Quiz 14

You are working on a hot summer day in an advanced life support (ALS) unit. You are two days away from a month off. Your plan is to disappear for a month from all pagers and radios and will ensure no one orders you back to work until you’re ready.

You are called to the local hospital by a frantic 9-1-1 call. It is not normal for the nurses to be in trouble. It is a small hospital with a physician who  is away today at the neighbouring community running a walk-in medical clinic. You commonly have coffee with the nurses and you know they have limited staff and if they are calling for help there is a good reason. Your partner “Mary” is a PCP and this is her first week at work; she is already nervous.

On arrival you are hustled into a patient’s room where a nurse is doing chest compression on what looks to be an older child. The nurse apparently had administered fentanyl IV as well as Maxeran IV after a post-op procedure and came back in 20 minutes to find the child unresponsive and pulseless. She had an open appendectomy for a ruptured appendicitis earlier today and was sent back to her home community to recover. Post-operatively she was slow to wake up, vomited a few times in the recovery room, but the post-surgery was uneventful otherwise.

Your partner runs to the airway. She appears to not be breathing. The patient is blue, pale looking, unresponsive and not responding to any stimuli. You immediately assess the patient and initiate lifesaving interventions and pray that time is on your side. This child, the mother of the child, as well as the nurse, need you more than you needed that holiday.

SAMPLE Hx (Emily 13 y/o female)

S – Sign/symptoms of either a respiratory or cardiac arrest for an unknown reason
A – No known allergies
M – Fentanyl 25 mcg, slow IV and Maxeran 5 mg, slow IV about 20 minutes ago, Ativan 0.5 mg IV just prior to surgery. There was a general anesthetic, A/B therapy was started and will be ongoing for three to five days. Immunizations are up-to-date.
P – NPO since yesterday, had tonsillectomy and adenoidectomy (T/A Surgery) at the age of three, with no other history or medical events.
E – Had an emergency surgery after having a ruptured appendectomy early this morning.

EMR – PCP (BLS Questions)

What is your next course of action? Complete a primary survey. Seek a complete SAMPLE history from the nurse to make sure nothing has been missed to rule out all the normal complications. Ensure your partner inserts an appropriate OPA and make sure she has an appropriately sized BVM ready to go immediately after the current cycle of chest compressions. All of the above.

Which of the following would be the most common causes of complications within the first 24 hours following intra-abdominal surgery? Hypoxia, dehydration, hypovolemia and medication errors. Malignant hyperthermia. Infection and sepsis. B and C.

Your partner inserts an OPA and suctions the airway while you assess the patient. What would be the rate to ventilate the patient with the BVM? 1 time every 6 seconds. 1 time every 15 seconds. 2 ventilations followed by 15 chest compressions every 30 seconds. 2 ventilations immediately followed by 30 chest compressions.

The patient is a 13-year-old female, about 45 kg. The rate of chest compressions should be at a rate of at least ______________ now. 120 per minute 80 per minute 160 per minute 100 per minute

The patient is starting to have some agonal respirations. You should continue ventilations and assess for a pulse at the end of the two minutes of CPR. True. False.

The patient has a heart rate of 45 beats per minute (sinus bradycardia) on the monitor but no palpable pulses. You should stop CPR and see if the heart rate increases over the next 30 seconds. True. False.

You have performed a primary examination. There is a penrose drain from the recent surgery with retention sutures over the lower right abdomen. The abdomen is only slightly distended with hyper-resonance on percussion. This is most likely from: larger or forceful BVM ventilations. intra-abdominal hemorrhage. infection and sepsis. all of the above.

The patient’s grandmother has a history of Type 2 gestational diabetes. The best way to ensure the patient is not suffering from a diabetic complication would be to: Call the lab tech to do a “Stat” blood sugar test. Do a bedside blood sugar test from your kit. There is no reason to do any lab work at this time. Kids can’t have Type 1 diabetes.

What would be the best way to assess the effectiveness of the ventilations? Bag until the peep valve pops off. Bag until the chest rises equally. Bag for two seconds and then pause for one second. The child needs 20 ml/kg per each ventilation every time.

