Kreziel D.

Escobar
MOCK CODE
CASE: Respiratory distress(Disordered Control of breathing)- Respiratory FailureVentricular Fibrillation
Scenario:
A 6 years old male came to emergency with trouble breathing, lethargic, increase
effort upon breathing, pale skin with history of cough, shortness of breath and fever
for 3 days. Known case of Bronchial Asthma and Cerebral Palsy with seizure
disorder.
Part 1:
First responder came and assist patient, placed non- rebreathing mask 10 liters
/minute.
Resus team arrives: Identification of name and role in the team
Nurse 1: Secure airway-suction secretions
Nurse 2: Procedure- connects to cardiac monitor
-apply pulse oximeter , take weight(broselow),check
temperature
Nurse 3: Medication prepare ventolin and atrovent
Nurse 4:Documentation
Vital signs:
T 39.7/rectal, PR 130/MIN ,peripheral pulse normal, BP 102/50, SPO2: 80%, RR
62/min, sterna retraction, excess secretions, coarse breath sounds
Weight: 18 kg by broselow
Nurse 3: Paracetamol given 270mg per rectal(15mg/kg)
Part 2: Secondary Assessment
Patient is lethargic, weak, with fever, cough, shortness of breath for 3 days ,
unknown allergies, on medication: phenobarbitone, topamax, Last meal taken per
gastrostomy 3 hours ago, vomitted after feeding with acute onset of respiratory
distress
Please repeat vital signs:

T 38.2/rectal, HR 120/min, SPO2 92% (Oxygen), BP 90/50, RR 52 with secretions,

still labored breathing

Part3
Kreziel: Please insert IV line , get blood works (CBC, U/E, Calcium,Magnesium, VBG,
HGT, Blood culture and sensitivity, Drug level
Nurse 2: IV line inserted , blood works taken, HGT- 4.5 mmol/l
Kreziel: Start IV bolus of 0.9 NaCl 360 ml 0ver 30 minutes (20ml/kg)
Maintenance : D50.45NaCl 70ml per hour
Also give ventolin 5mg and atrovent 250 mcg for 3 doses back to back
Please request portable chest xray (Suspected : Aspiration Pnuemonia)
Prepare ceftriaxone 1350mg IV(75mg/kg) max:2 gram, wt:18 kg
Nurse3: Ceftriaxone 1350 m given IV over 30 minutes
Part 4:
Reassessment of the patient
Vitals Signs
T 38C/rectal ,PR 152, BP 103/58, SPO2 70% (oxygen) desaturating , RR 14
Kreziel: Prepare Intubation
Nurse 1: Equipments for intubation prepared
(ET TUBE size:

, laryngoscope, stylet, 10 cc syringe , ky jelly)

Nurse 3: Rapid Sequence Intubation Medication prepared

( succynlcholine3.6mg (0.2mg/kg), atropine1.8mg(0.1mg/kg),
midazolam1.8 mg(0.1mg/kg)
Doctor: Successfully intubation done
Kreziel: Please rechecked saturation
Nurse 1: Now, saturating 98%
Kreziel: Request portable chest x-ray for confirmation of ET tube

Chest xray technician came and chest xray done: ET tube was in place
Part 5
Suddenly patient deteriorates, HR 52, BP 49/39mmhg, Spo2 95%
NURSE 2: Notice Ventricullar Defibrillation
Doctor: Please start compression and continue bagging
Prepare for defibrillation
NURSE 2: Compression started
Kreziel: turn the knob give 36 joules (2 joules/kg)
Doctor: Clear the patient for defibrillation, I am clear,your clear, everybody clear,
oxygen away, shocked delivered.
Nurse2: resume compression
Nurse1: Secured airway( bagging)
Kreziel: Good job Nurse 2 , your doing right in way: push hard ang fast , Nurse 1:
securing airway
Nurse2:( 3 cycles of CPR)
Kreziel: 3 MINUTES over , Lets assess the rhythm
Doctor: Still showing Ventricular Fibrillation
Kreziel: Prepare for next defibrillation 140joules (4joules/kg)
Resume Compression
Nurse 4: 3 minutes over
Kreziel: Lets analyze rhythm( Normal sinus rhythm)
Please check pulse
Nurse 2: peripheral pulse is present and matching the monitor
Kreziel : any laboratory available
CBC RESULTS :WBC-6.3, HGB:12 , HCT: 35.9% , MCV:83.4 MCH:27.9 MCHC:334 ,
RDW: 12.5 %PLATELET:198 neutrophils:41.3% LYMPHOCYTES 48.2% basophils 0.7%

UREA &ELECTROLYTES: RBS: 22.5mmol/l Urea:4.1mmol/l, creatinine 62 umol/l,

sodium 132mmol/l,potassium 2.8mmol/l, chloride 95 mmol/l, bicarbonate 27 mmol/l,
osmolality 290.3 mosm/kg
VENOUS BLOOD GAS: pH: 7.20, PCO2:38.9, PO2:46, BICARBONATE 20, TOTAL
CO2 24.9,OXYGEN SATURATUION 81% , haemoglobin12.9
Kreziel: Please change fluid to D50.45NACl + 30 mmol/liter KCL at 70 ml/hr
Part 6 :TERTIARYASSESSMENT
Afebrile 37C/rectal
PR 128/min
SPO2: 98%( intubated)
Normal sinus rhythm , with IV fluid
Patient is stable .Please call PICU and we will shift the patient.