WEBVTT 00:00:00.720 --> 00:00:03.839 Hey guys, this right here is going to be PALS, 00:00:03.940 --> 00:00:07.919 the Pediatric Advanced Life Support. And the 00:00:07.919 --> 00:00:09.640 way it's going to go is I'm going to try to keep 00:00:09.640 --> 00:00:13.380 it in this order. The systematic approach to 00:00:13.380 --> 00:00:17.699 the pediatric patients, pediatric shock recognition, 00:00:18.100 --> 00:00:23.199 pediatric management of shock, recognizing respiratory 00:00:23.199 --> 00:00:27.850 distress, managing respiratory distress. recognizing 00:00:27.850 --> 00:00:30.710 cardiac arrest, management of cardiac arrest, 00:00:31.109 --> 00:00:34.170 arrhythmias, recognition of those arrhythmias, 00:00:34.350 --> 00:00:37.670 and then management of those arrhythmias. I don't 00:00:37.670 --> 00:00:41.049 remember PALS being this deep, but again, it's 00:00:41.049 --> 00:00:43.829 been almost two years since I've taken PALS, 00:00:44.070 --> 00:00:47.689 but it seems like it's a lot more in depth than 00:00:47.689 --> 00:00:52.710 just your normal ACLS. So this material is coming 00:00:52.710 --> 00:00:56.840 straight from the book. For the course just make 00:00:56.840 --> 00:00:59.880 sure that you guys are reading that material 00:00:59.880 --> 00:01:06.680 Because I did not add some stuff in there like 00:01:06.680 --> 00:01:10.500 team dynamics or resources for respiratory care 00:01:10.500 --> 00:01:15.459 or Management of the post cardiac arrest, you 00:01:15.459 --> 00:01:17.760 know stuff like that. I didn't include that into 00:01:17.760 --> 00:01:22.260 this stuff So if you guys need that or want that, 00:01:22.299 --> 00:01:25.420 then by all means, read the book or, you know, 00:01:25.519 --> 00:01:29.359 Google it or whatever. But this right here is 00:01:29.359 --> 00:01:32.879 going to be the intro for the pals stuff. So 00:01:32.879 --> 00:01:35.439 I hope you guys enjoy the pediatric advanced 00:01:35.439 --> 00:01:50.120 life support material for the course. This is 00:01:50.120 --> 00:01:53.680 all going to happen super fast. Welcome to the 00:01:53.680 --> 00:02:27.289 emergency room. Welcome back to The Deep Dive. 00:02:27.430 --> 00:02:30.449 Today we are putting away the flashcards and 00:02:30.449 --> 00:02:33.189 really getting into the most critical zone of 00:02:33.189 --> 00:02:36.150 pediatric emergency care. If you're an ER nurse 00:02:36.150 --> 00:02:38.430 and you're gearing up for your PASS certification 00:02:38.430 --> 00:02:40.469 or maybe you just want to feel more confident 00:02:40.469 --> 00:02:42.569 when that pediatric respiratory call comes in, 00:02:42.789 --> 00:02:45.400 well, this Deep Dive is for you. That's absolutely 00:02:45.400 --> 00:02:48.039 right. And our focus today, it's not about just 00:02:48.039 --> 00:02:50.419 memorizing algorithms, not about where the arrows 00:02:50.419 --> 00:02:53.740 point on some flow chart. Our mission is to get 00:02:53.740 --> 00:02:57.580 into the path of physiology, the why behind the 00:02:57.580 --> 00:02:59.340 path of those guidelines. And we're going to 00:02:59.340 --> 00:03:01.319 be focusing specifically on that foundational 00:03:01.319 --> 00:03:05.540 pillar, which is recognizing and managing. pediatric 00:03:05.540 --> 00:03:07.919 respiratory distress and failure. We want to 00:03:07.919 --> 00:03:09.840 translate that textbook knowledge into what you 00:03:09.840 --> 00:03:12.199 actually do at the bedside. Exactly. And we're 00:03:12.199 --> 00:03:14.120 starting here for a reason, and it's, well, it's 00:03:14.120 --> 00:03:16.539 a bit grim, but it's absolutely essential. The 00:03:16.539 --> 00:03:18.539 pathos source material says this over and over 00:03:18.539 --> 00:03:21.280 again. Respiratory failure is the number one, 00:03:21.280 --> 00:03:24.830 the major cause of cardiac arrest in kids. It's 00:03:24.830 --> 00:03:26.849 the big one. It's not like adults, you know, 00:03:26.949 --> 00:03:29.449 where it's often a primary cardiac event. For 00:03:29.449 --> 00:03:32.210 kids, the arrest is usually the final step after 00:03:32.210 --> 00:03:34.710 they've been hypoxic for a while. And that means 00:03:34.710 --> 00:03:37.370 we have this tiny, tiny window to intervene, 00:03:37.650 --> 00:03:40.449 to do something before they code. Because once 00:03:40.449 --> 00:03:43.370 a child arrests, the outcomes, they're just dramatically 00:03:43.370 --> 00:03:46.129 worse. So the whole goal of PALLAS, especially 00:03:46.129 --> 00:03:49.409 for you, the ER nurse, is prevention. It's all 00:03:49.409 --> 00:03:52.099 about prevention. So if we can master spotting 00:03:52.099 --> 00:03:54.819 and aggressively managing that respiratory failure, 00:03:55.259 --> 00:03:57.599 we're actually changing the outcome. We're improving 00:03:57.599 --> 00:03:59.560 survival. We're improving survival and neurological 00:03:59.560 --> 00:04:01.939 outcomes. The difference between a good palace 00:04:01.939 --> 00:04:04.639 provider and a great one. It's often just speed 00:04:04.639 --> 00:04:07.199 and a systematic approach to breathing problems. 00:04:07.560 --> 00:04:10.159 OK, so let's unpack that, this clinical reality. 00:04:10.539 --> 00:04:12.580 You know, we're so often trained to think cardiac 00:04:12.580 --> 00:04:15.319 first with adults, but with a kid who's struggling 00:04:15.319 --> 00:04:17.199 to breathe, you're saying we have to flip that 00:04:17.199 --> 00:04:20.800 entire paradigm. What are the key physiological 00:04:20.800 --> 00:04:23.420 differences that make Pella so focused on respiratory 00:04:23.420 --> 00:04:26.560 first? Well, the differences are both anatomical 00:04:26.560 --> 00:04:29.220 and physiological. First off, just the anatomy. 00:04:29.660 --> 00:04:32.060 Kids, especially infants, they have much smaller 00:04:32.060 --> 00:04:34.120 airways. I mean, their trachea is shorter. It's 00:04:34.120 --> 00:04:36.120 narrower. So a little bit of swelling that an 00:04:36.120 --> 00:04:38.920 adult could handle is a huge deal. A huge deal. 00:04:38.980 --> 00:04:41.379 Think about croup. That little bit of swelling, 00:04:41.420 --> 00:04:44.120 which an adult might barely notice, becomes a 00:04:44.120 --> 00:04:46.420 life -threatening critical obstruction for a 00:04:46.420 --> 00:04:50.079 two -year -old. And second, they rely way more 00:04:50.079 --> 00:04:52.560 heavily on their diaphragm for breathing. Ah, 00:04:52.699 --> 00:04:54.860 which is why you see those retractions so clearly. 00:04:55.139 --> 00:04:57.779 Exactly. That's why seeing accessory muscle use, 00:04:58.060 --> 00:05:00.379 you know, the super sternal or subcostal retractions, 00:05:00.720 --> 00:05:03.060 that's an early and really significant sign of 00:05:03.060 --> 00:05:05.480 distress. And then there are the metabolic differences. 00:05:05.899 --> 00:05:07.500 I think this is where it gets really interesting. 00:05:07.720 --> 00:05:10.000 They have a higher metabolic rate. They just 00:05:10.000 --> 00:05:13.259 burn through oxygen faster. Precisely. So if 00:05:13.259 --> 00:05:15.819 they become hypoxemic, their oxygen reserves 00:05:15.819 --> 00:05:19.120 are depleted so, so rapidly. This is why that 00:05:19.120 --> 00:05:21.939 decline can be so fast. The kid looks distressed, 00:05:22.279 --> 00:05:24.600 then they get quiet, and then they crash. And 00:05:24.600 --> 00:05:27.399 that quiet phase is so dangerous. It's often 00:05:27.399 --> 00:05:30.139 mistaken for improvement, right? It's a classic, 00:05:30.439 --> 00:05:33.180 terrifying sign of fatigue and impending arrest. 00:05:33.759 --> 00:05:36.579 That shift from agitation to lethargy is a massive 00:05:36.579 --> 00:05:39.800 red flag. Recognizing that is absolutely fundamental. 