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 --> 00:02:27.310 emergency room. Welcome back to the deep dive. 00:02:27.509 --> 00:02:32.629 If you are an ER nurse, an ICU tech, or really 00:02:32.629 --> 00:02:35.229 anyone preparing to work the sharp end of pediatric 00:02:35.229 --> 00:02:39.180 critical care, this deep dive is absolutely custom 00:02:39.180 --> 00:02:42.080 built for you. We're cracking open the pay less 00:02:42.080 --> 00:02:45.120 algorithms today, not just to help you pass a 00:02:45.120 --> 00:02:47.860 test, but to really embed the clinical reasoning, 00:02:47.919 --> 00:02:51.099 the why behind every single action you take in 00:02:51.099 --> 00:02:53.300 the trauma bay. Yeah, this is so much more than 00:02:53.300 --> 00:02:55.740 just certification prep. In a high -stakes pediatric 00:02:55.740 --> 00:02:58.159 code, there is just no time to look at a handbook 00:02:58.159 --> 00:03:01.379 or trace lines on a little card. None. That knowledge, 00:03:01.580 --> 00:03:04.020 it has to be completely internalized. Our mission 00:03:04.020 --> 00:03:06.800 today is to translate those protocols into immediate, 00:03:06.979 --> 00:03:09.680 decisive action. And we do that by prioritizing 00:03:09.680 --> 00:03:11.520 the physiological understanding. We want you 00:03:11.520 --> 00:03:14.219 to move past memorization and into real clinical 00:03:14.219 --> 00:03:16.900 mastery. Absolutely. Our focus is on that comprehensive 00:03:16.900 --> 00:03:19.080 knowledge drawing entirely from the latest advanced 00:03:19.080 --> 00:03:20.900 life support guidelines. We're going to break 00:03:20.900 --> 00:03:24.639 down. the two vastly different pathways to pediatric 00:03:24.639 --> 00:03:27.460 arrest. We'll analyze the specific choreography 00:03:27.460 --> 00:03:30.379 of medications and explore how tools like capnography 00:03:30.379 --> 00:03:34.580 become like your third eye during CPR. We're 00:03:34.580 --> 00:03:37.460 going for rapid, thorough, and just completely 00:03:37.460 --> 00:03:39.560 applicable knowledge. Let's do it. Okay, let's 00:03:39.560 --> 00:03:41.120 unpack this and jump right into the critical 00:03:41.120 --> 00:03:44.099 foundation. The pediatric difference. So when 00:03:44.099 --> 00:03:47.439 a siren pulls up to the ED, the default expectation 00:03:47.439 --> 00:03:50.349 for an adult patient who's arrested is almost 00:03:50.349 --> 00:03:53.590 always a primary cardiac event. Always. We're 00:03:53.590 --> 00:03:56.789 talking coronary artery disease, V -fib, a certain 00:03:56.789 --> 00:03:59.569 electrical catastrophe. But when we shift our 00:03:59.569 --> 00:04:02.110 focus to pediatrics, that fundamental assumption, 00:04:02.169 --> 00:04:04.990 it changes completely. And if you forget that 00:04:04.990 --> 00:04:07.610 distinction, you really compromise the resuscitation 00:04:07.610 --> 00:04:10.669 from the very start. That contrast is, I think, 00:04:10.830 --> 00:04:13.270 the single most important concept in all of PALS. 00:04:13.629 --> 00:04:15.509 Cardiac arrest in children is overwhelmingly 00:04:15.509 --> 00:04:17.990 not a primary heart issue. Right. The key driver 00:04:17.990 --> 00:04:20.389 is the body's reaction to progressive systemic 00:04:20.389 --> 00:04:22.730 failure. So this means we are usually, almost 00:04:22.730 --> 00:04:25.069 always, dealing with the hypoxicus fixiola rest 00:04:25.069 --> 00:04:29.350 pathway. This is the end result of profound prolonged 00:04:29.350 --> 00:04:32.470 respiratory failure or shock that leads to severe 00:04:32.470 --> 00:04:35.870 hypoxemia and acidosis. And only then, after 00:04:35.870 --> 00:04:39.100 all that, does the heart finally stop. So, if 00:04:39.100 --> 00:04:41.379 the pediatric heart is typically healthy, why 00:04:41.379 --> 00:04:46.199 does it ultimately fail in a code? Is it just 00:04:46.199 --> 00:04:49.339 exhaustion from running on zero oxygen? Precisely. 