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 --> 00:02:27.430 emergency room. Welcome back to the deep dive. 00:02:27.729 --> 00:02:31.669 Today we are taking on one of the most high stakes 00:02:31.669 --> 00:02:34.810 information dense and frankly clinically relevant 00:02:34.810 --> 00:02:37.990 topics for anyone working in or preparing for 00:02:37.990 --> 00:02:39.990 critical care. We're talking about shock management. 00:02:40.150 --> 00:02:42.889 If you're studying for your mid -surg cert, getting 00:02:42.889 --> 00:02:45.150 ready for the NCLEX, or you just want to feel 00:02:45.150 --> 00:02:47.229 confident when that emergency call comes in, 00:02:47.550 --> 00:02:50.569 this deep dive is absolutely your shortcut. This 00:02:50.569 --> 00:02:52.930 is truly where the rubber meets the road. I mean, 00:02:53.210 --> 00:02:55.530 in clinical practice, the immediate informed 00:02:55.530 --> 00:02:59.300 action you take when shock is identified It directly 00:02:59.300 --> 00:03:01.139 dictates the patient's outcome. There's no room 00:03:01.139 --> 00:03:04.400 for hesitation. None. We know that early intervention, 00:03:04.400 --> 00:03:08.159 it significantly reduces both morbidity and mortality. 00:03:08.259 --> 00:03:10.280 And when you're prepping for an exam, you have 00:03:10.280 --> 00:03:12.139 to know the why behind the what. Right. Because 00:03:12.139 --> 00:03:13.979 the questions aren't just about defining shock. 00:03:14.060 --> 00:03:15.939 They're about prioritizing immediate nursing 00:03:15.939 --> 00:03:19.680 interventions based on the specific cause. Absolutely. 00:03:19.800 --> 00:03:21.800 And the sources we've aggregated for this are 00:03:21.800 --> 00:03:24.360 comprehensive clinical guides. They really provide 00:03:24.360 --> 00:03:27.180 the absolute blueprint for rapid assessment and 00:03:27.180 --> 00:03:29.639 management. tailored to each type of shock. So 00:03:29.639 --> 00:03:32.780 our mission today is a precise extraction. We're 00:03:32.780 --> 00:03:35.719 applying what we call the Pareto Principle. We're 00:03:35.719 --> 00:03:38.419 distilling that 20 % of clinical data that's 00:03:38.419 --> 00:03:40.740 going to yield 80 % of your mastery. And we're 00:03:40.740 --> 00:03:43.419 focusing relentlessly on nursing assessment, 00:03:43.719 --> 00:03:46.819 those critical facts, and the rapid -fire collaboration 00:03:46.819 --> 00:03:48.719 that has to happen in those first few minutes. 00:03:48.919 --> 00:03:51.219 We're basically converting those dense algorithms 00:03:51.219 --> 00:03:54.419 into clear, actionable steps. We will separate 00:03:54.419 --> 00:03:56.860 the fluid -hungry shocks from the ones where 00:03:56.860 --> 00:03:58.879 you need to be cautious with fluids. And the 00:03:58.879 --> 00:04:02.319 pump failures from the vascular disaster. Exactly. 00:04:02.439 --> 00:04:04.259 OK, let's unpack this, starting with the fundamental 00:04:04.259 --> 00:04:08.500 goals. Why do we intervene the way we do? You 00:04:08.500 --> 00:04:10.879 know, if you really understand the core problem 00:04:10.879 --> 00:04:13.219 in shock, the goals of management just become 00:04:13.219 --> 00:04:16.579 intuitive. At its heart, shock is just inadequate 00:04:16.579 --> 00:04:19.740 tissue perfusion and oxygen delivery. So every 00:04:19.740 --> 00:04:22.019 single thing we do is aimed at reversing that 00:04:22.019 --> 00:04:24.120 systemic failure. And what are those specific 00:04:24.120 --> 00:04:26.120 targets we're aiming for? Well, goal number one, 00:04:26.180 --> 00:04:29.319 the primary goal, is to directly improve oxygen 00:04:29.319 --> 00:04:32.579 delivery. That means optimizing the blood's oxygen 00:04:32.579 --> 00:04:35.000 content and then improving its flow. Second, 00:04:35.459 --> 00:04:38.160 we have to balance tissue perfusion with metabolic 00:04:38.160 --> 00:04:41.300 demand. Think about it, if the body is burning 00:04:41.300 --> 00:04:43.379 through resources faster than we can deliver 00:04:43.379 --> 00:04:46.399 them, like with a high fever or extreme pain, 00:04:47.180 --> 00:04:49.180 we're losing the battle. So we're not just flooding 00:04:49.180 --> 00:04:51.639 the system with oxygen and fluids, we're also 00:04:51.639 --> 00:04:54.459 trying to reduce the body's need for them. Precisely. 00:04:54.839 --> 00:04:57.750 Third, We need to actively reverse perfusion 00:04:57.750 --> 00:05:00.449 abnormalities. That might mean getting blood 00:05:00.449 --> 00:05:02.550 out of the capillary beds where it's pooling, 00:05:02.629 --> 00:05:06.009 like in distributive shock or overcoming a physical 00:05:06.009 --> 00:05:08.610 obstruction. And the ultimate goal. The overarching 00:05:08.610 --> 00:05:11.850 life saving goal is supporting vital organ function 00:05:11.850 --> 00:05:14.069 and critically preventing the progression to 00:05:14.069 --> 00:05:16.430 cardiac arrest. Because once that happens. Once 00:05:16.430 --> 00:05:19.029 cardiac arrest occurs secondary to shock, the 00:05:19.029 --> 00:05:21.550 prognosis is universally poor. I mean, our window 00:05:21.550 --> 00:05:24.589 for effective intervention just closes so rapidly. 00:05:24.779 --> 00:05:26.839 This might be the single most crucial area for 00:05:26.839 --> 00:05:29.839 nursing mastery then, spotting compensated shock. 00:05:29.980 --> 00:05:32.579 That's where the body is hiding the problem, 00:05:32.800 --> 00:05:36.379 fighting hard, and is buying us time. So what 00:05:36.379 --> 00:05:39.000 happens when those compensatory mechanisms start 00:05:39.000 --> 00:05:42.240 to fail? What are the priority cues that tell 00:05:42.240 --> 00:05:44.879 us the patient is deteriorating fast? You absolutely 00:05:44.879 --> 00:05:47.420 have to recognize that hypotension, a drop in 00:05:47.420 --> 00:05:50.160 blood pressure, is a late finding. It's a very 00:05:50.160 --> 00:05:51.759 late finding. So if you're waiting for that, 00:05:51.779 --> 00:05:53.379 you're already behind. You're way behind. If 00:05:53.379 --> 00:05:55.639 the blood pressure is low, The body has already 00:05:55.639 --> 00:05:58.579 exhausted its vasoconstrictive reserves, and 00:05:58.579 --> 00:06:01.500 perfusion to vital organs is severely compromised. 00:06:01.779 --> 00:06:04.100 Waiting for hypotension is waiting too long. 00:06:04.339 --> 00:06:06.800 So what should we be laser focused on before 00:06:06.800 --> 00:06:10.000 that BP alarm even thinks about sounding? The 00:06:10.000 --> 00:06:12.550 signs of failing compensation. The progression 00:06:12.550 --> 00:06:15.329 toward hypotensive shock. These are your priority 00:06:15.329 --> 00:06:18.470 manifestations. The first sign is often an escalating 00:06:18.470 --> 00:06:20.670 and persistent tachycardia. A heart rate that's 00:06:20.670 --> 00:06:22.949 just climbing and climbing. Exactly. If the heart 00:06:22.949 --> 00:06:24.589 rate is high for their age and it's just getting 00:06:24.589 --> 00:06:26.949 higher, it means the cardiac output is failing 00:06:26.949 --> 00:06:29.550 and the body's trying to compensate by just increasing 00:06:29.550 --> 00:06:32.709 the rate. And as the body clamps down on the 00:06:32.709 --> 00:06:34.970 periphery to protect the core, What does that 00:06:34.970 --> 00:06:37.870 do to the pulses? You'll see a dramatic contrast. 