00:05:40.009 --> 00:05:43.310 So we see the signs, we know we have to act fast. 00:05:43.769 --> 00:05:46.509 First step is always stabilization. Let's walk 00:05:46.509 --> 00:05:49.470 through that initial ABC framework. We stabilize 00:05:49.470 --> 00:05:52.129 oxygenation and ventilation, and only then do 00:05:52.129 --> 00:05:55.610 we hunt for the cause. Starting with A for airway 00:05:55.610 --> 00:05:59.389 interventions. What are the absolute non -negotiables 00:05:59.389 --> 00:06:02.069 to get that airway patent? Airway patency is 00:06:02.069 --> 00:06:04.870 everything. And, you know, the first, the simplest, 00:06:04.970 --> 00:06:07.170 and often the safest move is just allowing the 00:06:07.170 --> 00:06:09.379 child to find a position of comfort. So if they're 00:06:09.379 --> 00:06:11.920 sitting up, leaning forward in that tripod position, 00:06:12.000 --> 00:06:13.740 you just let them be. You let them be. Don't 00:06:13.740 --> 00:06:15.959 fight them. Anything you do that increases their 00:06:15.959 --> 00:06:18.019 agitation is going to increase their oxygen demand 00:06:18.019 --> 00:06:19.939 and can actually make the obstruction worse. 00:06:20.079 --> 00:06:21.899 But what if that's not enough? We have to intervene 00:06:21.899 --> 00:06:24.139 with maneuvers. The default is the head tilt 00:06:24.139 --> 00:06:26.220 chin lift, correct? Yes, that's the default. 00:06:26.459 --> 00:06:29.759 Unless, and this is a big dig, unless you have 00:06:29.759 --> 00:06:32.139 any suspicion of trauma or a C -spine injury. 00:06:32.399 --> 00:06:35.019 If that mechanism exists, you immediately switch 00:06:35.019 --> 00:06:37.420 to the jaw thrust maneuver without tilting the 00:06:37.420 --> 00:06:40.509 head. The goal is the same. Lift the tongue off 00:06:40.509 --> 00:06:42.829 the back of the pharynx. Beyond maneuvers, we 00:06:42.829 --> 00:06:45.790 have adjuncts. Let's get into the oropharyngeal 00:06:45.790 --> 00:06:48.850 airway, the OPA, and the nasopharyngeal, the 00:06:48.850 --> 00:06:51.829 NPA. They're crucial tools, but they come with 00:06:51.829 --> 00:06:55.250 risks, especially in kids. Absolutely. The OPA 00:06:55.250 --> 00:06:57.629 should only be used in a child who is deeply 00:06:57.629 --> 00:07:01.389 unconscious. I mean, truly flaccid, no gag reflex. 00:07:01.490 --> 00:07:03.889 And why is that so critical? Because if you stimulate 00:07:03.889 --> 00:07:05.790 that gag reflex, you're going to make them vomit. 00:07:06.620 --> 00:07:08.819 and that could lead to a lethal aspiration. And 00:07:08.819 --> 00:07:10.720 you have to size it right, from the corner of 00:07:10.720 --> 00:07:13.480 the mouth to the angle of the jaw. No guessing. 00:07:13.660 --> 00:07:16.540 And what about the MPA? It's usually better tolerated, 00:07:16.680 --> 00:07:18.819 right, even in a conscious child. But what are 00:07:18.819 --> 00:07:21.139 the big red flags that contraindications we have 00:07:21.139 --> 00:07:23.519 to look for? The MPA is great because it can 00:07:23.519 --> 00:07:26.259 bypass the tongue obstruction without causing 00:07:26.259 --> 00:07:29.139 that gagging. However, you have to use extreme 00:07:29.139 --> 00:07:31.319 caution if there's any known bleeding disorder, 00:07:31.779 --> 00:07:34.420 any significant facial trauma, or, critically, 00:07:34.759 --> 00:07:36.819 a suspected basal or skull fracture. Because 00:07:36.819 --> 00:07:38.600 you could actually insert it into the cranium. 00:07:39.019 --> 00:07:42.040 You could. It's a never event, but it's a known 00:07:42.040 --> 00:07:45.620 risk. And again, sizing is key. Tip of the nose 00:07:45.620 --> 00:07:48.240 to the tragus of the ear. Okay, that's A. Moving 00:07:48.240 --> 00:07:50.819 to B for breathing. We've got the pulse oxon, 00:07:50.879 --> 00:07:53.060 but we need to be thinking beyond that immediately. 00:07:53.399 --> 00:07:56.060 Immediately. You go straight to high -concentration 00:07:56.060 --> 00:07:59.100 oxygen with a non -rebreathing mask and NRB. 00:07:59.379 --> 00:08:03.199 We're aiming for 95 % saturation or higher. But 00:08:03.199 --> 00:08:05.939 you also need to be preparing for advanced respiratory 00:08:05.939 --> 00:08:08.839 monitoring. That means getting the end -title 00:08:08.839 --> 00:08:12.500 CO2 or ETQ -EROS monitor ready to go. because 00:08:12.500 --> 00:08:14.500 that tells you about ventilation and circulation. 00:08:14.720 --> 00:08:17.139 It gives you crucial data. And if it's indicated, 00:08:17.199 --> 00:08:19.720 say, a kid with a known history of asthma, you're 00:08:19.720 --> 00:08:22.079 giving inhaled meds right away. But the number 00:08:22.079 --> 00:08:24.740 one nursing priority here is preparation. You're 00:08:24.740 --> 00:08:27.040 always, always preparing for an advanced airway 00:08:27.040 --> 00:08:30.819 and the need for bag valve mask or BVM ventilation. 00:08:31.079 --> 00:08:32.679 Okay, I want to challenge that point a little 00:08:32.679 --> 00:08:34.539 because the second you bring out the BVM, you 00:08:34.539 --> 00:08:36.799 risk agitating the child. And you mentioned the 00:08:36.799 --> 00:08:39.120 risk of air trapping in some diseases. What's 00:08:39.120 --> 00:08:41.440 the clinical trigger? When do you make that leap 00:08:41.440 --> 00:08:43.460 from a non -rebreather to actually assisting 00:08:43.460 --> 00:08:46.120 their breaths with a BVM? That is a great question 00:08:46.120 --> 00:08:48.580 because you're right. The BVM is a high risk, 00:08:48.639 --> 00:08:52.000 high reward tool. The trigger is failing respiratory 00:08:52.000 --> 00:08:55.320 effort or a deteriorating mental status, even 00:08:55.320 --> 00:08:58.019 with high flow oxygen. If you see the child's 00:08:58.019 --> 00:09:00.440 respiratory rate plummeting. If they're becoming 00:09:00.440 --> 00:09:03.059 bradycardic, or if they just physically cannot 00:09:03.059 --> 00:09:06.019 maintain an adequate minute volume anymore, that's 00:09:06.019 --> 00:09:08.139 when you have to step in. So distress is one 00:09:08.139 --> 00:09:11.059 thing, but failure is the trigger. Distress is 00:09:11.059 --> 00:09:13.600 acceptable. Failure is not. That's the line. 00:09:13.840 --> 00:09:16.240 And C for circulation. Before we're even thinking 00:09:16.240 --> 00:09:18.440 about code meds, what's the ER nurse's first 00:09:18.440 --> 00:09:20.539 priority? You're monitoring the heart rate, the 00:09:20.539 --> 00:09:23.120 rhythm, the blood pressure, of course, but the 00:09:23.120 --> 00:09:26.259 absolute number one priority. is establishing 00:09:26.259 --> 00:09:29.539 vascular access, an IV or an intraosteus, an 00:09:29.539 --> 00:09:32.879 IO line immediately. Why so urgently? Because 00:09:32.879 --> 00:09:35.399 respiratory distress can progress to shock so 00:09:35.399 --> 00:09:37.559 fast. And if you wait until that child is hypotensive 00:09:37.559 --> 00:09:39.419 and crashing, their veins are going to collapse. 00:09:39.919 --> 00:09:41.620 Peripheral access becomes nearly impossible. 00:09:42.059 --> 00:09:44.340 You need that line ready for fluids and meds 00:09:44.340 --> 00:09:46.139 the second you need them, not a minute later. 00:09:46.419 --> 00:09:48.639 Let's isolate respiratory arrest for a moment. 00:09:49.139 --> 00:09:52.129 This is that critical point where The nurse is 00:09:52.129 --> 00:09:54.629 the only thing standing between the patient and 00:09:54.629 --> 00:09:57.990 a full cardiac arrest. How do we define it again, 00:09:57.990 --> 00:10:00.509 and what are the exact guidelines for rescue 00:10:00.509 --> 00:10:03.309 breathing? So respiratory arrest means the child 00:10:03.309 --> 00:10:05.889 is apneic, they're not breathing, but they still 00:10:05.889 --> 00:10:08.370 have a detectable pulse. There's still cardiac 00:10:08.370 --> 00:10:11.649 activity. Our job here is to profuse the brain 00:10:11.649 --> 00:10:14.750 and heart with oxygen before they also feel from 00:10:14.750 --> 00:10:16.970 the hypoxia. And the rhythm of those breaths. 00:10:17.169 --> 00:10:19.879 What's the specific rate? For infants and for 00:10:19.879 --> 00:10:22.000 children, you slow it way down compared to what 00:10:22.000 --> 00:10:24.159 you do in a full code. You're giving 12 to 20 00:10:24.159 --> 00:10:26.539 breaths per minute. That works out to one breath 00:10:26.539 --> 00:10:28.519 every three to five seconds. Okay, one breath 00:10:28.519 --> 00:10:30.879 every three to five seconds. Yep. And each breath 00:10:30.879 --> 00:10:32.700 should just take about one second to deliver, 00:10:32.860 --> 00:10:34.620 and you're just looking for visible chest rise. 00:10:34.899 --> 00:10:36.539 And of course, use oxygen as soon as you have 00:10:36.539 --> 00:10:38.860 it. So why is that three to five second interval 00:10:38.860 --> 00:10:41.580 so important? What's the physiology behind that 00:10:41.580 --> 00:10:44.299 specific timing? It's all about managing a delicate 00:10:44.299 --> 00:10:47.039 balance. You're trying to provide enough oxygen 00:10:47.039 --> 00:10:49.879 and allow for CO2 removal, but you're doing it 00:10:49.879 --> 00:10:52.340 without causing excessive gastric inflation. 