00:04:49.379 --> 00:04:51.600 That's a great way to put it. Unlike the adult 00:04:51.600 --> 00:04:54.220 heart, which fails because of a lack of blood 00:04:54.220 --> 00:04:55.939 flow to the muscle itself, you know, a blockage. 00:04:56.040 --> 00:04:58.019 A plumbing problem. A plumbing problem. The pediatric 00:04:58.019 --> 00:05:00.639 heart stops because the systemic oxygen delivery 00:05:00.639 --> 00:05:03.339 has completely collapsed and the metabolic demands 00:05:03.339 --> 00:05:05.519 of the body just can't be met. The heart muscle 00:05:05.519 --> 00:05:08.199 becomes acidotic, its start of oxygen, it loses 00:05:08.199 --> 00:05:10.540 its contractility, and it slows down until it 00:05:10.540 --> 00:05:13.139 becomes bradycardic and then eventually a systole 00:05:13.139 --> 00:05:15.540 or PEA. So the heart is the victim here, not 00:05:15.540 --> 00:05:17.560 the primary culprit. The heart is the victim, 00:05:17.920 --> 00:05:20.839 100%. Can you walk us through that fork in the 00:05:20.839 --> 00:05:23.620 road then? The guidelines distinguish two pretty 00:05:23.620 --> 00:05:25.819 clear pathways leading to arrest. Absolutely. 00:05:26.040 --> 00:05:28.360 So the main road, the one taken by about 80 % 00:05:28.360 --> 00:05:32.079 to 90 % of pediatric arrests, is that hypoxic 00:05:32.079 --> 00:05:36.079 -asphyxial pathway. OK. This is a slow, observable 00:05:36.079 --> 00:05:38.639 decline. You can see it happening. Respiratory 00:05:38.639 --> 00:05:41.600 distress leads to respiratory failure, or compensated 00:05:41.600 --> 00:05:44.720 shock leads to decompensated shock. And eventually, 00:05:45.019 --> 00:05:47.620 both of those paths, they merge into cardiopulmonary 00:05:47.620 --> 00:05:50.420 failure and arrest. And that's usually a systole 00:05:50.420 --> 00:05:53.459 or PEA. Usually a systole or PCA. The child is 00:05:53.459 --> 00:05:55.959 just... They're running out of their physiological 00:05:55.959 --> 00:05:57.959 reserve and the less common row the one that's 00:05:57.959 --> 00:05:59.779 more like the adult version that sudden electrical 00:05:59.779 --> 00:06:02.379 path That's the sudden cardiac arrest or the 00:06:02.379 --> 00:06:04.980 arrhythmia pathway. This one is rare. We're talking 00:06:04.980 --> 00:06:07.720 only five to fifteen percent of cases these are 00:06:07.720 --> 00:06:09.899 typically the result of an underlying structural 00:06:09.899 --> 00:06:12.819 heart disease something like hypertrophic cardiomyopathy 00:06:12.819 --> 00:06:17.560 or An anomalous coronary artery or it could be 00:06:17.560 --> 00:06:20.180 genetic electrical problems, the so -called channelopathies, 00:06:20.319 --> 00:06:22.319 like Long QT syndrome. So in that case, the heart 00:06:22.319 --> 00:06:24.639 does suddenly go into V -fib. It does. In that 00:06:24.639 --> 00:06:27.180 case, it suddenly enters ventricular fibrillation 00:06:27.180 --> 00:06:30.600 or pulsus ventricular tachycardia. Wow. This 00:06:30.600 --> 00:06:33.439 distinction has, I mean, massive clinical implications. 00:06:33.879 --> 00:06:37.939 If the common pathway is this slow hypoxic collapse, 00:06:38.000 --> 00:06:41.939 then our entire strategy has to pivot to prevention. 