00:06:38.009 --> 00:06:40.250 You'll get diminishing or even absent peripheral 00:06:40.250 --> 00:06:43.209 pulses and at the same time weakening central 00:06:43.209 --> 00:06:46.279 pulses. This is a major sign that the systemic 00:06:46.279 --> 00:06:49.360 vascular resistance, the SVR, is trying to climb, 00:06:49.500 --> 00:06:51.779 but the pump volume just isn't there. And you 00:06:51.779 --> 00:06:54.180 also mentioned pulse pressure. Yes. You have 00:06:54.180 --> 00:06:56.600 to monitor for a narrowing pulse pressure. That's 00:06:56.600 --> 00:06:58.480 the gap between your systolic and diastolic. 00:06:59.060 --> 00:07:02.300 A narrow pulse pressure, say less than 20 mmHg, 00:07:02.540 --> 00:07:04.879 indicates intense peripheral vasoconstriction. 00:07:04.920 --> 00:07:06.819 That physical assessment is just non -negotiable. 00:07:07.079 --> 00:07:09.660 Cold, clammy skin. That's the classic sign, right? 00:07:09.699 --> 00:07:12.480 Yes. Cold, distal extremities with a prolonged 00:07:12.480 --> 00:07:15.240 capillary refill. Anything greater than two seconds 00:07:15.240 --> 00:07:17.959 is a giant red flag. If it takes three, four, 00:07:18.000 --> 00:07:20.420 five seconds for color to return, perfusion is 00:07:20.420 --> 00:07:22.680 failing. And what about neurologically? And this 00:07:22.680 --> 00:07:24.579 is perhaps the most concerning for the brain, 00:07:25.160 --> 00:07:28.509 a decreasing level of consciousness. confusion, 00:07:28.509 --> 00:07:31.790 lethargy, decreased responsiveness. That means 00:07:31.790 --> 00:07:34.610 cerebral perfusion is dropping. These are the 00:07:34.610 --> 00:07:37.250 trends that demand immediate intervention no 00:07:37.250 --> 00:07:39.370 matter what that blood pressure reading says. 00:07:39.550 --> 00:07:41.649 Okay, so with those warning signs in mind, our 00:07:41.649 --> 00:07:43.490 treatment strategies are all about restoring 00:07:43.490 --> 00:07:46.230 that blood flow and oxygenation. Exactly. Four 00:07:46.230 --> 00:07:48.610 core strategies. Let's start with oxygen content. 00:07:48.670 --> 00:07:50.569 We need to maximize the vehicle carrying the 00:07:50.569 --> 00:07:54.269 oxygen right, the hemoglobin. Strategy one, optimizing 00:07:54.269 --> 00:07:57.899 O2 content. This means immediate administration 00:07:57.899 --> 00:08:01.199 of a high concentration of O2, usually 100 % 00:08:01.199 --> 00:08:03.660 via a non -rebreathing mask. And if that's not 00:08:03.660 --> 00:08:06.019 enough? If the patient has a low hemoglobin, 00:08:06.019 --> 00:08:08.600 maybe from a hemorrhage, we have to quickly administer 00:08:08.600 --> 00:08:12.079 packed red blood cells, PRBCs, because hemoglobin 00:08:12.079 --> 00:08:14.639 determines your oxygen carrying capacity. And 00:08:14.639 --> 00:08:17.220 if ventilation itself is the issue, we move quickly 00:08:17.220 --> 00:08:19.639 to mechanical ventilation. Strategy two involves 00:08:19.639 --> 00:08:22.740 flow and volume. Improving volume and distribution 00:08:22.740 --> 00:08:25.160 of cardiac output. This is where your fluid bolus 00:08:25.160 --> 00:08:27.689 is going. We're either addressing a true volume 00:08:27.689 --> 00:08:31.230 deficit, like in hypovolemia, or a relative one, 00:08:31.370 --> 00:08:33.769 like in distributive shock. And if fluids don't 00:08:33.769 --> 00:08:37.289 work? Then we move to vasoactive agents to fine 00:08:37.289 --> 00:08:40.350 -tune contractility, those are inodropes, or 00:08:40.350 --> 00:08:42.870 the vessel tone itself with vasopressors. Okay, 00:08:43.049 --> 00:08:45.269 strategy three is minimizing demand. This is 00:08:45.269 --> 00:08:48.549 a crucial point. Reducing O2 demand shock states 00:08:48.549 --> 00:08:50.549 increase your metabolic needs because of increased 00:08:50.549 --> 00:08:53.830 work of breathing, anxiety, pain, fever. So it's 00:08:53.830 --> 00:08:57.070 a vicious cycle. It is. So a core intervention 00:08:57.070 --> 00:08:59.629 is controlling those factors. We use analgesia, 00:08:59.870 --> 00:09:03.029 anxiolytics, antipyretics. Sometimes just putting 00:09:03.029 --> 00:09:05.269 a patient on a ventilator drastically reduces 00:09:05.269 --> 00:09:07.690 their metabolic burden from breathing. And finally, 00:09:08.210 --> 00:09:11.360 strategy four, correcting the chemistry. Correcting 00:09:11.360 --> 00:09:14.220 metabolic derangements. As the body shifts to 00:09:14.220 --> 00:09:16.759 anaerobic metabolism, acid builds up, glucose 00:09:16.759 --> 00:09:19.200 gets depleted, electrolytes shift all over the 00:09:19.200 --> 00:09:21.159 place. These chemical imbalances, which we'll 00:09:21.159 --> 00:09:23.360 get into, they have to be corrected because they 00:09:23.360 --> 00:09:26.360 directly impair cardiac contractility and how 00:09:26.360 --> 00:09:28.299 well our life -saving drugs work. All right, 00:09:28.299 --> 00:09:31.200 let's move into the hands -on section. When you 00:09:31.200 --> 00:09:34.399 walk into the room of a patient in shock, what 00:09:34.399 --> 00:09:36.299 are the first steps, the ones that happen almost 00:09:36.299 --> 00:09:38.629 at the same time? Right. We assess, monitor, 00:09:38.769 --> 00:09:42.070 and intervene, often concurrently. First, let's 00:09:42.070 --> 00:09:45.049 talk positioning. If the patient is stable and 00:09:45.049 --> 00:09:47.350 comfortable, we can just leave them be. But if 00:09:47.350 --> 00:09:49.889 they're unstable or hypotensive, they need to 00:09:49.889 --> 00:09:53.750 be placed supine, flat on their back unless this 00:09:53.750 --> 00:09:56.470 really compromises their ability to breathe. 00:09:56.809 --> 00:09:59.559 Why supine specifically? It just promotes venous 00:09:59.559 --> 00:10:02.159 return to the heart. It maximizes the efficiency 00:10:02.159 --> 00:10:05.460 of whatever blood volume we do have. And here's 00:10:05.460 --> 00:10:08.840 a key detail for your exam. In specific cases, 00:10:09.539 --> 00:10:11.860 like neurogenic shock, positioning the patient 00:10:11.860 --> 00:10:15.000 flat or even slightly head down can significantly 00:10:15.000 --> 00:10:17.240 help improve that lost venous return. Good to 00:10:17.240 --> 00:10:20.690 know. OK, next up. airway and oxygenation. We 00:10:20.690 --> 00:10:23.330 jump immediately to supplemental O2, high concentration, 00:10:23.470 --> 00:10:26.029 aim for 100%. If their work of breathing is increasing, 00:10:26.070 --> 00:10:27.610 if they look like they're tiring out, or if they 00:10:27.610 --> 00:10:29.509 have that altered mental status, we need to take 00:10:29.509 --> 00:10:32.129 over. We have to move fast. The shift to mechanical 00:10:32.129 --> 00:10:34.929 ventilation, either non -invasive like CPAP or 00:10:34.929 --> 00:10:38.190 invasive intubation, must be rapid. Fatigue and 00:10:38.190 --> 00:10:41.549 shock is lethal. And then vascular access. This 00:10:41.549 --> 00:10:45.070 is always a point of stress in the ER or ICU. 00:10:45.409 --> 00:10:47.629 How long do we spend trying to get a peripheral 00:10:47.629 --> 00:10:50.399 IV? Before we move on. You do not waste time. 00:10:51.159 --> 00:10:53.200 For compensated shock, sure, a peripheral IV 00:10:53.200 --> 00:10:56.220 is fine. But for any patient in hypotensive shock, 00:10:56.360 --> 00:10:58.159 or if you can't get peripheral access within, 00:10:58.159 --> 00:11:00.860 say, 90 seconds or two attempts. What's the move? 00:11:01.220 --> 00:11:04.799 Immediate intraosseous access. An IO is mandatory. 