00:10:52.720 --> 00:10:54.799 If you go too fast, you're just pumping air into 00:10:54.799 --> 00:10:57.820 the stomach. That can cause vomiting, aspiration, 00:10:58.179 --> 00:11:00.179 and it pushes up the diaphragm, which makes breathing 00:11:00.179 --> 00:11:03.799 even harder. It's a deliberate measured rate 00:11:03.799 --> 00:11:06.840 to maximize oxygen delivery and minimize those 00:11:06.840 --> 00:11:08.840 secondary problems. And how often do you check 00:11:08.840 --> 00:11:10.600 to see if things are changing? You have to check 00:11:10.600 --> 00:11:15.080 the pulse every two minutes. No longer. And if, 00:11:15.159 --> 00:11:17.340 during that check, the pulse is gone, or if the 00:11:17.340 --> 00:11:19.639 heart rate drops below 60 and you see signs of 00:11:19.639 --> 00:11:22.440 poor perfusion, you don't wait, you immediately 00:11:22.440 --> 00:11:24.559 transition, you shout for help, you start chest 00:11:24.559 --> 00:11:26.980 compressions, and you are now in the full CPR 00:11:26.980 --> 00:11:29.980 sequence, that rapid shift is essential because 00:11:29.980 --> 00:11:33.220 the clock on hypoxia is ticking down fast. OK, 00:11:33.440 --> 00:11:36.960 so once we've stabilized the ABCs, the Pale S 00:11:36.960 --> 00:11:39.200 framework tells us to get more specific with 00:11:39.200 --> 00:11:41.620 our management. We have to figure out which of 00:11:41.620 --> 00:11:44.620 the four big buckets this kid falls into. upper 00:11:44.620 --> 00:11:47.059 airway obstruction, lower airway obstruction, 00:11:47.539 --> 00:11:50.120 lung tissue disease, or disordered control of 00:11:50.120 --> 00:11:53.460 breathing. Let's start at the top. upper airway 00:11:53.460 --> 00:11:56.220 obstruction. Right. This involved the large airways, 00:11:56.320 --> 00:11:58.279 so the nose, the pharynx, the larynx. These are 00:11:58.279 --> 00:12:00.580 the patients we see all the time in the ER. And 00:12:00.580 --> 00:12:02.700 you have to remember, infants are so prone to 00:12:02.700 --> 00:12:04.539 this because their airways are just tiny and 00:12:04.539 --> 00:12:06.519 their tongue tends to fall back and obstruct 00:12:06.519 --> 00:12:08.919 when their muscle tone decreases. So the general 00:12:08.919 --> 00:12:11.120 management principles are all about keeping that 00:12:11.120 --> 00:12:13.279 airway open and, just as importantly, keeping 00:12:13.279 --> 00:12:16.460 the child calm. Beyond just positioning, what's 00:12:16.460 --> 00:12:18.679 the crisis pathway look like? Well, if those 00:12:18.679 --> 00:12:21.059 conservative measures aren't working and you 00:12:21.059 --> 00:12:23.679 see signs of pending respiratory failure, the 00:12:23.679 --> 00:12:25.820 conversation changes very quickly. You're moving 00:12:25.820 --> 00:12:28.220 towards advanced airway management, which means 00:12:28.220 --> 00:12:30.460 preparing for the possibility of a surgical airway 00:12:30.460 --> 00:12:33.039 like a tracheostomy or a crick. But thankfully, 00:12:33.220 --> 00:12:35.220 most cases will respond to the right medication 00:12:35.220 --> 00:12:37.460 for the specific cause. OK, let's drill into 00:12:37.460 --> 00:12:40.500 the classic example then, croup or laryngotracheal 00:12:40.500 --> 00:12:43.399 bronchitis. This viral infection causes swelling 00:12:43.399 --> 00:12:46.019 right below the vocal cords in the subglottic 00:12:46.019 --> 00:12:47.960 area, and that's what gives you that signature 00:12:47.960 --> 00:12:50.870 barking cough and stridor. How do you quickly 00:12:50.870 --> 00:12:53.649 assess how bad it is to guide your treatment? 00:12:54.250 --> 00:12:55.889 Severity assessment is everything because it 00:12:55.889 --> 00:12:58.309 can change so fast. You hear the barking cough, 00:12:58.330 --> 00:13:00.610 sure, but what you're really listening for is 00:13:00.610 --> 00:13:03.190 the stridor. Is it only there when the child 00:13:03.190 --> 00:13:06.950 is agitated or crying? Or is it present even 00:13:06.950 --> 00:13:09.570 when they're at rest? Stridor at rest is a big 00:13:09.570 --> 00:13:12.429 warning sign. A huge warning sign. Then you look 00:13:12.429 --> 00:13:15.149 at the retractions. Are they mild or are they 00:13:15.149 --> 00:13:17.470 deep and significant? And finally, what do you 00:13:17.470 --> 00:13:19.350 hear when you listen? How is their air entry? 00:13:19.450 --> 00:13:22.149 And the PAL -L -S guidelines give us a really 00:13:22.149 --> 00:13:24.629 clear tiered approach based on that assessment. 00:13:24.990 --> 00:13:26.830 Let's focus on that moderate to severe crude 00:13:26.830 --> 00:13:28.830 patient. You can hear the stridor at rest. You 00:13:28.830 --> 00:13:31.509 see significant retractions. What's the immediate 00:13:31.509 --> 00:13:34.309 game plan? The immediate game plan starts with 00:13:34.309 --> 00:13:37.509 humidified oxygen and you make them NPO, nothing 00:13:37.509 --> 00:13:41.029 by mouth. This minimizes aspiration risk and 00:13:41.029 --> 00:13:43.049 just reduces the work of breathing that comes 00:13:43.049 --> 00:13:45.570 with swallowing. The main medication, the one 00:13:45.570 --> 00:13:48.429 you go to right away, is nebulized epinephrine. 00:13:48.600 --> 00:13:52.259 Okay, so why nebulized epi and why is the follow 00:13:52.259 --> 00:13:54.659 -up period after you give it so incredibly important? 00:13:55.039 --> 00:13:58.080 Epinephrine is a powerful alpha adrenergic agonist. 00:13:58.360 --> 00:14:02.139 So when it's inhaled, it causes this rapid localized 00:14:02.139 --> 00:14:04.480 vasoconstriction in that swollen tissue in the 00:14:04.480 --> 00:14:06.940 subglottic area. It shrinks the swelling almost 00:14:06.940 --> 00:14:10.639 instantly. But, and this is a huge but, That 00:14:10.639 --> 00:14:13.200 effect is often temporary. It wears off. It wears 00:14:13.200 --> 00:14:15.340 off. And once that visa constriction is gone, 00:14:15.600 --> 00:14:17.460 usually within about two hours, the stridor can 00:14:17.460 --> 00:14:19.500 come right back. And sometimes it's even worse 00:14:19.500 --> 00:14:21.779 than before. And that is the essential clinical 00:14:21.779 --> 00:14:23.919 pearl for the ER nurse, isn't it? You cannot 00:14:23.919 --> 00:14:26.220 discharge or transfer that patient until they've 00:14:26.220 --> 00:14:28.440 been watched for at least two hours after that 00:14:28.440 --> 00:14:31.679 nebulized epi. Correct. That two hour observation 00:14:31.679 --> 00:14:34.700 period is completely non -negotiable. While the 00:14:34.700 --> 00:14:38.080 epi is giving you that rapid relief, you're simultaneously 00:14:38.080 --> 00:14:41.779 giving a systemic corticosteroid like dexamethasone, 00:14:42.059 --> 00:14:45.299 either PO, IV, or IM, to tackle the underlying 00:14:45.299 --> 00:14:47.899 inflammation with a longer -acting drug. Okay, 00:14:47.980 --> 00:14:51.039 now for the worst -case scenario. Impending respiratory 00:14:51.039 --> 00:14:54.700 failure and croup. The child is lethargic, pale, 00:14:54.970 --> 00:14:58.250 Maybe cyanotic. What now? Now is a full -blown 00:14:58.250 --> 00:15:00.669 emergency. You're continuing the high concentration 00:15:00.669 --> 00:15:03.210 oxygen, but you're probably providing assisted 00:15:03.210 --> 00:15:05.970 ventilation with a BVM to support that failing 00:15:05.970 --> 00:15:08.250 effort. You're given the dexamethasone, FETC, 00:15:08.429 --> 00:15:11.549 or IM for sure, and you are preparing for an 00:15:11.549 --> 00:15:14.549 advanced stairway for ET intubation. And is there 00:15:14.549 --> 00:15:16.990 a specific procedural trick for intubating a 00:15:16.990 --> 00:15:19.429 