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 --> 00:02:27.849 emergency room. Welcome to the deep dive. If 00:02:27.849 --> 00:02:31.909 you're joining us, you are probably bracing for 00:02:31.909 --> 00:02:34.610 the PLS certification exam. or maybe walking 00:02:34.610 --> 00:02:37.090 into a trauma bay right now. Exactly. And you 00:02:37.090 --> 00:02:40.370 need that lightning fast, high stakes clinical 00:02:40.370 --> 00:02:43.229 decision tree for pediatric arrhythmias. This 00:02:43.229 --> 00:02:45.729 isn't just about theory. No, not at all. This 00:02:45.729 --> 00:02:48.969 is about saving myocardium. And I mean, at the 00:02:48.969 --> 00:02:51.210 end of the day, saving a child's life. So this 00:02:51.210 --> 00:02:53.650 deep dive is really for that seasoned critical 00:02:53.650 --> 00:02:57.080 care or ER nurse. Right. We're not here to just, 00:02:57.080 --> 00:02:59.500 you know, recite algorithms from a card. We are 00:02:59.500 --> 00:03:02.000 here to unlock the clinical reasoning, the why 00:03:02.000 --> 00:03:04.560 behind every single critical step. Especially 00:03:04.560 --> 00:03:06.900 when that heart rate is threatening their stability. 00:03:07.159 --> 00:03:10.340 Yes. Our mission is singular, mastering the management 00:03:10.340 --> 00:03:12.500 of pediatric arrhythmias. We need to know how 00:03:12.500 --> 00:03:15.080 to quickly, and I mean quickly, determine instability 00:03:15.080 --> 00:03:17.699 and treat symptomatic bradycardia and tachycardia 00:03:17.699 --> 00:03:20.319 before they spiral. Before they go into irreversible 00:03:20.319 --> 00:03:22.939 shock or cardiac arrest. Presesimente. And we 00:03:22.939 --> 00:03:25.180 have to begin with the non -negotiable foundation 00:03:25.180 --> 00:03:28.159 of all pediatric critical care. Before we even 00:03:28.159 --> 00:03:29.879 glance at the monitor, before we think about 00:03:29.879 --> 00:03:32.379 a drug or a shock, what is the absolute priority? 00:03:32.580 --> 00:03:35.439 It's always the ABCs. Airway, breathing, and 00:03:35.439 --> 00:03:39.960 circulation. And at the same time, seeking and 00:03:39.960 --> 00:03:42.020 treating that underlying cause. That's the step 00:03:42.020 --> 00:03:44.080 that really separates the pros, isn't it? It 00:03:44.080 --> 00:03:46.080 is. It separates a true critical care provider 00:03:46.080 --> 00:03:48.919 from someone who just reads the card. You support 00:03:48.919 --> 00:03:51.659 oxygenation. You support ventilation. And then 00:03:51.659 --> 00:03:53.740 and only then do you look at the rhythm and decide 00:03:53.740 --> 00:03:56.340 if it's the main problem or just a symptom. OK, 00:03:56.340 --> 00:03:58.099 so let's really impact this. We're talking about 00:03:58.099 --> 00:04:01.879 an abnormal heart rate or rhythm. And pediatric 00:04:01.879 --> 00:04:04.319 hearts run faster than adult hearts to begin 00:04:04.319 --> 00:04:06.939 with. So what's the critical threshold? What's 00:04:06.939 --> 00:04:09.280 that specific line we cross where we go from, 00:04:09.280 --> 00:04:12.439 say, monitoring and diagnosing to emergency life 00:04:12.439 --> 00:04:15.840 -saving intervention? That line is hemodynamic 00:04:15.840 --> 00:04:19.199 instability, an abnormal rate or rhythm because 00:04:19.199 --> 00:04:22.040 a true emergency when it's causing significant 00:04:22.040 --> 00:04:24.220 cardiopulmonary compromise. And you have to figure 00:04:24.220 --> 00:04:26.300 that out in seconds. In seconds. You have to 00:04:26.300 --> 00:04:28.839 determine if the arrhythmia is the cause of the 00:04:28.839 --> 00:04:32.060 problem or just the result of it. The PLNS guidelines 00:04:32.060 --> 00:04:34.360 give us five, you know, need -to -know indicators 00:04:34.360 --> 00:04:37.769 that define instability. And these require immediate 00:04:37.769 --> 00:04:40.269 treatment. No waiting for labs, no... No waiting 00:04:40.269 --> 00:04:42.709 for an expert consult to call you back. You act. 00:04:43.089 --> 00:04:45.850 Okay, so let's detail those five signs, but with 00:04:45.850 --> 00:04:48.529 a focus on clinical insight. What do they actually 00:04:48.529 --> 00:04:50.329 look like at the bedside? Because sometimes these 00:04:50.329 --> 00:04:53.170 signs can be pretty subtle, especially in early 00:04:53.170 --> 00:04:57.050 shock. Absolutely. So number one is respiratory 00:04:57.050 --> 00:05:00.189 distress or failure. If that rapid heart rate 00:05:00.189 --> 00:05:02.750 is taxing the body so much that the child just 00:05:02.750 --> 00:05:05.230 can't keep up with their own oxygenation or ventilation, 00:05:05.790 --> 00:05:07.850 that's an emergency. Makes sense. The second 00:05:07.850 --> 00:05:11.790 is shock with poor end -organ perfusion. Now, 00:05:11.850 --> 00:05:14.189 this is often associated with hypotension, but 00:05:14.189 --> 00:05:16.230 here is the critical clinical parole for you. 00:05:16.910 --> 00:05:20.040 Okay. Shock can happen without hypotension. especially 00:05:20.040 --> 00:05:22.759 in kids. They compensate like crazy. They clamp 00:05:22.759 --> 00:05:24.740 down those vessels to maintain blood pressure 00:05:24.740 --> 00:05:27.000 right until the very end. So you can't wait for 00:05:27.000 --> 00:05:29.139 the cuff reading? You cannot wait for the cuff. 00:05:29.519 --> 00:05:31.579 You look for delayed capillary refill. You look 00:05:31.579 --> 00:05:34.199 for cool extremities, thready pulses. You look 00:05:34.199 --> 00:05:35.980 for those things before the blood pressure finally 00:05:35.980 --> 00:05:38.389 drops. That distinction is huge. I feel like 00:05:38.389 --> 00:05:40.189 there's always a tendency to wait for that number 00:05:40.189 --> 00:05:42.889 on the monitor, but the kid is often circling 00:05:42.889 --> 00:05:46.230 the drain long before that cuff reads low. They 00:05:46.230 --> 00:05:48.250 are. So what about the neurological indicators? 00:05:48.610 --> 00:05:51.550 The third is irritability, or decreased level 00:05:51.550 --> 00:05:54.430 of consciousness, you know, altered mental status. 00:05:54.589 --> 00:05:57.910 This is arguably the most powerful early indicator 00:05:57.910 --> 00:06:02.310 of poor cerebral perfusion. So a kid who's normally 00:06:02.310 --> 00:06:06.209 alert, but is now, what, lethargic? Agitated? 00:06:06.439 --> 00:06:09.500 Exactly. A child who suddenly becomes lethargic 00:06:09.500 --> 00:06:11.519 or agitated is basically screaming that their 00:06:11.519 --> 00:06:13.720 brain is not getting enough oxygenated blood. 00:06:14.180 --> 00:06:16.740 Fourth, we look for chest pain or a vague feeling 00:06:16.740 --> 00:06:19.040 of discomfort. More common in older kids, I imagine. 00:06:19.160 --> 00:06:21.160 Much more common in older kids who can actually 00:06:21.160 --> 00:06:24.060 tell you. It signifies myocardial ischemia because 00:06:24.060 --> 00:06:26.040 the heart is beating so fast it can't perfuse 00:06:26.040 --> 00:06:28.620 itself. And then finally, number five is sudden 00:06:28.620 --> 00:06:30.939 collapse. OK. If any of those five are present, 00:06:31.060 --> 00:06:32.779 the clock is running and you move straight to 00:06:32.779 --> 00:06:35.240 intervention. That makes the nursing priority. 00:06:35.830 --> 00:06:39.769 Crystal clear then. If we see symptomatic bradycardia 00:06:39.769 --> 00:06:43.009 or tachycardia, box one in the algorithm kicks 00:06:43.009 --> 00:06:45.850 in. Walk us through those mandatory initial steps 00:06:45.850 --> 00:06:48.170 at the bedside. So these steps have to happen 00:06:48.170 --> 00:06:50.449 simultaneously, right, as you're doing your assessment. 