Simulation Scenarios PDF

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Simulation Scenarios
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Academy of Pediatrics and the American College of Emergency Physicians. No endorsement of
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that contributors to the APLS materials are knowledgeable authorities in their fields. Readers
are nevertheless advised that the statements and opinions expressed are provided as guidelines
and should not be construed as official policy of the American Academy of Pediatrics or the
American College of Emergency Physicians. The recommendations in these accompanying
materials do not indicate an exclusive course of treatment. Variations, taking into account
individual circumstances, nature of medical oversight, and local protocols, may be appropriate.
The American Academy of Pediatrics, the American College of Emergency Physicians, and the
authors here within disclaim any liability or responsibility for the consequences of any actions
taken in reliance on these statements, opinions, or contents contained within these materials.
© 2015 by the American Academy of Pediatrics and the American College of Emergency Physicians
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Simulation Scenarios
Contents
Adrenal Insufficiency 1
Blunt Abdominal Trauma—Hypovolemic Shock 4
Cardiogenic Shock Due to Congenital Heart Disease 8
Altered Mental Status 10
Diabetic Ketoacidosis and Cerebral Edema 12
Hyperthermia 15
Hypothermia—Near Drowning 18
Iron Overdose 22
Myocarditis—Cardiogenic Shock 25
Occult Trauma (Intentional Trauma) 27
Postoperative Cardiac Patient—Ventricular Fibrillation 30
Septic Shock 33
Chest Crisis—Sickle Cell Disease 36
Status Asthmaticus 39
Status Epilepticus 42
Stridor Due to Foreign Body 45
Supraventricular Tachycardia 48
Tricyclic Antidepressant Overdose 50
Metabolic Crisis—Hyperammonemia 54
Adrenal Insufficiency
Adam Cheng, MD, FRCPC, FAAP
Mark Adler, MD
Learning Objectives
• D
escribe the signs and symptoms of an infant presenting with salt-wasting adrenal crisis associated with congenital adrenal hyperplasia
and adrenal insufficiency.
• Demonstrate the treatment of a newborn with salt-wasting crisis.
– Initial stabilizing steps.
– Replacement therapy.
Simulator: Infant Simulator
Scenario Patient Instructor Time,

Stage Condition Intervention Debriefing Notes min
STAGE 1 History Take a History: 5
• Three-week-old boy with unremarkable history, referred to • No ill contacts
emergency department from physician’s office with a low • No medications
serum sodium level (126 mmol/L) • No allergies
• Mother’s pregnancy was normal; she recalls no abnormal • Poor feeding over last week, spitting up more in past few
test results days
• Triage nurse was worried about how ill the child appears • No fever
• You arrive to assess the patient • Sleeping through feeding time last few days, slept most of
Weight: the last 12 h
• 3 kg • Has lost weight since last family physician visit
Condition: Airway:
• Very unwell, listless • Listen for breath sounds, present
Physical Examination Findings: • Apply oxygen via nonrebreather mask at 15 L/min
• Temperature 36.2°C (97.2°F), HR 152/min, RR 36/min, oxygen Breathing:
saturation 98% in room air, BP 72/58 mm Hg • Apply monitors, including oxygen saturation and blood
• CNS: asleep, wakes briefly with painful stimulation pressure
• CVS: pulses present centrally, absent peripherally • Auscultate chest and observe respiratory rate
• Respiratory: clear Circulation:
• Abdomen: no hepatosplenomegaly • Assess pulse, HR, capillary refill, BP
• Extremities/skin: capillary refill >4 s • Ask nurse for an IV catheter to be placed
• Ask for normal saline or lactated Ringer solution bolus of 20
mL/kg to be given quickly (push)
Medical Management:
• Order laboratory tests: (CBC, electrolytes, blood cultures,
venous blood gas, bedside glucose)
1 Simulation Scenarios
STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 5
• HR remains elevated and BP is now low Circulation:
• Nurse notes aloud, “His hands are just so cold.” • Reassess HR, pulse, capillary refill, BP after bolus
• Blood glucose level is low if bedside testing was performed • Order second bolus, also push
• Laboratory results: sodium 124 mmol/L, potassium 7.8 Medical Management:
mmol/L, bicarbonate 16 mmol/L, BUN and creatinine normal • Consult endocrinologist for treatment guidance; order tests
for age, pH from venous gas 7.26 they might request
Physical Examination • Order IV hydrocortisone
Findings: • Order D10W IV bolus to correct hypoglycemia
• HR 150/min, RR 36/min, oxygen saturation 99% on 100%
• Initiate management of hyperkalemia
oxygen (if placed), BP 73/60 mm Hg
• CNS: cries weakly with painful stimuli
• Respiratory: clear
• CVS: clamped down and cool extremities.
• Abdomen: no hepatosplenomegaly

• “He is looking around more now.” Circulation:
• Improved perfusion and alertness after second bolus • Reassess HR, pulse, capillary refill, BP
Physical Examination Findings: Medical Management:
• HR 138/min, RR 36/min, BP 78/48 mm Hg, saturation 98% on • Order recheck of electrolytes after bolus therapy
room air Disposition:
• Abdomen: no hepatosplenomegaly • Arrange for neonatal or pediatric ICU for monitoring
and frequent laboratory work until stabilized or plan for
transport to tertiary care facility (depending on presenting
facility resources)
Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; D10W, 10% dextrose in water; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR,
respiratory rate.
Notes
1. Potassium and sodium derangements usually do not require short-term treatment beyond fluid resuscitation and hydrocortisone.
Common Pitfalls
• Intravenous (IV) fluid for volume expansion is not delivered in a rapid and/or controlled manner.
– IV “wide open” fluid administration can lead to very rapid infusion of a whole liter of fluid OR can result in underresuscitation if there is significant re-
sistance to flow (small IV gauge). Infants and small children should always receive resuscitation fluids using a pump or push to allow for observation and
control of fluid delivery. Pressure bags can increase the likelihood of excessive fluid overload.
– Pushing fluid is accomplished by attaching a three-way stopcock in line with the IV catheter and pulling fluid directly from the bag (step 1) and then
switching the stopcock and pushing the fluid into the patient.
• Failing to check a bedside glucose level. Hypoglycemia is not always present in patients with congenital adrenal hyperplasia and salt-wasting crisis, but it can
occur.
• Delaying treatment with hydrocortisone to obtain diagnostic tests.
Blunt Abdominal Trauma—Hypovolemic Shock
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of a patient with hypovolemic shock.
• Demonstrate the management of circulatory failure due to hypovolemic shock.
– Demonstrate the approach to pediatric trauma: primary and secondary assessment.
– Demonstrate use of fluid resuscitation in patients with profound blood loss.
– Identify and manage abdominal injury in a trauma patient.
– Demonstrate use of rapid infuser in trauma care.
Simulator: Pediatric Simulator

STAGE 1 History: TAKE A HISTORY: 2
• Five-year-old boy From Paramedics:
• Playing in the driveway • Initially delirious, screaming, GCS score of 15/15
• Found by parents crushed and trapped underneath garage • Extraction took 10 min in total
door • IV antecubital one time
• Garage door directly over his abdomen • Given normal saline. 20 mL/kg
• No witnesses to the incident • Transport time, 15 min
• Ambulance arrived within 12 min PRIMARY SURVEY MANAGEMENT:
Weight: Airway:
• 18 kg • Assess airway, talk to the patient
Condition: Breathing:
• Moaning in pain • Check oxygen saturation
• Temperature 36°C (96.8°F), HR 150/min, RR 30/min, BP 85/50 • Apply monitors
mm Hg, oxygen saturation 96% room air • Auscultate chest
• Monitor: sinus tachycardia • Check for chest rise
• CNS: cervical collar on patient; moaning in pain, answers • Apply 100% oxygen
questions, asking for mom, confused at times, GCS score
Circulation:
of 15.
• Apply monitors
• H/N: cervical spine not tender, no obvious facial injury
• Check pulse, capillary refill, BP
• CVS: capillary refill 4 s, pulses palpable but weak
• Identify the rhythm
• Respiratory: chest clear
• Check first IV catheter, asks for second large-bore IV catheter
• Abdomen: bruising all over abdomen
• Ask for rapid infuser and bolus of IV normal saline
• Neurologic: normal
• Order trauma blood work, including type and cross.
• Musculoskeletal: normal
• Activate trauma team/call for help
• The patient’s condition has worsened slightly, BP lower, GCS Airway:
score unchanged • Maintain cervical spine precautions
Physical Examination Findings: Breathing:
• Temperature 36°C (96.8°F), HR 170/min, RR 40/min, BP 80/40 • Auscultate chest
mm Hg, saturation 100% with oxygen by mask
Circulation:
• Monitor: sinus tachycardia
• Reassess HR, pulses, BP, capillary refill
• CNS: cervical spine collar on patient; moaning in pain,
• Ask for second bolus of IV normal saline
answers questions, asking for mom, confused at times, GCS
• Reaffirm need for rapid infuser
score of 15
• Order blood
• H/N: cervical spine not tender, no obvious facial injury
Performs Secondary Survey:
• CVS: capillary refill 4 s, pulses palpable but weak
• H/N: pupils equal and reactive to light, facial bones not
• Respiratory: chest clear
tender, neck supple and not tender
• Chest: trachea midline, chest clear.
• CVS: profoundly tachycardic, color mottled now, pulses
weak, and capillary refill 5 s
• Abdomen: soft. Bowel sounds absent, tender all over
abdomen (screams in pain)
• Pelvis: stable.
• Genitalia: no blood at meatus
• Back: good rectal tone, no tenderness
Medical Management:
• Pain control: IV morphine
• Immediate consultation: general surgery
• Order radiographs: cervical spine, chest, pelvis
• Insert nasogastric tube
• Insert Foley catheter
STAGE 3 Condition: REASSESSMENT OF PATIENT: 5
• The patient is less responsive, BP is decreasing, eyes still open, Airway: Intubation:
GCS score of 13 • Prepare for intubation due to decreasing level of
Physical Examination Findings: consciousness
• Temperature 36°C (96.8°F), HR 180/min, RR 40/min, BP 70/30 • Preoxygenate
mm Hg, saturation 100% with oxygen by mask • Prepare equipment and ETCO2
• Monitor: sinus tachycardia • IV atropine
• CNS: cervical spine collar on patient; moaning in pain, • IV ketamine or etomidate
intermittently answers questions, confused and delirious at • IV succinylcholine
times, GCS score of 13. • Check tube placement after intubation, order chest
• H/N: cervical spine not obviously tender, no obvious facial radiograph if intubation is performed
injury
Breathing:
• CVS: capillary refill 5 s, pulses palpable but very weak • Assess chest before and after intubation
• Respiratory: chest clear • Monitor oxygen saturation
Circulation:
• Identify worsening shock
• Order third bolus of IV normal saline and blood (O negative
if cross-matched not available)
Blood Work:
• WBC 15,500/mm3, hemoglobin 7 g/dL, platelets 500,000/
mm3
• Sodium 135 mmol/L, potassium 4.5 mmol/L, urea
4.2 mmol/L, creatinine 46 mmol/L, glucose normal
• pH 7.20, Pco2 40 mm Hg, Po2 80 mm Hg, bicarbonate
15 mmol/L, base excess −11 mmol/L
Imaging:
• Normal radiographs
Medical Management:
• General surgeon arrives: discuss need to perform CT of the
abdomen vs direct to operating room
• Consider focused abdominal sonography for trauma
• Discuss need for CT of the H/N and chest.
Abbreviations: BP, blood pressure; CNS, central nervous system; CT, computed tomography; CVS, cardiovascular system; ETCO2, end-tidal carbon dioxide; GCS, Glasgow Coma Scale; H/N, head and neck; HR, heart rate; IV, intravenous; RR,
respiratory rate; WBC, white blood cell count.
Notes
1. Makeup can be applied to the mannequin to simulate bruises on the abdomen.
2. Use of a prerecorded focused abdominal sonography for trauma (FAST) video can be projected on a computer screen while FAST is being performed
Common Pitfalls
• Failure to stabilize cervical spine during assessment and treatment of patient.
• Failure to perform a complete secondary survey (eg, failure to log roll patient or failure to assess neurologic status of lower extremity).
• Sedation and/or paralysis of patient before completing neurologic assessment of patient.
• Treatment of patient without support of consultants.
Cardiogenic Shock Due to Congenital Heart Disease
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of an infant with cardiogenic shock.
• Demonstrate the management of circulatory failure due to cardiogenic shock.
– Obtain a chest radiograph to confirm suspected cause of cardiac shock.
– Use normal saline to expand circulatory volume in a limited manner.
– Obtain consultative services urgently.