00:11:05.000 --> 00:11:07.860 Drill into the bone. Yes. Perfusion is poor. 00:11:08.179 --> 00:11:10.759 The veins are collapsed. I .O. access into the 00:11:10.759 --> 00:11:13.480 tibia or femur is rapid, it's reliable, and it's 00:11:13.480 --> 00:11:15.559 just as effective as a central line for rapid 00:11:15.559 --> 00:11:18.299 fluid and drug delivery. This single step can 00:11:18.299 --> 00:11:20.539 separate a good outcome from a poor one. With 00:11:20.539 --> 00:11:23.440 access secured, we move to fluid. Yes. Isotonic 00:11:23.440 --> 00:11:26.580 crystalloids, either normal saline S or lactated 00:11:26.580 --> 00:11:28.620 ringers LR. These are the workhorses. The high 00:11:28.620 --> 00:11:30.580 yield number we all need to have memorized is 00:11:30.580 --> 00:11:33.460 the standard bolus rate. 20 millilaterums over 00:11:33.460 --> 00:11:36.399 five to 20 minutes. But the clock is crucial 00:11:36.399 --> 00:11:39.990 here for severe hypovolemic or septic shock. 00:11:40.370 --> 00:11:42.570 You are pushing that fluid rapidly. You're aiming 00:11:42.570 --> 00:11:45.049 for that five to ten minute window. This is where 00:11:45.049 --> 00:11:47.210 the nurse's skill in delivery is really tested. 00:11:47.389 --> 00:11:50.330 And here comes the critical exception. The smallest 00:11:50.330 --> 00:11:53.389 detail that prevents a catastrophe. Cardiogenic 00:11:53.389 --> 00:11:56.429 shock. If we even suspect the pump is failing, 00:11:56.909 --> 00:11:59.309 giving a huge rapid bolus will drown the lungs 00:11:59.309 --> 00:12:01.789 in fluid. So what's the adjustment? The bolus 00:12:01.789 --> 00:12:04.500 is smaller and it's slower. 5 to 10 milliliter 00:12:04.500 --> 00:12:07.659 alkylidrams over 10 to 20 minutes. The goal is 00:12:07.659 --> 00:12:10.419 to gently test the heart's response without causing 00:12:10.419 --> 00:12:12.500 pulmonary edema. Let's talk about the physics 00:12:12.500 --> 00:12:14.460 of that. As you mentioned, a standard IV pump 00:12:14.460 --> 00:12:17.340 is way too slow. If a patient weighs 50 kilograms, 00:12:17.620 --> 00:12:20.039 a 20 milliliter alkylidram bolus is a full liter. 00:12:20.159 --> 00:12:22.340 How does a nurse get a liter of fluid into a 00:12:22.340 --> 00:12:24.620 patient in 10 minutes? This is hands -on nursing. 00:12:24.679 --> 00:12:26.840 It's not passive. You have to use a large bore 00:12:26.840 --> 00:12:29.360 IV or that IO catheter. You need a pressure bag, 00:12:29.720 --> 00:12:31.440 a specialized sleeve that you inflate around 00:12:31.440 --> 00:12:33.700 the fluid bag, and it physically compresses it, 00:12:33.700 --> 00:12:35.559 forcing the fluid into the patient. And if you 00:12:35.559 --> 00:12:37.600 don't have one. If a pressure bag isn't right 00:12:37.600 --> 00:12:41.259 there, you use 30 or 60 mL syringes to manually 00:12:41.259 --> 00:12:43.539 push the fluid through a stopcock directly into 00:12:43.539 --> 00:12:47.399 line. It's labor intensive, it's tiring, but 00:12:47.399 --> 00:12:50.139 it's the only way to get true bolus rates of 00:12:50.139 --> 00:12:53.480 thousands of mL per hour that you need for resuscitation. 00:12:54.200 --> 00:12:56.500 Relying on a standard pump during active shock 00:12:56.500 --> 00:12:59.440 is just not enough. The moment that fluid starts 00:12:59.440 --> 00:13:02.820 flowing, the continuous assessment begins. We're 00:13:02.820 --> 00:13:05.059 looking for trends, not single snapshots, right? 00:13:05.080 --> 00:13:07.759 Right. Because no single parameter confirms that 00:13:07.759 --> 00:13:09.779 you're resuscitating them adequately. That's 00:13:09.779 --> 00:13:12.139 right. And you reassess after every single fluid 00:13:12.139 --> 00:13:14.779 bolus. So what are the key positive changes we're 00:13:14.779 --> 00:13:17.440 looking for after a bolus? We want to see those 00:13:17.440 --> 00:13:20.720 signs of compensation resolving. That means the 00:13:20.720 --> 00:13:22.440 heart rate should start declining toward normal 00:13:22.440 --> 00:13:25.179 limits. We want peripheral pulses to strengthen 00:13:25.179 --> 00:13:27.980 and become less bounding. Capillary refill should 00:13:27.980 --> 00:13:30.440 shorten to less than two seconds. The skin should 00:13:30.440 --> 00:13:32.620 warm up. And blood pressure. Blood pressure should 00:13:32.620 --> 00:13:34.320 increase toward a normal range, but you have 00:13:34.320 --> 00:13:36.919 to remember, BP accuracy is really compromised 00:13:36.919 --> 00:13:39.019 when perfusion is poor. So don't hang your hat 00:13:39.019 --> 00:13:41.659 on that alone. And our key indicator for end 00:13:41.659 --> 00:13:44.139 organ perfusion. Yeah. The kiddies. Exactly. 00:13:44.580 --> 00:13:47.179 Urine output is a direct measure of renal perfusion 00:13:47.179 --> 00:13:49.919 and adequate flow. For infants and young children, 00:13:50.220 --> 00:13:53.960 we're aiming for 1 .5 to 2 millipede CHR. For 00:13:53.960 --> 00:13:57.259 older kids and adolescents, about 1 LOK CHR. 00:13:57.480 --> 00:14:00.700 If urine output is dropping, or zero, a nuria, 00:14:01.000 --> 00:14:03.600 hypoperfusion is ongoing. What about the negative 00:14:03.600 --> 00:14:06.240 trends? What tells us to stop the fluids? You're 00:14:06.240 --> 00:14:08.360 looking for signs of volume overload, especially 00:14:08.360 --> 00:14:11.019 in the lungs. The development of crackles or 00:14:11.019 --> 00:14:14.059 rails or a sudden, dramatic increase in the work 00:14:14.059 --> 00:14:16.740 of breathing suggests pulmonary edema is developing. 00:14:16.919 --> 00:14:19.120 And that's the signal to stop. That is the signal 00:14:19.120 --> 00:14:21.000 to halt the crystalloids and reconsider the cause. 00:14:21.220 --> 00:14:24.120 Maybe we missed a cardiac component. And a foundational 00:14:24.120 --> 00:14:27.159 exam fact here. Because assessment relies on 00:14:27.159 --> 00:14:29.259 so many parameters, remember that hypotension 00:14:29.259 --> 00:14:32.600 is a very late, very grave sign. Relying only 00:14:32.600 --> 00:14:35.440 on BP can be really misleading. Let's shift to 00:14:35.440 --> 00:14:38.240 the body's chemistry during shock. The failure 00:14:38.240 --> 00:14:40.960 to deliver oxygen just turns the internal environment 00:14:40.960 --> 00:14:43.480 toxic. What are the four high -yield metabolic 00:14:43.480 --> 00:14:46.399 complications we have to anticipate? Hypoglycemia, 00:14:46.700 --> 00:14:49.620 hypocalcemia, hyperkalemia, and severe metabolic 00:14:49.620 --> 00:14:53.600 acidosis, lactic acidosis. And all four of them 00:14:53.600 --> 00:14:57.299 actively make myocardial function worse. Hypoglycemia. 00:14:57.480 --> 00:15:00.620 Why is low blood sugar such a danger here? Well, 00:15:00.759 --> 00:15:03.200 glucose is the brain's primary fuel, and the 00:15:03.200 --> 00:15:05.279 heart muscle relies on it for consistent energy. 00:15:05.779 --> 00:15:08.379 In shock, especially septic shock, the body just 00:15:08.379 --> 00:15:10.600 burns through its glycogen stores so quickly. 00:15:11.200 --> 00:15:13.600 Untreated hypoglycemia can cause irreversible 00:15:13.600 --> 00:15:15.440 brain injury and seizures. It has to be ruled 00:15:15.440 --> 00:15:19.240 out instantly. Okay, and hypocalcemia. Low calcium, 00:15:19.500 --> 00:15:21.519 that seems a little less intuitive than low sugar. 00:15:21.620 --> 00:15:23.940 Calcium is absolutely essential for smooth muscle 00:15:23.940 --> 00:15:25.960 contraction. That includes the heart and the 00:15:25.960 --> 00:15:28.779 blood vessels, what we call vasomotor tone. So 00:15:28.779 --> 00:15:32.279 hypocalcemia, low ionized calcium, significantly 00:15:32.279 --> 00:15:34.639 reduces your cardiac output, and you frequently 00:15:34.639 --> 00:15:37.179 see it after large volume blood transfusions. 