croup patient? There is. Because that swelling 00:15:19.429 --> 00:15:22.009 is subglottic, the airway below the vocal cords 00:15:22.009 --> 00:15:24.090 is much narrower than you'd expect. So you have 00:15:24.090 --> 00:15:26.129 to anticipate this and choose an endotracheal, 00:15:26.129 --> 00:15:29.409 or ET, tube that is often a half size to a full 00:15:29.409 --> 00:15:31.950 size, smaller than what the age -based formula 00:15:31.950 --> 00:15:33.830 would predict. Because if you try to force the 00:15:33.830 --> 00:15:35.929 predicted size, you could cause more trauma and 00:15:35.929 --> 00:15:37.909 completely obstruct the airway. You could make 00:15:37.909 --> 00:15:41.350 the situation a hundred times worse. Yeah. Let's 00:15:41.350 --> 00:15:44.139 shift gears to anaphylaxis. This also creates 00:15:44.139 --> 00:15:46.360 upper airway obstruction but through a totally 00:15:46.360 --> 00:15:49.259 different mechanism, a severe systemic allergic 00:15:49.259 --> 00:15:51.820 reaction. So we're dealing with both swelling 00:15:51.820 --> 00:15:55.539 or edema and bronchospasm, and it's often complicated 00:15:55.539 --> 00:15:58.899 by hypotension. Anaphylaxis is a multi -system, 00:15:59.360 --> 00:16:02.340 incredibly fast -moving emergency. For any moderate 00:16:02.340 --> 00:16:05.679 to severe reaction, the absolute undisputed first 00:16:05.679 --> 00:16:08.720 priority is epinephrine. And what are the details 00:16:08.720 --> 00:16:10.740 of that epi -administration? How is it given? 00:16:11.139 --> 00:16:14.070 Intramuscular. I am epinephrine right away, either 00:16:14.070 --> 00:16:16.110 with an auto injector or a standard syringe. 00:16:16.509 --> 00:16:18.509 And you can repeat it every 10 to 15 minutes 00:16:18.509 --> 00:16:20.350 as you need to. The mechanism is what makes it 00:16:20.350 --> 00:16:22.590 so perfect. It causes rapid vasoconstriction 00:16:22.590 --> 00:16:24.970 to reverse the hypotension and shrink that laryngeal 00:16:24.970 --> 00:16:27.549 edema. And it's also a bronchodilator to treat 00:16:27.549 --> 00:16:29.590 the wheezing. It is the single most important 00:16:29.590 --> 00:16:31.909 drug you will give. OK, so after the epine, we 00:16:31.909 --> 00:16:34.190 add the secondary meds to control that inflammatory 00:16:34.190 --> 00:16:36.970 response. Why this cocktail of steroids and two 00:16:36.970 --> 00:16:39.309 different kinds of antihistamines? We use IV 00:16:39.309 --> 00:16:42.009 corticosteroids like methylprednisolone. to prevent 00:16:42.009 --> 00:16:44.370 what's called a biphasic reaction, where the 00:16:44.370 --> 00:16:46.590 symptoms come back hours later, and to treat 00:16:46.590 --> 00:16:49.549 that underlying inflammation. And we aggressively 00:16:49.549 --> 00:16:52.509 treat the bronchospasm with continuous nebulized 00:16:52.509 --> 00:16:56.169 albuterol. And the antihistamines. We give diffenhydramine, 00:16:56.190 --> 00:16:58.649 which is an H1 blocker, but the guidelines also 00:16:58.649 --> 00:17:02.899 say to add an H2 blocker, like ranitidine. What's 00:17:02.899 --> 00:17:06.380 the rationale for the H2 blocker? Well, the defenhydramine, 00:17:06.380 --> 00:17:08.900 the H1 blocker, it targets the immediate symptoms 00:17:08.900 --> 00:17:11.980 like hives and itching. The H2 blockers help 00:17:11.980 --> 00:17:14.079 prevent the further release of histamine from 00:17:14.079 --> 00:17:16.420 mast cells, and they address the vasodilation 00:17:16.420 --> 00:17:18.380 and leaky capillaries that are contributing to 00:17:18.380 --> 00:17:21.259 the shock. The evidence for H2 blockers alone 00:17:21.259 --> 00:17:24.460 is a bit debated, but in PALS, the goal is comprehensive 00:17:24.460 --> 00:17:26.779 histamine blockade. What if the patient is already 00:17:26.779 --> 00:17:28.720 crashing into hypotensive shock? Fluid's the 00:17:28.720 --> 00:17:31.160 next step. What's the initial bolus? Immediate 00:17:31.160 --> 00:17:34.200 resuscitation. You lay the child flat, supine, 00:17:34.519 --> 00:17:37.420 and you give a 20 inoleller per kilogram bolus 00:17:37.420 --> 00:17:40.779 of an isotonic crystalloid. So normal saline 00:17:40.779 --> 00:17:43.019 or lactated ringers. And you have to be ready 00:17:43.019 --> 00:17:45.500 to repeat that bolus, sometimes two, three, even 00:17:45.500 --> 00:17:48.960 four times. Anaphylaxis causes a massive capillary 00:17:48.960 --> 00:17:51.779 leak, and these kids become profoundly volume 00:17:51.779 --> 00:17:54.819 depleted very, very quickly. And if the hypotension 00:17:54.819 --> 00:17:57.980 is just not responding to fluids and the IM epinephrine, 00:17:58.039 --> 00:18:00.079 what's the next escalation? You have to start 00:18:00.079 --> 00:18:03.119 a titratable IV epinephrine infusion, a continuous 00:18:03.119 --> 00:18:06.000 drip. You titrate it to achieve an adequate mean 00:18:06.000 --> 00:18:08.660 arterial pressure and good perfusion. And this 00:18:08.660 --> 00:18:10.140 just highlights why it's so critical to have 00:18:10.140 --> 00:18:13.420 that early IV or IO axis we talked about. Finally 00:18:13.420 --> 00:18:16.039 in this category, foreign body airway obstruction 00:18:16.039 --> 00:18:19.319 or FBAO. This might be the highest stress scenario 00:18:19.319 --> 00:18:22.259 because the fix is purely mechanical. We have 00:18:22.259 --> 00:18:25.019 to reinforce that key distinction. Responsive 00:18:25.019 --> 00:18:27.519 versus unresponsive. The PLS source material 00:18:27.519 --> 00:18:29.720 is crystal clear on this. If the child is responsive, 00:18:29.720 --> 00:18:31.619 they can make sounds or they're coughing forcefully. 00:18:31.980 --> 00:18:34.259 You do not intervene physically. You let them 00:18:34.259 --> 00:18:37.000 cough. Encourage them to keep coughing. Their 00:18:37.000 --> 00:18:38.900 own cough is almost always more effective than 00:18:38.900 --> 00:18:41.660 anything we can do manually. We only step in 00:18:41.660 --> 00:18:43.599 when that cough becomes silent or ineffective. 00:18:43.859 --> 00:18:46.559 They can't speak or you see poor air exchange. 00:18:46.920 --> 00:18:49.640 And the maneuvers themselves differ by age? They 00:18:49.640 --> 00:18:53.259 do. For an infant so younger than one year, you 00:18:53.259 --> 00:18:55.720 do a sequence of five rapid back slaps between 00:18:55.720 --> 00:18:58.460 the shoulder blades, followed by up to five chest 00:18:58.460 --> 00:19:00.799 thrusts, which are basically compressions. You 00:19:00.799 --> 00:19:03.240 repeat that cycle until the object is out or 00:19:03.240 --> 00:19:06.000 the infant becomes unresponsive. For a child, 00:19:06.259 --> 00:19:08.859 one year and older, you move to abdominal thrusts, 00:19:08.960 --> 00:19:11.960 the Heimlich maneuver. Again, you repeat until 00:19:11.960 --> 00:19:14.619 the object is expelled or they become unresponsive. 00:19:14.759 --> 00:19:16.779 And if they do become unresponsive, we immediately 00:19:16.779 --> 00:19:19.480 switch to our code protocol. What's that pathway? 00:19:19.660 --> 00:19:22.420 You activate EMS or your code team and you start 00:19:22.420 --> 00:19:25.819 CPR immediately. And this is important. You don't 00:19:25.819 --> 00:19:28.059 waste time with an initial pulse check if they're 00:19:28.059 --> 00:19:30.559 unresponsive and not breathing or only gasping. 00:19:30.859 --> 00:19:32.579 You just start compressions. Then every time 00:19:32.579 --> 00:19:34.380 you open the airway to give your two breaths, 00:19:34.579 --> 00:19:37.099 you look in the mouth for the object. And what's 00:19:37.099 --> 00:19:39.420 the clinical pearl about actually removing the 00:19:39.420 --> 00:19:41.759 object? You only attempt to remove it if you 00:19:41.759 --> 00:19:44.980 can clearly see it. The absolute rule is do not 00:19:44.980 --> 00:19:47.839 perform a blind finger sweep. You risk pushing 00:19:47.839 --> 00:19:50.859 that object deeper, turning a partial obstruction 00:19:50.859 --> 00:19:53.640 into a complete one, or causing serious trauma. 00:19:54.180 --> 00:19:57.119 If you see it, carefully remove it. If you don't, 00:19:57.259 --> 00:19:59.099 you just keep going with compressions and ventilation. 