00:06:50.589 --> 00:06:53.310 First, maintain a patent airway and assist breathing. 00:06:53.870 --> 00:06:55.310 That might just be a manual airway maneuver. 00:06:55.430 --> 00:06:57.949 A jaw thrust? Simple jaw thrust. Then immediately 00:06:57.949 --> 00:07:00.740 provide high concentration oxygen. usually a 00:07:00.740 --> 00:07:03.740 non -rebreather, critically establish vascular 00:07:03.740 --> 00:07:06.920 access IV or IO immediately. You can't give life 00:07:06.920 --> 00:07:09.279 -saving drugs without it. You can't. And if you 00:07:09.279 --> 00:07:11.699 even suspect instability, you call for the IO 00:07:11.699 --> 00:07:14.160 supplies right away. Don't wait for three failed 00:07:14.160 --> 00:07:16.459 peripheral IV attempts. Right. And while the 00:07:16.459 --> 00:07:18.759 team is working on ABCs and getting access, we're 00:07:18.759 --> 00:07:20.620 getting the monitors ready? Precisely. Attach 00:07:20.620 --> 00:07:22.720 the cardiac monitor, the defibrillator, the pulse 00:07:22.720 --> 00:07:25.100 oximeter, get them on right away. And here's 00:07:25.100 --> 00:07:27.879 where we hit that diagnostic caveat. The 12 lead 00:07:27.879 --> 00:07:30.980 ECG. Right. Obtain a 12 lead ECG if available. 00:07:31.439 --> 00:07:33.519 But the pay the last guideline is rigid on this. 00:07:34.019 --> 00:07:36.839 Do not delay therapy waiting for it. If the patient 00:07:36.839 --> 00:07:39.639 is unstable, treatment comes first. Treatment 00:07:39.639 --> 00:07:42.560 always supersedes a precise diagnosis in that 00:07:42.560 --> 00:07:44.800 moment. You can get your blood pressure, your 00:07:44.800 --> 00:07:48.639 blood gas, glucose, tox screens, but urgent intervention 00:07:48.639 --> 00:07:51.680 is the priority. The information you get from 00:07:51.680 --> 00:07:54.439 a 12 lead does not outweigh the risk of delaying 00:07:54.439 --> 00:07:57.120 cardioversion in an unstable kid. That's such 00:07:57.120 --> 00:07:59.600 a critical point for the ER nurse. You might 00:07:59.600 --> 00:08:01.740 feel this pressure to get the perfect strip for 00:08:01.740 --> 00:08:04.459 the cardiologist, but if the patient is seizing 00:08:04.459 --> 00:08:07.000 from poor perfusion, the strip is irrelevant 00:08:07.000 --> 00:08:09.500 until you fix the rhythm. Exactly. Stabilize 00:08:09.500 --> 00:08:11.399 the patient first. Don't worry about perfecting 00:08:11.399 --> 00:08:13.620 the paperwork. OK, let's move on. Here's where 00:08:13.620 --> 00:08:16.459 we make a really fundamental physiological distinction. 00:08:17.279 --> 00:08:20.040 Radycardia in an adult, that's often a primary 00:08:20.040 --> 00:08:22.139 electrical failure, right? Like sick sinus syndrome 00:08:22.139 --> 00:08:24.480 or a block. Right. But in kids, it's a totally 00:08:24.480 --> 00:08:26.680 different ballgame. It is fundamentally different. 00:08:27.000 --> 00:08:29.779 Pediatric bradycardia is usually secondary to 00:08:29.779 --> 00:08:32.600 a respiratory or metabolic issue. It's that late 00:08:32.600 --> 00:08:35.460 bad sign that profound hypoxia has set in. That 00:08:35.460 --> 00:08:37.980 is the core clinical truth, isn't it? It is. 00:08:38.200 --> 00:08:39.679 You have to remember, pediatric cardiac output 00:08:39.679 --> 00:08:42.120 is highly rate dependent. They rely on a high 00:08:42.120 --> 00:08:44.649 heart rate to move volume around. They can't 00:08:44.649 --> 00:08:46.769 increase their stroke volume like adults can. 00:08:46.870 --> 00:08:49.690 Exactly. So when that rate slows down, it means 00:08:49.690 --> 00:08:52.169 the heart muscle is exhausted or it's ischemic 00:08:52.169 --> 00:08:55.309 or it's been poisoned. The pediatric bradycardia 00:08:55.309 --> 00:08:58.029 algorithm is specifically structured to treat 00:08:58.029 --> 00:09:00.710 that secondary cause first. So when you hit the 00:09:00.710 --> 00:09:03.529 algorithm, you immediately reassess for compromised 00:09:03.529 --> 00:09:06.190 hypertension, altered mental status, signs of 00:09:06.190 --> 00:09:08.730 shock. And if it's there, you move fast. You 00:09:08.730 --> 00:09:11.210 go very fast. Let's talk about the ultimate red 00:09:11.210 --> 00:09:14.039 flag in this algorithm, the CPR trick. That's 00:09:14.039 --> 00:09:16.559 box three. If everything we've done to improve 00:09:16.559 --> 00:09:19.600 oxygenation and ventilation has failed, when 00:09:19.600 --> 00:09:21.700 do we actually start chest compressions on a 00:09:21.700 --> 00:09:24.039 child who still technically has a pulse? This 00:09:24.039 --> 00:09:26.639 is a decision point that gives a lot of providers 00:09:26.639 --> 00:09:30.059 pause, but Paul is very clear on it. If bradycardia 00:09:30.059 --> 00:09:32.559 persists, and we define that as a heart rate 00:09:32.559 --> 00:09:34.899 less than 60 beats per minute. A hard line at 00:09:34.899 --> 00:09:37.720 60. A hard line at 60. If it's under 60 despite 00:09:37.720 --> 00:09:40.179 adequate oxygenation and ventilation, You start 00:09:40.179 --> 00:09:44.820 high quality CPR immediately. Because a persistent 00:09:44.820 --> 00:09:48.620 rate below 60 in a symptomatic child means the 00:09:48.620 --> 00:09:51.360 heart is failing to generate enough cardiac output 00:09:51.360 --> 00:09:54.460 to sustain life. External circulation is now 00:09:54.460 --> 00:09:57.159 required. The lack of oxygen has depressed the 00:09:57.159 --> 00:10:00.100 myocardium so severely that the body just can't 00:10:00.100 --> 00:10:08.529 compensate anymore. two minutes and we're sure 00:10:08.529 --> 00:10:11.169 their respiratory effort is supported, we compress. 00:10:11.289 --> 00:10:13.370 You compress. Let's quickly review the metrics 00:10:13.370 --> 00:10:16.190 for high quality CPR because execution here matters 00:10:16.190 --> 00:10:18.809 so much more than intention. These are foundational 00:10:18.809 --> 00:10:22.110 facts you have to know cold. Push fast. 100 to 00:10:22.110 --> 00:10:25.009 120 compressions per minute. Push hard. Yeah. 00:10:25.149 --> 00:10:27.350 At least one third the depth of the chest. Which 00:10:27.350 --> 00:10:29.850 is about 1 .5 inches in an infant or two inches 00:10:29.850 --> 00:10:32.309 in a child. Right. And you have to ensure complete 00:10:32.309 --> 00:10:34.960 chest recoil. Minimizing interruptions is vital. 00:10:35.259 --> 00:10:37.700 Aim for a compression fraction of at least 60%. 00:10:37.700 --> 00:10:39.759 And the ventilation ratio. If you're manually 00:10:39.759 --> 00:10:42.659 ventilating, it's 15 .2 for two providers, or 00:10:42.659 --> 00:10:45.220 30 .2 if you're a lone rescuer, that is, until 00:10:45.220 --> 00:10:47.679 they're intubated. After that, compressions are 00:10:47.679 --> 00:10:49.700 continuous and you give breath every two to three 00:10:49.700 --> 00:10:52.360 seconds. Okay, so once we're doing high quality 00:10:52.360 --> 00:10:55.200 CPR because of persistent bradycardia, we move 00:10:55.200 --> 00:10:57.740 immediately to the drugs. And the primary drug, 00:10:57.919 --> 00:11:00.460 the heavy hitter, is epinephrine. Epinephrine 00:11:00.460 --> 00:11:02.879 is the central nervous system drug in cardiac 00:11:02.879 --> 00:11:06.100 arrest and severe bradycardia. Its mechanism 00:11:06.100 --> 00:11:08.279 is beautifully dual. And if you understand this, 00:11:08.399 --> 00:11:10.440 you understand why it's the first choice. OK. 00:11:10.840 --> 00:11:13.080 Think of the alpha effect as tightening the pipes. 