STAGE 1 History: Take a History: 5
• Five-month-old boy with history of poor feeding and weight • No ill contacts
loss for past month • No upper respiratory tract infection symptoms, no diarrhea
• Sent from physician’s office for evaluation • Takes a long time to eat and tires out; sweats a lot with feeding
• You are called to evaluate patient • Was noted to have a “hole in the heart” on a prenatal
Weight: ultrasonogram but had no murmur at birth—no follow-up
• 5 kg was performed
Condition: • No allergies
• Very unwell, gray, with respiratory distress • Reflux medications started for poor feeding
Physical Examination Findings: • Approximately 0.5-kg weight lost during last 2 wk
• Temperature 37.3°C (99°F), HR 158/min, RR 58/min, oxygen Airway:
saturation 91% in room air, BP 72/58 mm Hg • Listen for breath sounds
• CNS: cries weakly, lays still in bed • Apply oxygen via nonrebreather mask at 15 L/min
• CVS: pulses present centrally, weak peripherally Breathing:
• Respiratory: bilateral crackles, retractions • Apply monitors, including oxygen saturation and blood
• Abdomen: liver is firm and enlarged to the umbilicus in the pressure
midclavicular line • Auscultate chest and observe respiratory rate
• Extremities/skin: capillary refill approximately 3 s Circulation:
• Assess pulse, HR, capillary refill, BP
• Murmur and gallop rhythm heard
• Ask nurse to obtain IV access
• Ask for normal saline or lactated Ringer solution bolus of 5
or 10 mL/kg
• Palpate abdomen for organomegaly as a sign of right heart
failure
STAGE 1, Medical Management:
continued • Order laboratory tests (CBC, electrolytes, venous blood gas,
bedside glucose, consider infection laboratory work at this
time as diagnosis not clear)
• Order ECG and a chest radiograph

• Condition is unchanged Circulation:
• Venous gas reveals acidosis (pH 7.21, Pco2 28 mm Hg, Po2 32 • Nurse cannot obtain IV access; intraosseous needle placed
mm Hg, base excess −16 mmol/L) by participant
• Blood glucose level is normal • Reassess HR, pulse, capillary refill, BP after bolus
• Chest radiograph reveals marked cardiomegaly with • Call for cardiologist to consult and perform
pulmonary markings consistent with fluid overload echocardiography; if not locally available, begin process of
Physical Examination Findings: transferring patient
• HR 163/min, RR 60/min, oxygen saturation 98% in 100% • Consider IV furosemide for fluid overload
oxygen (if placed), BP 78/53 mm Hg • Consider afterload reduction (eg, milrinone)
• Examination findings unchanged Medical Management:
• Consider bicarbonate for acidosis
STAGE 3 Condition: REASSESS THE PATIENT: 5

• Patient stabilizes Disposition:
Physical Examination Findings: • Arrange for ICU admission or transport to tertiary care
• HR 162/min, RR 52/min, BP 78/62 mm Hg, saturation 98% on facility (depending on presenting facility resources)
nonrebreather mask • Obtain second IV access other than intraosseous access
Abbreviations: BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ECG, electrocardiogram; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate
Notes
1. Radiography can be performed via a simulator (some models support this) or as a “wet read” result communicated to the team noting the large heart and
fluid overload.
2. The quality of cardiac and respiratory sounds varies considerably among simulator models. Comments from the nurse confederate can help clarify
findings—“I listened at triage and thought I heard a loud murmur.”
Common Pitfalls
• Misrecognition of patient as having respiratory distress due to reactive airway disease and administration of albuterol (salbutamol). Patient will get worse
with this therapy.
• Misrecognition of patient as having sepsis, with excessive fluid delivery, resulting in increasing heart rate and respiratory rate and decreased oxygen
saturations. Nurse confederate notes that the child “looks worse after that bolus.”
– Both of these problems occur when an inadequate history is obtained—the history provided is a clear indication of a primary cardiac cause.
• Treatment of patient without support of consultants. Echocardiography is an important step in management planning, and the initial steps in performing
this test should be started as soon as possible.
Altered Mental Status
Mark Adler, MD
Learning Objectives
• Describe the common causes of altered mental status in an infant.
• Demonstrate the treatment of an infant with altered mental status.
– Assessing for possible ingestion.
– Checking glucose at bedside.
– Treating hypoglycemia and confirming that treatment was effective.

STAGE 1 History: Take a History: 3–4
• Eleven-month-old found unresponsive, was with • No allergies
grandmother, who is his usual babysitter • Patient takes no medications
• Brought to ED by grandmother • No ill contacts
• Unresponsive at triage, brought to resuscitation bay • No idea at all what has happened
• You are called to assess patient • No history of trauma or fall
Weight: • No other children in home
• 9 kg • If asked specifically, grandmother takes oral sulfonylurea
Condition: (glyburide), which she keeps in a bedside drawer
• Infant is pink and well-perfused but comatose Airway:
Physical Examination Findings: • Listen for breath sounds
• Temperature 37.2°C (99°F), HR 94/min, RR 28/min, oxygen Breathing:
• CNS: unresponsive to painful stimulation if given. Pupils 3 pressure
mm and reactive bilaterally • Auscultate chest and observe respiratory rate
• CVS: pulses intact Circulation:
• Respiratory: clear • Assess pulse, HR, capillary refill, BP
• Abdomen: soft and without hepatosplenomegaly • Ask nurse to obtain IV access
• Extremities/skin: no bruising noted (if asked specifically) Disability:
• Quick neurologic assessment (pupils, response to pain)
STAGE 2 Condition: Medical Management: 5
• Mental status unchanged • Recognize and treat hypoglycemia (5 mL/kg D10W using the
• Blood glucose level is low if measured “rule of 50”—see note below)
Physical Examination Findings: • Perform further ingestion laboratory tests (urine toxicology,
• Vitals unchanged acetaminophen [paracetamol], salicylates, ethanol, +/–
digitalis levels)
STAGE 3 Condition: Medical Management: 5

• Patient is now more awake and cries • Order recheck of glucose level in 15–30 min
• HR 125/min, RR 28/min, BP 85/62 mm Hg, saturation 98% on • Recognize need to provide supplementary IV glucose and
room air admit due to long-acting oral diabetic agent
Disposition:
• Hospital or ICU for frequent IV glucose level checks
Abbreviations: BP, blood pressure; CNS, central nervous system; CVS, cardiovascular system; D10W, 10% dextrose in water; ED, emergency department; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate.
Notes
1. Rule of 50 = to give half of a gram of glucose per kilogram of body weight, the product of the glucose concentration (eg, D10) and the dose in milliliters per
kilogram should equal 50. Note that this dosing is different than recommended by the Neonatal Resuscitation Program course, and this can be a source of
confusion among participants.
CONCENTRATION DOSE PRODUCT
D10 5 mL/kg 50
D25 2 mL/kg 50
D50 Not recommended due to high osmolarity
2. To discourage the use of the term “amp,” our practice is to state that we do not have adult amps available at this time.
3. Specific drug screening practices vary. Although polyingestions are more common in adolescents, most of the listed drugs above are high-risk, treatable
entities.
Common Pitfalls
• Participants do not ask about medication in the home but only what the child is taking.
• Participants check the glucose level and treat the patient according to the glucose level but fail to obtain a follow-up glucose measurement.
Diabetic Ketoacidosis and Cerebral Edema
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of a child presenting with diabetic ketoacidosis (DKA).
• Describe the signs and symptoms of moderate dehydration.
• Demonstrate the treatment of a child with DKA.
– Management of suspected cerebral edema.

STAGE 1 History: Takes a History: 5
• Six-year-old girl • Excessive drinking, bedwetting, and increasing tiredness
• Two-week history of fever and lethargy • “Growing but not gaining weight”
• Very unwell in last 24 h: excessively drowsy, very poor • Unwell for 36 h with increasing fatigue, vague abdominal
energy, difficulty breathing, abdominal pains pain
Weight: • Polyuria, polydipsia, enuresis, 5-kg weight loss
• 20 kg • No vomiting
Condition: • Becoming progressively lethargic today
• Looks unwell; GCS score of 13 (motor response 6, vocal • Medical history: unremarkable
response 4, eye response 3) Airway:
Physical Examination Findings: • Assess airway
• Temperature 37.4°C (99.3°F), HR 160/min, RR 30/min, BP • Provide head tilt, chin lift, jaw thrust as needed
90/50 mm Hg, oxygen saturation 98% on room air Breathing:
• Very flushed cheeks • Check oxygen saturation
• Monitor: sinus tachycardia • Auscultate chest
• CNS: sleepy, pupils normal • Identify Kussmaul respirations
• CVS: normal heart sounds, capillary refill 3 s, pulses weak Circulation:
• Respiratory: Kussmaul respirations, lung fields clear • Apply monitors
• Mucous membranes: mouth/lips very dry, crying a few tears • Check HR, BP, capillary refill
• Abdomen: mild diffuse tenderness • Insert IV catheter, keeps patient nothing by mouth
• Identify sinus tachycardia
STAGE 1, Assesses Hydration:
continued • Capillary refill
• Skin turgor
• Mucous membranes
• Urine output
• Assign degree of dehydration
• Strict monitoring of intake and output
CNS:
• Establish baseline examination
• Express need to monitor for cerebral edema
Medical Management:
• Order blood work: CBC, differential, electrolytes, renal
function, capillary gas, bedside glucose, serum osmolality,
and urine dip for glucose/ketones
• Bedside glucose: critically high
• Urine dip or ketones 4+
• Identify DKA as diagnosis
Begin DKA protocol:
• Have patient weighed/ask for patient weight
• Consider need for IV normal saline bolus (10 mL/kg)
• Calculate IV rate assuming need to replace deficit evenly
over 48 h
• Use appropriate replacement fluid pending laboratory
results
• Order IV insulin infusion
• Use flow sheet to track laboratory results, vital signs

• Patient less responsive, GCS score decreasing Airway:
Physical Examination Findings: • Suction the airway
• GCS score of 8 (motor response 3, vocal response 3, eye • Reposition the head with head tilt, chin lift, jaw thrust
response 2) • Reapply oxygen mask
• Temperature 37.5°C (99.5°F), HR 120/min, RR 24/min, BP Breathing:
110/60 mm Hg, oxygen saturation 98% on room air • Reassess
• Monitor: sinus tachycardia • Prepare for possible intubation: draws up rapid sequence
• CNS: grumpy and tired, mumbling, eyes closed intubation medication
• CVS: normal HS, capillary refill 2 s, pulses still weak Circulation:
• Respiratory: a bit less labored • Reassess HR, BP, capillary refill
• Abdomen: seems less tender
• Rest of examination results unchanged
STAGE 2, CNS:
continued
• Reassess GCS score
• Institute frequent neuro checks
• Look for Cushing triad, posturing
Medical Management:
• Laboratory results: glucose critically high (at bedside); urine 4+
ketones, 4+ glucose, urine specific gravity (SG) 1.030
• Continue DKA protocol
• Recheck fluid-rate calculations
• Consider impending cerebral edema and transtentorial
herniation
• Call ICU for consultation
• Consider management of increased intracranial pressure:
IV mannitol or 3% sodium chloride solution (ie, hypertonic
saline)
• Repeat bedside glucose measurement
• Order repeat laboratory tests
• Calculate corrected sodium level
• Recognize coexisting hypernatremia and need for slow
rehydration
Abbreviations: BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; DKA, diabetic ketoacidosis; GCS, Glasgow Coma Scale; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR,
respiratory rate.
Notes
1. Management of DKA involves the preparation and administration of various types of medications and fluids. The realism of the scenario can be increased
by preparing labeled syringes with the names and concentrations of these medications and preparing an intravenous (IV) catheter with a drain so that the
students are able to push fluids through the catheter.
2. Laboratory results should be ready for the students and are best given to them on a slip of paper (as opposed to verbally provided by the instructor).
Common Pitfalls
• IV fluid for volume expansion is delivered too aggressively.
– If the students do this, the instructor can decide to change the scenario slightly and make the child decompensate by altering his level of consciousness
further or have the patient demonstrate signs of increased intracranial pressure.
– Failing to check a bedside glucose level. Instead, the students might only order a glucose measurement to be processed by the laboratory.
– Failure to recognize signs of cerebral edema and thus not preparing medications for management of increased intracranial pressure.
Hyperthermia
Mark Adler, MD
Learning Objectives
• Recognize the features of environmental hyperthermia.
• Demonstrate the steps in the initial treatment of a hyperthermic infant.