00:15:37.340 --> 00:15:40.179 Why is that? Because the citrate preservative 00:15:40.179 --> 00:15:42.860 they use in packed red blood cells binds to the 00:15:42.860 --> 00:15:45.139 patient's calcium, which lowers the free active 00:15:45.139 --> 00:15:47.700 calcium levels. It's a key nursing consideration. 00:15:47.600 --> 00:15:50.440 when you're transfusing blood rapidly. So this 00:15:50.440 --> 00:15:53.039 leads us to mandatory nursing actions. Absolutely. 00:15:53.639 --> 00:15:56.899 A rapid point of K glucose check is non -negotiable 00:15:56.899 --> 00:15:59.279 for any critically ill patient who presents with 00:15:59.279 --> 00:16:01.620 shock or altered mental status. And if we find 00:16:01.620 --> 00:16:04.360 it's low, how do we intervene? We give dextrose. 00:16:05.659 --> 00:16:08.820 D25W or D10W depending on the patient's size, 00:16:09.200 --> 00:16:11.080 but here's that smallest detail that prevents 00:16:11.080 --> 00:16:14.820 a new crisis. Never rapidly infuse large volumes 00:16:14.820 --> 00:16:17.500 of concentrated dextrous fluids if it's not clinically 00:16:17.500 --> 00:16:19.919 indicated. Why not? What's the risk? If you dump 00:16:19.919 --> 00:16:22.740 highly concentrated sugar in rapidly, it creates 00:16:22.740 --> 00:16:25.539 hyperosmolarity in the bloodstream. This pulls 00:16:25.539 --> 00:16:27.679 fluid out of the cells, causes diuresis, and 00:16:27.679 --> 00:16:30.440 can actually lead to dehydration and severe electrolyte 00:16:30.440 --> 00:16:33.259 shifts, especially hyponatremia. So we treat 00:16:33.259 --> 00:16:35.980 the low glucose carefully, not carelessly. OK, 00:16:36.200 --> 00:16:39.220 now metabolic acidosis. The result of that anaerobic 00:16:39.220 --> 00:16:42.139 metabolism. Lactic acid buildup is the defining 00:16:42.139 --> 00:16:44.580 feature. How does the nurse manage that? The 00:16:44.580 --> 00:16:47.179 primary intervention is always, always to restore 00:16:47.179 --> 00:16:49.440 tissue perfusion. If we can get oxygen flowing 00:16:49.440 --> 00:16:51.340 again, the body will start making lactic acid. 00:16:51.419 --> 00:16:53.860 Simple as that. But what if it's really profound? 00:16:54.110 --> 00:16:57.250 If the acidosis is so profound, with a very low 00:16:57.250 --> 00:16:59.990 pH, that it's impairing vital function so the 00:16:59.990 --> 00:17:02.669 heart can't contract effectively or the vasopressors 00:17:02.669 --> 00:17:05.089 aren't working, we might use buffer therapy. 00:17:05.210 --> 00:17:08.480 That means sodium bicarbonate. Yes, but sodium 00:17:08.480 --> 00:17:10.900 bicarb is a temporary measure. It's a bridge. 00:17:11.220 --> 00:17:13.960 It buffers the excess hydrogen ions, which buys 00:17:13.960 --> 00:17:17.220 us time, but it only works until the primary 00:17:17.220 --> 00:17:19.960 issue, which is perfusion, is corrected through 00:17:19.960 --> 00:17:22.960 fluids and drugs or until ventilation is optimized 00:17:22.960 --> 00:17:25.319 to blow off the CO2 it creates. Let's review 00:17:25.319 --> 00:17:27.559 the lab studies that guide our therapy. starting 00:17:27.559 --> 00:17:30.220 with the CBC. Complete blood count. Look at the 00:17:30.220 --> 00:17:33.240 hemoglobin and hematocrit. If HDB and HDAT are 00:17:33.240 --> 00:17:35.819 decreased, it suggests hemorrhage or hemodilution. 00:17:35.960 --> 00:17:38.359 The intervention there is obvious. Right. Control 00:17:38.359 --> 00:17:41.880 the bleeding, maximize O2, transfuse, PRBCs. 00:17:41.960 --> 00:17:44.180 On the other hand, an increased white blood cell 00:17:44.180 --> 00:17:46.900 count, WBC, immediately makes you suspicious 00:17:46.900 --> 00:17:49.119 of sepsis. That means you need to get cultures 00:17:49.119 --> 00:17:52.480 and start antibiotics fast. Next, lactate. This 00:17:52.480 --> 00:17:54.599 is the gold standard for tracking hyco perfusion, 00:17:54.680 --> 00:17:57.589 isn't it? It is. Elevated lactate is the product 00:17:57.589 --> 00:18:00.210 of anaerobic metabolism. The intervention is 00:18:00.210 --> 00:18:03.250 to improve tissue perfusion. But the critical 00:18:03.250 --> 00:18:05.450 application for the nurse is serial monitoring. 00:18:05.759 --> 00:18:08.839 Watching the trend. Exactly. We watch for lactate 00:18:08.839 --> 00:18:11.019 clearance. If the lactate level is falling, our 00:18:11.019 --> 00:18:13.500 resuscitation is working. If it stays high, we 00:18:13.500 --> 00:18:16.019 need to escalate therapy, maybe change our agents, 00:18:16.180 --> 00:18:19.079 or reassess the source of the shock. Persistent 00:18:19.079 --> 00:18:21.480 hyperlactatemia is a sign of refractory shock, 00:18:21.519 --> 00:18:24.299 and it carries a very poor prognosis. We mentioned 00:18:24.299 --> 00:18:27.039 acidosis that's tracked on the ABG. Barterial 00:18:27.039 --> 00:18:30.519 blood gas. A decreased pH in bicarbonate confirms 00:18:30.519 --> 00:18:33.220 acidosis. We also look at the anion gap. If it's 00:18:33.220 --> 00:18:35.609 widened, that helps confirm it's from... acid 00:18:35.609 --> 00:18:38.329 production, like lactic acid. Intervention is 00:18:38.329 --> 00:18:40.470 fluids, ventilation support, and maybe that buffer 00:18:40.470 --> 00:18:42.329 therapy we talked about. And finally the more 00:18:42.329 --> 00:18:46.670 advanced concept, SCVO2. SCVO2 or central venous 00:18:46.670 --> 00:18:49.690 oxygen saturation. This measures how much oxygen 00:18:49.690 --> 00:18:51.329 is left in the blood returning to the heart. 00:18:51.869 --> 00:18:55.890 A low SCVO2, typically less than 70%, means tissues 00:18:55.890 --> 00:18:57.910 are extracting too much oxygen because delivery 00:18:57.910 --> 00:19:00.569 is inadequate. So you need to increase delivery. 00:19:01.009 --> 00:19:03.789 Increase delivery. Transfuse blood, increase 00:19:03.789 --> 00:19:07.309 cardiac output. Interestingly, though, a high 00:19:07.309 --> 00:19:11.089 SCVO2 over 70 % can also be a problem. You often 00:19:11.089 --> 00:19:13.190 see that in warm septic shock where the tissues 00:19:13.190 --> 00:19:15.329 can't effectively use the oxygen being delivered. 00:19:15.730 --> 00:19:17.910 It's a maldistribution problem. Okay, let's do 00:19:17.910 --> 00:19:21.309 a deep dive into hypovolemic shock, the volume 00:19:21.309 --> 00:19:23.710 issue. Hypovolemic shock is the most frequent 00:19:23.710 --> 00:19:25.990 type you'll see, and it results from a really 00:19:25.990 --> 00:19:29.380 simple, direct problem. not enough intravascular 00:19:29.380 --> 00:19:31.900 volume. Because the container is the right size, 00:19:32.000 --> 00:19:34.460 but the volume inside is low, it's usually highly 00:19:34.460 --> 00:19:36.960 responsive to fluids. And the causes are divided 00:19:36.960 --> 00:19:40.500 into nonhemorrhagic and hemorrhagic. Nonhemorrhagic 00:19:40.500 --> 00:19:42.319 means you're losing fluid without losing red 00:19:42.319 --> 00:19:44.920 blood cells. I think GI losses like vomiting 00:19:44.920 --> 00:19:48.019 and diarrhea, big fluid shifts from burns, DKA 00:19:48.019 --> 00:19:51.319 with its osmotic diuresis or diabetes insipidus. 00:19:51.519 --> 00:19:53.940 And hemorrhagic. Hemorrhagic is just acute blood 00:19:53.940 --> 00:19:56.579 loss, usually from trauma. The key difference 00:19:56.579 --> 00:19:58.299 in management, though the initial fluids are 00:19:58.299 --> 00:20:00.279 the same, is the rapid need for blood products 00:20:00.279 --> 00:20:02.809 in the hemorrhagic type. Since non -hemorrhagic 00:20:02.809 --> 00:20:05.609 shock is often preceded by dehydration, let's 00:20:05.609 --> 00:20:07.509 analyze the progression of those clinical signs. 