00:06:42.019 --> 00:06:44.750 It must. The critical concept here is that if 00:06:44.750 --> 00:06:46.829 your intervention happens early when the child 00:06:46.829 --> 00:06:49.129 is still just in respiratory distress or compensated 00:06:49.129 --> 00:06:51.509 shock, you know, before they progress to cardiopulmonary 00:06:51.509 --> 00:06:54.430 failure, the outcome is usually reversible and 00:06:54.430 --> 00:06:56.769 favorable and highly favorable. Once they progress 00:06:56.769 --> 00:07:00.709 to a systole or PEA, the chance of survival just 00:07:00.709 --> 00:07:03.110 plummets. It falls off a cliff because the entire 00:07:03.110 --> 00:07:06.350 system is profoundly acidotic and damaged. So 00:07:06.350 --> 00:07:08.470 we're intervening not just to restart the heart, 00:07:08.509 --> 00:07:10.750 but to restore effective breathing and perfusion 00:07:10.750 --> 00:07:13.100 that brings us right to the heart. data. The 00:07:13.100 --> 00:07:16.060 survival numbers are, they're stark, and they 00:07:16.060 --> 00:07:18.300 really show why prevention is so much more effective 00:07:18.300 --> 00:07:20.600 than resuscitation in pediatrics. What are the 00:07:20.600 --> 00:07:22.459 key metrics we need to internalize about these 00:07:22.459 --> 00:07:25.459 survival rates? Yeah, the statistics are sobering, 00:07:25.459 --> 00:07:27.379 especially when you compare the location and 00:07:27.379 --> 00:07:30.139 the rhythm. The overall outcome for children 00:07:30.139 --> 00:07:32.740 who experience an out -of -hospital cardiac arrest, 00:07:32.920 --> 00:07:36.819 or OHCA, is tragically poor. It's hovering around 00:07:36.819 --> 00:07:41.040 8 % survival to hospital discharge. 8%, that's 00:07:41.040 --> 00:07:43.540 terrible. It's terrible. The community resources, 00:07:43.540 --> 00:07:45.959 you know, they often arrive too late, and the 00:07:45.959 --> 00:07:48.839 period of hypoxia has just been too long. But 00:07:48.839 --> 00:07:50.939 the moment that child hits the hospital door, 00:07:51.180 --> 00:07:53.779 especially if they arrest in -house, those numbers 00:07:53.779 --> 00:07:56.939 change dramatically. They do. Survival for an 00:07:56.939 --> 00:08:00.160 in -hospital cardiac arrest, IHCA, is significantly 00:08:00.160 --> 00:08:01.819 better. We're looking at something approaching 00:08:01.819 --> 00:08:05.199 43%. Wow. And this improvement, it really reflects 00:08:05.199 --> 00:08:07.579 early recognition by trained staff, immediate 00:08:07.579 --> 00:08:10.459 initiation of high -quality CPR, and just rapid 00:08:10.480 --> 00:08:13.060 access to advanced interventions. Okay, now let's 00:08:13.060 --> 00:08:14.959 look at the rhythm because there's a huge split 00:08:14.959 --> 00:08:17.600 in prognosis here and it really confirms the 00:08:17.600 --> 00:08:19.339 importance of that two pathway model you talked 00:08:19.339 --> 00:08:21.779 about. Absolutely. The survival rate is highest. 00:08:21.860 --> 00:08:24.740 It ranges from about 38 to 43 percent when the 00:08:24.740 --> 00:08:28.540 presenting rhythm is shockable. VF or PVT. VFPVT, 00:08:28.639 --> 00:08:30.839 this is the electrical problem, right? And it's 00:08:30.839 --> 00:08:33.419 often more responsive to intervention. Now, you 00:08:33.419 --> 00:08:35.980 compare that to the non -shockable rhythms, a 00:08:35.980 --> 00:08:38.659 systole or PEA, which are the end stage of that 00:08:38.659 --> 00:08:41.980 hypoxic collapse. Survival rates there drop significantly, 00:08:42.220 --> 00:08:45.360 typically only 11 to 27%. It's so counterintuitive 00:08:45.360 --> 00:08:47.879 to think that the rare electrical arrest gives 00:08:47.879 --> 00:08:50.659 the patient a better chance, but the data is 00:08:50.659 --> 00:08:54.159 just crystal clear. Why is that initial rhythm 00:08:54.159 --> 00:08:57.100 so prognostic? Because a shockable rhythm implies 