00:11:13.559 --> 00:11:15.779 Vasoconstriction. Exactly. Vasoconstriction. 00:11:15.960 --> 00:11:18.200 This increases systemic vascular resistance, 00:11:18.600 --> 00:11:21.460 which raises aortic diastolic pressure. That 00:11:21.460 --> 00:11:24.820 is crucial for perfusing the coronary arteries 00:11:24.820 --> 00:11:27.379 in the brain. Then you have the beta effect. 00:11:27.600 --> 00:11:30.419 The beta effect is speeding up the pump. Speeding 00:11:30.419 --> 00:11:32.860 up the pump. It increases heart rate and cardiac 00:11:32.860 --> 00:11:35.840 contractility. So this simultaneous action supports 00:11:35.840 --> 00:11:39.159 both oxygenation and perfusion when that myocardium 00:11:39.159 --> 00:11:41.419 is just completely compromised. So we're not 00:11:41.419 --> 00:11:42.960 just trying to make the heart beat faster. We're 00:11:42.960 --> 00:11:45.600 trying to literally squeeze the arteries to drive 00:11:45.600 --> 00:11:48.100 blood back into the heart muscle itself. You 00:11:48.100 --> 00:11:49.799 have to get that coronary perfusion pressure 00:11:49.799 --> 00:11:53.350 up. The indication is clear. Symptomatic bradycardia 00:11:53.350 --> 00:11:55.350 that persists despite effective oxygenation, 00:11:55.470 --> 00:11:58.070 ventilation, and CPR. And the dose. The standard 00:11:58.070 --> 00:12:02.830 IV or IO dose is 0 .01 millochi kilogram. That's 00:12:02.830 --> 00:12:07.250 0 .1 millochi IG of the standard 1 .00 concentration. 00:12:07.870 --> 00:12:10.009 And you repeat that dose every three to five 00:12:10.009 --> 00:12:11.629 minutes. And you have to be strict with that 00:12:11.629 --> 00:12:13.350 timing. You have to be. Stick to that three to 00:12:13.350 --> 00:12:16.429 five minute interval. What about the less reliable 00:12:16.429 --> 00:12:19.590 route, endotracheal? The ET route. Absorption 00:12:19.590 --> 00:12:22.059 is unreliable. It's inconsistent. and it needs 00:12:22.059 --> 00:12:24.600 a much higher dose. If you have absolutely no 00:12:24.600 --> 00:12:27.620 IV or IO access, the ET dose is 10 times higher, 00:12:27.960 --> 00:12:30.200 0 .1 milliliter kilogram. But that's a last resort. 00:12:30.320 --> 00:12:32.720 It has to be a rescue ride only. Your priority 00:12:32.720 --> 00:12:35.269 is to get IO access immediately. Okay, next up 00:12:35.269 --> 00:12:38.409 is atropine, the parasympathetic. Its role is 00:12:38.409 --> 00:12:41.490 very specific in PAELs. Very specific. Atropine 00:12:41.490 --> 00:12:44.470 sulfate is an anti -colonergic drug. Its mechanism 00:12:44.470 --> 00:12:46.809 is to accelerate the sinus or atrial pacemakers 00:12:46.809 --> 00:12:49.649 and enhance AV conduction by blocking vagal tone. 00:12:49.850 --> 00:12:52.049 So it's the drug of choice for bradycardia that's 00:12:52.049 --> 00:12:54.090 specifically caused by increased vagal tone. 00:12:54.330 --> 00:12:57.269 Right, like from intubation attempts or surgical 00:12:57.269 --> 00:13:00.710 stimulus or poisoning by colonergic agents or 00:13:00.710 --> 00:13:03.389 for a primary AV block. You mentioned before 00:13:03.389 --> 00:13:06.190 why epinephrine is generally preferred over atropine 00:13:06.190 --> 00:13:09.549 in the sort of general symptomatic bradycardia 00:13:09.549 --> 00:13:11.809 algorithm. Can you just reiterate that for us? 00:13:11.830 --> 00:13:15.009 Yeah. I mean, if the child is profoundly hypoxic 00:13:15.009 --> 00:13:17.990 or ischemic, atropine won't fix the underlying 00:13:17.990 --> 00:13:21.090 problem. The muscle is just too sick. Epinephrine's 00:13:21.090 --> 00:13:23.509 broader ALSA and beta effects are just superior 00:13:23.509 --> 00:13:26.389 for that generally compromised myocardium. So 00:13:26.389 --> 00:13:28.370 if the child doesn't respond to atropine? You 00:13:28.370 --> 00:13:30.639 pivot. You pivot immediately to epinephrine and 00:13:30.639 --> 00:13:32.539 compression. Atropine is a targeted drug for 00:13:32.539 --> 00:13:34.879 a very targeted cause. What's the dose for atropine? 00:13:34.940 --> 00:13:40.100 It's 0 .02mg in kilogram IV or IO. You must respect 00:13:40.100 --> 00:13:43.120 the minimum dose of 0 .1mg. If you give less, 00:13:43.139 --> 00:13:45.120 you can get a paradoxical slowing of the heart 00:13:45.120 --> 00:13:48.299 rate. Oh, wow. Yeah. And the maximum single dose 00:13:48.299 --> 00:13:51.120 is 0 .5mg. You can repeat it once. And the clinical 00:13:51.120 --> 00:13:53.480 pearl about its use in heart blocks? Atropine 00:13:53.480 --> 00:13:56.039 may be useful for a symptomatic second degree 00:13:56.039 --> 00:13:59.500 AV block. Either Mobitz is the first, and third 00:13:59.500 --> 00:14:02.539 degree AV block. But, and this is a big but, 00:14:02.940 --> 00:14:05.860 if the block is low down in the bundle of his 00:14:05.860 --> 00:14:08.779 or the Purkinje Fibers Atropine is unlikely to 00:14:08.779 --> 00:14:11.220 work. And then you're looking at pacing. Then 00:14:11.220 --> 00:14:13.700 you need to prepare for transcutaneous pacing, 00:14:13.960 --> 00:14:16.980 which is... Honestly, very challenging in pediatric 00:14:16.980 --> 00:14:19.820 patients and usually a bridge to getting transvenous 00:14:19.820 --> 00:14:22.419 pacing after they're stabilized. Okay, now we 00:14:22.419 --> 00:14:24.919 get to what I think is the core of critical nursing 00:14:24.919 --> 00:14:27.919 in PALS. If we give epinephrine without fixing 00:14:27.919 --> 00:14:29.799 the root problem, the code is going to fail. 00:14:30.159 --> 00:14:32.840 We have to master the H's and T's. This is everything. 00:14:33.200 --> 00:14:35.500 What are the two most common potentially reversible 00:14:35.500 --> 00:14:37.779 causes of pediatric bradycardia that we see in 00:14:37.779 --> 00:14:40.440 the trauma bay? Hypoxia and hydrogen ion, which 00:14:40.440 --> 00:14:43.379 is acidosis. If a child's rate drops below 80 00:14:43.379 --> 00:14:45.879 or certainly below 60, your first thought has 00:14:45.879 --> 00:14:47.759 to be their airway and their breathing. Those 00:14:47.759 --> 00:14:49.919 two have to be addressed aggressively. Immediately 00:14:49.919 --> 00:14:51.840 and aggressively. So let's run through the full 00:14:51.840 --> 00:14:54.539 table of reversible causes. Give us the why and 00:14:54.539 --> 00:14:56.600 the specific treatment for the ER nurse on the 00:14:56.600 --> 00:14:59.259 front line. Okay, for hypoxia, the treatment 00:14:59.259 --> 00:15:02.879 is foundational. Give high concentration supplementary 00:15:02.879 --> 00:15:05.360 oxygen with assisted ventilation. You must ensure 00:15:05.360 --> 00:15:07.740 the chest rises symmetrically and that the pulse 00:15:07.740 --> 00:15:10.139 ox improves. And if it doesn't? If it doesn't, 00:15:10.200 --> 00:15:12.480 you check for a misplaced tube or a foreign body 00:15:12.480 --> 00:15:14.779 obstruction. You troubleshoot that airway. Okay, 00:15:15.299 --> 00:15:18.559 next. Hydrogen ion. Acidosis. Right. Remember, 00:15:18.879 --> 00:15:20.980 acidosis depresses myocardial function. It makes 00:15:20.980 --> 00:15:23.600 the heart muscle weak. So you treat the respiratory 00:15:23.600 --> 00:15:26.080 component first. You provide ventilation to blow 00:15:26.080 --> 00:15:28.820 off CO2 and correct that respiratory acidosis. 