. TT tube size?
3.5 or 4.0 TT
Expected ETCO2 wave form to confirm
intubation? Might show poor wave
form if pulmonary perfusion is
poor, in which case, cannot be
used
How to confirm
can chest trach
compressions and ventilations
intubation.
be monitored and optimized?
Auscultate, chest movement,
ETCO2. Check pulse, BP,
optimize pulse ox perfusion and
oxygenation.
 Other Considerations
Glucose check? 110
Prognosis? Poor mg%
Duration of resuscitation attempt?
Available data suggest about
30 minutes.
Reversible causes of pulseless arrest?
H’s, T’s: Hypoxemia,
hypovolemia, hypothermia,
hyponatremia, hyperkalemia,
hypoglycemia, tamponade,
tension pneumothorax, toxic
ingestion, thromboembolism
 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?
Epiglottitis
• Vital signs:
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)? Yes, so
strategy to optimally deliver
BMV
Why should
did he arrest? Isbe
hisconsidered.
airway completely
closed? 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?
Two-man method to optimize
mask seal and ventilation
effortpositioning?
• Supine 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.
Upright Mouth Leaning forward

Mouth
E
E
C C

T
T

Epiglottitis x-ray He prefers to lean forward

Epiglottis (E), Vocal cords because this moves the
(C), Trachea (T) epiglottis off his airway opening.
Mouth Prone (face down)

E
C T
C T
E

Supine (face up) Mouth

When supine, epiglottis When prone, epiglottis
falls onto airway falls anteriorly off airway
opening, worsening opening, improving airway
airway obstruction. 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 algorithm
Should the patient be given drugs or electricity
Defib x3 first
first?
Should the patient be defibrillated or
cardioverted?Defibrillated
2 J/kg, then 2-4 J/kg, 4 J/kg
How many joules?
What reversible cause of pulseless arrest is
possible in this patient?
Hyperkalemia. Rhythm often
resembles VT.
 Hyperkalemia
• No improvement after 1 round of epinephrine
and defibrillation x4.
What drug most rapidly reverses dysrhythmia
due to hyperkalemia?Calcium
What other measures can be taken to lower
potassium levels in this patient and in non-
dialysis patients? NaBicarbonate,
albuterol, insulin/glucose,
furosemide,
What Kayexalate,
other conditions predispose to dialysis
hyperkalemia? 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? No.
What is the next intervention? 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 Algorithm
Is it appropriate to perform abdominal thrusts,
back blows, or chest compressions?
Five abdominal thrusts are
indicated. Other choices are
Is indicated in infants.
this more optimally done with the patient
supine, leaning forward, prone, or upside
down? Can be done upright or
supine. Other positions are
Anydifficult but have
role for laryngoscopy or advantages.
use of Magill
forceps? 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 Outcome
Can a marble fit into the trachea of a 2-year-
old? No
Where could the marble go, and how does it
obstruct the airway?
1) Esophagus – compress
trachea
• 2) Larynx
Airway – block
obstruction vocal cords
algorithm:
– Abdominal thrusts for children
– Back blows, chest compressions for infants
– Laryngoscopy
 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?
2.5 or 3.0 TT, airway
equipment,
Breathing suction
preparations?
Manual resuscitator, mask,
oxygen,
Circulation oximeter
preparations?
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? PEA (formerly
called
What is the EMD)
likely cause in this case?
H’s and T’s. In this case, likely
due to hypovolemia.
 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? Yes, but
it is unlikely to succeed in
hypothermic
Should patient be givenpatients.
epinephrine?
Yes, but it is unlikely to
succeed.
 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 saline
4) 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?
1° -2°C per hour
What lab tests should be ordered during
rewarming period?
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? It can be
attempted earlier but is
unlikely to succeed if core
In temp isarrest
pulseless lessVFthan 30°C.
algorithm, what is the
ratio of defibrillation shocks to epinephrine
doses? 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?
Tension pneumothorax
What procedure should you do immediately,
and what side should you start on?
Needle thoracentesis of the
right
What side
result are you anticipating?
Aspiration of air with
noticeable improvement in
patient’s cardiopulmonary
status
 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
 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 Considerations
List 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?
Yes, AEDs are approved for use in
children 8 years and older. Special
pediatric AEDs can be used in
children
Which <8 and
teenagers >1 year.
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.
 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? ABCs. Open
airway. Since infant is apneic,
begin BMV with oxygen.
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.
 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.