00:08:57.100 --> 00:08:59.860 a relatively healthy, or at least a metabolically 00:08:59.860 --> 00:09:02.220 compensated system that experienced a sudden 00:09:02.220 --> 00:09:04.879 electrical fault. If you correct that fault quickly 00:09:04.879 --> 00:09:07.159 with defibrillation, the heart is often ready 00:09:07.159 --> 00:09:09.899 to disresume function. Non -shockable rhythms, 00:09:10.240 --> 00:09:12.500 PEA and a systole, they mean the entire system 00:09:12.500 --> 00:09:15.919 is failing. Profound hypoxia, severe acidosis, 00:09:16.200 --> 00:09:18.500 electrolyte derangement. You have to fix the 00:09:18.500 --> 00:09:21.279 root cause, the H's and T's, while you're attempting 00:09:21.279 --> 00:09:23.769 CPR, which is just far more complex and time 00:09:23.769 --> 00:09:25.990 -consuming than delivering a single electrical 00:09:25.990 --> 00:09:28.789 jolt. That survival disparity is the ultimate 00:09:28.789 --> 00:09:31.429 driver for why Pali's focus is so relentlessly 00:09:31.429 --> 00:09:34.009 on early intervention before you get to that 00:09:34.009 --> 00:09:36.970 point of no return. Exactly. So every algorithm, 00:09:37.230 --> 00:09:40.009 every medication, every single intervention rests 00:09:40.009 --> 00:09:45.250 on one core task, high quality CPR. You can't 00:09:45.250 --> 00:09:48.250 run a successful code without it. We adhere to 00:09:48.250 --> 00:09:51.980 the CAB sequence compressions, airway breathing, 00:09:52.100 --> 00:09:54.440 and the guidelines give us these incredibly specific 00:09:54.440 --> 00:09:57.519 metrics. What are the non -negotiables an ER 00:09:57.519 --> 00:10:00.580 nurse must nail for pediatric CPR? The foundational 00:10:00.580 --> 00:10:01.919 metrics are everything. Let's start with the 00:10:01.919 --> 00:10:04.580 easiest one, the rate. It's standardized across 00:10:04.580 --> 00:10:08.580 all ages from an infant to an adult. 100 to 120 00:10:08.580 --> 00:10:11.539 compressions per minute. You can use the beat 00:10:11.539 --> 00:10:13.320 of staying alive if you need a mental anchor, 00:10:13.440 --> 00:10:16.360 but do not go over 120. Why not? Because overly 00:10:16.360 --> 00:10:18.620 rapid compressions can actually compromise the 00:10:18.620 --> 00:10:20.360 recoil. You don't give the chest enough time 00:10:20.360 --> 00:10:23.860 to expand. Ah, OK. Now for the tricky part, depth. 00:10:24.620 --> 00:10:26.360 This changes based on the size of the child. 00:10:26.759 --> 00:10:28.759 And maintaining that depth manually is, I mean, 00:10:28.879 --> 00:10:31.080 it's way harder than it sounds. It is. The target 00:10:31.080 --> 00:10:33.519 is always at least one third of the anterior, 00:10:33.740 --> 00:10:36.720 posterior, or AP chest diameter. To make it practical, 00:10:36.840 --> 00:10:39.179 for infants under one year, the depth is about 00:10:39.179 --> 00:10:41.820 one and a half inches, or four centimeters. And 00:10:41.820 --> 00:10:43.559 you're using two fingers for that. You're often 00:10:43.559 --> 00:10:46.840 using two fingers, or even better, two thumbs 00:10:46.840 --> 00:10:50.120 encircling the chest. For children, the depth 00:10:50.120 --> 00:10:53.139 increases to about two inches or five centimeters. 00:10:53.639 --> 00:10:55.639 This often requires one or two hands, depending 00:10:55.639 --> 00:10:58.679 on the child's size. And then for larger adolescents, 00:10:58.679 --> 00:11:00.960 you just move to the full adult standard, which 00:11:00.960 --> 00:11:03.840 is at least two inches. But and this is crucial, 00:11:04.360 --> 00:11:06.940 not more than two point four inches. OK, the 00:11:06.940 --> 00:11:09.340 next crucial point and one that often gets missed, 00:11:09.559 --> 00:11:14.279 especially when fatigue sets in, is recoil. Why 00:11:14.279 --> 00:11:17.480 is full chest recoil so vital? If you lean on 00:11:17.480 --> 00:11:20.299 the chest, you prevent the heart from fully expanding. 