00:20:08.049 --> 00:20:10.269 This is where nursing assessment really guides 00:20:10.269 --> 00:20:12.630 what you need to do first. We use the estimated 00:20:12.630 --> 00:20:15.029 percentage of weight loss as a marker for severity. 00:20:15.630 --> 00:20:18.130 Mild dehydration, maybe 5 % loss, often just 00:20:18.130 --> 00:20:20.890 presents with slightly dry mucous membranes, 00:20:20.950 --> 00:20:24.309 maybe they're thirsty, slight alguria. Was the 00:20:24.309 --> 00:20:26.529 diagnostic pitfall there a common mistake? The 00:20:26.529 --> 00:20:29.079 pitfall is assuming one sign is definitive. For 00:20:29.079 --> 00:20:31.619 example, a child might have dry mucus membranes 00:20:31.619 --> 00:20:33.400 just because they're mouth breathing from a stuffy 00:20:33.400 --> 00:20:36.680 nose. You have to combine these cues. And skin 00:20:36.680 --> 00:20:39.500 turgor is notoriously unreliable in an obese 00:20:39.500 --> 00:20:42.599 patient. Right. Moving to moderate dehydration, 00:20:42.779 --> 00:20:45.720 about 10 % loss. Now we're seeing clear physical 00:20:45.720 --> 00:20:47.940 signs. Yes. The classic signs start to appear. 00:20:48.400 --> 00:20:51.380 poor skin trigger, or skin tinting, a sunken 00:20:51.380 --> 00:20:53.819 fontanel in infants, marked ulgeria, and that 00:20:53.819 --> 00:20:56.819 increasing tachycardia. You might also see quiet 00:20:56.819 --> 00:20:59.180 tachypnea, which is the body trying to blow off 00:20:59.180 --> 00:21:02.140 CO2 to compensate for a developing metabolic 00:21:02.140 --> 00:21:04.559 acidosis. And then the life -threatening stage, 00:21:04.960 --> 00:21:07.920 severe dehydration, 15 % loss or more. This is 00:21:07.920 --> 00:21:10.440 compensated shock on the verge of complete failure. 00:21:10.880 --> 00:21:13.220 You should expect marked tachycardia, weak or 00:21:13.220 --> 00:21:16.700 absent peripheral pulses, anuria, no urine output, 00:21:16.859 --> 00:21:18.980 and then those late signs we talked about, a 00:21:18.980 --> 00:21:20.799 narrow pulse pressure, and eventually altered 00:21:20.799 --> 00:21:23.940 mental status and hypotension. Intervention here 00:21:23.940 --> 00:21:27.960 has to be immediate IV or IO access and rapid 00:21:27.960 --> 00:21:31.599 fluid bolusing. Focusing now on blood loss. Hemorrhagic 00:21:31.599 --> 00:21:34.480 shock. The initial management is still that 20 00:21:34.480 --> 00:21:38.730 milli uki NS or LR. bolus repeated. But when 00:21:38.730 --> 00:21:41.309 do we stop relying just on crystalloids? You 00:21:41.309 --> 00:21:43.750 can give up to about three boluses, so 60 milli 00:21:43.750 --> 00:21:46.329 -UQA total, before you have to seriously consider 00:21:46.329 --> 00:21:48.950 the patient refractory and move on to blood products. 00:21:49.150 --> 00:21:52.230 Let's explain the 3 -MLL to 1 -MLL rule. This 00:21:52.230 --> 00:21:54.509 is such a critical concept for trauma and hemorrhagic 00:21:54.509 --> 00:21:57.049 shock. Why do we need three times the crystalloid 00:21:57.049 --> 00:21:59.369 volume for every unit of blood lost? It's all 00:21:59.369 --> 00:22:01.809 about where the fluid goes. Isotonic crystalloids, 00:22:01.910 --> 00:22:03.789 like normal saline, they don't stay in the blood 00:22:03.789 --> 00:22:05.680 vessels. Right, they leak out. They distribute 00:22:05.680 --> 00:22:08.579 rapidly throughout the entire extracellular space, 00:22:09.019 --> 00:22:11.680 which includes the interstitial space. Only about 00:22:11.680 --> 00:22:14.099 a third of what you give actually stays in the 00:22:14.099 --> 00:22:17.200 vessels after 30 minutes. So, to effectively 00:22:17.200 --> 00:22:20.039 replace one LML of lost blood volume, you have 00:22:20.039 --> 00:22:22.900 to infuse three mmL of crystalloid just to make 00:22:22.900 --> 00:22:24.559 sure enough stays inside the vessels to raise 00:22:24.559 --> 00:22:26.940 the blood pressure. So when do we make the switch 00:22:26.940 --> 00:22:30.009 to blood? If hypotension persists, despite those 00:22:30.009 --> 00:22:32.970 initial boluses, we immediately switch to packed 00:22:32.970 --> 00:22:36.829 red blood cells, PRBCs. We give a 10 millilangmg 00:22:36.829 --> 00:22:39.529 bolus. Blood is critical because it replaces 00:22:39.529 --> 00:22:42.250 both the volume and the oxygen carrying capacity. 00:22:42.589 --> 00:22:45.210 What about the details on emergency blood administration, 00:22:45.650 --> 00:22:47.779 the blood type? If the patient is bleeding out 00:22:47.779 --> 00:22:49.940 and unstable, you can't wait for a cross match. 00:22:50.059 --> 00:22:53.079 You use universal donor blood. Type O negative 00:22:53.079 --> 00:22:55.539 is what we prioritize for females of childbearing 00:22:55.539 --> 00:22:58.500 age because of rhesus factor concerns. For everyone 00:22:58.500 --> 00:23:01.660 else, O negative or O positive can be used. If 00:23:01.660 --> 00:23:03.839 the hypotension is severe and they're still bleeding, 00:23:04.160 --> 00:23:06.660 you use unmatched blood immediately. You prioritize 00:23:06.660 --> 00:23:09.059 saving their life over the small risk of a reaction. 00:23:09.440 --> 00:23:11.140 Okay, let's move on to distributive shock. Yep. 00:23:11.420 --> 00:23:13.400 The vessel issue. This is the opposite scenario, 00:23:13.480 --> 00:23:15.640 right? Yeah. The volume is okay, but the container's 00:23:15.640 --> 00:23:19.180 just too Exactly. Massive vasodilation has expanded 00:23:19.180 --> 00:23:21.900 the vascular space, which leads to a relative 00:23:21.900 --> 00:23:24.940 hypovolemia. Septic shock is the most common 00:23:24.940 --> 00:23:27.279 and dangerous example. So with septic shock, 00:23:27.500 --> 00:23:30.000 what's happening pathophysiologically? It's an 00:23:30.000 --> 00:23:32.599 overwhelming systemic inflammatory response to 00:23:32.599 --> 00:23:35.349 an infection. Inflammatory mediators are released, 00:23:35.390 --> 00:23:38.390 leading to massive vasodilation, which gives 00:23:38.390 --> 00:23:41.670 you a low SVR capillary leak, so fluid shifts 00:23:41.670 --> 00:23:44.190 out of the vessels, and sometimes it directly 00:23:44.190 --> 00:23:47.630 depresses the myocardium. Our goals are comprehensive, 00:23:48.190 --> 00:23:50.869 restore stability, support the organs, and control 00:23:50.869 --> 00:23:53.470 the infection. This sounds like it demands rapid 00:23:53.470 --> 00:23:55.839 integrated care. What does that interprofessional 00:23:55.839 --> 00:23:57.500 management look like in the first hour? It's 00:23:57.500 --> 00:24:00.039 a synchronized dance. The MD or DO is focused 00:24:00.039 --> 00:24:02.680 on diagnosis, source control, titrating drugs. 00:24:03.099 --> 00:24:05.740 Nursing is the absolute driver, securing access, 00:24:05.859 --> 00:24:07.960 delivering rapid fluids, initiating monitoring, 00:24:08.119 --> 00:24:10.799 making sure drugs are given on time. And pharmacy. 00:24:11.000 --> 00:24:14.640 Pharmacy has to ensure those crucial antibiotics 00:24:14.640 --> 00:24:16.980 and vasoactive agents are mixed and immediately 00:24:16.980 --> 00:24:21.119 available, and you need early subspecialty consultation 00:24:21.119 --> 00:24:24.000 infectious disease critical care to make sure 00:24:24.000 --> 00:24:26.440 the treatment plan is comprehensive, especially 00:24:26.440 --> 00:24:28.890 if the shock isn't responding. So let's get into 00:24:28.890 --> 00:24:31.289 the nursing management. The first hour bundle 00:24:31.289 --> 00:24:34.430 is basically the law here. The urgency just cannot 00:24:34.430 --> 00:24:36.369 be overstated. So what are the interventions 00:24:36.369 --> 00:24:38.349 that have to happen immediately, no matter where 00:24:38.349 --> 00:24:40.970 the patient is? You have to recognize the signs 00:24:40.970 --> 00:24:44.069 altered mental status, perfusion changes, temperature 00:24:44.069 --> 00:24:46.569 dysregulation, which can be either very high 00:24:46.569 --> 00:24:49.190 or surprisingly low. Right. Then you secure access. 