00:15:28.899 --> 00:15:31.470 What about sodium bicarbonate? Sodium bicarb 00:15:31.470 --> 00:15:34.610 may be considered in a severe documented metabolic 00:15:34.610 --> 00:15:37.629 acidosis or for hyperkalemia, but you always 00:15:37.629 --> 00:15:40.830 ensure ventilation is maximized first. Bicarb 00:15:40.830 --> 00:15:43.009 generates CO2, and if you can't ventilate that 00:15:43.009 --> 00:15:45.490 out, you paradoxically make the intracellular 00:15:45.490 --> 00:15:49.210 acidosis worse. Good point. Okay, moving to electrolytes 00:15:49.210 --> 00:15:51.929 hyperkalemia. We see this in renal failure or 00:15:51.929 --> 00:15:54.649 severe crush injuries. Why does it cause such 00:15:54.649 --> 00:15:57.740 profound bradycardia? I potassium hyperkalemia. 00:15:57.740 --> 00:16:00.960 It destabilizes the cardiac cell membrane. On 00:16:00.960 --> 00:16:03.879 the ECG, you'll see those classic tall peak T 00:16:03.879 --> 00:16:06.759 waves followed by a widening of the QRS and then 00:16:06.759 --> 00:16:09.299 ultimately a sine wave arrest. And the treatment 00:16:09.299 --> 00:16:12.159 is multifaceted. Very. You have to stabilize 00:16:12.159 --> 00:16:14.379 the myocardium first with calcium chloride or 00:16:14.379 --> 00:16:16.840 calcium gluconate that protects the heart from 00:16:16.840 --> 00:16:19.220 the potassium. Then you shift the potassium back 00:16:19.220 --> 00:16:21.899 into the cells using insulin and dexrose and 00:16:21.899 --> 00:16:25.289 potentially sodium bicarb or albuterol. But calcium 00:16:25.289 --> 00:16:27.850 is the immediate lifesaver. Calcium is the first 00:16:27.850 --> 00:16:30.029 thing you give. It's the immediate lifesaver. 00:16:30.350 --> 00:16:33.590 Next, temperature. Hypothermia. I feel like this 00:16:33.590 --> 00:16:36.149 is an often ignored cause, especially if the 00:16:36.149 --> 00:16:38.250 patient was found down. It is. If the child is 00:16:38.250 --> 00:16:40.549 hypothermic, you have to warm them gently but 00:16:40.549 --> 00:16:43.309 effectively. Core temperatures below 30 degrees 00:16:43.309 --> 00:16:45.590 Celsius make the myocardium highly irritable 00:16:45.590 --> 00:16:47.950 and refractory to standard resuscitation drugs. 00:16:48.049 --> 00:16:51.029 So you defer shocking and drugs. You defer shocking 00:16:51.029 --> 00:16:53.809 and drugs until the core temp is above 30 degrees 00:16:53.809 --> 00:16:56.370 Celsius, if possible. And you have to be careful 00:16:56.370 --> 00:16:58.990 not to trigger dysrhythmia by moving the patient 00:16:58.990 --> 00:17:01.850 roughly during warming. That cold myocardium 00:17:01.850 --> 00:17:04.890 can flip into VFib very easily. OK. Then we have 00:17:04.890 --> 00:17:07.750 the massive category of toxins, poisons, and 00:17:07.750 --> 00:17:10.269 drugs. How do we even begin to narrow the treatment 00:17:10.269 --> 00:17:13.450 here? This requires a highly specific antidote 00:17:13.450 --> 00:17:16.750 or very targeted supportive care. If it's a calcium 00:17:16.750 --> 00:17:19.950 channel blocker or beta blocker overdose, your 00:17:19.950 --> 00:17:22.369 first line therapy is often high -dose glucagon, 00:17:22.430 --> 00:17:25.309 calcium, or high -dose insulin euglycemic therapy, 00:17:25.710 --> 00:17:28.140 not just epi. And opioids. If it's an opioid 00:17:28.140 --> 00:17:30.779 overdose, you give Narcan. You have to ask about 00:17:30.779 --> 00:17:33.799 recent medications, access to drugs, or suicidal 00:17:33.799 --> 00:17:36.119 ideation immediately. Finally, the warning sign 00:17:36.119 --> 00:17:39.180 in the neuro or trauma patient, bradycardia associated 00:17:39.180 --> 00:17:41.480 with the head injury. This is the classic Cushing's 00:17:41.480 --> 00:17:44.099 Reflex Hypertension, bradycardia, and irregular 00:17:44.099 --> 00:17:47.859 respirations. It signifies severe increased intracranial 00:17:47.859 --> 00:17:50.359 pressure or ICP. So the body is clamping down 00:17:50.359 --> 00:17:52.500 the arteries to try and force blood into the 00:17:52.500 --> 00:17:54.880 skull. causing the hypertension, and that high 00:17:54.880 --> 00:17:57.420 blood pressure triggers a reflex slowing of the 00:17:57.420 --> 00:17:59.579 heart rate. So the bradycardia is actually a 00:17:59.579 --> 00:18:01.319 protective mechanism, even though it's failing. 00:18:01.599 --> 00:18:03.940 What's the nursing intervention? Your first steps 00:18:03.940 --> 00:18:07.180 are oxygenation and ventilation. If there are 00:18:07.180 --> 00:18:09.539 signs of impending herniation, like pupillary 00:18:09.539 --> 00:18:12.799 changes or posturing, a brief period of mild 00:18:12.799 --> 00:18:15.200 hyperventilation can be used as a temporary rescue 00:18:15.200 --> 00:18:19.119 therapy to acutely decrease that ICP. But ultimately, 00:18:19.339 --> 00:18:22.430 this child needs a surgeon. The bradycardia isn't 00:18:22.430 --> 00:18:24.349 a heart problem. It's a brain problem. You have 00:18:24.349 --> 00:18:26.970 to treat the head. Okay, switching gears completely 00:18:26.970 --> 00:18:30.029 to fast rates. With tachycardia, speed matters. 00:18:30.589 --> 00:18:32.589 A heart rate that's too fast doesn't allow enough 00:18:32.589 --> 00:18:34.869 diastolic filling time, and that leads to shock 00:18:34.869 --> 00:18:37.970 really fast. Right. PLS is very clear here. If 00:18:37.970 --> 00:18:40.589 the child is unstable, do not delay emergency 00:18:40.589 --> 00:18:42.829 treatment while you wait for an expert consult. 00:18:43.029 --> 00:18:46.450 The initial management is still your ABCs, monitoring, 00:18:46.690 --> 00:18:49.529 and getting vascular access. The problem here 00:18:49.529 --> 00:18:51.809 is that the rapid rate reduces stroke volume 00:18:51.809 --> 00:18:54.390 so drastically that cardiac output just falls 00:18:54.390 --> 00:18:56.630 off a cliff. So unlike bradycardia, where we 00:18:56.630 --> 00:18:58.829 focus on the secondary cause, with tachycardia, 00:18:58.849 --> 00:19:00.630 we're really focused on the rhythm itself if 00:19:00.630 --> 00:19:03.009 it's pathological. Exactly. The critical moment 00:19:03.009 --> 00:19:06.369 in the tachycardia algorithm is box two. Evaluate 00:19:06.369 --> 00:19:09.730 the QRS duration. This immediately splits our 00:19:09.730 --> 00:19:12.410 pathway and dictates our entire therapeutic approach. 00:19:12.630 --> 00:19:15.609 It does. The QRS duration tells us where the 00:19:15.609 --> 00:19:18.420 electrical impulse is coming from. If it originates 00:19:18.420 --> 00:19:20.740 above the ventricles, the path down is normal 00:19:20.740 --> 00:19:23.539 and fast, so you get a narrow QRS. And if it 00:19:23.539 --> 00:19:25.460 originates in the ventricles? Then the path is 00:19:25.460 --> 00:19:28.839 slow and aberrant and you get a wide QRS. So 00:19:28.839 --> 00:19:31.279 an narrow complex is defined as less than or 00:19:31.279 --> 00:19:35.259 equal to 0 .09 seconds. This suggests probable 00:19:35.259 --> 00:19:37.980 sinus tachycardia or supraventricular tachycardia 00:19:37.980 --> 00:19:41.039 SVT. And a wide complex is greater than 0 .09 00:19:41.039 --> 00:19:43.900 seconds. Which is presumed ventricular tachycardia 00:19:43.900 --> 00:19:47.079 VT or maybe SVT with some aberrant conduction. 