00:11:21.000 --> 00:11:23.820 Full chest recoil allows the ventricles to passively 00:11:23.820 --> 00:11:26.139 refill with blood during that relaxation phase. 00:11:26.299 --> 00:11:29.159 This refill is what creates the coronary perfusion 00:11:29.159 --> 00:11:31.419 pressure, the pressure gradient you need to push 00:11:31.419 --> 00:11:34.419 blood into the heart muscle itself. No recoil 00:11:34.419 --> 00:11:36.879 means no blood gets to the heart, and so your 00:11:36.879 --> 00:11:39.440 CPR is just ineffective. The compressor must 00:11:39.440 --> 00:11:41.399 lift their weight completely off the chest between 00:11:41.399 --> 00:11:43.580 every single compression. And the ratio, this 00:11:43.580 --> 00:11:45.659 determines the flow of the entire BLS effort, 00:11:45.980 --> 00:11:47.440 especially before you get an advanced airway. 00:11:47.659 --> 00:11:49.740 The compression ventilation ratio, it differs 00:11:49.740 --> 00:11:52.240 based on the team size. For a single rescuer, 00:11:52.419 --> 00:11:55.100 it doesn't matter what the child's age is. It's 00:11:55.100 --> 00:11:58.139 30 compressions to two ventilations. 30 .2. 30 00:11:58.139 --> 00:12:01.139 .2. But for two or more rescuers, which is standard 00:12:01.139 --> 00:12:05.000 in hospital, it's 15 compressions to two ventilations. 00:12:05.220 --> 00:12:09.559 15 .2. Yep, 15 .2. And that ratio maximizes compressions 00:12:09.559 --> 00:12:12.240 while still prioritizing the ventilation needs 00:12:12.240 --> 00:12:16.360 of the typically hypoxic pediatric patient. Finally, 00:12:16.779 --> 00:12:19.080 the metric that separates an organized team from 00:12:19.080 --> 00:12:23.220 just chaos. Minimizing interruptions. Yes. Interruptions 00:12:23.220 --> 00:12:26.120 must be kept to less than 10 seconds. This applies 00:12:26.120 --> 00:12:28.320 to your rhythm checks, shock delivery, or even 00:12:28.320 --> 00:12:31.019 placing an advanced airway. If you stop compressions 00:12:31.019 --> 00:12:33.620 for longer than 10 seconds, the drop in coronary 00:12:33.620 --> 00:12:36.220 perfusion pressure is immediate, and it is severe. 00:12:36.440 --> 00:12:38.200 And it takes multiple compressions after that 00:12:38.200 --> 00:12:40.159 to build that pressure back up. So this is a 00:12:40.159 --> 00:12:42.620 huge team coordination goal. A critical one. 00:12:42.899 --> 00:12:45.220 Be prepared, move fast, and get back on the chest. 00:12:45.419 --> 00:12:47.700 Okay, so with that foundation of high quality 00:12:47.700 --> 00:12:50.879 CPR established, let's move into the PLS algorithm 00:12:50.879 --> 00:12:53.600 itself. It's conceptually split into two sides, 00:12:53.919 --> 00:12:56.580 right? The shockable rhythms, the electrical 00:12:56.580 --> 00:12:58.799 emergencies, and the non -shockable rhythms, 00:12:58.980 --> 00:13:01.200 the systemic failures. Let's start with the higher 00:13:01.200 --> 00:13:04.559 survival path on the left. V -fib and pulseless 00:13:04.559 --> 00:13:07.220 V -tatch. These are those relatively rare electrical 00:13:07.220 --> 00:13:09.639 faults. They represent, you know, maybe five 00:13:09.639 --> 00:13:12.240 to fifteen percent of pediatric arrests, but 00:13:12.240 --> 00:13:15.080 they demand immediate action because early defibrillation 00:13:15.080 --> 00:13:18.720 is highly effective. As the nurse, how do I visually 00:13:18.720 --> 00:13:20.940 distinguish these on the monitor, and why do 00:13:20.940 --> 00:13:23.840 they lack a pulse? OK, so ventricular fibrillation, 00:13:23.840 --> 00:13:27.440 or VF, is easy to spot. It's just chaotic, irregular 00:13:27.440 --> 00:13:29.580 electrical activity. The heart is just quivering. 