00:19:59.910 --> 00:20:02.250 Okay, let's move down the respiratory tract into 00:20:02.250 --> 00:20:04.690 lower airway obstruction, things like bronchiolitis 00:20:04.690 --> 00:20:07.450 and asthma. Now the problem is in those tiny 00:20:07.450 --> 00:20:09.910 distal airways, the bronchioles, deep inside 00:20:09.910 --> 00:20:12.170 the chest, this has to change our whole approach 00:20:12.170 --> 00:20:14.460 to ventilation, right? It changes everything. 00:20:14.839 --> 00:20:16.740 With lower airway obstruction, the problem isn't 00:20:16.740 --> 00:20:19.700 getting air in, it's getting air out. Those small 00:20:19.700 --> 00:20:21.940 downstream airways collapse during expiration 00:20:21.940 --> 00:20:24.299 and that leads to massive air trapping. So we 00:20:24.299 --> 00:20:27.319 have to completely rethink how we assist their 00:20:27.319 --> 00:20:29.599 breathing. This is where we need to talk about 00:20:29.599 --> 00:20:32.460 the huge life -threatening risks of hyperventilation. 00:20:33.079 --> 00:20:34.960 The PLS materials really stress this, but let's 00:20:34.960 --> 00:20:38.299 get into the physiological why. Why is the bag 00:20:38.299 --> 00:20:40.559 valve mask, if you use it wrong, maybe the most 00:20:40.559 --> 00:20:42.880 dangerous tool you have in a severe asthma attack? 00:20:43.460 --> 00:20:45.900 Because you're essentially forcing air into a 00:20:45.900 --> 00:20:48.759 closed off container. If you give too many breaths 00:20:48.759 --> 00:20:50.720 per minute or the breaths are too large, you 00:20:50.720 --> 00:20:52.539 just don't give the child enough time for passive 00:20:52.539 --> 00:20:55.660 expiration. This leads to a phenomenon called 00:20:55.660 --> 00:20:58.420 dynamic hyperinflation, where the lungs just 00:20:58.420 --> 00:21:01.059 get more and more full of trapped air with every 00:21:01.059 --> 00:21:03.059 breath you give. And what's the physiological 00:21:03.059 --> 00:21:05.420 cascade? How does that trapped air lead to a 00:21:05.420 --> 00:21:08.289 cardiac arrest? It causes a few catastrophic 00:21:08.289 --> 00:21:10.450 things to happen all at once. First, gastric 00:21:10.450 --> 00:21:12.710 distension, which increases aspiration risk. 00:21:13.250 --> 00:21:15.630 Second, the high pressures increase the risk 00:21:15.630 --> 00:21:18.170 of a pneumothorax, a collapsed lung. But the 00:21:18.170 --> 00:21:20.589 deadliest result is that the severe air trapping 00:21:20.589 --> 00:21:23.210 creates this massive increase in intra -thoracic 00:21:23.210 --> 00:21:25.509 pressure. And when that pressure inside the chest 00:21:25.509 --> 00:21:28.029 goes up, what does that do to the heart? The 00:21:28.029 --> 00:21:30.650 pressure physically squeezes the large veins, 00:21:31.470 --> 00:21:33.890 the superior and inferior vena cava that are 00:21:33.890 --> 00:21:35.509 returning blood to the right side of the heart. 00:21:35.799 --> 00:21:38.819 This crushes venous return, which means less 00:21:38.819 --> 00:21:41.819 preload, which instantly means less stroke volume, 00:21:42.180 --> 00:21:44.500 and therefore a sudden drop in cardiac output. 00:21:44.980 --> 00:21:47.700 It's basically a form of obstructive shock that 00:21:47.700 --> 00:21:50.240 we, the providers, are causing. The child can 00:21:50.240 --> 00:21:52.220 crash from that sudden drop in cardiac output 00:21:52.220 --> 00:21:54.920 and the worsening hypoxemia. So our attempt to 00:21:54.920 --> 00:21:57.339 save them with ventilation can actually be the 00:21:57.339 --> 00:21:59.680 thing that causes the arrest? It can precipitate 00:21:59.680 --> 00:22:02.740 the arrest, yes. That clinical reasoning is so 00:22:02.740 --> 00:22:05.140 important. The solution is slow, effective ventilation. 00:22:05.640 --> 00:22:08.059 We stick to that slow rate one breath every three 00:22:08.059 --> 00:22:10.380 to five seconds to give them as much time as 00:22:10.380 --> 00:22:12.460 possible for expiration to minimize that air 00:22:12.460 --> 00:22:14.660 trapping. Prioritize exhalation time. That's 00:22:14.660 --> 00:22:16.839 the mantra, absolutely. Don't rush the breaths. 00:22:17.119 --> 00:22:19.000 Okay, so let's apply that to managing an acute 00:22:19.000 --> 00:22:21.970 asthma attack. Assessment comes first. How does 00:22:21.970 --> 00:22:24.450 the PLS severity assessment guide our decisions? 00:22:24.829 --> 00:22:27.130 We use a set of objective criteria which are 00:22:27.130 --> 00:22:29.309 laid out right in the PAL materials. We look 00:22:29.309 --> 00:22:31.170 at their ability to speak. Can they speak in 00:22:31.170 --> 00:22:34.410 full sentences, phrases, or only single words? 00:22:34.930 --> 00:22:36.650 That tells you how much work it's taking them 00:22:36.650 --> 00:22:38.809 to breathe. We look at the respiratory rate. 00:22:38.990 --> 00:22:41.630 Anything over 30 per minute is severe. We look 00:22:41.630 --> 00:22:44.130 for accessory muscle use, but most importantly 00:22:44.130 --> 00:22:46.329 we look at the objective measures. What are the 00:22:46.329 --> 00:22:48.890 warning signs that just scream impending failure? 00:22:49.170 --> 00:22:51.970 An oxygen saturation below 90 % despite being 00:22:51.970 --> 00:22:54.569 on supplemental oxygen. That is a massive red 00:22:54.569 --> 00:22:57.089 flag. We can also look at peak expiratory flow 00:22:57.089 --> 00:22:59.849 or PEF if the child can cooperate. A reading 00:22:59.849 --> 00:23:02.230 below 60 % of their predicted value is a sign 00:23:02.230 --> 00:23:04.630 of a severe life -threatening attack. Well what's 00:23:04.630 --> 00:23:06.869 that critical cardiovascular sign? The one that 00:23:06.869 --> 00:23:09.640 means the child is right at the edge. bradycardia. 00:23:09.799 --> 00:23:11.980 If you see the heart rates start to drop in a 00:23:11.980 --> 00:23:14.420 patient who has been tachypneic and working this 00:23:14.420 --> 00:23:17.740 hard, it means they are exhausted. They are profoundly 00:23:17.740 --> 00:23:19.839 hypoxic and they are about to have a respiratory 00:23:19.839 --> 00:23:22.819 arrest. bradycardia in a pediatric respiratory 00:23:22.819 --> 00:23:25.460 patient should trigger an immediate code activation 00:23:25.460 --> 00:23:28.140 and prep for advanced interventions. Let's run 00:23:28.140 --> 00:23:30.319 through the interventions for a moderate to severe 00:23:30.319 --> 00:23:32.680 acute asthma attack. We're fighting two battles 00:23:32.680 --> 00:23:35.519 at once, inflammation and bronchoconstriction. 00:23:35.680 --> 00:23:38.099 So we give high concentration, humidified oxygen 00:23:38.099 --> 00:23:41.480 to keep their SO2 at 95 % or higher. We use inhaled 00:23:41.480 --> 00:23:44.200 bronchodilators, albuterol, often mixed with 00:23:44.200 --> 00:23:47.119 iprotropium bromide through a nebulizer or an 00:23:47.119 --> 00:23:51.359 MDI with a spacer. And we give oral or IV corticosteroids 00:23:51.359 --> 00:23:53.559 right away to break that inflammatory cycle. 00:23:54.019 --> 00:23:56.640 What about when the asthma is refractory? The 00:23:56.640 --> 00:23:59.240 child is failing despite all that standard therapy. 00:23:59.660 --> 00:24:02.220 We have to escalate. The first one is magnesium 00:24:02.220 --> 00:24:04.460 sulfate. What's its mechanism and what is the 00:24:04.460 --> 00:24:07.039 nurse's priority when giving it? Magnesium sulfate 00:24:07.039 --> 00:24:09.759 is a potent, smooth muscle relaxant. It acts 00:24:09.759 --> 00:24:12.680 as a secondary bronchodilator. It can be a true 00:24:12.680 --> 00:24:15.599 lifesaver in status osmaticus. The dose is given 00:24:15.599 --> 00:24:18.559 as an IV infusion over 15 to 30 minutes. And 00:24:18.559 --> 00:24:20.859 the critical nursing priority is continuous cardiac 00:24:20.859 --> 00:24:23.000 monitoring and frequent blood pressure checks. 00:24:23.359 --> 00:24:25.500 If you give it too fast, it can cause profound 00:24:25.500 --> 00:24:28.000 hypotension and bradycardia. So you have to be 00:24:28.000 --> 00:24:30.480 ready to slow the infusion or give fluids. And 00:24:30.480 --> 00:24:32.519 if they're still failing, even after the magnesium? 