00:19:47.319 --> 00:19:49.220 Okay, let's talk about the stable patient. If 00:19:49.220 --> 00:19:51.539 the child has good pulses, good perfusion, their 00:19:51.539 --> 00:19:54.220 mentation is intact. We have a little bit of 00:19:54.220 --> 00:19:56.119 time, precious time to think and differentiate 00:19:56.119 --> 00:19:59.039 between sinus tach and SVT. And this distinction 00:19:59.039 --> 00:20:01.559 is the single most common diagnostic error I 00:20:01.559 --> 00:20:04.720 see in the PEDS ER. I believe it! It is! Because 00:20:04.720 --> 00:20:07.180 if you treat ST like it's SVT, you're treating 00:20:07.180 --> 00:20:09.700 the compensation, not the problem, and you risk 00:20:09.700 --> 00:20:12.029 a really serious error. So we have to distinguish 00:20:12.029 --> 00:20:14.349 them. OK, let's nail down those differentiating 00:20:14.349 --> 00:20:17.410 factors. Sinus tachycardia, or ST, is compatible 00:20:17.410 --> 00:20:20.809 with a known cause. Fever, pain, anxiety, dehydration. 00:20:21.230 --> 00:20:23.490 You look for normal P waves. Crucially, the R 00:20:23.490 --> 00:20:25.869 to R interval is variable. The heart rate speeds 00:20:25.869 --> 00:20:28.349 up and slows down. It does, depending on the 00:20:28.349 --> 00:20:30.670 child's activity or hydration. And the rate limits 00:20:30.670 --> 00:20:33.529 are usually less than 220 in infants and less 00:20:33.529 --> 00:20:36.529 than 180 in children. ST is the heart just doing 00:20:36.529 --> 00:20:40.130 its job to compensate. Okay, and SVT is the pathological 00:20:40.130 --> 00:20:43.150 one, the sudden rhythm. SVT is sudden onset. 00:20:43.829 --> 00:20:46.750 The history is also not compatible with ST. The 00:20:46.750 --> 00:20:48.549 heart rate is usually constant and does not vary 00:20:48.549 --> 00:20:51.509 with activity. The RR is fixed? It's fixed. P 00:20:51.509 --> 00:20:53.750 waves are usually absent, or they're merged with 00:20:53.750 --> 00:20:56.109 the QRS, or they look abnormal, and the rates 00:20:56.109 --> 00:20:59.089 are extreme. Usually 220 are greater in infants 00:20:59.089 --> 00:21:02.089 and 180 are greater in children. If the rate 00:21:02.089 --> 00:21:04.890 is that high and it was sudden, it's SVT until 00:21:04.890 --> 00:21:07.599 you prove otherwise. So if it's sinus tachycardia, 00:21:07.740 --> 00:21:10.200 we have to resist that urge to slow the heart 00:21:10.200 --> 00:21:12.519 down with drugs. You absolutely have to. You 00:21:12.519 --> 00:21:15.359 treat the cause. You give a fluid bolus if they're 00:21:15.359 --> 00:21:17.660 dehydrated or acetaminophen if they're febrile. 00:21:18.000 --> 00:21:20.319 You do not give adenosine or other antiarrhythmics. 00:21:20.400 --> 00:21:23.200 If you do, you take away the child's essential 00:21:23.200 --> 00:21:25.680 compensatory mechanism and you risk sending them 00:21:25.680 --> 00:21:29.529 into shock. But if we have stable SVT, we move 00:21:29.529 --> 00:21:32.410 to rhythm control, starting with vagal maneuvers. 00:21:32.569 --> 00:21:35.069 Always attempt these first. They stimulate the 00:21:35.069 --> 00:21:37.509 vagus nerve and slow down that AV conduction. 00:21:38.130 --> 00:21:40.329 If they work, they terminate the rhythm instantly. 00:21:40.869 --> 00:21:43.990 No drugs needed. But the technique is very age 00:21:43.990 --> 00:21:46.920 dependent. So what are the specific nursing coaching 00:21:46.920 --> 00:21:49.579 techniques here? For infants, the safest most 00:21:49.579 --> 00:21:51.900 effective method is the ice water facial immersion. 00:21:52.559 --> 00:21:54.660 You place a bag of ice water over the upper half 00:21:54.660 --> 00:21:57.480 of the face for about 15 to 20 seconds. But don't 00:21:57.480 --> 00:21:59.839 cover their nose or mouth? Critically, do not 00:21:59.839 --> 00:22:01.730 cover their nose or mouth. For older children 00:22:01.730 --> 00:22:03.849 who can follow directions, the modern approach 00:22:03.849 --> 00:22:06.210 is a modified Valsalva maneuver. How does that 00:22:06.210 --> 00:22:08.549 work? You have them blow forcefully into a 10 00:22:08.549 --> 00:22:11.269 millil syringe trying to move the plunger, or 00:22:11.269 --> 00:22:13.809 through an obstructed straw for 15 seconds while 00:22:13.809 --> 00:22:15.769 they're lying flat. And then you immediately 00:22:15.769 --> 00:22:17.809 raise their legs up to 45 degrees for another 00:22:17.809 --> 00:22:21.670 15 seconds. That combination significantly increases 00:22:21.670 --> 00:22:24.609 the success rate. Okay, if vagal maneuvers fail... 00:22:24.640 --> 00:22:27.500 We move to the definitive drug for stable SVT, 00:22:27.740 --> 00:22:29.940 Adenosine. Adenosine is the drug of choice for 00:22:29.940 --> 00:22:34.160 reentrant SVT. Its mechanism is pretty dramatic. 00:22:34.359 --> 00:22:36.960 It blocks conduction through the AV node and 00:22:36.960 --> 00:22:39.190 temporarily stops the heart. Let's spend some 00:22:39.190 --> 00:22:41.490 time on the dosing and maybe more importantly 00:22:41.490 --> 00:22:43.430 the nursing technique. This is where clinical 00:22:43.430 --> 00:22:46.130 failure so often happens. It really is. Dosing 00:22:46.130 --> 00:22:50.289 is 0 .1mgkg IV or IO with a max first dose of 00:22:50.289 --> 00:22:52.930 6mg. If it's ineffective, you immediately give 00:22:52.930 --> 00:22:56.190 the second dose, 0 .2mgkg with a max second dose 00:22:56.190 --> 00:22:59.049 of 12mg. And the technique is everything. It's 00:22:59.049 --> 00:23:01.759 paramount. A tenocene has an incredibly short 00:23:01.759 --> 00:23:04.619 half -life, less than 10 seconds. You must use 00:23:04.619 --> 00:23:07.619 a central or proximal IV line if you can. You 00:23:07.619 --> 00:23:09.720 give the doses a rapid IV bolus and you follow 00:23:09.720 --> 00:23:12.720 it immediately with a rapid flush of 5 to 10 00:23:12.720 --> 00:23:15.240 milliliter of normal saline, elevating the arm 00:23:15.240 --> 00:23:18.319 at the same time. This just shoves the drug into 00:23:18.319 --> 00:23:20.460 the central circulation so it can get to the 00:23:20.460 --> 00:23:22.980 AV node before it gets metabolized. Okay, now 00:23:22.980 --> 00:23:25.859 let's shift to the wide QRS, greater than 0 .09 00:23:25.859 --> 00:23:29.079 seconds, but in a stable patient. This is presumed 00:23:29.079 --> 00:23:31.740 VT until proven otherwise, and the stakes just 00:23:31.740 --> 00:23:33.599 immediately go up, even if the patient looks 00:23:33.599 --> 00:23:36.259 okay for the moment. A wide QRS strongly suggests 00:23:36.259 --> 00:23:38.940 a ventricular origin, which carries a high risk 00:23:38.940 --> 00:23:41.599 of degenerating into VFib. If the rhythm has 00:23:41.599 --> 00:23:45.319 a uniform QRS morphology and a regular RR interval, 00:23:45.599 --> 00:23:48.200 and the patient is stable, we treat it as VT. 00:23:48.599 --> 00:23:51.220 This situation, box 12 demands immediate expert 00:23:51.220 --> 00:23:54.289 consultation. A cardiologist or an ICU doc? Yes, 00:23:54.410 --> 00:23:55.690 but you have to start treatment while you're 00:23:55.690 --> 00:23:57.329 waiting for them to arrive. And provided the 00:23:57.329 --> 00:23:59.670 patient is truly stable, we consider pharmacologic 00:23:59.670 --> 00:24:03.450 conversion here. Yes. The primary drugs are amiodarone 00:24:03.450 --> 00:24:07.349 or prokanamide. You consider amiodarone at 5 00:24:07.349 --> 00:24:11.049 millijoy kilogram given IV or IO, but slowly, 00:24:11.190 --> 00:24:14.750 over 20 to 60 minutes. Or, prokanamide at 15 00:24:14.750 --> 00:24:17.670 millijoy kilograms infused over 30 to 60 minutes. 