• Eight-month-old infant was unintentionally left in a car for • Previously healthy
2 h; temperature outside was 32.2°C (90°F) • No medications or allergies
• Child was apneic, pulseless, and cyanotic • Immunizations up to date
• CPR was initiated by paramedics with bag-mask ventilation. • Paramedics have been doing CPR for 5 min
• Child brought to ED by paramedics with CPR in progress Airway:
Weight: • Continue bag-mask ventilation
• 8 kg • Clear or suction the airway
Condition: • Prepare for possible intubation (gathers equipment)
• Apneic and now with faint pulses (EMS reports pulse return Breathing:
at arrival) • Check oxygen saturation
• Temperature 42°C (107.6°F), HR 185/min, RR 0/min, BP 62/50 • Apply monitors
mm Hg, oxygen saturation 93% (bag-mask) • Auscultate chest
• Monitor: sinus tachycardia • Check for adequacy of chest rise with bagging
• CNS: obtunded, nonresponsive Circulation:
• Cardiovascular: capillary refill 6–7 s, weak pulse centrally • Apply monitors
• Respiratory: coarse crackles bilaterally • Check pulse, capillary refill, BP
• Abdomen: soft, no organomegaly • Establish IO access (IV attempts fail)
• Skin: hot, dry • Give 20-mL/kg normal saline bolus
• Order vasopressor (dobutamine vs dopamine, avoids
primarily α-agonists)
Disability and Exposure:
• Check neurologic status
• Remove clothes
• Active cooling measures: cooling blanket, ice bags, lower
room temperature, peritoneal lavage (latter rarely used)
• Monitor rectal temperature
Hyperthermia
continued
• Order blood work: CPK, electrolytes, BUN, creatinine, CBC,
LFTs, bedside glucose
• Order ECG

• Some cooling has occurred Airway:
Physical Examination Findings: • May consider intubation
• Temperature 40.5°C (105°F), HR 169/min, RR 20/min • Bagged at rate of 8–10/min
(bagged), BP 65/59 mm Hg, oxygen saturation 98% Breathing:
• Monitor: sinus tachycardia • Not breathing spontaneously
• CNS: obtunded, nonresponsive Circulation:
• CVS: weak pulses • Place urinary catheter to assess renal function
• Respiratory: clear • Begin dobutamine or dopamine
• Abdomen: soft Medical Management:
• Skin warm and dry • Send urine sample for myoglobin/UA
Laboratory test results:
• Glucose level normal
• Electrolytes (from laboratory or gas tests if ordered): sodium
148 mmol/L, potassium 4.6 mmol/L, chloride 110 mmol/L,
calculated bicarbonate 8 mmol/L, ionized calcium 1.01
mmol/L

• Improvement Airway:
Physical Examination Findings: • Reassess airway (considers intubation if not already done)
• Temperature 39.6°C (103.3°F), HR 159/min, RR 10/min Breathing:
(bagged), BP 63/59 mm Hg, saturation 98% with 100% • Assess breathing
oxygen Circulation:
• Monitor: sinus tachycardia • Titrate pressors
• CNS: unconscious Medical Management:
• CVS: capillary refill 4 s, pulses weak • Consider further management for possible rhabdomyolysis
• Respiratory: clear (furosemide and/or mannitol)
• Skin: warm • Notify critical care personnel
Laboratory test results:
• CPK, 400 IU/L; UA and hemoglobin
Hyperthermia
STAGE 4 Disposition: • Arrange Disposition to ICU 2
Condition:
• Stable
Physical Examination Findings:
• Temperature 39.2°C (102.6°F), HR 155/min, RR 10/min
(bagged), BP 63/59 mm Hg, saturation 98% with 100%
oxygen
• CNS: unconscious
• CVS: capillary refill 3 s, pulses weak
• Respiratory: clear
• Skin: warm
Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CPK, creatine phosphokinase; CPR, cardiopulmonary resuscitation; CVS, cardiovascular system; ECG,
electrocardiogram; ED, emergency department; EMS, emergency medical services; HR, heart rate; ICU, intensive care unit; IO, intraosseous; IV, intravenous; LFTs, liver function tests; RR, respiratory rate; UA, urinalysis.
Common Pitfalls
1. Lack of aggressive active cooling.
2. Failure to consider and look for sequelae of hyperthermia—electrolyte disturbances, hypoglycemia, rhabdomyolysis.
Hyperthermia
Hypothermia—Near Drowning
Mark Adler, MD
Learning Objectives
• Describe the definition, signs, and symptoms of hypothermia.
• Demonstrate the treatment of a patient with submersion injury.
– Recognize the importance of airway management and cervical spine protection in submersion injury.
– Demonstrate passive and active rewarming techniques for hypothermia.

• Six-year-old boy • Previously healthy
• Was boating with his father when the small boat • No medications or allergies
inadvertently hit a large wave and flipped over • Immunizations up to date
• Child was not wearing a life jacket • Paramedics have been doing CPR for 10 min
• Father survived and swam with unconscious child to shore Airway:
• CPR initiated on the scene and 911 called • Maintain cervical spine precautions
• On arrival, paramedics noted child was apneic, pulseless, • Take over bagging and CPR immediately
and cyanotic • Clear or suction the airway
• CPR was initiated by paramedics with bag-mask ventilation • Identify needs for immediate intubation
and cervical collar applied • Intubate patient without sedation or paralysis
• Child brought to ED by paramedics with CPR in progress Breathing:
Weight: • Check oxygen saturation
• 20 kg • Apply monitors
• Auscultate chest
• Check for adequacy of chest rise after tube is placed
• Identify that ETCO2 detection not helpful because child is
pulseless
• Order chest radiograph to confirm tube placement
Condition: Circulation:
• Apneic and pulseless • Apply monitors
• Temperature 28°C (82.4°F), HR 40/min, RR 0/min, BP NA, • Check pulse, capillary refill, BP
oxygen saturation NA • Identify PEA
• Monitor: sinus bradycardia • Insert IV or IO catheter
• CNS: obtunded, nonresponsive, GCS score 3, cervical spine • Do not order epinephrine (adrenaline) because core
collar on patient, bruises and cuts on face temperature is below 32°C (89.6°F)
• CVS: cap refill 6–7 s, no pulse palpable • Give warmed IV fluids through IO catheter and attempt to
• Respiratory: coarse crackles bilaterally obtain second IV/IO access
• Abdomen: bruising all over abdomen Disability and Exposure:
• Rest of examination results normal • Check GCS score and neurologic status
• Expose patient completely to conduct a secondary survey
• Apply warm blankets
Medical Management:
• Order blood work: arterial blood gas, lactate, electrolytes,
BUN, creatinine, CBC, LFTs, glucose, crossmatch
• Consider internal rewarming techniques: gastric lavage,
bladder irrigation, and possibly peritoneal irrigation
• Activate extracorporeal membrane oxygenation team and
PICU team

• The patient’s condition has not changed apart from an Airway:
increase in the temperature. • Intubate patient
Physical Examination Findings: • Bag at rate of 8–10/min
• Temperature 33°C (91.4°F), HR 45/min, RR 10/min (bagged), • Maintain cervical spine precautions
BP NA, oxygen saturation NA Breathing:
• Monitor: sinus bradycardia • Not breathing spontaneously
• CNS: obtunded, nonresponsive, GCS score of 3, cervical Circulation:
spine collar on patient, bruises and cuts on face • Continue CPR
• CVS: cap refill 6–7 s, no pulse palpable • Identify PEA, temperature has increased now to 33°C
• Respiratory: coarse crackles bilaterally (91.4°F).
• Abdomen: bruising all over abdomen • Deliver defibrillation at 2 J/kg
• Rest of examination results normal • Continue CPR and order epinephrine (adrenaline) via IO
catheter
• Continue CPR
• Give IV normal saline fluid bolus
continued
• Chest radiograph: bilateral hazy lung fields, endotracheal
tube in good position
• ABG: pH 6.9, Pco2 15 mm Hg, Po2 60 mm Hg, bicarbonate 3
mmol/L, base excess −27 mmol/L
• Lactate 8.0 mmol/L
• Glucometer: critical low: corrects this with bolus if IV D10W
• Unable to obtain other laboratory tests

• The patient is back to a perfusing rhythm Airway:
Physical Examination Findings: • Intubate and sedate
• Temperature 35°C (95°F), HR 80/min, RR 10/min (bagged), BP • Maintain cervical spine precautions
60/P mm Hg, saturation 91% with 100% oxygen Breathing:
• Monitor: sinus rhythm • Assess breathing
• CNS: intubated and unconscious Circulation:
• CVS: capillary refill 4 s, pulses weak • Identify hypotension
• Respiratory: coarse crackles bilaterally • Identify sinus rhythm
• Abdomen: bruising all over the abdomen • Stop chest compressions
• Rest of examination results normal • Give IV normal saline fluid bolus
• Order inotrope infusion IV (dopamine or epinephrine
[adrenaline])
• Arrange transfer to ICU for admission to hospital
Medical Management:
• Perform CT scan of head, neck, and abdomen
• Consult general surgeon
• Consult neurosurgeon
• Notify parents
Abbreviations: ABG, arterial blood gas; BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CPR, cardiopulmonary resuscitation; CT, computed tomography; CVS, cardiovascular system;
D10W, 10% dextrose in water; ETCO2, end-tidal carbon dioxide; ED, emergency department; HR, heart rate; ICU, intensive care unit; IO, intraosseous; IV, intravenous; LFTs, liver function tests; NA, not applicable; PEA, pulseless electrical activity;
PICU, pediatric intensive care unit; RR, respiratory rate.
Notes
1. The scenario should begin with two instructors performing cardiopulmonary resuscitation (CPR) on the patient. The history should be taken at the bedside
while CPR is performed.
2. The core temperature should not be provided unless the students ask for it.
3. Makeup or moulage should be used to add bruises to the abdomen.
4. The patient should be made wet by adding some water on the top of the mannequin.
Common Pitfalls
• Failure to consistently maintain cervical spine protection during the resuscitation.
• One common mistake is to aggressively resuscitate the patient with multiple doses of epinephrine (adrenaline) despite the patient being hypothermic
(temperature <32°C [89.6°F]).
• Failure to dry off the patient with a towel.
• Delaying insertion of venous access by attempting multiple intravenous catheter insertions. Ideally, students should start immediately with attempted
intraosseous access.
Iron Overdose
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of an infant with an iron overdose.
• Demonstrate the management of acute iron intoxication.