00:24:32.660 --> 00:24:35.180 At that point, we might consider subcutaneous. 00:24:35.119 --> 00:24:38.220 or IAM epinephrine or turbutaline, but really 00:24:38.220 --> 00:24:40.759 the next big step is moving to non -invasive 00:24:40.759 --> 00:24:44.119 positive pressure ventilation or NIV like CPAP 00:24:44.119 --> 00:24:47.359 to try and stent those airways open, or we prepare 00:24:47.359 --> 00:24:50.980 for ET intubation. And intubating a fever asthmatic 00:24:50.980 --> 00:24:53.380 has got to be one of the highest risk procedures 00:24:53.380 --> 00:24:55.799 in pediatric critical care. What are the key 00:24:55.799 --> 00:24:58.269 things to think about? You have to anticipate 00:24:58.269 --> 00:25:01.130 extremely high peak inspiratory pressures because 00:25:01.130 --> 00:25:03.650 of that severe airway resistance. The team needs 00:25:03.650 --> 00:25:06.589 to use paralytics carefully, ensure deep sedation, 00:25:06.690 --> 00:25:09.190 and be ready to use very slow ventilation rates 00:25:09.190 --> 00:25:11.450 once that tube is in place to allow for exhalation. 00:25:11.950 --> 00:25:14.529 The risk of barotrauma and causing a pneumothorax 00:25:14.529 --> 00:25:16.910 is incredibly high. It's a rescue procedure you 00:25:16.910 --> 00:25:19.569 perform with extreme caution. OK, let's shift 00:25:19.569 --> 00:25:22.029 to the next category, lung tissue disease or 00:25:22.029 --> 00:25:24.710 parenteral disease. This is when the alveoli 00:25:24.710 --> 00:25:26.809 themselves, the gas exchange units, are sick. 00:25:27.150 --> 00:25:29.170 So things like pneumonia, cardiogenic pulmonary 00:25:29.170 --> 00:25:32.210 edema or ARDS. The common thread here is severe 00:25:32.210 --> 00:25:34.410 hypoxemia that doesn't get better with just oxygen. 00:25:34.750 --> 00:25:36.569 Exactly. And the management for all of these 00:25:36.569 --> 00:25:39.269 fundamentally relies on supporting those failing 00:25:39.269 --> 00:25:42.789 alveoli. And that means using positive end -expertory 00:25:42.789 --> 00:25:46.190 pressure or PEEP. PEEP is what keeps those tiny 00:25:46.190 --> 00:25:48.269 airways and alveoli from collapsing at the end 00:25:48.269 --> 00:25:51.190 of expiration, and it maximizes the surface area 00:25:51.190 --> 00:25:53.910 you have for gas exchange. Let's compare two 00:25:53.910 --> 00:25:56.829 big causes where PEEP is used, but for slightly 00:25:56.829 --> 00:25:59.470 different reasons. In fact, just pneumonia and 00:25:59.470 --> 00:26:01.910 cardiogenic pulmonary edema. Let's start with 00:26:01.910 --> 00:26:04.450 pneumonia. For infectious pneumonia, you need 00:26:04.450 --> 00:26:08.150 urgent diagnostics, an ABG, a chest x -ray, blood 00:26:08.150 --> 00:26:10.910 cultures, and the nurse has to ensure that antibiotics 00:26:10.910 --> 00:26:13.509 are on board within the first hour, especially 00:26:13.509 --> 00:26:15.529 if you're worried about sepsis. You can treat 00:26:15.529 --> 00:26:18.009 any associated wheezing with albuterol, but the 00:26:18.009 --> 00:26:20.329 main supportive strategy is PEEP, delivered either 00:26:20.329 --> 00:26:23.730 via NIV or a ventilator, to overcome that alveolar 00:26:23.730 --> 00:26:26.269 collapse and fix the hypoxemia. You also have 00:26:26.269 --> 00:26:28.789 to aggressively manage any fever to reduce their 00:26:28.789 --> 00:26:31.430 metabolic demand. Now, cardiogenic pulmonary 00:26:31.430 --> 00:26:34.099 edema. This is fluid in the lungs because the 00:26:34.099 --> 00:26:36.259 heart's ventricle isn't working right. How does 00:26:36.259 --> 00:26:39.130 PEEP work here physiologically? This is a really 00:26:39.130 --> 00:26:41.789 elegant piece of clinical reasoning. In cardiogenic 00:26:41.789 --> 00:26:44.410 edema, yes, PEEP helps push fluid out of the 00:26:44.410 --> 00:26:46.869 lungs, but it also has a profound hemodynamic 00:26:46.869 --> 00:26:49.430 effect. By increasing the pressure inside the 00:26:49.430 --> 00:26:52.349 chest, PEEP actually helps reduce venous return. 00:26:52.670 --> 00:26:54.950 It decreases the preload to the failing left 00:26:54.950 --> 00:26:58.390 atrium. It essentially unloads the failing ventricle, 00:26:58.549 --> 00:27:00.609 which lowers the pressure in the capillaries 00:27:00.609 --> 00:27:02.930 and slows down the leakage of fluid into the 00:27:02.930 --> 00:27:05.130 lungs. So in this case, PEEP is acting a bit 00:27:05.130 --> 00:27:07.450 like a diuretic by lowering that hydrostatic 00:27:07.500 --> 00:27:09.859 pressure on top of helping with oxygenation. 00:27:10.680 --> 00:27:12.680 What other non -ventilatory treatments do we 00:27:12.680 --> 00:27:15.299 use? Diuretics are absolutely critical, something 00:27:15.299 --> 00:27:17.559 like furosemite, to quickly pull off circulating 00:27:17.559 --> 00:27:20.019 volume and lower that left atrial pressure. And 00:27:20.019 --> 00:27:21.880 if the ventricular dysfunction is really severe, 00:27:22.059 --> 00:27:24.839 we'd also consider inotropic support or actor 00:27:24.839 --> 00:27:28.160 load -reducing agents. And finally, ARDS, or 00:27:28.160 --> 00:27:30.950 acute respiratory distress syndrome. This is 00:27:30.950 --> 00:27:33.529 non -cardiogenic lung injury from something systemic 00:27:33.529 --> 00:27:36.329 like sepsis or major trauma. This is diffuse 00:27:36.329 --> 00:27:39.150 severe injury to the lungs. How do we define 00:27:39.150 --> 00:27:42.880 ARDS in the PLS world? ARDS is defined by its 00:27:42.880 --> 00:27:46.259 acute onset, severe hypoxemia, that is refractory 00:27:46.259 --> 00:27:49.819 to oxygen, and bilateral infiltrates, or whiteout, 00:27:49.920 --> 00:27:53.059 on a chest x -ray. We quantify that hypoxemia 00:27:53.059 --> 00:27:57.299 using the PO2 -FIO2 ratio. If that ratio is below 00:27:57.299 --> 00:28:00.539 300, it's suggestive of ARDS. The management 00:28:00.539 --> 00:28:02.460 strategy here is very specialized. It's called 00:28:02.460 --> 00:28:04.700 lung protective ventilation, which brings us 00:28:04.700 --> 00:28:07.279 to this complex idea of permissive hypercarbia. 00:28:07.420 --> 00:28:09.920 Why on earth would we intentionally let the carbon 00:28:09.920 --> 00:28:12.529 dioxide level in the blood get high? We accept 00:28:12.529 --> 00:28:15.089 that elevated PACO2, the hypercarbia, to protect 00:28:15.089 --> 00:28:16.990 the injured lungs from what's called ventilator 00:28:16.990 --> 00:28:20.049 -induced lung injury, or VILI. We do this by 00:28:20.049 --> 00:28:21.650 strictly limiting the amount of air we deliver 00:28:21.650 --> 00:28:24.230 with each breath, so low tidal volumes around 00:28:24.230 --> 00:28:26.849 5 to 8 millimals per kilo, and by keeping the 00:28:26.849 --> 00:28:29.299 peak inspiratory pressures low, If we try to 00:28:29.299 --> 00:28:31.819 blow off all that CO2 by pushing more air, we 00:28:31.819 --> 00:28:34.480 overstretch and damage the already injured alveoli, 00:28:34.480 --> 00:28:36.599 making everything worse. So we're trading a mild 00:28:36.599 --> 00:28:39.819 respiratory acidosis for mechanical safety. Exactly. 00:28:40.019 --> 00:28:42.420 We are prioritizing protecting the lung tissue 00:28:42.420 --> 00:28:45.619 over getting perfect lab numbers. We're deliberately 00:28:45.619 --> 00:28:47.599 setting the ventilator to be gentle, knowing 00:28:47.599 --> 00:28:50.819 that the priority is surviving the injury, not 00:28:50.819 --> 00:28:54.220 having a normal blood gas. Correcting the hypoxemia 00:28:54.220 --> 00:28:57.259 is still the number one priority, but we permit 00:28:57.259 --> 00:29:00.869 the CO2. The final big category of respiratory 00:29:00.869 --> 00:29:04.430 failure is disordered control of breathing. This 00:29:04.430 --> 00:29:06.569 is when the central or peripheral nervous system 00:29:06.569 --> 00:29:09.500 fails to actually run the show. Things like increased 00:29:09.500 --> 00:29:12.720 intracranial pressure or ICP and poisoning or 00:29:12.720 --> 00:29:15.599 drug overdose. Right. Starting with increased 00:29:15.599 --> 00:29:18.039 intracranial pressure. This can be from trauma, 00:29:18.259 --> 00:29:20.920 a hemorrhage, a severe infection. And the respiratory 00:29:20.920 --> 00:29:23.339 consequence is huge because it directly affects 00:29:23.339 --> 00:29:25.460 the central respiratory drive in the brain stem 00:29:25.460 --> 00:29:27.740 leading to weird breathing patterns or just stopping 00:29:27.740 --> 00:29:30.180 breathing altogether apnea. And the classic sign 00:29:30.180 --> 00:29:32.759 is Cushing's triad irregular breathing, hypertension, 00:29:33.140 --> 00:29:35.670 and bradycardia. but the Bilalosaurus gives a 00:29:35.670 --> 00:29:38.490 really important warning for kids. It does. While 00:29:38.490 --> 00:29:40.950 we all learn about bradycardia, children with 00:29:40.950 --> 00:29:43.589 a rapidly rising ICP might initially present 00:29:43.589 --> 00:29:46.109 with hypertension and tachycardia, or even a 00:29:46.109 --> 00:29:48.150 normal heart rate. They don't always show that 00:29:48.150 --> 00:29:51.230 profound bradycardia you see in adults. We can't 00:29:51.230 --> 00:29:53.009 wait for the heart rate to drop to intervene. 