00:24:18.529 --> 00:24:21.690 The key word here is slow. Why slow? Because 00:24:21.690 --> 00:24:24.170 these drugs can induce pretty severe hypotension 00:24:24.170 --> 00:24:26.109 and just make the situation worse if you push 00:24:26.109 --> 00:24:28.789 them too fast. What about the absolute caution 00:24:28.789 --> 00:24:31.549 regarding combining these two powerful drugs? 00:24:31.690 --> 00:24:34.230 This is a huge safety concern. Do not routinely 00:24:34.230 --> 00:24:36.650 administer amyterone and procainamide together. 00:24:36.829 --> 00:24:39.349 Both are strong sodium and potassium channel 00:24:39.349 --> 00:24:41.650 blockers, and they both prolong the QT interval. 00:24:41.809 --> 00:24:43.809 So you get an additive effect. A very dangerous 00:24:43.809 --> 00:24:46.170 additive effect. You significantly increase the 00:24:46.170 --> 00:24:48.269 chance of inducing a lethal rhythm, specifically 00:24:48.269 --> 00:24:51.250 polymorphic VT or torsades de pointes. If one 00:24:51.250 --> 00:24:52.950 fails, you can switch to the other, but you never 00:24:52.950 --> 00:24:55.109 combine them. And what about using adenosine 00:24:55.109 --> 00:24:57.789 in a wide complex tachycardia? I know a lot of 00:24:57.789 --> 00:24:59.829 providers get tripped up there. It's high risk. 00:25:00.009 --> 00:25:02.769 I mean, if the wide complex rhythm is truly VT, 00:25:03.049 --> 00:25:04.890 adenosine won't terminate it, and it might even 00:25:04.890 --> 00:25:07.470 accelerate it, which is dangerous. The only time 00:25:07.470 --> 00:25:09.769 you might even consider it is if you have really 00:25:09.769 --> 00:25:12.690 strong evidence that the rhythm is actually SVT 00:25:12.690 --> 00:25:15.089 with aberrancy. Meaning the patient has a pre 00:25:15.089 --> 00:25:17.690 -existing bundle branch block or something? Exactly. 00:25:17.829 --> 00:25:20.809 But honestly, if you're not sure, you treat the 00:25:20.809 --> 00:25:24.930 wide QRS as VT, you use the designated antiarrhythmics, 00:25:25.069 --> 00:25:28.039 or you prepare for cardioversion. And this is 00:25:28.039 --> 00:25:30.819 that critical transition. When the stable tachycardia 00:25:30.819 --> 00:25:33.480 patient suddenly becomes unstable, poor perfusion, 00:25:33.720 --> 00:25:36.559 hypotension, signs of shock, we skip all the 00:25:36.559 --> 00:25:38.539 drug trials. We move straight to electricity. 00:25:39.119 --> 00:25:41.559 Time is myocardium. That's right. When we hit 00:25:41.559 --> 00:25:44.000 cardiopulmonary compromise, we go straight to 00:25:44.000 --> 00:25:46.539 synchronized cardioversion. This is the definitive 00:25:46.539 --> 00:25:49.519 intervention for hemodynamically unstable SVT, 00:25:49.740 --> 00:25:52.539 atrial flutter, or VT with a pulse. It takes 00:25:52.539 --> 00:25:55.720 seconds, not minutes, to deliver. Now, cardioversion 00:25:55.720 --> 00:25:58.000 is a painful procedure, so how do we balance 00:25:58.000 --> 00:26:00.339 the need for sedation and analgesia with the 00:26:00.339 --> 00:26:02.680 urgency of delivering that shock? That is the 00:26:02.680 --> 00:26:05.519 art of critical care, right there. If the patient 00:26:05.519 --> 00:26:08.480 is unstable and has a depressed level of consciousness, 00:26:08.920 --> 00:26:11.039 you skip sedation and you shock immediately. 00:26:11.200 --> 00:26:13.299 And if they're awake? If the child is unstable 00:26:13.299 --> 00:26:15.880 but awake, you should quickly deliver a rapid 00:26:15.880 --> 00:26:18.579 sequence, analgesic or sedative, something like 00:26:18.579 --> 00:26:22.339 ketamine or midozolam. if it's available, but 00:26:22.339 --> 00:26:25.380 the pay -alist instruction is firm. You do not 00:26:25.380 --> 00:26:27.640 delay the shock waiting for the sedation to kick 00:26:27.640 --> 00:26:30.359 in or for the perfect airway setup if the patient 00:26:30.359 --> 00:26:33.319 is crashing. A brief moment of pain is worth 00:26:33.319 --> 00:26:36.039 avoiding a full -blown cardiac arrest. Absolutely. 00:26:36.099 --> 00:26:37.920 Let's focus on the energy dose. It's lower than 00:26:37.920 --> 00:26:40.519 for V -fib defibrillation. Right. Cardiaversion 00:26:40.519 --> 00:26:42.599 requires less energy because we're just trying 00:26:42.599 --> 00:26:45.019 to reset the electrical rhythm, not completely 00:26:45.019 --> 00:26:48.119 depolarize the entire heart. The initial dose 00:26:48.119 --> 00:26:51.400 is 0 .5 to 1 joule. per kilogram. And if that 00:26:51.400 --> 00:26:53.740 doesn't work? If that shock is ineffective, you 00:26:53.740 --> 00:26:55.599 have to increase the dose for the next attempt. 00:26:56.099 --> 00:26:58.000 You escalate to the second dose of two joules 00:26:58.000 --> 00:27:00.400 per kilogram. Always use the lowest effective 00:27:00.400 --> 00:27:02.880 dose. Okay, now for the critical nursing steps 00:27:02.880 --> 00:27:05.759 for synchronized cardioversion. What are the 00:27:05.759 --> 00:27:08.299 common pitfalls you see that jeopardize the shock? 00:27:08.740 --> 00:27:11.700 Pitfall number one. And it's a big one, not selecting 00:27:11.700 --> 00:27:14.299 synchronization. You have to turn on the defibrillator, 00:27:14.539 --> 00:27:16.839 select your pads, and most importantly, select 00:27:16.839 --> 00:27:18.779 the synchronize mode. And you have to see the 00:27:18.779 --> 00:27:20.779 sync marks. You must look for the sync marks 00:27:20.779 --> 00:27:23.680 to appear above the R waves on the monitor. If 00:27:23.680 --> 00:27:26.099 you can't see them, increase the gain or switch 00:27:26.099 --> 00:27:28.680 leads until you can. And if you can't see them 00:27:28.680 --> 00:27:31.519 and you shock anyway, what's the risk? The machine 00:27:31.519 --> 00:27:34.180 will deliver an unsynchronized shock. That means 00:27:34.180 --> 00:27:36.700 the energy could land exactly on that vulnerable 00:27:36.700 --> 00:27:40.279 period of the T wave. R on T phenomenon. Exactly. 00:27:40.660 --> 00:27:43.539 Hitting the T wave can induce ventricular fibrillation, 00:27:43.819 --> 00:27:46.619 turning a salvageable rhythm into a full cardiac 00:27:46.619 --> 00:27:49.599 arrest. Confirming synchronization is a mandatory 00:27:49.599 --> 00:27:52.640 safety check. OK, sync is confirmed. We charge 00:27:52.640 --> 00:27:55.259 and deliver. You announce charging defibrillator, 00:27:55.480 --> 00:27:58.160 make sure everyone is clear, and crucially, you 00:27:58.160 --> 00:28:00.299 have to hold the shock button down until it delivers. 00:28:00.960 --> 00:28:03.180 The machine is waiting for the next R wave. If 00:28:03.180 --> 00:28:05.500 you press and release too quickly, it won't fire. 00:28:05.619 --> 00:28:08.259 And then immediately after. Immediately after, 00:28:08.460 --> 00:28:11.980 you check the monitor. If VF develops a total 00:28:11.980 --> 00:28:14.480 catastrophe, you must immediately turn off the 00:28:14.480 --> 00:28:17.359 synchronization mode and proceed to unsynchronized 00:28:17.359 --> 00:28:20.640 defibrillation and CPR. And remember, the defibrillator 00:28:20.640 --> 00:28:22.859 defaults back to unsynchronized mode after every 00:28:22.859 --> 00:28:25.660 shock. You have to reselect synchronization for 00:28:25.660 --> 00:28:27.900 every subsequent cardioversion attempt. Okay, 00:28:27.960 --> 00:28:29.839 let's dedicate this section to the high -level 00:28:29.839 --> 00:28:32.079 nursing implications of our PANS drug arsenal. 