• Twelve-month-old boy found at home sleepy • No ill contacts
• No preceding illness • No medications
• Chaotic home setting with four other children and a single • Patient has vomited at home and had loose stools
mother, shares home with another family • If asked, sibling is receiving iron supplementation for anemia
Weight: • Mom has large bottle of iron liquid medication at home
• 10 kg Airway:
Condition: • Listen for breath sounds, present
• Ill appearance and tachypnea, sleepy • Apply oxygen via nonrebreather mask at 15 L/min
• Temperature 36.6°C (97.9°F), HR 158/min, RR 42/min, oxygen • Apply monitors, including oxygen saturation and blood
saturation 97% in room air, BP 68/42 mm Hg pressure
• CNS: asleep, wakes briefly with stimulation • Auscultate chest and observe respiratory rate
• CVS: pulses present centrally, absent peripherally Circulation:
• Abdomen: no hepatosplenomegaly • Ask nurse to place IV catheter
• Extremities/skin: capillary refill approximately 3 s • Ask for normal saline or lactated Ringer solution bolus of 20
mL/kg to be given quickly (push)
Medical Management:
• Order laboratory tests (CBC, electrolytes, coagulation
studies, blood cultures, venous blood gas, bedside glucose)
Iron Overdose
• HR remains elevated and BP is now 68/52 mm Hg Airway/Breathing:
• Blood glucose level is slightly elevated if bedside glucose • Reassess airway patency, RR, and saturations
was measured Circulation:
• Venous gas: pH 7.06, Pco2 28 mm Hg, Po2 39 mm Hg, base • Reassess HR, pulse, capillary refill, BP after bolus
excess −20 mmol/L • Order second bolus, also push
• Patient vomits again • Order vasopressor (dopamine) to bedside (“That will take
• Iron overdose exceeds 60 mg/kg body weight (provided if about 10–15 minutes to get from the pharmacy”) in
team asks dose) anticipation of need later
• HR 163/min, RR 36/min, oxygen saturation 98% in 100% • If team fails to suspect overdose, can prompt with statement
oxygen (if placed), BP 63/52 mm Hg “Someone has called to inform the mom that a bottle of
• CNS: barely responds to any stimuli sibling medication labeled ferrous sulfate is open and empty
• Respiratory: clear on the floor.”
• CVS: clamped down and cool extremities • Orders additional tests
• Abdomen: no hepatosplenomegaly - Venous gas to assess pH
- Iron, salicylate, and acetaminophen (paracetamol) levels
- Abdominal radiograph for pill fragments (given history of
liquid ingestion)
• Consult poison control for recommendations

• “He doesn’t seem much better.” Circulation:
• Remains tachycardic after second bolus • Reassess HR, pulse, capillary refill, BP
• Poison control recommends treatment with IV deferoxamine Medical Management:
Physical Examination Findings: • Order third bolus of IV saline push
• Unchanged from stage 2 except that HR is now 150/min and • Begin administration of dopamine as it arrives, titrates to
BP is 66/52 mm Hg improve BP (this happens when dopamine is running at 10
• Abdomen: no hepatosplenomegaly mcg/kg/min)
• Consult intensive care service for admission
• Order deferoxamine as recommended

• Patient improves with vasopressor support Disposition:
• HR 148/min, BP 78/62 mm Hg, saturation 98% on facility (depending on presenting facility resources)
nonrebreather mask
• Extremities feel warmer
• Child is somewhat more alert
Abbreviations: BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate
Iron Overdose
Notes
1. Time course of case precludes availability of full electrolyte panel, which would reveal an anion gap acidosis. This could be reported if a rapid electrolyte
test is available.
2. Deferoxamine therapy is not without risks (hypotension), and poison control consultation is recommended even if the team were to come up with this
treatment on its own.
Common Pitfalls
– IV “wide open” fluid administration can lead to very rapid infusion of a whole liter of fluid OR can result in underresuscitation if there is significant resis-
tance to flow (small IV gauge). Infants and small children should always receive resuscitation fluids using either a pump or push to allow for observation
and control of fluid delivery. Pressure bags can increase the likelihood of excessive fluid overload.
• Failing to consider ingestion as a cause of a septic shock–like picture. Metabolic derangements, both inborn errors and those due to ingestions, can mimic
sepsis. The sudden onset and absence of fever are clues, as is the history of lead toxic effects (suggesting pica) and the chaotic home setting.
• Waiting until the third bolus is started or finished to order pressors. Participants should recognize and anticipate that infant and pediatric pressor drips
must be prepared individually for a patient’s weight and are not stock items because these items are for adults. Depending on the institution, there might
be a significant delay in preparation and delivery of pressor drips.
Iron Overdose
Myocarditis—Cardiogenic Shock
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of cardiogenic shock.
• Demonstrate the treatment of a child in cardiogenic shock.
– Order the appropriate investigations.
– Select the appropriate inotrope.

• Five-year-old boy • Previously healthy
• Cough, runny nose, and fever for 5 d • Other kids at school sick with similar cough, cold symptoms
• Diaphoretic and chills today • Unwell today, slept most of the day
• Short of breath and felling unwell • Woke up, vomited five times
• Taken to the emergency department for assessment • Diaphoretic and chills
• Given acetaminophen (paracetamol) only
Weight:
• 20 kg Airway:
• Talk to the patient
Condition:
• Optimize airway position: head tilt, chin lift, jaw thrust
• Looks very unwell, toxic
Breathing:
• Check oxygen saturation
• Temperature 39°C (102.2°F), HR 170/min, RR 40/min, BP 95/P
• Give 100% oxygen
mm Hg, oxygen saturation 88% on room air
Circulation:
• CNS: awake, GCS score of 15
• Ask for monitors
• CVS: gallop rhythm, soft murmur, cap refill 3 s, pulses weak
• Respiratory: crackles bilaterally • Identify the rhythm (sinus tachycardia) and recognizes
• Abdomen: liver edge palpable uncompensated shock
• Rest of examination results normal • Insert IV catheter two times (large bore)
• Order IV normal saline bolus
Medical Management:
• Order blood work: CBC, differential, blood culture,
electrolytes, BUN, creatinine, glucose, blood gas, LFTs, PTT,
and INR
• Order IV antibiotics
• The patient’s condition deteriorates as the BP decreases and Airway:
perfusion worsens after the first bolus of normal saline • Reassess airway
Physical Examination Findings: • Suction airway as needed
• Temperature 39°C (102.2°F), HR 180/min, RR 45/min, BP 70/P Breathing:
mm Hg, oxygen saturation 90% on 100% oxygen • Consider assisting ventilations with anesthesia bag/self-
• Monitor: sinus tachycardia inflating bag
• CNS: drowsy but arousable, GCS score of 12 Circulation:
• CVS: gallop rhythm, soft murmur, cap refill 4 s, pulses weak • Identify worsening shock
• Respiratory: crackles • Order second bolus of IV normal saline
• Abdomen: liver edge palpable • Insert second IV catheter (if not done already)
• Rest of examination results normal Medical Management:
• Order chest radiograph to evaluate for cardiogenic shock
• Order ECG

• The patient’s perfusion is getting worse with the second Airway:
fluid bolus • Reassess airway
Physical Examination Findings: • Suction airway as needed
• Temperature 39°C (102.2°F), HR 180/min, RR 45/min, BP • Prepare for rapid sequence intubation
65/P mm Hg, oxygen saturation 92% on 100% oxygen with Breathing:
assisted ventilations • Assist ventilations with anesthesia bag/self-inflating bag
• Monitor: sinus tachycardia Circulation:
• CNS: drowsy but arousable, GCS score of 12 • Identify worsening shock
• CVS: gallop rhythm, soft murmur, cap refill 5 s, pulses weak • Order IV inotrope infusion for suspected cardiogenic shock
• Respiratory: crackles (dopamine/milrinone/epinephrine [adrenaline]).
• Abdomen: liver edge palpable Medical Management:
• Rest of examination results normal • Chest radiograph: bilateral hazy, wet lung fields with an
enlarged heart
Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ECG, electrocardiogram; GCS, Glasgow Coma Scale; HR, heart rate; INR, international
normalized ratio; IV, intravenous; LFTs, liver function tests; PTT, partial thromboplastin time; RR, respiratory rate
Notes
1. An actor or confederate nurse can be used to report a palpable enlarged liver and prolonged capillary refill.
Common Pitfalls
• Overly aggressive fluid resuscitation and failure to consider cardiogenic shock in the differential diagnosis.
• Delay in ordering antibiotics.
• Ordering a chest radiograph or electrocardiogram are not considered as part of the workup for this patient.
Occult Trauma (Non-accidental Trauma)
Mark Adler, MD
Learning Objectives
• Describe the “red flags” in a history that raise concern for non-accidental trauma (and recognize these might or might not be present in all cases).
• Describe the signs and symptoms of an infant with nonoccult multisystem trauma.
• Demonstrate the management of multisystem trauma.
– Conduct a trauma evaluation (primary and secondary survey).
– Consider stabilizing the cervical spine.
– Control airway due to depressed level of consciousness, using appropriate medication.
– Recognize and treat signs of elevated intracranial pressure.
– Consider and evaluate for clinical significant injuries other than head injuries.

IMPORTANT REMINDER: If required, change the lens of the simulator to simulate dilated pupil on the LEFT.

• Six-month-old child found by parent in crib, unarousable • No allergies
after nap • No medications
• Babysitter put him down a few hours ago, thought he • No ill contacts
was fine • No idea at all what has happened
• Child was completely well when parent left this morning • No history of trauma or fall
• Triage nurse has rushed patient back to resuscitation room • No other children in home
because he is barely responsive at triage • Babysitter has been with them approximately 1 month
• You arrive to assess the patient
Airway:
Weight: • Listen for breath sounds, present but slow
• 7 kg • Apply oxygen via nonrebreather mask at 15 L/min
• Infant is pink and well perfused but comatose • Apply monitors, including oxygen saturation and BP
Physical Examination Findings: • Auscultate chest and observe respiratory rate
• Temperature 37.2°C (99°F), HR 104/min, RR 12/min, oxygen Circulation:
saturation 97% in room air, BP 89/66 mm Hg • Assess pulse, HR, capillary refill, BP
• CNS: unresponsive, if painful stimulation is given (nailbed • Ask nurse to obtain IV access, ideally two larger IV catheters
pressure or sternal rub, demonstrate EXTENSOR posturing:
“The child did this [demonstrate] when you did that?”)
STAGE 1, – If examined, the left pupil is dilated maximally and fixed; Disability:
continued right is 2–3 mm and barely reactive • Quick neurologic assessment (pupils, response to pain)
• CVS: pulses intact • Assessment of GCS score
• Respiratory: clear and slow Environment and Exposure:
• Abdomen: soft and without hepatosplenomegaly • Remove patient clothing, examine completely
• Extremities/skin: no bruising noted (if asked) • Keep patient euthermic (blanket or warming equipment)

• Mental status unchanged Airway/Breathing:
• Blood glucose level is normal if obtained • Prepare for intubation due to poor mental status
• BP is increasing and HR is slowing steadily • Gather necessary materials (SOAP mnemonic)
Physical Examination Findings: – Suction
• HR 94/min, RR 6–8/min (irregular if this is a supported – Oxygen equipment (bag-mask, endotracheal tube,
feature), BP 106/88 mm Hg (if simulator supports, this trend qualitative ETCO2 detector, or ETCO2 monitor)
can be set to progress over the first 4–5 min) – Airway equipment (laryngoscope and blade)
• CNS: unchanged – Pharmacy: rapid sequence medication
• Respiratory: clear, rate is now slower
Circulation:
• CVS: unchanged
• Consider fluid management in light of signs of intracranial
• Abdomen: somewhat more full than before, no
pressure
organomegaly
Disability:
• May elevate head of bed
• Consult neurosurgery
Medical Management:
• Order laboratory tests (LFTs with or without pancreatic
enzymes to screen for abdominal trauma, type and cross)
• Order CT scan of head and abdomen, notify scanner of
arrival as soon as patient is intubated
STAGE 3 Condition: INTUBATION: 5

• Unchanged except for continuing trend (HR 82/min, BP Airway/Breathing:
110/92 mm Hg) • Complete rapid sequence intubation
– Ordering a chest radiograph – Consider lidocaine (lignocaine) premedication
• Secure tube (can be done by nurse confederate) – Sedation medication
– Paralytic medication
– Tube placed with optional cricoid pressure
• Tube placement confirmed by:
– Auscultation
– Direct visualization of chest movement
– ETCO2 detector
STAGE 3, Circulation:
continued • Reassess HR, pulse, capillary refill, BP
Disability:
• Avoid excessive hyperventilation for elevated ICP (see note
below)
• Consider IV mannitol (or other similar agents)
Medical Management:
• Review ordered laboratory test results

• Stable (see note) Disposition:
• Arrange for transport for CT scan with appropriate staff
(someone who could reintubate if airway is lost)
• Notify surgeon of abdominal findings
• Notify parents
• Plan social work consult and report of suspected child abuse
Abbreviations: BP, blood pressure; CNS, central nervous system; CT, computed tomography; CVS, cardiovascular system; ETCO2, end-tidal carbon dioxide; GCS, Glasgow Coma Scale; HR, heart rate; ICP, intracranial pressure; IV, intravenous;
LFTs, liver function tests; RR, respiratory rate.
Notes
1. This is an important topic for which some specific management steps vary among institutions. This case content reflects the Advanced Pediatric Life Support recommended
management. The case can be tailored to your institutional practice, as it pertains to rapid sequence drug choices, endotracheal tube type (cuffed or not), use of mannitol or
other osmotic agents, or short-term mild hyperventilation.
2. This case can incorporate intraosseous needle insertion if the simulator permits this procedure—have the nurse confederate report he or she cannot obtain access.
3. This case is written to be only mildly suggestive of non-accidental trauma to prevent immediate identification of the problem to the exclusion of all other causes. It is our
experience that pediatric health care workers are sensitized to the more obvious “red flags” (eg, mom’s boyfriend at home alone with child). Similarly, a bulging fontanelle (which
might be present in a patient) is often so obvious on some simulators as to be a distractor and should be used at the instructor’s discretion after evaluating this functionality on the
simulator device to be used.
4. The role of sonography for trauma is not yet broadly established in pediatrics at this time and is not discussed here.
Common Pitfalls
• Participants do not recognize the severity of the medical condition, with an extended history obtained before resuscitation.
• F ocus on the intracranial process to the exclusion of other injuries. This patient has a grade 5 liver laceration that is currently not causing hemodynamic issues. If the patient
were to go to the operating room (OR) with this injury not identified, the personnel present in the OR (neurosurgeon) would not be the personnel best prepared to deal with
intra-abdominal bleeding.
• The team considers sending the patient for computed tomography (CT) without airway control. The confederate nurse states, “This patient seems too ill to go to CT like this.”
• Team does not know the correct intubation medications. In this case, treatment can be stopped before intubation, and this material can be reviewed as discussed in the text.
• The team intubates the patient without any medications. Allow the case to proceed and discuss afterward the likely impact on intracranial pressure of this approach.
Postoperative Cardiac Patient—Ventricular Fibrillation
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of a child presenting with unstable ventricular tachycardia.
• Describe the signs and symptoms of a child presenting with ventricular fibrillation and cardiac arrest.
• Demonstrate the treatment of a child with unstable ventricular tachycardia.
– Demonstrates knowledge of the Pediatric Advanced Life Support (PALS) unstable ventricular tachycardia algorithm.
• Demonstrate the treatment of a child with ventricular fibrillation.
– Recognize ventricular fibrillation.
– Recognize the importance of high-quality chest compressions and early defibrillation.
– Demonstrates proper use of the defibrillator.
– Demonstrates knowledge of the PALS ventricular fibrillation algorithm.