00:24:49.329 --> 00:24:51.269 You draw blood cultures and labs immediately. 00:24:51.789 --> 00:24:54.410 But the most time sensitive, life saving intervention 00:24:54.410 --> 00:24:57.609 is administering adequate broad spectrum antibiotics. 00:24:57.480 --> 00:25:00.799 within the first hour of recognition. Don't delay 00:25:00.799 --> 00:25:03.180 antibiotics waiting for test results. You treat 00:25:03.180 --> 00:25:05.319 empirically. And fluid resuscitation remains 00:25:05.319 --> 00:25:09.019 aggressive. Yes. We start the 20 -mL -degylde 00:25:09.019 --> 00:25:11.960 isotonic crystalloid boluses and we repeat them. 00:25:12.440 --> 00:25:15.059 But you must reassess for signs of overload those 00:25:15.059 --> 00:25:18.319 crackles between each bolus. It is very common 00:25:18.319 --> 00:25:21.259 for children in septic shock to need 40 to 60 00:25:21.259 --> 00:25:24.299 -mL -degyldes, sometimes more, in that first 00:25:24.299 --> 00:25:27.460 hour. So what defines fluid refractory shock 00:25:27.460 --> 00:25:29.779 and sepsis and what's the immediate nursing intervention 00:25:29.779 --> 00:25:33.380 then? If the shock persists despite 40 to 60 00:25:33.380 --> 00:25:35.859 milliliter illigerics of crystalloids, it is 00:25:35.859 --> 00:25:38.880 by definition fluid refractory. The intervention 00:25:38.880 --> 00:25:41.960 is immediate initiation of vasoactive drug therapy 00:25:41.960 --> 00:25:45.039 vasopressors. And crucially, you have to consider 00:25:45.039 --> 00:25:47.200 hydrocortisone administration if you suspect 00:25:47.200 --> 00:25:49.579 adrenal insufficiency. Especially in patients 00:25:49.579 --> 00:25:52.140 with a history of chronic steroid use. Especially 00:25:52.140 --> 00:25:54.180 then, yeah. Okay, the choice of vasoactive agent 00:25:54.180 --> 00:25:56.400 is really high yield because it depends on the 00:25:56.400 --> 00:25:58.619 clinical presentation. Are they cold or warm? 00:25:58.910 --> 00:26:01.910 This is a classic test question. Cold shock means 00:26:01.910 --> 00:26:04.390 the patient has poor peripheral perfusion cold 00:26:04.390 --> 00:26:07.329 extremities and often low cardiac alcohol. This 00:26:07.329 --> 00:26:09.789 usually suggests severely depressed myocardium 00:26:09.789 --> 00:26:12.650 or intense vasoconstriction leading to poor systemic 00:26:12.650 --> 00:26:15.289 flow. And for that the preferred agent is epinephrine. 00:26:15.309 --> 00:26:17.589 Why epinephrine specifically for cold shock? 00:26:17.910 --> 00:26:20.539 Epinephrine is a balanced drug. It stimulates 00:26:20.539 --> 00:26:22.920 both alpha -edrenergic receptors, which causes 00:26:22.920 --> 00:26:26.539 vasoconstriction and raises SVR, and beta -edrenergic 00:26:26.539 --> 00:26:29.380 receptors, which gives you positive inotropic 00:26:29.380 --> 00:26:31.880 effects, increasing contractility. So it hits 00:26:31.880 --> 00:26:34.500 both problems. It addresses both the pump failure 00:26:34.500 --> 00:26:37.140 and the loss of tone, making it ideal for that 00:26:37.140 --> 00:26:39.599 cold shock state. And then we have warm shock. 00:26:39.859 --> 00:26:43.019 Warm shock is often seen in early sepsis. The 00:26:43.019 --> 00:26:45.779 extremities are warm. Cap refill might even be 00:26:45.779 --> 00:26:48.440 brisk. But the blood pressure is low, and the 00:26:48.440 --> 00:26:53.380 SCVO is often high. This points to profound vasodilation 00:26:53.380 --> 00:26:56.279 and maldistribution of flow. So the problem is 00:26:56.279 --> 00:26:58.700 vascular collapse. It is. So the preferred agent 00:26:58.700 --> 00:27:01.279 here is norepinephrine. Which is known as a pure 00:27:01.279 --> 00:27:03.380 pressor, right? That's right. Norepinephrine 00:27:03.380 --> 00:27:06.779 is a powerful alpha -adrenergic agonist. It primarily 00:27:06.779 --> 00:27:09.740 causes vasoconstriction, which dramatically increases 00:27:09.740 --> 00:27:12.920 SVR to combat that massive vasodilation without 00:27:12.920 --> 00:27:15.980 significantly jacking up myocardial oxygen consumption 00:27:15.980 --> 00:27:18.380 like a powerful inotrope might. We use it to 00:27:18.250 --> 00:27:21.049 regain vascular tone. And if both of those primary 00:27:21.049 --> 00:27:23.690 agents fail, what are the next lines of defense? 00:27:23.930 --> 00:27:26.589 If the shock is refractory to both fluid and 00:27:26.589 --> 00:27:29.450 norepinephrine, we might add vasopressin. It's 00:27:29.450 --> 00:27:31.690 a non -adrenergic presser that works on different 00:27:31.690 --> 00:27:35.069 receptors to increase SVR. And if myocardial 00:27:35.069 --> 00:27:37.690 dysfunction is clearly evident, the pump is failing, 00:27:37.869 --> 00:27:40.309 we might use milrinone. And what's unique about 00:27:40.309 --> 00:27:43.849 milrinone? Milrinone is a phosphodiesterase inhibitor. 00:27:43.990 --> 00:27:46.710 It enhances contractility, so it's an inotrope, 00:27:46.710 --> 00:27:49.089 but it also acts as a powerful vasodilator, which 00:27:49.089 --> 00:27:52.430 reduces afterload. This unique profile is excellent 00:27:52.430 --> 00:27:54.349 for improving heart function without forcing 00:27:54.349 --> 00:27:57.369 it to pump against extreme pressure. Okay, switching 00:27:57.369 --> 00:28:00.670 gears to another distributive issue, anaphylactic 00:28:00.670 --> 00:28:03.069 shock. This is life -threatening because of that 00:28:03.069 --> 00:28:06.509 rapid release of mediators. What is the non -negotiable 00:28:06.509 --> 00:28:09.410 immediate first -line intervention? Epinephrine. 00:28:09.720 --> 00:28:12.319 It has to be given immediately, usually IM in 00:28:12.319 --> 00:28:15.400 the vastus lateralis, to slow mediator release, 00:28:16.019 --> 00:28:18.440 reverse bronchospasm, and stabilize the vessels. 00:28:19.039 --> 00:28:21.880 For severe sustained hypotension, a low -dose 00:28:21.880 --> 00:28:24.119 IV epinephrine fusion is started to maintain 00:28:24.119 --> 00:28:26.519 perfusion. And beyond epinephrine, what does 00:28:26.519 --> 00:28:28.299 the rest of the medication approach look like? 00:28:28.430 --> 00:28:30.930 We aim to control all the subsequent effects. 00:28:31.609 --> 00:28:35.009 So, albuterol for bronchospasm. We use antihistamines, 00:28:35.190 --> 00:28:37.849 both H1 blockers like diffenhydramine and H2 00:28:37.849 --> 00:28:40.150 blockers like ranadetine, because the combination 00:28:40.150 --> 00:28:43.680 is highly effective. And corticosteroids. Finally, 00:28:43.940 --> 00:28:46.220 corticosteroids, like methylprednisolone, are 00:28:46.220 --> 00:28:48.920 given, not for the acute reversal, but to prevent 00:28:48.920 --> 00:28:51.240 the dangerous and unpredictable late phase symptoms 00:28:51.240 --> 00:28:53.900 that can occur hours after the initial reaction 00:28:53.900 --> 00:28:56.200 seems to have resolved. And fluid replacement 00:28:56.200 --> 00:28:58.200 is still needed here because of the capillary 00:28:58.200 --> 00:29:01.440 leak, correct? Absolutely. The vasodilation and 00:29:01.440 --> 00:29:03.859 capillary leak lead to a significant relative 00:29:03.859 --> 00:29:07.700 hypovolemia. So those 20 LLKG NSLR boluses are 00:29:07.700 --> 00:29:10.440 necessary. And the key education point for the 00:29:10.440 --> 00:29:13.400 family and for your exam is that risk of a biphasic 00:29:13.400 --> 00:29:17.259 reaction. About 25 % to 30 % of patients experience 00:29:17.259 --> 00:29:19.680 these late symptoms, which means they need prolonged 00:29:19.680 --> 00:29:21.740 monitoring, even if they look stable initially. 