00:28:32.420 --> 00:28:34.619 We've covered the doses. Now let's focus on the 00:28:34.619 --> 00:28:36.799 how and the what to watch for. The titration, 00:28:36.980 --> 00:28:38.960 the side effects, the complex stuff. Great idea. 00:28:39.319 --> 00:28:42.119 Let's start with adenosine for SVT. So we know 00:28:42.119 --> 00:28:44.400 adenosine blocks conduction through the AV node 00:28:44.400 --> 00:28:47.539 and causes that transient assistal. The nursing 00:28:47.539 --> 00:28:49.619 management is all centered around its rapid decay. 00:28:50.099 --> 00:28:52.319 That half -life is so short, you need to use 00:28:52.319 --> 00:28:54.940 a three -way stopcock or a proximal port. Pushing 00:28:54.940 --> 00:28:57.839 the drug, spinning the stopcock, flushing immediately. 00:28:58.140 --> 00:29:00.240 Rapidly, yes. What should the nurse warn the 00:29:00.240 --> 00:29:02.220 patient or the family about, especially if the 00:29:02.220 --> 00:29:04.519 child is conscious during this? The child will 00:29:04.519 --> 00:29:07.259 likely feel a sensation of profound momentary 00:29:07.259 --> 00:29:10.079 chest pressure or dizziness as their heart stops. 00:29:10.460 --> 00:29:12.859 You have to warn them about this brief cardiac 00:29:12.859 --> 00:29:15.160 standstill which lasts maybe 10 to 15 seconds. 00:29:15.849 --> 00:29:17.869 explain that it's necessary to reset the rhythm. 00:29:18.670 --> 00:29:20.950 That anxiety management is key. And you're glued 00:29:20.950 --> 00:29:23.710 to the ECG monitor. Continuous ECG monitoring 00:29:23.710 --> 00:29:27.089 is essential. If the SVT converts, your immediate 00:29:27.089 --> 00:29:29.829 priority is monitoring for recurrence. Okay, 00:29:29.950 --> 00:29:33.509 Omiodurone for a wide QRS. It's a complex drug. 00:29:34.250 --> 00:29:36.650 For the nurse, what are the primary concerns 00:29:36.650 --> 00:29:39.250 when you're infusing this for a perfusing VT? 00:29:39.990 --> 00:29:42.049 Amidurone affects pretty much everything, sodium, 00:29:42.190 --> 00:29:44.890 potassium, calcium channels, and it has anti 00:29:44.890 --> 00:29:47.230 -adrenergic properties. So our immediate concerns 00:29:47.230 --> 00:29:50.269 are twofold. First, hypotension. Okay. Rapid 00:29:50.269 --> 00:29:53.109 administration, even over 20 to 60 minutes, can 00:29:53.109 --> 00:29:55.589 cause significant peripheral vasodilation and 00:29:55.589 --> 00:29:57.450 decreased contractility. You have to monitor 00:29:57.450 --> 00:29:59.369 their blood pressure every five minutes during 00:29:59.369 --> 00:30:01.869 that infusion. And the second major concern related 00:30:01.869 --> 00:30:04.309 to its mechanism. The second concern is related 00:30:04.309 --> 00:30:07.710 to its effect on potassium channels, QT prolongation. 00:30:08.700 --> 00:30:11.279 Amiodarone increases the risk of dangerous arrhythmias, 00:30:11.640 --> 00:30:14.140 particularly torsades to point. The nurse has 00:30:14.140 --> 00:30:16.519 to ensure the patient isn't also hypokalemic 00:30:16.519 --> 00:30:18.920 or hypomagnesemic, because those electrolyte 00:30:18.920 --> 00:30:20.819 issues just exacerbate the risk of torsades. 00:30:20.960 --> 00:30:24.000 Right, and the dose is 5 mg of a kilogram IVIO 00:30:24.000 --> 00:30:27.079 infused slowly. Very slowly. The slower the better 00:30:27.079 --> 00:30:29.480 if they're perfusing. And remember, the maximum 00:30:29.480 --> 00:30:33.839 cumulative dose is 15 mg per day. Okay, prokainamide. 00:30:34.380 --> 00:30:37.859 Our other strong option for wide QRS, how does 00:30:37.859 --> 00:30:40.720 its mechanism, mainly sodium channel blockade, 00:30:40.880 --> 00:30:42.980 translate to different nursing management concerns 00:30:42.980 --> 00:30:45.240 compared to amiodarone? Procatamide primarily 00:30:45.240 --> 00:30:47.400 blocks a sodium channel, so it slows conduction 00:30:47.400 --> 00:30:50.079 velocity and it prolongs the QRS duration. It's 00:30:50.079 --> 00:30:52.240 highly effective, but it comes with significant 00:30:52.240 --> 00:30:54.940 risks. The main nursing focus is just preventing 00:30:54.940 --> 00:30:57.920 toxicity by infusing it slowly. So you're infusing 00:30:57.920 --> 00:31:01.099 15 milligrams over 30 to 60 minutes. Right. What 00:31:01.099 --> 00:31:03.279 are the key signs of procatamide toxicity that 00:31:03.279 --> 00:31:05.019 would make you stop the infusion immediately. 00:31:05.420 --> 00:31:07.720 The three big ones are hypotension just like 00:31:07.720 --> 00:31:11.640 amiodarone and then excessive QRS or QT interval 00:31:11.640 --> 00:31:15.640 prolongation. If the QRS complex widens by 50 00:31:15.640 --> 00:31:18.890 % or more from baseline Or if it widens to greater 00:31:18.890 --> 00:31:22.269 than 0 .12 seconds, you stop the infusion immediately. 00:31:22.490 --> 00:31:24.009 Because that's a sign of dangerous conduction 00:31:24.009 --> 00:31:26.150 depression. Exactly. And again, the combination 00:31:26.150 --> 00:31:28.730 of amiodarone and brocanamide is strictly avoided 00:31:28.730 --> 00:31:31.210 because of that additive QT risk. Okay, let's 00:31:31.210 --> 00:31:34.089 touch on magnesium and sodium bicarb. These have 00:31:34.089 --> 00:31:36.690 really specific roles, often tied to the H's 00:31:36.690 --> 00:31:39.509 and T's. Right. Magnesium sulfate is specifically 00:31:39.509 --> 00:31:42.630 indicated for two situations, torsades de pointe, 00:31:42.789 --> 00:31:45.890 that polymorphic VT, and severe refractory asthma. 00:31:46.109 --> 00:31:49.130 It acts as a physiologic calcium channel blocker, 00:31:49.210 --> 00:31:51.069 and it's crucial for stabilizing the membrane 00:31:51.069 --> 00:31:54.009 when torsides is present. And sodium bicarb. 00:31:54.390 --> 00:31:56.769 Sodium bicarbonate is used to treat severe documented 00:31:56.769 --> 00:31:59.750 metabolic acidosis or specific drug overdoses, 00:32:00.069 --> 00:32:02.210 like presciclic antidepressants, where it helps 00:32:02.210 --> 00:32:04.549 narrow the QRS and counter that tartar toxicity. 00:32:05.029 --> 00:32:07.069 But remember, it's not a generalized drug. Maximize 00:32:07.069 --> 00:32:09.630 ventilation first. Finally, let's address the 00:32:09.630 --> 00:32:12.009 drug that must be avoided in a specific pediatric 00:32:12.009 --> 00:32:15.230 population and explain the critical physiological 00:32:15.230 --> 00:32:19.440 why. Varepamil. It's a calcium channel blocker, 00:32:19.700 --> 00:32:21.960 and it should not be used routinely to treat 00:32:21.960 --> 00:32:25.579 SVT in infants. This is a Palau certification 00:32:25.579 --> 00:32:27.859 deal -breaker question. And the physiological 00:32:27.859 --> 00:32:31.539 reason is profound. It is. Infants, especially 00:32:31.539 --> 00:32:34.220 those under one year, are highly rate dependent, 00:32:34.579 --> 00:32:37.920 and they rely heavily on adequate cardiac contractility. 