• Four-year-old boy • Unwell today, slept most of the day
• Recent cardiac surgery for congenital heart disease 4 d ago • Difficult to awaken this afternoon, brought to ED
• Vomited three times today Airway:
• Feeling unwell, lightheaded • Talk to the patient
• Taken to the ED for assessment • Open airway
Weight: • Head tilt, chin lift, jaw thrust
• 20 kg • Prepare for rapid sequence intubation
• Looks very unwell, toxic • Check oxygen saturation
Physical Examination Findings: • Apply 100% oxygen by mask
• Temperature 37.4°C (99.3°F), HR 170/min, RR 35/min, BP • Auscultate chest
60/P mm Hg, oxygen saturation 88% in room air Circulation:
• Monitor: ventricular tachycardia • Apply monitors
• CNS: drowsy and difficult to arouse, GCS score of 10 • Check pulse, capillary refill, BP
• CVS: gallop rhythm, loud murmur, cap refill 4 s, pulses weak • Identify unstable ventricular tachycardia
• Respiratory: clear • Insert IV catheter 2 times
• Rest of examination results normal
STAGE 1, • Order IV sedative (eg, ketamine) and prepares for
continued synchronized cardioversion (this particular point is
controversial and would be a good discussion point because
the patient might be too unstable to tolerate a sedative)
Medical Management:
• Synchronize cardioversion as per PALS protocol
• Order blood work: CBC, differential, blood culture,
electrolytes, BUN, creatinine, glucose, blood gas, LFTs, PTT,
and INR

• The patient is unconscious, GCS score of 3 Airway:
• Rhythm: ventricular fibrillation • Recheck airway
Physical Examination Findings: • Intubate patient now without sedation or paralysis
• Temperature 37.4°C (99.3°F), HR NA, RR 0/min, BP NA, Breathing:
oxygen saturation NA • Reassess breathing
• Monitor: ventricular fibrillation • Manually provide the patient with ventilatory assistance
• CNS: GCS score of 3 Circulation:
• CVS: capillary refill 8 s, pulses not palpable • Identify ventricular fibrillation
• Respiratory: clear • Start CPR immediately with backboard in place
• Rest of examination results normal • Defibrillation at 2 J/kg then CPR as per PALS protocol
• Continue CPR and then defibrillates again at 4 J/kg
• Give IV/IO epinephrine (adrenaline)
• Reassess pulse and rhythm

• Looks very unwell, toxic, rhythm changes to normal sinus Airway:
rhythm • Recheck airway and tube
• Temperature 37.4°C (99.3°F), HR 80/min, RR 6/min, BP 70/P • Reassess breathing
mm Hg, oxygen saturation 90% with bagging • Continue to bag ventilate the patient
• Monitor: sinus rhythm
Circulation:
• CNS: unresponsive, intubated, GCS score of 3 • Identify change to sinus rhythm, checks for pulse
• Stop CPR
• Administer normal saline bolus
• Start inotrope infusion: dopamine or epinephrine
(adrenaline)
STAGE 3, • CVS: gallop rhythm, soft murmur, capillary refill 5 s, pulses Medical Management:
continued
very weak • Consult ICU and cardiology personnel
• Respiratory: bilateral crackles • Order ECG and chest radiograph
Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CPR, cardiopulmonary resuscitation; CVS, cardiovascular system; ECG, electrocardiogram; ED, emergency
department; GCS, Glasgow Coma Scale; HR, heart rate; ICU, intensive care unit; INR, international normalized ratio; IV, intravenous; IO, intraosseous; LFTs, liver function tests; NA, not applicable; PALS, Pediatric Advanced Life Support; PTT,
partial thromboplastin time; RR, respiratory rate
Notes
1. A dressing or bandage should be applied to the chest to mimic recent cardiac surgery or sternotomy scar.
2. An orientation to the defibrillator should be provided before starting this scenario—ensure the students are aware of how to safely operate the defibrillator.
Common Pitfalls
• Defibrillation of unstable ventricular tachycardia (instead of synchronized cardioversion).
• Management of unstable ventricular tachycardia with medication only.
• Delayed defibrillation after recognition of ventricular fibrillation.
• Delayed initiation of chest compressions after recognition of ventricular fibrillation.
• Management of airway (intubation) before defibrillation or chest compressions while the patient is in ventricular fibrillation.
• Failure to adequately prepare medications for ventricular fibrillation. Instructors should encourage students to prepare epinephrine (adrenaline), amiodarone,
and lidocaine (lignocaine) immediately on recognition of the rhythm.
Septic Shock
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of an infant with septic shock.
• Demonstrate the management of circulatory failure due to sepsis.
– Use of normal saline or lactated Ringer solution to expand circulatory volume.
– Order and deliver a pressor to support blood pressure in a timely manner.
– Recognize the need for hydrocortisone stress dosing for specific pediatric populations (those taking steroid medications).

• Seven-month-old boy, in treatment for acute lymphocytic • No ill contacts
leukemia presents with temperatures to 39.6°C (103.3°F) • Has a double-lumen port
(temporal) • Has had one previous admission for fever and neutropenia
• Decreased activity since yesterday at 1 month age
• Chemotherapy last given 4 d ago, don’t know what drugs • Vomited once en route to the ED
were given • Takes trimethoprim-sulfamethoxazole 3 d per week, got
• Triage nurse was worried how little he responded to her ibuprofen at triage; is taking prednisone as part of his
examination chemotherapy
• You arrive to assess the patient • Allergic to vancomycin (red man syndrome)
Weight: Airway:
• 7 kg • Listen for breath sounds, present
Condition: • Apply oxygen via nonrebreather mask at 15 L/min
• Very unwell, listless, feels warm over core but hands are cool Breathing:
Physical Examination Findings: • Apply monitors, including oxygen saturation and blood
• Temperature 39.6°C (103.3°F), HR 158/min, RR 36/min, pressure
oxygen saturation 96% in room air, BP 72/58 mm Hg • Auscultate chest and observe respiratory rate
• CNS: asleep, wakes briefly with painful stimulation Circulation:
• CVS: pulses present centrally, absent peripherally • Assess pulse, HR, capillary refill, BP
• Respiratory: clear • Ask nurse to access port
• Abdomen: no hepatosplenomegaly • Ask for normal saline or lactated Ringer solution bolus of 20
• Extremities/skin: capillary refill >4 s, scattered petechiae mL/kg to be given quickly (push)
Medical Management:
• Order laboratory tests (CBC, electrolytes, coagulation
studies, blood cultures, venous blood gas, bedside glucose)
Septic Shock
• HR remains elevated and BP is now 63/52 mm Hg Circulation:
• Nurse notes aloud, “His hands are just so cold.” • Reassess HR, pulse, capillary refill, BP after bolus
• Blood glucose level is normal if bedside glucose test was • Order second bolus, also push
performed • Order vasopressor (dopamine) to bedside (“That will
Physical Examination Findings: take about 10–15 minutes to get from the pharmacy.”) in
• HR 163/min, RR 36/min, oxygen saturation 98% in 100% anticipation of need later
oxygen (if placed), BP 63/52 mm Hg Medical Management:
• CNS: barely responds to any stimuli • Order antibiotics (broad spectrum to include coverage for
• Respiratory: clear pseudomonas, eg, ceftazidime or meropenem/imipenem)
• CVS: clamped down and cool extremities
• Abdomen: no hepatosplenomegaly

• “He doesn’t seem much better.” Circulation:
• Remains tachycardic after second bolus • Reassess HR, pulse, capillary refill, BP
• Unchanged from stage 2 except that HR is now 150/min and • Order third bolus of normal saline IV push
BP is 66/52 mm Hg • Begin dopamine as it arrives, titrates to improve BP (this
• Abdomen: no hepatosplenomegaly happens when dopamine is running at 10 mcg/kg/min)
• Order hydrocortisone stress dose given patient’s daily
prednisone (can ask for help with dosing)
• Consult intensive care service

• Patient improves Disposition:
• HR 148/min, BP 78/62/min, saturation 98% on 100% oxygen facility (depending on presenting facility resources)
• Extremities feel warmer
• Child is somewhat more alert
Abbreviations: BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ED, emergency department; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate
Septic Shock
Common Pitfalls
– IV “wide open” fluid administration can lead to very rapid infusion of a whole liter of fluid OR can result in underresuscitation if there is significant resis-
tance to flow (small IV gauge). Infants and small children should always receive resuscitation fluids using either a pump or push to allow for observation
and control of fluid delivery. Pressure bags can increase the likelihood of excessive fluid overload.
• Withholding antibiotics until either the patient improves or cultures and/or testing is complete. This infant is critically ill and antibiotics should be given as
early as is practical.
• Failing to check a bedside glucose level. Hypoglycemia is a treatable cause of altered mental status, and ill infants with poor glycogen stores and a poor recent
oral intake due to illness are prone to this condition.
• Waiting until the third bolus is started or finished to order pressors. Participants should recognize and anticipate that infant and pediatric pressor drips must
be prepared individually for a patient’s weight and are not stock items because these items are for adults. Depending on the institution, there might be a
significant delay in preparation and delivery of pressor drips.
Septic Shock
Chest Crisis—Sickle Cell Disease
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of a child presenting with chest crisis and sickle cell disease.
• Demonstrate the treatment for a child with a sickle cell chest crisis.
– Perform fluid management and resuscitation.
– Understand the importance of repeat assessment in children with chest crisis.
– Demonstrate knowledge of appropriate antibiotic therapy.