You have an IV established with an 18 gauge in the left AC, 1,000 ml NS and a 10-drop set. At which rate do you run the IV? 250 ml bolus. 10 ml/kg bolus. 20 ml/kg bolus.

What is the best way to know whether the CPR is good and effective? There is a good femoral or central pulse with each chest compression. There is a good waveform with the end tidal C02. The Sp02 registers and is at a normal range. B and C only.

Your patient now has better skin colour but remains pulseless. What is your next course of action? Continue CPR. Assess the core temperature. Assess the Sp02, C02 and then reassess the lung sounds with each ventilation. All of the above.

Your partner has been doing CPR for two complete cycles. Your partner should now switch out from chest compressions. True. False.

You know CPR should be done up to two times longer in children than in adult, while ensuring good BLS or ALS interventions. True. False.

You intubate the patient and notice there is a greater chest rise on the left than on the right. This is likely from a left stem intubation; a common event. True. False.

The patient’s Sp02 is low and your partner is having difficulty ventilating as she states “the chest is tight.” What do you think this patient needs most right now? A CXR. Immediate bilateral chest percussion, followed by a needle decompression for a tension pneumothorax of the right chest. To wait for the doctor who is almost back to insert a chest tube. A and C only.

The end tidal C02 is registering at 28 and just two minutes ago it was less than 10, with a good waveform. This is most likely from a spontaneous return of circulation in the patient. True. False.

The patient is most likely hypoxic. The best way to prevent long-term deficits from an anoxic brain event is to: ventilate the patient one time every five to six seconds after a return of an adequate pulse. ensure the Sp02 is above 92%. bag the patient at a rate to ensure the C02 is between 35 to 45 mmHg. All of the above.

This patient has a BP of 64/32 with a pulse rate of 56 bpm. The best therapy is to: ensure an adequate fluid bolus has been administered. initiate an epinephrine infusion from 0.01 mg/kg using (1:10,000 sol) IV/IO q3-5min prn or use a 0.5 to 10 mcg/min infusion and titrate for effect. initiate a dopamine infusion at 2.5 to 20 mcg/kg/min until stable. do all of the above.

The lab has returned with the preliminary lab work post-arrest. The Hgb comes back at 94 g/l with a lactate of 3.2, and a blood pH of 7.02 on an ABG. The potassium comes back at 3.4 as well. The best treatment would be to: repeat fluid bolus and administer sodium bicarbonate at 1 to 2 mEq/kg and then repeat the lab work in one hour. increase the dopamine infusion, discontinue fluid boluses and administer potassium chloride 10 mEq over one hour and then repeat the lab work. do nothing as the patient is probably stable now. initiate fluid bolus and administer sodium bicarbonate at 4 to 6 mEq/kg and repeat lab work in one hour.

The patient is starting to move and respond to stimulation. You should get ready to extubate the patient when she wakes up and see how she does medically. True. False.

This patient should be prepared for: a stat transfer to a Pediatric Intensive Care Unit by the quickest and safest mode of transport with online physician referral. someone to do a CXR and ensure the endotracheal tube is adequate and ensure the OG is at the correct level. someone to initiate a second IV and also insert a Foley catheter to see if there is adequate urinary output. all of the above.

The patient’s BP has improved and the HR is in a normal range. When should you consider discontinuing the pressor agent? When the patient is ready to transfer to PICU. When the renal perfusion is adequate at least 1 ml/kg, the heart rate is stable and the BP is remaining in a normal range. The pressor agent should be kept at the same range throughout the transfer. A or B.

This event could be viewed from an outsider as a medical nightmare. There is always blame aimed at everyone involved for medical errors or omissions in patient care. The best way to prevent this type of event in the future would be to: asses the Sp02 and C02 after the surgical event until the child is stable and deemed recovered. participate in an open and constructive debriefing with all parties to try to prevent this from occurring after the event is over. participate in a Pediatric Advanced Life Support Course every two to three years and also encourage the local physicians and nurse as well as the LPNs and NA to attend as well. do all of the above.

The best way to help the parents deal with this matter is to be honest and tell them what is happening and what is going to happen in her care even if legal action might arise at a later date. True. False.