00:29:22.019 --> 00:29:24.980 OK. Last one for distributive. Neurogenic shock. 00:29:25.630 --> 00:29:27.609 Neurogenic shock, usually from a high spinal 00:29:27.609 --> 00:29:29.809 cord injury, is unique because of its effect 00:29:29.809 --> 00:29:32.250 on the sympathetic nervous system. You get that 00:29:32.250 --> 00:29:34.569 loss of vascular tone, but it's compounded by 00:29:34.569 --> 00:29:37.150 the loss of cardiac accelerator function. And 00:29:37.150 --> 00:29:39.670 this gives us that classic triad of manifestations. 00:29:40.509 --> 00:29:43.750 Hypotension, a wide pulse pressure, and critically, 00:29:44.009 --> 00:29:46.930 bradycardia, a slow heart rate. This is a sharp 00:29:46.930 --> 00:29:49.509 contrast to the compensatory tachycardia you 00:29:49.509 --> 00:29:52.509 see in almost every other type of shock. So interventions 00:29:52.509 --> 00:29:55.430 focus on volume first and then replacing that 00:29:55.430 --> 00:29:58.250 lost tone. Right. We start with a trial of isotonic 00:29:58.250 --> 00:30:00.970 crystalloid fluids to make sure any hypovolemia 00:30:00.970 --> 00:30:03.490 is addressed. If it's fluid refractory, we need 00:30:03.490 --> 00:30:06.529 potent vasopressors, norepinephrine or epinephrine, 00:30:06.890 --> 00:30:09.309 to artificially restore that systemic vascular 00:30:09.309 --> 00:30:12.400 tone. And a vital nursing point for these patients 00:30:12.400 --> 00:30:15.099 is temperature regulation. They lose the ability 00:30:15.099 --> 00:30:17.640 to vasoconstrict or vasodilate to maintain core 00:30:17.640 --> 00:30:20.180 temp, so you often need aggressive supplementary 00:30:20.180 --> 00:30:22.839 warming or cooling. We shift now to cardiogenic 00:30:22.839 --> 00:30:25.500 and obstructive shock. Let's start with cardiogenic. 00:30:25.710 --> 00:30:27.990 This is a fundamental failure of the pump. It 00:30:27.990 --> 00:30:30.089 is. It's a failure of the myocardial pump to 00:30:30.089 --> 00:30:32.670 generate adequate cardiac output, usually from 00:30:32.670 --> 00:30:35.349 cardiomyopathy, severe congenital heart disease, 00:30:35.589 --> 00:30:37.609 arrhythmias. Something wrong with the heart muscle 00:30:37.609 --> 00:30:39.890 itself. And what's happening pathophysiologically? 00:30:40.269 --> 00:30:42.869 The output is low, so pressure builds up in the 00:30:42.869 --> 00:30:44.710 venous system because the pump can't push it 00:30:44.710 --> 00:30:47.410 forward. Clinically, you see signs of systemic 00:30:47.410 --> 00:30:50.339 venous congestion. rails and crackles from pulmonary 00:30:50.339 --> 00:30:54.039 edema, jugular venous distension or JDD, and 00:30:54.039 --> 00:30:56.859 hepatomegaly and enlarged liver from all that 00:30:56.859 --> 00:30:59.660 backup. Given that backup, our fluid strategy 00:30:59.660 --> 00:31:02.980 has to change completely. No more 20 -millikio 00:31:02.980 --> 00:31:06.240 G boluses. Absolutely not. Cautious fluid administration 00:31:06.240 --> 00:31:08.940 is mandatory. Bollaces are smaller and slower. 00:31:09.480 --> 00:31:12.359 5 to 10 millikyoji administered over 10 to 20 00:31:12.359 --> 00:31:15.019 minutes. And the nurse has to be listening for 00:31:15.019 --> 00:31:17.339 those signs of pulmonary edema continuously. 00:31:18.000 --> 00:31:20.200 If you hear crackles developing, you stop the 00:31:20.200 --> 00:31:22.579 fluid immediately. The risk of drowning the lungs 00:31:22.579 --> 00:31:24.759 is just too high. So if we can't use aggressive 00:31:24.759 --> 00:31:26.660 fluids, we have to rely on medications to fix 00:31:26.660 --> 00:31:29.140 the mechanics. We use medications to reduce the 00:31:29.140 --> 00:31:31.319 heart's workload and boost its contractility, 00:31:31.859 --> 00:31:35.039 diuretics to reduce preload and congestion, vasodilators 00:31:35.039 --> 00:31:37.160 to reduce afterload, the pressure the heart pumps 00:31:37.160 --> 00:31:40.019 against, and inotropes like dopamine, dobutamine, 00:31:40.200 --> 00:31:42.680 milrinone, or epinephrine are used to increase 00:31:42.680 --> 00:31:45.079 contractility. And milrinone seems to be a favorite 00:31:45.079 --> 00:31:47.640 here, too. It is because it helps the pump and 00:31:47.640 --> 00:31:50.160 eases the afterload at the same time. Interprofessional 00:31:50.160 --> 00:31:52.220 management here involves immediate consultation, 00:31:52.339 --> 00:31:55.329 I assume. Early consultation with pediatric critical 00:31:55.329 --> 00:31:58.750 care and cardiology is non -negotiable. If the 00:31:58.750 --> 00:32:01.549 patient is refractory to maximum drug therapy, 00:32:02.150 --> 00:32:04.730 mechanical support like ECMO, extracorporeal 00:32:04.730 --> 00:32:07.670 membrane oxygenation, becomes the definitive 00:32:07.670 --> 00:32:10.069 treatment. Okay, now, obstructive shock. Yeah. 00:32:10.190 --> 00:32:13.009 A physical blockage. Right. The pump works, the 00:32:13.009 --> 00:32:15.210 volume might be fine, but there is a physical 00:32:15.210 --> 00:32:18.089 impedance to flow, reducing venous return or 00:32:18.089 --> 00:32:21.390 cardiac outflow. Examples being tension pneumothorax, 00:32:21.849 --> 00:32:24.430 cardiac tamponade, a massive pulmonary embolism, 00:32:24.809 --> 00:32:27.029 and certain ductal -dependent congenital heart 00:32:27.029 --> 00:32:29.410 lesions. The management principle is simple. 00:32:30.130 --> 00:32:33.039 Identify and remove the obstruction fast. An 00:32:33.039 --> 00:32:35.440 initial fluid bolus might be attempted, but it's 00:32:35.440 --> 00:32:37.759 secondary to the definitive intervention. So 00:32:37.759 --> 00:32:39.759 delaying treatment to push fluids is a mistake. 00:32:39.839 --> 00:32:42.839 A huge mistake. Let's focus on those two immediate 00:32:42.839 --> 00:32:45.900 life -saving interventions. First, tension pneumothorax. 00:32:46.119 --> 00:32:48.779 Air accumulates, it compresses the lung, and 00:32:48.779 --> 00:32:51.900 it pushes the entire mediastinum, including the 00:32:51.900 --> 00:32:55.259 vena cava, over to the other side. Venous return 00:32:55.259 --> 00:32:58.400 just plummets, and shock ensues rapidly. And 00:32:58.400 --> 00:33:00.319 the intervention is immediate needle decompression. 00:33:00.599 --> 00:33:03.059 Where exactly is the nurse aiming? You use an 00:33:03.059 --> 00:33:05.839 18 to 20 gauge catheter and you insert it over 00:33:05.839 --> 00:33:08.160 the rib at the top of the child's third rib in 00:33:08.160 --> 00:33:11.140 the mid -clavicular line or the second intercostal 00:33:11.140 --> 00:33:14.380 space. This is an emergency procedure that releases 00:33:14.380 --> 00:33:16.900 that trapped air and immediately restores venous 00:33:16.900 --> 00:33:20.099 return. And the most critical point. This intervention 00:33:20.099 --> 00:33:22.500 should not wait for a chest x -ray confirmation. 00:33:23.079 --> 00:33:25.180 Clinical suspicion based on unilateral breath 00:33:25.180 --> 00:33:27.619 sounds and tracheal deviation is enough to act. 00:33:28.140 --> 00:33:30.319 This is followed by a formal chest tube, of course. 