• Seven-year-old boy • Multiple previous admissions
• Known homozygous sickle cell disease. • History of chest crisis two times with admission to ICU for
• Fever this afternoon exchange transfusion
• Coughing 2 times per day • Sepsis one time, dactylitis one time, bony (vaso-occlusive)
• Feeling unwell and brought to the hospital crisis five times
• Initial oxygen saturation at triage is 88% in room air • Taking prophylactic antibiotics
Weight: • Immunizations up to date
• 22 kg Airway:
Condition: • Open the airway
• Very unwell, listless, feels warm over core but hands are cool • Head tilt, chin lift, jaw thrust
• Temperature 39.5°C (103°F), HR 130/min, RR 30/min, oxygen • Apply monitors
saturation 88% in room air, BP 95/P mm Hg • Auscultate chest and observes respiratory rate
• CNS: awake and alert • Oxygen saturation
• Respiratory: diffuse crackles bilaterally with poor air entry to • Apply oxygen (100%)
right • Get self-inflating bag ready
• CVS: pulses strong, capillary refill 2 s Circulation:
• Musculoskeletal: no bony tenderness or pain • Assess pulse, HR, capillary refill, BP
• Rest of examination results normal • Obtain IV access
continued
• Blood work: CBC, differential, blood culture, gas, electrolytes,
BUN, creatinine, glucose
• IV ceftriaxone and erythromycin
• Chest radiograph
• IV fluids (D5NS) at half to one times maintenance

• Looks unwell, moderate-severe distress, not oxygenating Airway:
well with face mask oxygen, blood pressure decreasing, and • Suction the airway
perfusion worsening • Reposition the head with head tilt, chin lift, jaw thrust
Physical Examination Findings: • Reapply oxygen mask
• Temperature 39.5°C (103°F), HR 130/min, RR 38/min, Intubation:
saturation 88% with 100% oxygen, BP 70/P mm Hg • Preparation/equipment
• CNS: becoming more drowsy • Preoxygenation; RR 12–15./min
• Respiratory: diffuse crackles bilaterally with poor air entry to • Cricoid pressure
right • Premedication: IV atropine
• CVS: pulses weak, capillary refill 4 s • Sedation: IV ketamine
• Rest of examination results normal • Paralysis: IV succinylcholine or rocuronium
• Intubate with ETT
• Check tube placement with end-tidal carbon dioxide,
auscultation and chest radiograph
Breathing:
• Reassess breathing and RR
• Call for help
• Consider using high-flow oxygen or anesthesia bag to
provide some CPAP
• Support ventilation: bag-mask ventilation
Circulation:
• Reassess HR, pulse, capillary refill, BP
• IV access obtained by now
• Give normal saline bolus then repeats as necessary
• Perform ABG measurement
• Looks unwell, oxygenation and BP improved slightly Airway:
Physical Examination Findings: • Suction the ETT: some thin mucus or secretions
• Temperature 39.5°C (103°F), HR 130/min, RR 30/min, oxygen Breathing:
saturation 94% intubated and ventilated, BP 80/P mm Hg • Auscultate the chest
• CNS: paralyzed and sedated • Check chest movement and symmetry
• Respiratory: diffuse crackles bilaterally with poor air entry to Circulation:
right • Check pulse and BP
• CVS: pulses weak, capillary refill 4 s • Consider repeat IV fluid bolus for hypotension
• Order inotrope infusion and titrates infusion to increase the
BP
Medical Management:
• Call ICU consultant for help
• Prepare for transport
• Follow up on chest radiograph
• Consider adding vancomycin
Abbreviations: ABG, arterial blood gas; BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, nervous system; CPAP, continuous positive airway pressure; CVS, cardiovascular system; D5NS, 5% dextrose in
normal saline; ETT, endotracheal tube; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate
Common Pitfalls
• Overly aggressive fluid resuscitation, leading to pulmonary edema and respiratory failure.
• Delayed administration of antibiotics.
• Failure to reassess patient and delayed recognition of respiratory decompensation.
Status Asthmaticus
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of a child presenting in status asthmaticus.
• Recognize the signs and symptoms of respiratory failure.
• Demonstrate the treatment of a child with status asthmaticus.
– Demonstrate knowledge of medical management of status asthmaticus.
– Understand dangers of intubating a sick asthmatic patient.

• Five-year-old boy • Recent contact with younger sibling with URI symptoms
• Known to have asthma • Four previous admissions and once to the ICU, never
• Taking albuterol (salbutamol) and fluticasone puffers at intubated
home • Vomited once at home
• Increasing cough and shortness of breath at home today • Took albuterol (salbutamol), two puffs six times at home
• Febrile with no improvement, then came to the ED
• Initial oxygen saturation at triage is 88% in room air Airway:
• Treated by ED nursing staff right away and given albuterol • Talk to the patient
(salbutamol) and ipratropium bromide • Suction secretions
• You arrive to assess the patient. • Call for help: respiratory therapy
Weight: Breathing:
• 20 kg • Apply monitors, including oxygen saturation
Condition: • Auscultate chest and observe respiratory rate
• Very unwell, severe distress • Apply oxygen via nonrebreather (100%) OR move directly to
Physical Examination Findings: second nebulization
• Temperature 38°C (100.4°F), HR 130/min, RR 36/min, oxygen • Consider albuterol (salbutamol) and ipratropium bromide
saturation 88% in room air, BP 110/50 mm Hg back to back three times in total
• CNS: awake and alert • Get anesthesia bag or self-inflating bag ready.
• CVS: pulses strong, capillary refill 2 s • Give oral steroid (dexamethasone or prednisolone or
• Respiratory: scattered, diffuse wheezes bilaterally, prednisone) or parenteral steroid
retractions Circulation:
• Rest of examination results normal • Assess pulse, HR, capillary refill, BP
Status Asthmaticus
• After the back to back albuterol (salbutamol) and Airway:
ipratropium, patient is still unwell • Suction the airway
• Coughing persistently • Reposition the head with head tilt, chin lift, jaw thrust
• Persistent respiratory distress (recognizing this child is distressed and vomiting, might be
• Child suddenly vomits profusely better to have him on his side as well)
• Temperature 38°C (100.4°F), HR 150/min, RR 40/min, oxygen Breathing:
saturation 92% in 100% oxygen, BP 100/55 mm Hg • Reassess breathing and RR
• CNS: gagging, irritable, coughing persistently • Call for help from respiratory therapy (if not done already)
• Respiratory: diffuse wheezes bilaterally with indrawing, • Give continuous albuterol (salbutamol) via nebulization
tracheal tug, and worsening retractions Circulation:
• CVS: pulses strong, capillary refill 2 s • Reassess HR, pulse, capillary refill, BP
• Rest of examination results normal • IV access
• Give steroids (IV) because he might have vomited oral
steroids
• Give magnesium sulfate (IV)
Medical Management:
• Perform blood work with IV start: CBC, differential, culture,
electrolytes, gas
• Get immediate chest radiograph and give antibiotics if signs
of focal consolidation

• Your patient seems to be working harder to breath Airway:
• Severe respiratory distress • Suction the airway
• No longer responding to verbal commands • Reposition the head with head tilt, chin lift, jaw thrust
• Temperature 39°C (102.2°F), HR 160/min, RR 40/min, BP • Consider towel roll at this point
110/55 mm Hg, oxygen saturation 84% in 100% oxygen. If learner proceeds with intubation:
• CNS: drowsy • Preparation/equipment
• Respiratory: diffuse wheezes, retractions • Preoxygenation; RR, 8–12/min with prolonged expiratory
phase
• CVS: well perfused, capillary refill 2 s
• Cricoid pressure
• Rest of examination results unchanged from above
• Premedication: IV atropine
• Sedation: ketamine IV.
• Paralysis: IV succinylcholine
• Intubate with ETT 5.0 cuffed
• Check tube placement with ETCO2, auscultation, chest
radiograph
• Nasogastric tube placement
Status Asthmaticus
STAGE 3, Breathing:
continued
• Reassess breathing and RR
• Obtain chest radiograph if not already done by now
Circulation:
• Reassess HR, pulse, capillary refill, BP
Medical Management:
• Call ICU for help
• Consider IV aminophylline or IV b-agonist.
• Consider BiPAP or CPAP

• Patient condition deteriorates after intubation Airway:
• Very difficult to provide ventilation • Consider direct visualization of the tube with laryngoscope
• Poor chest rise bilaterally Breathing:
• Temperature 38°C (100.4°F), HR 80/min, RR bagging, • Auscultate the chest
saturation 78% in 100% oxygen, BP 80/50 mm Hg • Check for signs of tension pneumothorax (trachea midline,
• CNS: sedated/paralyzed blood pressure, percussion of chest, jugular venous
• Respiratory: poor chest rise and air entry bilaterally with pressure)
wheezing • Give continuous nebulized in-line albuterol (salbutamol)
• CVS: pulses weak, capillary refill 4 s • Check oxygen/equipment
• Bag-mask ventilates at a slower rate with a prolonged
expiratory phase
Circulation:
• Insert second IV catheter
• Give IV bolus of normal saline
Abbreviations: BiPAP, bilevel positive airway pressure; BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CPAP, continuous positive airway pressure; CVS, cardiovascular system; ED, emergency department;
ETCO2, end-tidal carbon dioxide; ETT, endotracheal tube; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate; URI, upper respiratory tract infection.
Notes
1. “Albuterol” is the drug name in the United States. In many other countries the drug name is “salbutamol.”
2. Albuterol (salbutamol) and ipratropium bromide should ideally be administered via metered-dose inhaler.
Common Pitfalls
• Overventilation of the patient—leads to breath stacking and potential for pneumothorax or depressed cardiac return and eventual cardiac arrest.
• Early intubation attempt without consideration of other possible management options (eg, magnesium sulfate, noninvasive ventilation).
Status Asthmaticus
Status Epilepticus
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of a child presenting in status epilepticus.
• Demonstrate the treatment of a child with status epilepticus.
– Understand complications associated with the treatment of status epilepticus.
– Demonstrate knowledge of rapid sequence intubation for a seizing patient.

• Four-year-old boy • Previously healthy, no prior seizures
• High fever for 3 d • Unimmunized
• Headache and neck pain for 2 d Airway:
• Irritable today • Open airway
• Found drowsy and unresponsive at home on the floor • Head tilt, chin lift, jaw thrust
• Paramedics bringing child to the ED • Suction
• Seizing en route for 5 min • Assign someone to attend to airway
• Call respiratory therapy for help
Weight:
• 15 kg Breathing:
• Check oxygen saturation
Condition:
• Apply monitors
• Actively seizing patient on arrival
• Apply oxygen by mask
• Temperature 39.5°C (103°F), HR 160/min, RR 25/min, BP
Circulation:
110/P mm Hg, oxygen saturation 92% in room air
• Apply monitors
• CNS: seizing (generalized)
• IV access not obtainable initially
• CVS: normal heart sounds, capillary refill 2 s, pulses strong
Medical Management:
• Respiratory: clear, poor air entry bilaterally
• Check glucose level: 5.0 mmol/L (90 mg/dL) (normal)
• Rest of examination results normal
• Give lorazepam or diazepam PR, then IV lorazepam two times
• Order phenytoin/fosphenytoin
• Order blood work: CBC, electrolytes, blood gas, lactate, renal
function, blood culture
• Order antibiotics: ceftriaxone, vancomycin, acyclovir
Status Epilepticus
• Actively seizing patient, child vomiting profusely and Airway:
frothing at the mouth, then desaturates • Maintain the airway: jaw thrust, chin lift, head tilt
Physical Examination Findings: • Suction vigorously
• Temperature 39.5°C (103°F), HR 160/min, RR 25/min, BP • Consider intubation and prepares equipment
110/P mm Hg, saturation 85% in room air Breathing:
• Monitor: sinus tachycardia • Increase oxygen delivery to 100% by using nonrebreather
• CNS: seizing still mask
• CVS: normal heart sounds, capillary refill 2 s, pulses strong • Prepare self-inflating bag
• Respiratory: poor air entry bilaterally Circulation:
• Rest of examination results normal • IV access two times
• Check HR, BP, capillary refill, pulses
• Cycle BP every 3–5 min
Medical Management:
• Laboratory test results come back:
– Sodium 130 mmol/L, potassium 3.5 mmol/L, glucose
normal
– ABG: pH 7.15, Pco2 60 mm Hg, Po2 90 mm Hg, bicarbonate
20 mmol/L, base excess −7 mmol/L

• Actively seizing patient, blood pressure and respiratory rate Airway: Intubation:
start to decrease • Preoxygenation
Physical Examination Findings: • Premedication: IV atropine IV optional
• Temperature 39.5°C (103°F), HR 160/min, RR 12/min, BP 70/P • Cricoid pressure
mm Hg, saturation 89% in room air • Sedation: IV ketamine, IV midazolam, IV thiopental, or IV
• Monitor: sinus tachycardia propofol
• CNS: seizing • Paralysis: IV succinylcholine
• CVS: normal heart sounds, capillary refill 3–4 s, pulses weak • Check tube placement with ETCO2 detector, auscultation of
• Respiratory: poor air entry bilaterally chest, observation of chest rise and order chest radiograph
• Rest of examination results normal Breathing:
• Reassess breathing
• Start to provide ventilatory assistance to the patient
Circulation:
• Identify hypoxia and worsening hypotension
• Reassess blood pressure, pulse, capillary refill
• Give IV normal saline bolus
Status Epilepticus
continued
• Call ICU
• Start infusion of other anticonvulsants (good discussion
point); options include levetiracetam (often given first line
instead of fosphenytoin) and phenobarbital
• IV antibiotics (cefotaxime/vancomycin or similar and
acyclovir) to cover the possibilities of bacterial meningitis
and herpes encephalitis

• Actively seizing patient, blood pressure still low, but oxygen Airway:
saturations improved after intubation • Secure endotracheal tube
• Temperature 39.5°C (103°F), HR 160/min, RR 12/min, BP 70/P • Reassess breathing
mm Hg, saturation 95% with oxygen • Continue to provide manual ventilation to the patient
• Monitor: sinus tachycardia Circulation:
• CNS: generalized, tonic-clonic seizure • Identify worsening hypotension
• CVS: normal heart sounds, capillary refill 2 s, pulses strong • Reassess blood pressure, pulse, capillary refill
• Respiratory: shallow air entry bilaterally • Give another IV normal saline bolus
• Rest of examination results normal Medical Management:
• Call intensive care specialist for consultation
• Consider rectal paraldehyde (not available in the United
States but might be available in other countries)
• Consider IV midazolam infusion or an additional dose of
phenytoin/fosphenytoin/phenobarbital/levetiracetam
Abbreviations: ABG, arterial blood gas; BP, blood pressure; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ED, emergency department; ETCO2, end-tidal carbon dioxide; HR, heart rate; ICU, intensive
care unit; IV, intravenous; PR, per rectum; RR, respiratory rate
Notes
1. Playing a video of a seizing child helps to add realism to the simulation.
2. Medications ordered will be institution specific. If your institution uses fosphenytoin, consider having the patient be normotensive and instead focus on
airway management of the seizing patient.
Common Pitfalls
• Failure to insert multiple intravenous catheters, thus delaying adjunct therapies (eg, antibiotics or fluids).
• Delay in checking bedside glucose level.
• Assumption that seizures have “stopped” after paralytic is given for intubation
Status Epilepticus
Stridor Due to Foreign Body
Mark Adler, MD
Learning Objectives
• Describe the possible causes of stridor in an infant.
• Demonstrate the management of upper airway obstruction due to a foreign body.