00:29:53.329 --> 00:29:55.769 If you see hypertension and a decreasing level 00:29:55.769 --> 00:29:58.750 of consciousness, you have to act. And the interventions 00:29:58.750 --> 00:30:02.410 are about optimization. Head midline, C -spine 00:30:02.410 --> 00:30:05.059 stabilization if needed, maintain an open airway. 00:30:05.539 --> 00:30:07.740 But the caution around hyperventilation here 00:30:07.740 --> 00:30:10.279 is maybe the most heavily emphasized point in 00:30:10.279 --> 00:30:12.900 the entire Pallas manual. It's the ultimate tightrope 00:30:12.900 --> 00:30:14.880 walk. You have to maintain the airway and ensure 00:30:14.880 --> 00:30:17.940 adequate ventilation, but you must, must avoid 00:30:17.940 --> 00:30:20.480 prophylactic severe hyperventilation. You cannot 00:30:20.480 --> 00:30:22.839 just start bagging them fast to drive that CO2 00:30:22.839 --> 00:30:25.640 down. Why is severe hyperventilation so dangerous 00:30:25.640 --> 00:30:28.660 when ICP is high? Because our main goal in ICP 00:30:28.660 --> 00:30:31.720 management is to maintain adequate cerebral perfusion 00:30:31.720 --> 00:30:35.220 pressure, or CPP, and CPP is your mean arterial 00:30:35.220 --> 00:30:38.380 pressure minus your ICP. Hyperventilation blows 00:30:38.380 --> 00:30:42.119 off CO2, and that causes rapid cerebral vasoconstriction. 00:30:42.559 --> 00:30:45.240 The blood vessels in the brain clamp down. While 00:30:45.240 --> 00:30:47.440 this does shrink the volume in the skull and 00:30:47.440 --> 00:30:51.019 acutely lowers the ICP, it also drastically reduces 00:30:51.019 --> 00:30:53.480 blood flow to the brain. So you're starving the 00:30:53.480 --> 00:30:56.099 already injured brain of oxygen and blood. You 00:30:56.099 --> 00:30:57.799 lower the pressure, but you reduce the supply. 00:30:58.160 --> 00:31:00.559 Precisely. You might get a great ICP number on 00:31:00.559 --> 00:31:02.640 the monitor, but you're actually making the underlying 00:31:02.640 --> 00:31:05.420 brain injury worse. That's why Pallas is so strict 00:31:05.420 --> 00:31:07.519 about avoiding severe hyperventilation after 00:31:07.519 --> 00:31:10.539 that initial 48 -hour period. So when is it okay 00:31:10.539 --> 00:31:13.720 to use mild hyperventilation? Only as a temporary 00:31:13.720 --> 00:31:16.579 last -ditch rescue therapy for acute deterioration. 00:31:16.799 --> 00:31:19.099 You see signs of impending brain herniation like 00:31:19.099 --> 00:31:21.880 a blown pupil or sudden bradycardia. It's a break. 00:31:21.769 --> 00:31:24.430 It buys you minutes while you get osmotic agents 00:31:24.430 --> 00:31:27.009 like mannitol or hypertonic saline ready. It 00:31:27.009 --> 00:31:29.450 is never a long -term strategy. Okay, let's move 00:31:29.450 --> 00:31:32.910 to poisoning or drug overdose. This usually causes 00:31:32.910 --> 00:31:36.230 respiratory failure by just depressing the central 00:31:36.230 --> 00:31:38.190 respiratory drive. Yeah, and supportive care 00:31:38.190 --> 00:31:40.690 is everything here. Airway and ventilation support 00:31:40.690 --> 00:31:42.910 are paramount because the patient can become 00:31:42.910 --> 00:31:45.789 apneic very, very quickly. You need to contact 00:31:45.789 --> 00:31:48.190 poison control immediately and you have to be 00:31:48.190 --> 00:31:51.029 ready for aggressive suctioning. Loss of consciousness 00:31:50.990 --> 00:31:54.210 means a huge risk of vomiting and aspiration. 00:31:54.450 --> 00:31:56.569 And the specific drug we often see used in the 00:31:56.569 --> 00:31:59.799 ER. If you suspect an opioid overdose and the 00:31:59.799 --> 00:32:01.599 patient is in respiratory arrest but still has 00:32:01.599 --> 00:32:05.460 a pulse, you give naloxone. The IM or intranasal 00:32:05.460 --> 00:32:07.759 routes are often faster than waiting to get an 00:32:07.759 --> 00:32:10.559 IV. But remember, if the patient is pulseless, 00:32:10.680 --> 00:32:12.700 you don't mess with naloxone, you go straight 00:32:12.700 --> 00:32:15.059 to CPR. And of course, you're sending off a whole 00:32:15.059 --> 00:32:17.960 panel of diagnostics, ABG, ECG, drug screens 00:32:17.960 --> 00:32:20.400 to guide the rest of the care. We've got a few 00:32:20.400 --> 00:32:23.140 crucial procedural airway perils that an ER nurse 00:32:23.140 --> 00:32:25.539 prepping for this exam has to have down cold, 00:32:25.680 --> 00:32:27.599 especially around and advanced airway management. 00:32:27.839 --> 00:32:30.059 First one is about cuffed ET tubes, which are 00:32:30.059 --> 00:32:32.700 now standard in pediatrics. The nursing team 00:32:32.700 --> 00:32:34.960 has to be meticulous about managing that cuff 00:32:34.960 --> 00:32:37.220 pressure. Why is that? What's the target range? 00:32:37.400 --> 00:32:39.759 You want to keep that cuff pressure between 20 00:32:39.759 --> 00:32:42.660 to 25 centimeters of water. If the pressure is 00:32:42.660 --> 00:32:45.059 too low, you get a big air leak around the tube, 00:32:45.460 --> 00:32:48.240 which means ineffective ventilation. That's especially 00:32:48.240 --> 00:32:51.180 bad in ARDS or asthma, where you need high pressures. 00:32:51.720 --> 00:32:53.839 But if the pressure is too high, you risk causing 00:32:53.839 --> 00:32:56.970 tracheal ischemia and long damage to the airway. 00:32:57.509 --> 00:32:59.470 It needs to be checked regularly with a cuff 00:32:59.470 --> 00:33:02.009 manometer. And another big procedural pearl is 00:33:02.009 --> 00:33:05.430 about using neuromuscular blocking agents paralytics 00:33:05.430 --> 00:33:08.470 for intubation, specifically succinylcholine. 00:33:08.599 --> 00:33:11.220 You have to be so cautious with succinylcholine 00:33:11.220 --> 00:33:13.839 in kids, especially if you suspect an underlying 00:33:13.839 --> 00:33:16.619 neuromuscular disease or in patients with burns, 00:33:16.880 --> 00:33:20.420 crush injuries, or prolonged immobility. Succinylcholine 00:33:20.420 --> 00:33:23.500 can cause a massive dangerous efflux of potassium 00:33:23.500 --> 00:33:26.500 from the cells. It can lead to severe hyperkalemia 00:33:26.500 --> 00:33:29.660 and fatal arrhythmias, or it can trigger malignant 00:33:29.660 --> 00:33:32.400 hyperthermia. And what's a key drug interaction 00:33:32.400 --> 00:33:34.740 pearl that relates to respiratory muscle weakness? 00:33:35.000 --> 00:33:37.220 The clinical pearl here is to remember that some 00:33:37.220 --> 00:33:41.309 of our most antibiotics, specifically amino glycosides 00:33:41.309 --> 00:33:44.490 like gentamicin and also vancomycin, they have 00:33:44.490 --> 00:33:47.029 some intrinsic neuromuscular blocking activity. 00:33:47.250 --> 00:33:49.630 So if you have a child with a known neuromuscular 00:33:49.630 --> 00:33:52.789 issue or even just a very septic kid who is already 00:33:52.789 --> 00:33:55.250 weak and struggling to breathe, giving these 00:33:55.250 --> 00:33:57.829 antibiotics can actually worsen their respiratory 00:33:57.829 --> 00:34:00.150 muscle weakness and make it harder to ventilate 00:34:00.150 --> 00:34:03.650 them. Lastly, let's just confirm the absolute 00:34:03.650 --> 00:34:06.750 necessity. of end -tidal CO2 monitoring across 00:34:06.750 --> 00:34:08.789 all of these different respiratory problems. 