Scenario Template
ADVANCED PAEDIATRIC LIFE SUPPORT
Learning objectives
Target Audience
Setting
Overview
Mannikin/Moulage
Actors/Confederates
Whitley, September 2016
 Applying up-to-date APLS algorithm and skills to paediatric
arrest scenario
 CRM principles/team-work and leadership
 Resuscitation in presence of relative, emotional impact of
paediatric resuscitation
 DEM Senior House Officers
 Scenario will require: 4 x SHO’s (Team leader, Airway,
Circulation and Defib)
 Gympie emergency department night shift, midnight
 SHO is most senior on-site doctor, has JHO on shift too
 Two SHO colleagues have fortunately stayed late to finish
patient notes
 SMO now on call from home – 15mins away
 Two capable and competent nurses to assist
 Mother runs into the ED holding a limp infant (12
month old, ALS infant) who has been in severe
respiratory distress at home and has stopped
breathing and become unresponsive just as she
was arriving at the ED.
 Triage nurse races into resusc with mum and infant,
finds a lone SHO
 Participant expected to recognize paediatric arrest,
call for help and initiate APLS algorithm while
assembling a team rapidly
 Triage nurse will be very capable and assist as
required
 Role allocations may change as team leader steps
back for overview
 Scenario to go through at least 3 rounds of CPR to
allow participants to demonstrate: control of
airway/breathing; correct compression to ventilation
ratio; good CPR technique; early application of
defib pads; recognition of non-shockable rhythm
with safe defib use, IO access and correct dosage
of adrenaline.
 Once team has successfully demonstrated the
above, infant will get ROSC and scenario will end
 Confederate acting as mother will be distressed and
anxious but not overly interfering
 Simbaby in baby grow
 Distressed and anxious mother
 Capable triage/ED nurse
 If ask for extra nurse, Michelle Sumner to assist as
confederate
Faculty Required
Jo Deverill = facilitator
Tanya = course co-ordinator, debrief
Michelle Sumner = facilitator
Mark Kelly = triage nurse
Mark Harrington = SIMCO
Ellie Wood = mum
Megan = videography/photographer
Resources
Checklist
ALS infant wrapped in
blanket(confederate runs in with ALS
baby but SIM runs with SIMbaby)
SIMbaby (dressed in onesie)
on resusc trolley
Paediatric airway trolley with:
OPA sizes 00, 0, 1, 2, 3
NPA sizes 3.5 and 4.5
Paediatric BVM
Masks size 0,1&2 (infant)
LMA size 1, 2
Syringe 10ml x 3
Syringe 20mls
Equipment + Supplies
Lubricant spray
Defib machine
Paediatric Defib pads
EZ IO pack with:
Drill
Red and blue IO needles
EZ IO connect
10ml saline flush
10ml syringe
IO secure device
Drug Box supplies:
Adrenaline 1mg x 1
Blunt drawing up needle
10ml N/saline flush x 2
N/saline 1 litre bag
Pressure bag
50ml syringe
Timing device
MONASH paediatric resource
manual
Pre-brief
4 participants needed in the SIM, one elected as T/L
Set the scene: Gympie ED, midnight
Will be required to demonstrate principles of APLS
Staffing available: night shift SHO and JHO, two SHO
colleagues who have stayed late, 1 nurse (who is
confederate triage nurse)
Scenario Template
Told that will not be given any other patient info
Will need to assemble team quickly
Have access to Monash Paediatric Reference Book
Very brief history supplied by mum as above – limited initially
as CPR underway. “He woke up struggling to breathe and
the inhaler didn’t help. Then he just stopped breathing as I
arrived here…. Oh my god, he’s dead isn’t he?”
If team leader asks for more history once CPR in progress
(may never get time for this):
Handover
Pre-term birth at 36 weeks, some time in special care
nursery on CPAP but did well after that, 2 short previous
hospital admissions with bronchiolitis but never in ICU, is up
to date with immunizations. Had URTI features in the
evening with moderate WOB around 9pm, responded well to
Ventolin puffs but woke up again with worsening respiratory
distress. Lives 5 mins from hospital so thought quicker to
drive him here than wait for QAS. Just as she pulled up to
ED – Jimmy stopped breathing and became unconscious.
Events
Phase 1
Whitley, September 2016
 Phase 1: Pale, lifeless infant brought in mum’s arms – call
for help, initiate CPR then application of pads with
allocation of team roles. unable to ventilate if no airway
adjunct used
 Phase 2: continue APLS algorithm and recognize
shockable vs non-shockable (in this case PEA, non
shockable) rhythm with safe operation of defib
 Phase 3: continue APLS algorithm, recognize ongoing NS
rhythm, gain IO access and give appropriately timed
Adrenaline
 Phase 4: ROSC if deliver adequate APLS, remains
arrested if not – scenario will conclude regardless.
Consider/verbalise causes of paediatric arrest.
Phase 2
Phase 3
Phase 4
GCS
ECG
HR
BP
RR
SpO2
3
PEA
n/a
n/a
n/a
n/a
GCS
ECG
HR
BP
RR
SpO2
3
PEA
n/a
n/a
n/a
n/a
GCS
ECG
HR
BP
RR
SpO2
3
PEA
n/a
n/a
n/a
n/a
GCS
3
ECG
Sinus brady
HR
58
BP
n/a
RR
4
SpO2 unrecordable
WOB
BS
Temp
WOB
BS
Temp
WOB
BS
Temp
WOB
Pain
Temp
Unable to ventilate
if no airway
adjunct used.
Ventilating adequately if
good technique/adjuncts
NS rhythm on rhythm check
NS rhythm on
rhythm check
What is happening?
Mum: Oh Jimmy,
my baby!
Mum: What’s happening?
Don’t you need to shock
him?
Investigations
Expected Actions
Pitfalls
Discussion points
Mum: What are you
doing to his leg?
Is he still dead?
 BSL 3.4 if taken from IO sample
 IO sample VBG: pH 6.8, bicarb 8, lactate 8
 Identification of paediatric arrest (respiratory most likely
cause)






Initiate call for help (which won’t arrive)
Initiate CPR with ABC approach
Role allocation and leadership
Early application of defib pads
Safe operation of defib (COACHED mnemonic, correct
joules/kg)
Recognition of non-shockable rhythm (PEA)
Adherence to APLS algorithm and timings
Establish IO access
Administer safe and correct dose of adrenaline
Consider/verbalise likely cause(s) of paediatric arrest
Allocate resource to look after mum










Poor leadership and role allocation
Delay in initiating CPR
Delay to application of defib pads
Delaying rhythm assessment to complete cycle of CPR
Incorrect compression ratios
Unsafe defibrillator use
Failure to recognise NS rhythm (PEA)
Incorrect adrenaline dosing
Not using available aide-memoire (Monash book)
Not dealing with mum sensitively and appropriately





Scenario Template




Author/Date
Whitley, September 2016
Recent changes to ILCOR APLS guidelines
Most paediatric arrests = respiratory and unlikely to
be a shockable rhythm (10% only)
Crew Resource Management/team work in a crisis
situation
Emotional impact of paediatric resuscitation, dealing
with distressed relatives
Dr Tanya Whitley
September 2016