NOTE: Simulator should be placed in a sitting position at the beginning of case and a small object placed in the hypopharynx as the foreign body
(eg, toy, pen cap, rolled-up piece of medical tape).

• Twelve-month-old with sudden onset of stridor and • No ill contacts
respiratory distress • Has been well
• Parents rushed him to the ED for evaluation • No medications
• You are called to see the patient • No allergies
Weight: • Was playing unsupervised in playroom and mom heard
• 10 kg coughing and then noticed the trouble breathing when she
Condition: entered room
• Alert and anxious, sitting upright in bed Airway:
Physical Examination Findings: • Listen for breath sounds, stridor easily noted, child is sitting
• Temperature 37.2°C (99°F), HR 153/min, RR 40/min, oxygen and does not wish to be moved from sitting position
saturation 88% in room air, BP 85/68 mm Hg • Ask for bag-mask, suction, laryngoscope, ETT, and Magill
• CNS: alert forceps to bedside
• CVS: pulses present Breathing:
• Respiratory: clear • Apply monitors, including oxygen saturation and blood
• Extremities/skin: capillary refill <2 s pressure
• Auscultate chest and observe respiratory rate
• If health care worker attempts to place mask or inspect
mouth, state “child becomes more anxious and pushes you
away—do you want me to hold the child?”
Circulation:
• Assess pulse, HR, capillary refill, BP
Medical Management:
• Request ENT or anesthesia consultation
• Minimize stimuli: no painful procedures
• Airway obstruction (complete) Airway (ENT/anesthesia consultant not present yet):
• Occurs at 4 min regardless of actions OR if the health care • Lay child flat
workers look in mouth with tongue blade, force oxygen • Attempt to bag-mask patient with neck properly positioned
mask on to child, or place IV catheter and using two-person technique
Physical Examination Findings: • When this fails to work, perform direct laryngoscopy and
• Immediately: respiratory effort without stridor; rapidly remove small foreign body
lapses until unconsciousness Circulation:
• RR: initially 40/min but then decreases to 0/min in 30 s • Monitor decreasing vital signs, prepare to start
• HR: increases to 170/min in first minute then decreases to compressions if HR decreases below 60/min
65/min in next 90 s
• BP: 70/58 mm Hg
• Saturation: decreases from 88% to 30% in 30 s
STAGE 3 Recovery: REASSESSMENT OF THE PATIENT: 3–5

• Patient is now easily bagged Airway:
Physical Examination Findings: • Continue to bag patient
• HR and saturation return to normal • Place nasogastric tube to avoid stomach distension
• RR remains zero as bagging continues • May choose to intubate (can stop case before this is
complete for time constraints)
• Chest radiograph to assess for other possible foreign bodies
(if radio-opaque)
Disposition:
• ICU for observation
Abbreviations: BP, blood pressure; CNS, central nervous system; CVS, cardiovascular system; ED, emergency department; ENT, ear, nose, throat; ETT, endotracheal tube; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate.
Notes
1. It is easier to decrease and leave the respiratory rate at zero to both observe the quality of bagging and to avoid the participants being confused by the
simulator’s breathing effort.
2. This case can be changed to have foreign body below the vocal cords and having the participants intubate and push the foreign body into the right mainstem
bronchus. The point of having the removable foreign body is to reinforce the Magill forceps as a useful tool.
3. For simulators that support obstructing air entry into the lungs, simulators should be turned on when obstruction occurs to stop chest movement. This can
be a tangible visual cue that improves the case realism.
Common Pitfalls
• Beginning to treat for croup rather than aspiration.
• Trigger obstruction by stimulating child. This child should be taken to the operating room by an ear, nose, and throat surgeon and/or anesthesia personnel
where a controlled evaluation and removal can be performed. Ideally, the child is placed in a parent’s lap awaiting this event.
• Once complete obstruction occurs, failing to attempt airway evaluation and removal of obstruction or attempting intubation. The child now has an emergent
condition that cannot await airway expertise.
Supraventricular Tachycardia
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of an infant with supraventricular tachycardia.
• Demonstrate the management of stable supraventricular tachycardia using chemical cardioversion with appropriate monitoring.

• Seven-month-old girl with fussiness and poor feeding for • No ill contacts
approximately 1 day • No family history of heart problems
• No upper respiratory tract symptoms or fever • Given ibuprofen without relief but no cold medications
• Sent from physician’s office because of fast heart rate • No allergies
Weight: Airway:
• 7 kg • Listen for breath sounds, present
• Alert but cranky, pale • Apply monitors. Including oxygen saturation and blood
Physical Examination Findings: pressure
• Temperature 36.9°C (98.4°F), HR 226/min, RR 36/min, oxygen • Apply oxygen mask
saturation 98% in room air, BP 79/65 mm Hg • Auscultate chest and observe respiratory rate
• CNS: alert Circulation:
• CVS: pulses present • Assess pulse, HR, capillary refill, BP
• Respiratory: clear • Ask nurse to obtain IV access
• Abdomen: liver edge approximately 2 cm below costal Medical Management:
margin • Order an ECG
• Extremities/skin: capillary refill approximately 2 s • Attempt vagal maneuvers

• HR remains elevated Circulation:
Physical Examination Findings: • Reassess HR, pulse, capillary refill, BP after bolus
• HR 226/min, RR 36/min, oxygen saturation 100% in 100% • Order adenosine
oxygen (if placed), BP 81/68 mm Hg • Describe to nurse confederate how to deliver medication
when asked (“I am not sure how to give this medication.”)
• Prepare for conversion by:
– Ensuring availability of defibrillator (might or might not
connect pads)
STAGE 2, – Having ECG machine connected and running during
continued
conversion attempt
• Deliver first adenosine bolus (no or brief effect) after
considering contacting cardiology or intensive care support
personnel

• Infant cries when medication given Circulation:
• HR remains elevated • Reassess HR, pulse, capillary refill, BP
• Unchanged from stage 2 • Order a repeat dose of adenosine

• Patient improves (HR 145/min and sinus) • Disposition:
Physical Examination Findings: • Arrange for ICU or cardiology admission or transport to
• HR 148/min, BP 78/62/min, saturation 98% on tertiary care facility (depending on presenting facility
nonrebreather mask resources)
• Child is more comfortable
Abbreviations: BP, blood pressure; CNS, central nervous system; CVS, cardiovascular system; ECG, electrocardiogram; HR, heart rate; ICU, intensive care unit; IV, intravenous; RR, respiratory rate.
Notes
1. Some institutions have specific guidelines about the presence of cardiology personnel at chemical cardioversion. If this is required, anticipation of this need
should be discussed (calling as early as practical).
2. Simulating the patient monitor changes typically seen with cardioversion requires some practice and might not be an ideal representation of the clinical
experience (eg, longer pause, delay in rhythm change on monitor). Testing of this effect on the planned device is recommended.
Common Pitfalls
• Problems with delivering the adenosine in a rapid push/rapid flush manner.
• Electrical cardioversion in this stable patient (less common).
Tricyclic Antidepressant Overdose
Lina Al-Bakry, MD
Mark Adler, MD
Learning Objectives
• Describe the signs and symptoms of the anticholinergic toxidrome.
• Demonstrate the treatment of a child with tricyclic antidepressant (TCA) intoxication.
– Identify tachyarrhythmia secondary to TCA intoxication.
– Manage TCA intoxication with appropriate supportive and therapeutic interventions.

• Four-year-old boy, brought in by parents • No sick contacts
• Found extremely sleepy after dinner, slumped over on • No prior history of seizures
couch, minimally responsive • No history of trauma
• No fever or antecedent illness • No allergies
• Previously well • No medications
Weight: • Supervised by mother all day
• 15 kg • Grandparents arrived from England just before dinner
Physical Examination Findings: • Not sure if there are prescription medications in the home
• Temperature 37.5°C (99.5°F), HR 150/min, RR 24/min, oxygen Airway:
saturation 98% in room air, BP 85/50 mm Hg • Talk to the patient
• CNS: eyes closed intermittently, no spontaneous movement, • Optimize airway position: head tilt, chin lift, jaw thrust
intermittent verbalization Breathing:
• Respiratory: spontaneous respirations, no abnormal breath • Check oxygen saturation
sounds, air entry is normal • Apply monitors
• CVS: palpable pulses, slightly cool extremities, normal heart • Provide oxygen
sounds, tachycardia
• Abdomen: no bowel sounds, palpable full bladder
Circulation:
• Apply monitors
• Check pulse, capillary refill, BP—skin feels warm and dry
• Start IV access
STAGE 1, Disability:
continued
• Eyes closed intermittently, opens eyes with stimulation
• Moans and vocalizes with stimuli.
• Localizes to painful stimuli, otherwise no movement
• Pupils 5 mm, sluggish reaction symmetrically
Expose the Patient:
• Warm, dry skin
• No rash, no petechiae
• Identify abnormality on cardiac tracing (sinus tachycardia
with wide QRS)
• Identify need for 12-lead ECG
• Order blood work: CBC, differential, electrolytes, glucose,
creatinine, BUN, serum osmolality, blood gas, serum
acetaminophen and aspirin levels, urine toxicology screen
STAGE 2 Condition: Parent calls on telephone—grandmother has 20–30 missing 3

• The patient’s condition evolves—worsening level of antidepressant pills from her medication cabinet
consciousness. REASSESSMENT OF THE PATIENT:
Physical Examination Findings: Airway:
• Temperature 37.5°C (99.5°F) orally, HR 150/min, RR 24/min, • Prepare equipment for intubation
saturation 98% with 100% oxygen, BP 85/50 mm Hg • Prepare medication for rapid sequence intubation
• CNS: eyes closed, no spontaneous movement, moaning, Intubation:
infrequent verbalization • Preparation/equipment
• Chest: spontaneous respirations, no abnormal air entry or • Preoxygenation.
breath sounds • Cricoid pressure
• CVS: palpable pulses, slightly cool extremities, normal heart • Premedication: IV atropine
sounds, tachycardia
• Sedation: IV ketamine
• Abdomen: no bowel sounds, palpable full bladder
• Paralysis: IV succinylcholine
• Intubate with ETT
• Check tube placement with ETCO2, auscultation, and chest
radiograph
Breathing:
• Reassessment of breathing, auscultation—no change
• Apply 100% oxygen—no change in clinical appearance
Circulation:
• Reassess HR, pulse, BP
• Consider giving IV bolus of normal saline
continued
• IV sodium bicarbonate bolus
• Glucometer: normal results
• Continuous ECG monitoring
• Call for ICU consultation
• Call for toxicology consultation/poison control