00:34:09.110 --> 00:34:11.750 ET Co -euros monitoring is completely essential 00:34:11.750 --> 00:34:15.030 and non -negotiable. It gives you instant continuous 00:34:15.030 --> 00:34:18.269 feedback on three critical things. First, ventilation 00:34:18.269 --> 00:34:20.289 effectiveness. It tells you if you're actually 00:34:20.289 --> 00:34:22.969 clearing CO2. This is so important when you're 00:34:22.969 --> 00:34:25.929 trying for permissive hypercarbia in ARDS or 00:34:25.929 --> 00:34:28.590 using those slow rates in asthma. Confirmation 00:34:28.590 --> 00:34:31.550 of tube placement. After you intubate, ET Co 00:34:31.550 --> 00:34:33.489 -euros is the gold standard for confirming that 00:34:33.489 --> 00:34:35.820 the tube is in the trachea and not in the esophagus. 00:34:36.000 --> 00:34:38.019 And third, it's an indicator of circulation, 00:34:38.079 --> 00:34:40.539 which is so important during an arrest. Yes. 00:34:41.300 --> 00:34:44.119 During a respiratory arrest or full -blown CPR, 00:34:44.559 --> 00:34:47.239 the ETKO level reflects pulmonary blood flow, 00:34:47.380 --> 00:34:49.519 which is directly tied to your cardiac output. 00:34:50.000 --> 00:34:53.760 A sudden drop in ETKO during CPR means your compressions 00:34:53.760 --> 00:34:56.800 are bad or circulation is failing. And on the 00:34:56.800 --> 00:35:00.320 flip side, a sudden sustained jump in ETKO is 00:35:00.320 --> 00:35:02.619 the earliest sign you'll get a return of spontaneous 00:35:02.619 --> 00:35:05.530 circulation. or ROSC. It connects the breath 00:35:05.530 --> 00:35:08.429 to the heart. So, to synthesize this whole respiratory 00:35:08.429 --> 00:35:11.269 management approach, PALIS success is overwhelmingly 00:35:11.269 --> 00:35:14.409 measured in prevention. We win when we recognize 00:35:14.409 --> 00:35:16.889 and manage that respiratory distress and impending 00:35:16.889 --> 00:35:19.489 failure long before the patient becomes pulseless. 00:35:19.750 --> 00:35:22.530 That shift from compensated distress to uncompensated 00:35:22.530 --> 00:35:25.429 failure is so fast, and it requires mastery of 00:35:25.429 --> 00:35:27.309 these targeted drugs and ventilation strategies. 00:35:27.409 --> 00:35:29.050 Okay, let's do a quick final review of the key 00:35:29.050 --> 00:35:30.989 pharmacological agents just to reinforce that 00:35:30.989 --> 00:35:33.130 structured PALIS thinking. will categorize them 00:35:33.130 --> 00:35:35.570 by the condition they treat. Perfect. For upper 00:35:35.570 --> 00:35:37.889 airway obstruction like croup, it's that one 00:35:37.889 --> 00:35:40.630 -two punch of rapid -acting nebulized epinephrine 00:35:40.630 --> 00:35:43.769 and the long -acting corticosteroids like dexamethasone. 00:35:44.210 --> 00:35:47.150 For anaphylaxis, immediate IM epinephrine, that's 00:35:47.150 --> 00:35:49.170 number one, followed by your bronchodilators, 00:35:49.389 --> 00:35:52.210 corticosteroids, and that dual anahistamine blockade. 00:35:52.400 --> 00:35:54.940 For lower airway obstruction, specifically that 00:35:54.940 --> 00:35:57.880 really bad refractory asthma, the foundation 00:35:57.880 --> 00:36:00.260 is still bronchodilators and corticosteroids, 00:36:00.280 --> 00:36:03.239 but the big rescue drug is that magnesium sulfate 00:36:03.239 --> 00:36:05.679 infuser. And for lung tissue disease, whether 00:36:05.679 --> 00:36:09.739 it's pneumonia, cardiogenic edema, or ARDS, the 00:36:09.739 --> 00:36:12.280 key mechanical support is PEEP. Then you add 00:36:12.280 --> 00:36:14.380 diuretics for the cardiogenic causes and, of 00:36:14.380 --> 00:36:17.480 course, antibiotics for infection. And for disordered 00:36:17.480 --> 00:36:19.860 control of breathing, the most critical interventions 00:36:19.860 --> 00:36:22.650 are defensive. You're avoiding hypoxia. avoiding 00:36:22.650 --> 00:36:25.389 severe hypercarbia, and avoiding hyperthermia 00:36:25.389 --> 00:36:27.630 in your ICP patients. And you're having the right 00:36:27.630 --> 00:36:29.869 antidote, like naloxone for an overdose, ready 00:36:29.869 --> 00:36:32.889 to go. And translating all this palace knowledge 00:36:32.889 --> 00:36:34.869 into the high -pressure world of the ER, the 00:36:34.869 --> 00:36:37.550 ICU, that really requires internalizing a few 00:36:37.550 --> 00:36:40.349 essential clinical pearls. Okay, first, let's 00:36:40.349 --> 00:36:43.510 hammer home the importance of constant, meticulous 00:36:43.510 --> 00:36:45.909 reassessment, especially after you've given certain 00:36:45.909 --> 00:36:49.400 drugs. never ever assume stability, especially 00:36:49.400 --> 00:36:51.840 with croup and asthma. We talked about that post 00:36:51.840 --> 00:36:53.940 -epinephrine observation for croup. They can 00:36:53.940 --> 00:36:56.739 rebound hard. And similarly, in severe asthma, 00:36:57.159 --> 00:36:59.679 a kid who goes from being anxious and fighting 00:36:59.679 --> 00:37:02.760 to being quiet and lethargic, that child is often 00:37:02.760 --> 00:37:04.440 entering the failure phase. They're just too 00:37:04.440 --> 00:37:06.679 tired to compensate anymore. The quiet child 00:37:06.679 --> 00:37:09.500 is the most frightening child. Second, the critical 00:37:09.500 --> 00:37:12.840 nursing priority of getting early vascular access 00:37:12.840 --> 00:37:15.639 in those moderate to severe cases. If you see 00:37:15.639 --> 00:37:18.440 a kid with moderate to severe anaphylaxis or 00:37:18.440 --> 00:37:21.159 status asthmaticus, your first thought after 00:37:21.159 --> 00:37:24.500 oxygen should be getting that IV or IO access 00:37:24.500 --> 00:37:26.920 immediately. You're going to need it for high 00:37:26.920 --> 00:37:29.619 volume fluid resuscitation, for continuous infusions 00:37:29.619 --> 00:37:33.039 of steroids, magnesium, maybe even IV epinephrine. 00:37:33.360 --> 00:37:35.860 If you wait until they're crashing, that peripheral 00:37:35.860 --> 00:37:38.099 vasoconstriction will make getting access nearly 00:37:38.099 --> 00:37:39.960 impossible and you'll have a critical delay. 00:37:40.340 --> 00:37:42.039 And finally, the need for concurrent management. 00:37:42.320 --> 00:37:44.340 You're treating the cause while aggressively 00:37:44.340 --> 00:38:04.320 providing support care at the same time. So mastering 00:38:04.320 --> 00:38:06.800 PALS respiratory management really means training 00:38:06.800 --> 00:38:09.420 your eye to see those subtle cues, the change 00:38:09.420 --> 00:38:11.559 in how they're speaking, the depth of the retractions, 00:38:11.880 --> 00:38:14.659 that slow shift toward bradycardia long before 00:38:14.659 --> 00:38:17.039 the patient ever needs chest compressions. That 00:38:17.039 --> 00:38:19.599 systemic physiologically based knowledge is your 00:38:19.599 --> 00:38:22.199 ultimate power in that critical moment. So as 00:38:22.199 --> 00:38:24.320 you take this deep dive and integrate it into 00:38:24.320 --> 00:38:27.420 your clinical prep, here's one final provocative 00:38:27.420 --> 00:38:30.000 thought for you to think about. This one is specifically 00:38:30.000 --> 00:38:32.460 about that high stakes procedure we discussed. 00:38:33.319 --> 00:38:36.360 Given the profound risks of hyperkalemia from 00:38:36.360 --> 00:38:39.340 using succinylcholine in certain pediatric patients, 00:38:40.039 --> 00:38:42.139 especially those with an unknown or underlying 00:38:42.139 --> 00:38:45.079 neuromuscular disease, and the absolute need 00:38:45.079 --> 00:38:48.519 for rapid paralysis for intubation, how does 00:38:48.519 --> 00:38:50.860 that risk assessment change your immediate choice 00:38:50.860 --> 00:38:54.920 of paralytic agent, say, rocoronium versus succinylcholine, 00:38:55.300 --> 00:38:58.300 during a non -traumatic severe status asthmaticus 00:38:58.300 --> 00:39:00.980 presentation in the chaos of the emergency department? 00:39:01.130 --> 00:39:03.030 Think about that clinical judgment call, the 00:39:03.030 --> 00:39:05.250 trade -off between speed and safety and how you 00:39:05.250 --> 00:39:07.349 prepare your drugs ahead of time. We'll catch 00:39:07.349 --> 00:39:09.170 you next time for the next Deep Dive.