00:32:38.240 --> 00:32:41.210 They're anotropy. Calcium channel blockers kill 00:32:41.210 --> 00:32:43.769 contractility. So when you combine that severe 00:32:43.769 --> 00:32:46.690 decrease in squeeze with a rapid SDT -induced 00:32:46.690 --> 00:32:49.970 rate, you cause immediate refractory hypotension 00:32:49.970 --> 00:32:52.430 and cardiac collapse. It's just too risky. Far 00:32:52.430 --> 00:32:54.529 too risky in that age group. In older children, 00:32:54.730 --> 00:32:56.930 if it's used for stable SVT that's resistant 00:32:56.930 --> 00:32:59.849 to adenosine, it requires an immediate cardiologist 00:32:59.849 --> 00:33:01.789 consult. Okay, this is where we bring the textbook 00:33:01.789 --> 00:33:04.069 back to the bedside. We've covered the mechanics, 00:33:04.190 --> 00:33:06.650 but algorithms fail when humans make high pressure 00:33:06.650 --> 00:33:09.250 errors. Let's talk about the common traps and 00:33:09.250 --> 00:33:11.750 pitfalls we see in real -life codes. The algorithms 00:33:11.750 --> 00:33:14.150 are clear, but clinical pressure definitely warps 00:33:14.150 --> 00:33:16.470 decision -making. Let's start with the bradycardia 00:33:16.470 --> 00:33:18.990 trap. The natural instinct is to grab the epinephrine 00:33:18.990 --> 00:33:21.250 when you see that heart rate dropping. And that's 00:33:21.250 --> 00:33:23.529 the trap. You see a low number on the monitor 00:33:23.529 --> 00:33:25.910 and you react to the monitor. But you have to 00:33:25.910 --> 00:33:29.299 remember Pediatric bradycardia is almost always 00:33:29.299 --> 00:33:31.579 a sign of a ventilation or oxygenation failure 00:33:31.579 --> 00:33:33.740 first. So don't jump to epinephrine. Don't jump 00:33:33.740 --> 00:33:36.440 to epinephrine if you haven't maximized oxygenation 00:33:36.440 --> 00:33:38.839 and ventilation. I remember a case where the 00:33:38.839 --> 00:33:41.180 teen treated the low heart rate first, forgetting 00:33:41.180 --> 00:33:43.839 the patient was profoundly hypoxemic from an 00:33:43.839 --> 00:33:46.400 unsecured airway. The pump was pressed, but the 00:33:46.400 --> 00:33:49.220 gas tank was empty. Exactly. Always maximize 00:33:49.220 --> 00:33:52.920 your ABCs first, then compress or medicate. Then 00:33:52.920 --> 00:33:55.160 there's the more subtle but equally dangerous 00:33:55.160 --> 00:33:59.440 tachycardia trap. Mistaking ST for SVT. This 00:33:59.440 --> 00:34:01.400 is where treating the patient, not the monitor, 00:34:01.640 --> 00:34:04.660 is absolutely paramount. Sinus tachycardia is 00:34:04.660 --> 00:34:07.519 a sign of an underlying systemic illness sepsis, 00:34:07.720 --> 00:34:10.699 hemorrhage, severe dehydration. And if you mistakenly 00:34:10.699 --> 00:34:12.900 treat that with adenosine? You interrupt the 00:34:12.900 --> 00:34:15.199 child's attempt to maintain cardiac output via 00:34:15.199 --> 00:34:17.800 rate. You've taken away their only coping mechanism. 00:34:18.219 --> 00:34:20.280 You have to treat the underlying cause -give 00:34:20.280 --> 00:34:23.199 fluids for dehydration, blood products for hemorrhage. 00:34:23.440 --> 00:34:26.480 A continuous ECG should show that heart rate 00:34:26.480 --> 00:34:29.340 coming down as the underlying issue is resolved. 00:34:29.699 --> 00:34:32.239 And the cardinal sin during electrical intervention, 00:34:33.199 --> 00:34:35.840 the cardioversion mistake. Forgetting to hit 00:34:35.840 --> 00:34:38.460 the sync button. It seems so obvious when we're 00:34:38.460 --> 00:34:40.239 sitting here talking about it, but in the chaos 00:34:40.239 --> 00:34:43.639 of a code, providers forget. And the result is 00:34:43.639 --> 00:34:46.900 a potentially harmful unsynchronized shock. Right. 00:34:47.079 --> 00:34:50.230 Risking induced V -fib. Always confirm those 00:34:50.230 --> 00:34:52.150 sync marks are visible before you charge and 00:34:52.150 --> 00:34:54.110 deliver, and remember to check it again after 00:34:54.110 --> 00:34:56.090 the first shock, as the machine always reverts 00:34:56.090 --> 00:34:58.750 back to unsynchronized mode. As the ER nurse, 00:34:59.530 --> 00:35:01.969 documentation is essential for quality improvement 00:35:01.969 --> 00:35:04.719 for legal defense. What are the absolute essentials 00:35:04.719 --> 00:35:06.699 that have to be captured during a high stakes, 00:35:07.000 --> 00:35:09.480 tacky, or bratty event? We need objective evidence 00:35:09.480 --> 00:35:12.139 of the rhythm and the interventions effect. So 00:35:12.139 --> 00:35:14.800 that means an ECG strip before and after every 00:35:14.800 --> 00:35:17.440 single intervention. Bagel maneuver, every drug, 00:35:17.679 --> 00:35:20.610 every shock. Every single one. For adenosine, 00:35:20.829 --> 00:35:23.130 you have to record the exact timing and dosage 00:35:23.130 --> 00:35:26.150 and the precise size of that flush, like six 00:35:26.150 --> 00:35:28.150 milligram adenosine followed immediately by 10 00:35:28.150 --> 00:35:30.510 milliliter LNS flush. For electrical therapy, 00:35:30.889 --> 00:35:33.289 the exact energy dose for every single attempt 00:35:33.289 --> 00:35:35.730 is mandatory. So what's the final thought we 00:35:35.730 --> 00:35:37.789 leave the ER nurse with as they're walking into 00:35:37.789 --> 00:35:40.320 that critical situation? When you're managing 00:35:40.320 --> 00:35:43.260 pediatric arrhythmias, you have to master the 00:35:43.260 --> 00:35:46.079 distinction between adequate and poor perfusion. 00:35:46.539 --> 00:35:48.900 That single assessment determines your timeline. 00:35:49.079 --> 00:35:51.000 Poor perfusion means you have seconds. You have 00:35:51.000 --> 00:35:53.400 30 seconds to deliver a life -saving shock or 00:35:53.400 --> 00:35:56.019 start compressions. If perfusion is adequate, 00:35:56.300 --> 00:35:58.360 you have little time for precise diagnosis, for 00:35:58.360 --> 00:36:01.239 an expert consult, for non -electrical interventions. 00:36:01.820 --> 00:36:04.599 Use that QRS split wide versus narrow to narrow 00:36:04.599 --> 00:36:07.099 your drug choice. And never forget that pediatric 00:36:07.099 --> 00:36:10.289 bradycardia is most often airway problem disguised 00:36:10.289 --> 00:36:12.869 as a heart problem. We covered a tremendous amount 00:36:12.869 --> 00:36:15.269 of ground today. The critical signs of instability, 00:36:15.610 --> 00:36:18.570 respiratory failure, shock with or without hypotension, 00:36:18.690 --> 00:36:21.369 and altered mental status. We emphasize that 00:36:21.369 --> 00:36:24.269 in bradycardia, the ABCs come before drugs, and 00:36:24.269 --> 00:36:26.769 that a persistent bradycardia below 60 means 00:36:26.769 --> 00:36:30.530 immediate, high -quality CPR. Yes. We broke down 00:36:30.530 --> 00:36:33.210 the critical QRS split, the high -stakes technique 00:36:33.210 --> 00:36:36.070 of synchronized cardioversion, and detailed the 00:36:36.070 --> 00:36:39.050 crucial nursing implications for amiodarone and 00:36:39.050 --> 00:36:41.110 procainamide. And if you take one lesson away 00:36:41.110 --> 00:36:44.489 from this... Let it be this. Always remember 00:36:44.489 --> 00:36:47.469 the reversible causes of bradycardia. Often the 00:36:47.469 --> 00:36:49.989 best cardiac care you can provide is swift and 00:36:49.989 --> 00:36:52.190 effective pulmonary care. Good ventilation and 00:36:52.190 --> 00:36:55.309 oxygenation. Exactly. Never forget that the child's 00:36:55.309 --> 00:36:57.809 slow heart rate is usually their body's final 00:36:57.809 --> 00:37:01.010 desperate attempt to survive hypoxia. The solution 00:37:01.010 --> 00:37:03.849 is often right there in your hands managing the 00:37:03.849 --> 00:37:06.269 airway and breathing long before you ever reach 00:37:06.269 --> 00:37:08.570 for the epinephrine. An excellent point to end 00:37:08.570 --> 00:37:10.469 on. Thank you for going on this deep dive with 00:37:10.469 --> 00:37:12.449 us, focusing on the details that truly matter 00:37:12.449 --> 00:37:15.329 when facing critical pediatric arrhythmias. Stay 00:37:15.329 --> 00:37:15.989 sharp out there.