00:33:30.700 --> 00:33:33.160 Second, cardiac tamponade. Fluid around the heart 00:33:33.160 --> 00:33:35.039 squeezes the ventricles, preventing them from 00:33:35.039 --> 00:33:38.240 filling. The intervention is pericardiocentesis, 00:33:38.440 --> 00:33:40.220 draining the fluid from the pericardial sac. 00:33:40.339 --> 00:33:43.240 Okay, and lastly, the unique one, ductal -dependent 00:33:43.240 --> 00:33:46.119 lesions. This is a unique form of obstructive 00:33:46.119 --> 00:33:49.119 shock seen in newborns. Their circulation relies 00:33:49.119 --> 00:33:52.509 on the patent ductus arteriosus, the PDA. If 00:33:52.509 --> 00:33:55.089 it closes, either systemic or pulmonary blood 00:33:55.089 --> 00:33:57.490 flow is catastrophically blocked. And this requires 00:33:57.490 --> 00:34:00.609 a specific drug to keep that ductus open. An 00:34:00.609 --> 00:34:03.430 immediate continuous infusion of prostaglandin 00:34:03.430 --> 00:34:07.990 E or PGE. PGE is a potent vasodilator that maintains 00:34:07.990 --> 00:34:10.650 the patency of the ductus, and it can often reverse 00:34:10.650 --> 00:34:13.210 severe shock symptoms within minutes, buying 00:34:13.210 --> 00:34:16.090 time until surgery is possible. A nurse has to 00:34:16.090 --> 00:34:18.510 have this ready immediately if this diagnosis 00:34:18.510 --> 00:34:20.650 is even suspected. All right. We have covered 00:34:20.650 --> 00:34:23.389 a massive amount of material. This final summary 00:34:23.389 --> 00:34:26.059 is designed to be a rapid recall tool. We'll 00:34:26.059 --> 00:34:29.099 focus on the core defect, the fluid rule, the 00:34:29.099 --> 00:34:31.780 vasoactive priority, and the single most critical 00:34:31.780 --> 00:34:34.199 nursing action for each type. Let's synthesize 00:34:34.199 --> 00:34:35.940 these high -yield facts. Let's start with general 00:34:35.940 --> 00:34:39.000 shock. The core defect is inadequate tissue perfusion. 00:34:39.280 --> 00:34:42.300 Fluid management is a 20 mL -L -Q -G -N -G -N 00:34:42.300 --> 00:34:45.079 -S -L -R bolus. Repeat as needed. Vasoactive 00:34:45.079 --> 00:34:47.300 agents are used when it's fluid refractory. And 00:34:47.300 --> 00:34:49.440 the nursing priority cue is frequent reassessment 00:34:49.440 --> 00:34:52.539 after every bolus. Remember, hypotension is a 00:34:52.539 --> 00:34:55.440 late sign. Hypovolemic shock. The defect is volume 00:34:55.440 --> 00:34:58.699 loss. Fluid management is a rapid 20 mL -L -Q 00:34:58.699 --> 00:35:01.059 -G -G bolus using that 3 to 1 crystalloid to 00:35:01.059 --> 00:35:03.829 blood loss rule. Vasopressors are generally not 00:35:03.829 --> 00:35:06.949 indicated. And the nursing priority is IO access 00:35:06.949 --> 00:35:09.849 if peripheral is delayed and transfuse PRBCs 00:35:09.849 --> 00:35:13.179 early if it's hemorrhagic. Septic shock. Distributive. 00:35:13.360 --> 00:35:16.480 The defect is massive vasodilation and maldistribution. 00:35:16.800 --> 00:35:19.159 Fluid management is aggressive boluses, often 00:35:19.159 --> 00:35:22.480 40 -60 millilkeragy, plus antibiotics. Vasoactive 00:35:22.480 --> 00:35:25.400 priority is epinephrine for cold shock, norepinephrine 00:35:25.400 --> 00:35:28.360 for warm shock. And the nursing priority is antibiotics 00:35:28.360 --> 00:35:30.500 within one hour, and consider hydrocortisone. 00:35:30.599 --> 00:35:33.320 Cardiogenic shock. Defect is pump failure, myocardial 00:35:33.320 --> 00:35:36.260 dysfunction. Fluid management is cautious, slow, 00:35:36.420 --> 00:35:39.539 small boluses. 5 -10 millikiruging over 10 -20 00:35:39.539 --> 00:35:41.940 minutes. Vasoactive priority is inotropes like 00:35:41.940 --> 00:35:44.320 milrinone or dobutamine. And the nursing priority 00:35:44.320 --> 00:35:46.739 is to monitor for pulmonary edema, those crackles, 00:35:46.860 --> 00:35:48.659 and stop fluids immediately if you hear them. 00:35:48.920 --> 00:35:51.559 And finally, obstructive shock. The defect is 00:35:51.559 --> 00:35:54.760 a physical blockage. Fluid management is an optional 00:35:54.760 --> 00:35:57.039 initial bolus followed by definitive treatment. 00:35:57.820 --> 00:36:00.500 Vasoactives are not applicable. And the nursing 00:36:00.500 --> 00:36:02.900 priority is immediate needle decompression for 00:36:02.900 --> 00:36:06.699 attention pneumothorax, or PGE, for ductal -dependent 00:36:06.699 --> 00:36:09.820 lesions. That table is the ultimate clinical 00:36:09.820 --> 00:36:12.860 roadmap. It really separates the push fluid hard 00:36:12.860 --> 00:36:15.239 scenarios from the hold the fluid scenarios. 00:36:15.780 --> 00:36:18.360 Knowing that 5 to 10 milnealkio... exception 00:36:18.360 --> 00:36:20.500 for cardiogenic shock is just essential to pass 00:36:20.500 --> 00:36:23.900 those scenario -based exam questions. We've navigated 00:36:23.900 --> 00:36:26.500 the complexities of shock management, prioritizing 00:36:26.500 --> 00:36:28.960 the nursing implications and the precise knowledge 00:36:28.960 --> 00:36:31.900 you need to intervene effectively and pass your 00:36:31.900 --> 00:36:34.300 critical care exams. Remember the urgency of 00:36:34.300 --> 00:36:36.800 early intervention, the power of IO access, and 00:36:36.800 --> 00:36:39.239 the absolute necessity of reevaluating that fluid 00:36:39.239 --> 00:36:41.619 strategy after every single bolus. You know, 00:36:41.619 --> 00:36:43.840 if we connect this to the bigger picture... The 00:36:43.840 --> 00:36:46.340 rapid shift from compensated to hypotensive shock 00:36:46.340 --> 00:36:48.440 is the single most crucial trend the nurse must 00:36:48.440 --> 00:36:50.420 anticipate and intervene on. It means you have 00:36:50.420 --> 00:36:52.179 to be ahead of the curve, constantly checking 00:36:52.179 --> 00:36:54.820 those perfusion parameters, cap refill, pulses, 00:36:55.159 --> 00:36:57.219 mental status, not just the BP. And to wrap up 00:36:57.219 --> 00:37:00.280 with that final advanced detail that often separates 00:37:00.280 --> 00:37:03.480 the expert from the novice, the hydrocortisone 00:37:03.480 --> 00:37:06.780 question in sepsis. That's the key clinical pearl 00:37:06.780 --> 00:37:09.320 that often determines the outcome in a fluid 00:37:09.320 --> 00:37:12.480 refractory septic patient. If a patient is severely 00:37:12.480 --> 00:37:14.940 septic and their blood pressure is failing despite 00:37:14.940 --> 00:37:17.460 aggressive fluid resuscitation and they're already 00:37:17.460 --> 00:37:20.420 on a vasopressor, you have to consider adrenal 00:37:20.420 --> 00:37:22.340 insufficiency. Especially with that history of 00:37:22.340 --> 00:37:25.260 steroid use. Exactly. If they have a history 00:37:25.260 --> 00:37:28.039 of chronic steroid use or features of an adrenal 00:37:28.039 --> 00:37:30.400 crisis, giving them stress dose hydrocortisone 00:37:30.400 --> 00:37:33.320 is required. If you fail to address this relative 00:37:33.320 --> 00:37:36.559 lack of their own endogenous steroids, the vasopressors 00:37:36.559 --> 00:37:38.699 we're relying on will be ineffective and the 00:37:38.699 --> 00:37:42.000 patient will continue to decline. So keep hydrocortisone 00:37:42.000 --> 00:37:44.400 in your mental checklist for refractory septic 00:37:44.400 --> 00:37:47.219 shock. A perfect high stakes final thought. Thank 00:37:47.219 --> 00:37:49.179 you for joining us on this deep dive into shock 00:37:49.179 --> 00:37:51.219 management. You are now armed with the knowledge 00:37:51.219 --> 00:37:53.559 to make those life -saving priority decisions. 00:37:54.000 --> 00:37:54.860 Go ace that exam.