• The patient’s condition evolves: ventricular tachycardia Airway:
Physical Examination Findings: • Position airway
• Temperature 37.5°C (99.5°F) orally, HR 180/min, RR 10/min, • Oropharyngeal airway—still in place
saturation 98%, BP 85/50 mm Hg Breathing:
• CNS: eyes closed, no spontaneous movement—paralyzed • Reassess auscultation, breathing
and sedated • Manual ventilation—patient intubated
• Respiratory: air entry equal Circulation:
• CVS: palpable pulses, slightly cool extremities, capillary refill • Reassess HR, pulse, BP, capillary refill
2s • Gives IV normal saline bolus
• Abdomen: no bowel sounds, palpable full bladder • ECG: ventricular tachycardia
Medical Management:
• Follow PALS protocol
• Prepare for synchronized cardioversion
• Consult cardiologist

• Patient condition deteriorates after intubation Airway:
• Very difficult to ventilate • Consider direct visualization of the tube with laryngoscope
• Poor chest rise bilaterally Breathing:
• Temperature 38°C (100.4°F), HR 80/min, RR bagging, • Auscultate the chest
saturation 78% in 100% oxygen, BP 80/50 mm Hg • Check for signs of tension pneumothorax (trachea midline,
• CNS: sedated/paralyzed blood pressure, percussion of chest, jugular venous pressure)
• Respiratory: poor chest rise and air entry bilaterally with • Give continuous nebulized inline albuterol (salbutamol)
wheezing • Check oxygen/equipment
• CVS: pulses weak, capillary refill 4 s • Bag-mask ventilate at a slower rate with a prolonged
expiratory phase
Circulation:
• Insert second IV catheter
• Give IV bolus of normal saline
Abbreviations: BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; ECG, electrocardiogram; ETCO2, end-tidal carbon dioxide; ETT, endotracheal tube; HR,
heart rate; ICU, intensive care unit; IV, intravenous; PALS, Pediatric Advanced Life Support; RR, respiratory rate.
Notes
1. Have someone serve as poison control personnel and provide advice to the medical team over the telephone.
2. “Albuterol” is the drug name in the United States. In many other countries the drug name is “salbutamol.”
Common Pitfalls
• Delay in eliciting further history, thus leading to delay in making the diagnosis.
• Failure to recognize and anticipate the potential cardiac complications of TCA overdose.
Metabolic Crisis—Hyperammonemia
Mark Adler, MD
Debra Weiner, MD
Learning Objectives
• Describe the common causes of vomiting and lethargy in a neonate.
• Demonstrate the treatment of a neonate with altered mental status and suspected metabolic crisis.
– Manage airway, breathing, and circulation.
– Check appropriate laboratory test results—glucose at bedside, blood gas, and serum ammonia.
– Treat hypoglycemia and confirm that treatment was effective.
– Treat acidosis.
– Arrange for treatment of hyperammonemia.

• One-week-old with progressive poor feeding, vomiting, and • Term, birth weight 3.3 kg, uncomplicated pregnancy,
lethargy for the past 3 d delivery
• Brought to ED by parents • No medications or no allergies
• Looks very unwell at triage, brought to resuscitation room • Spitting up first few days of life, during last 3 d increased
• You are called to assess patient frequency and amount, today four times
Weight: • Weight currently 10% less than birth weight
• 3 kg • No fever, diarrhea, rash
Condition: • No sick contacts or travel
• Infant is pale and lethargic, looks unwell Airway:
Physical Examination Findings: • Listen for breath sounds
• Temperature 36.2°C (97.2°F), HR 165/min, RR 46/min, oxygen Breathing:
• CNS: eyes open spontaneously, pupils 3 mm and reactive pressure
bilaterally • Auscultate chest and observe respiratory rate
• CVS: pulses intact but weak Capillary refill 3 s Circulation:
• Abdomen: soft and without hepatosplenomegaly • Ask nurse to obtain IV access
• Extremities/skin: loose skinfolds, no bruising noted Disability:
• Quick neurologic assessment (pupils, response to pain)
continued
• Order a bedside glucose, electrolytes, BUN, creatinine, LFTs,
ammonia, blood gas, CBC, blood culture, urine, urine culture
tests, blood to hold for possible additional studies
• Orders IV fluid bolus of 10 mL/kg of normal saline

• Infant minimally responsive to painful stimulus. Does not Airway:
open eyes spontaneously, no verbalization/cooing • Maintain the airway: jaw thrust, chin lift, head tilt
Physical Examination Findings: • Suction vigorously
• Temperature 36.2°C (97.2°F), HR 175/min, RR 52/min, oxygen • Prepare intubation equipment
saturation 94% in 100% oxygen, BP 70/30 mm Hg Breathing:
• CNS: unresponsive, unconscious, pupils 3 mm and reactive • Increase oxygen delivery to 100% by using nonrebreather
bilaterally • Assist ventilations as required
• CVS: pulses intact but weak, capillary refill 4 s Circulation:
• Respiratory: clear • Ensure IV access two times
• Abdomen: soft and without hepatosplenomegaly • Recheck HR, BP, capillary refill, pulses
• Extremities/skin: no bruising noted • Cycle BP every 3–5 min
Medical Management:
• Laboratory test results come back:
– Sodium 135 mmol/L, potassium 3.5 mmol/L, glucose 35
mg/dL (low)
• Administer D10W, 0.5 g/kg IV
• ABG: pH 7.05, Pco2 30 mm Hg, Po2 90 mm Hg, bicarbonate 8
mmol/L, base excess −20 mmol/L
• Ammonia, 350 µg/dL (205 µmol/L).
• WBC and hemoglobin level normal
• Metabolic or genetics consultation

• Neonate still unresponsive, does not open eyes Airway: Intubation:
spontaneously or to painful stimuli, no verbalization/ • Preoxygenation
cooing, intermittent jittering movements of both arms and • Premedication: IV atropine optional
stiffening suspicious for seizures • Cricoid pressure
Physical Examination Findings: • Sedation: discussion: etomidate vs other options: midazolam
• Temperature 36.2°C (97.2°F), HR 175/min, RR 52/min, oxygen plus IV fentanyl
saturation 94% in 100% oxygen, BP 70/30 mm Hg • Paralysis: IV rocuronium or IV succinylcholine
• CNS: unresponsive, unconscious, pupils 3 mm and reactive • Check tube placement with ETCO2 detector, auscultation of
bilaterally chest, observation of chest rise, and order chest radiograph
• CVS: pulses intact but weak, capillary refill 4 s
STAGE 3, • Respiratory: clear Breathing:
continued
• Abdomen: soft and without hepatosplenomegaly • Reassess breathing
• Extremities/skin: no bruising noted • Start to provide manual ventilation to the patient
Circulation:
• Reassess blood pressure, pulse, capillary refill
• Give IV normal saline bolus
Medical Management:
• Call for ICU consultation
• Order dose of lorazepam for suspected seizure
• Call for metabolism consultation if not already done
• Administer bicarbonate
• Arrange for hemodialysis, give sodium phenylacetate,
sodium benzoate if hemodialysis will be delayed
Abbreviations: ABG, arterial blood gas; BP, blood pressure; BUN, blood urea nitrogen; CBC, complete blood cell count; CNS, central nervous system; CVS, cardiovascular system; D10W, 10% dextrose in water; ED, emergency department;
ETCO2, end-tidal carbon dioxide; HR, heart rate; ICU, intensive care unit; IV, intravenous; LFTs, liver function tests; RR, respiratory rate; WBC, white blood cell count.
Notes
1. Consider inborn error of metabolism (IEM) with, not after, other potential diagnoses. History and laboratory findings (hypoglycemia, acidosis,
hyperammonemia, neutropenia, anemia) are most suggestive of organic acidemia. Other IEMs most likely to present with catastrophic decompensation in a
neonate include aminoacidopathies, urea cycle defects, fatty acid oxidation defects, and mitochondrial disorders.
2. Recognize that results of a newborn screen might not be available at 1 week of age or that child might not have had a newborn screen.
3. Normal pregnancy, delivery, and examination findings are not uncommon with IEM.
4. Family history might be negative given autosomal recessive inheritance of most IEMs.
5. Physical examination findings usually normal except for acute manifestations of illness.
6. Manifestations of seizure in neonates might be subtle. For seizures unresponsive to conventional treatment, consider pyridoxine, folate, and/or biotin.
7. Perform laboratory tests to evaluate for IEMs before any treatment, including glucose or fluids. Initial laboratory tests include bedside glucose, electrolytes,
blood urea nitrogen, creatinine, glucose, blood gas, complete blood cell count, blood culture, liver function tests, ammonia, urine, and urine culture. If
hypoglycemia, acidosis, and/or hyperammonemia are present, send serum samples for amino acids, acylcarnitine profile, and ketones measurement and urine
samples for organic acids and urine acylglycine measurement. Consider taking lactate and pyruvate samples. Blood samples for IEM studies can be sent on
newborn screen filter paper. Lactate and pyruvate samples require special tubes.
8. Consultation with metabolism specialist recommended if laboratory test results support suspicion of IEM.
9. Bicarbonate to correct acidosis. No consensus on pH for which to give or dose; consider for pH less than 7.0 to 7.2.
10. Hemodialysis for hyperammonemia. Extracorporeal membrane oxygenation hemodialysis is faster than conventional dialysis but has increased risks in
neonates. Sodium phenylacetate or sodium benzoate should be administered per package insert directions if there will be a delay in hemodialysis.
Common Pitfalls
• Potential diagnosis of IEM is not considered until late, which increases the risk of long-term disease and/or death.
• Participants check and treat the glucose level but fail to obtain a follow-up glucose measurement. A high concentration of glucose is not always maintained
with maintenance fluids.
• Acidosis is not treated.
• Ammonia is not checked.
• Failure to recognize and treat seizure.

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module

Simulator: Infant Simulator

Scenario Patient Instructor Time,

STAGE 3 Condition: REASSESSMENT OF THE PATIENT: 5

Simulator: Pediatric Simulator

Simulator: Infant Simulator

Scenario Patient Instructor Time,

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 7

STAGE 3 Condition: REASSESS THE PATIENT: 5

Simulator: Infant Simulator

Scenario Patient Instructor Time,

STAGE 3 Condition: Medical Management: 5

D50 Not recommended due to high osmolarity

Simulator: Pediatric Simulator

Scenario Patient Instructor Time,

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 5

Simulator: Infant Simulator

Scenario Patient Instructor Time,

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 5

STAGE 3 Condition: REASSESS THE PATIENT: 5

Simulator: Pediatric Simulator

Scenario Patient Instructor Time,

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 2

STAGE 3 Condition: REASSESS THE PATIENT: 5

Simulator: Infant Simulator

Scenario Patient Instructor Time,

STAGE 3 Condition: REASSESSMENT OF THE PATIENT: 5

STAGE 4 Condition: REASSESS THE PATIENT: 5

Simulator: Pediatric Simulator

Scenario Patient Instructor Time,

STAGE 3 Condition: REASSESSMENT OF THE PATIENT: 5

Simulator: Infant Simulator

Scenario Patient Instructor Time,

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 3

STAGE 3 Condition: INTUBATION: 5

STAGE 4 Condition: REASSESS THE PATIENT: 5

Simulator: Pediatric Simulator

Scenario Patient Instructor Time,

STAGE 2 Condition: REASSESSMENT OF PATIENT: 3

STAGE 3 Condition: REASSESSMENT OF PATIENT: 2

Simulator: Infant Simulator

STAGE 3 Condition: REASSESSMENT OF THE PATIENT: 5

STAGE 4 Condition: REASSESS THE PATIENT: 5

Simulator: Pediatric Simulator

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 5

Simulator: Pediatric Simulator

Scenario Patient Instructor Time,

STAGE 3 Condition: REASSESSMENT OF THE PATIENT: 5

STAGE 4 Condition: REASSESS THE PATIENT: 5

Simulator: Pediatric Simulator

Scenario Patient Instructor Time,

STAGE 3 Condition: REASSESSMENT OF PATIENT: 5

STAGE 4 Condition: REASSESSMENT OF PATIENT: 5

Simulator: Infant Simulator

Scenario Patient Instructor Time,

STAGE 3 Recovery: REASSESSMENT OF THE PATIENT: 3–5

Simulator: Infant Simulator

Scenario Patient Instructor Time,

STAGE 2 Condition: REASSESSMENT OF THE PATIENT: 3

STAGE 3 Condition: REASSESSMENT OF THE PATIENT: 5

STAGE 4 Condition: REASSESS THE PATIENT: 5

Simulator: Pediatric Simulator

Scenario Patient Instructor Time,