00:13:29.639 --> 00:13:31.639 It's not pumping. It's generating no mechanical 00:13:31.639 --> 00:13:34.240 force. And because there's no coordinated contraction, 00:13:34.320 --> 00:13:36.080 there's no cardiac output, and so there's no 00:13:36.080 --> 00:13:39.299 pulse. Pulseless ventricular tachycardia, PVT, 00:13:39.299 --> 00:13:41.159 is a bit more organized, but just as deadly. 00:13:41.500 --> 00:13:44.679 You'll see these wide, often rapid QRS complexes 00:13:44.679 --> 00:13:47.429 that look rhythmic. But the electrical signal 00:13:47.429 --> 00:13:49.750 is so disorganized in the ventricles that the 00:13:49.750 --> 00:13:52.289 mechanical pump function fails to generate any 00:13:52.289 --> 00:13:54.789 palpable cardiac output. You have to feel for 00:13:54.789 --> 00:13:56.470 a pulse. If it looks like V -tach, but there's 00:13:56.470 --> 00:13:59.809 no pulse, you treat it as PVT. And we also briefly 00:13:59.809 --> 00:14:02.269 mentioned Torasad's the point, the twisting of 00:14:02.269 --> 00:14:05.610 the points. How do we spot that specific? often 00:14:05.610 --> 00:14:08.809 drug -induced variants. The torsides is a distinct 00:14:08.809 --> 00:14:11.250 polymorphic V -tach, and it's characterized by 00:14:11.250 --> 00:14:14.029 the cyclical change in the amplitude of the QRS 00:14:14.029 --> 00:14:16.710 complexes. It literally appears to twist around 00:14:16.710 --> 00:14:19.049 the baseline. It's often linked to a prolonged 00:14:19.049 --> 00:14:21.529 QT interval, and it requires a very specific 00:14:21.529 --> 00:14:24.029 antiarrhythmic intervention. Got it. Okay, let's 00:14:24.029 --> 00:14:27.129 follow the VFPVT algorithm steps. We start CPR. 00:14:27.860 --> 00:14:30.159 Immediately check for a rhythm, and if it's shockable, 00:14:30.240 --> 00:14:32.860 step two is the shock. What's the rationale for 00:14:32.860 --> 00:14:34.639 the energy dose and why do we go immediately 00:14:34.639 --> 00:14:37.360 back to CPR? So the initial shock dose is two 00:14:37.360 --> 00:14:40.480 joules per kilogram, two J's per kilogram. The 00:14:40.480 --> 00:14:42.759 rationale is to deliver just enough energy to 00:14:42.759 --> 00:14:45.120 depolarize a critical mass of the ventricular 00:14:45.120 --> 00:14:47.539 myocardium. We are essentially giving the heart 00:14:47.539 --> 00:14:50.460 a reboot command. A hard reset. A hard reset, 00:14:50.519 --> 00:14:53.320 hoping the SA node, the natural pacemaker, can 00:14:53.320 --> 00:14:55.820 regain control. And immediately after delivery, 00:14:56.059 --> 00:14:59.059 you resume CPR. Do not check for a pulse. Do 00:14:59.059 --> 00:15:01.100 not look at the rhythm. You resume compressions 00:15:01.100 --> 00:15:03.220 immediately for two full minutes to ensure blood 00:15:03.220 --> 00:15:05.659 flow while the heart, you know, hopefully recovers. 00:15:06.019 --> 00:15:08.379 After those two minutes of CPR and establishing 00:15:08.379 --> 00:15:11.200 IV or IO access, we check the rhythm again. That's 00:15:11.200 --> 00:15:14.059 step five. If it's still shockable, we deliver 00:15:14.059 --> 00:15:17.940 shock two. Do we escalate the dose here? No, 00:15:17.940 --> 00:15:20.200 not yet. The initial increase in dose happens 00:15:20.200 --> 00:15:22.899 later. Shock two is also delivered at two joules 00:15:22.899 --> 00:15:25.200 per kilogram initially. But if it persists, then 00:15:25.200 --> 00:15:28.360 we move to step six epinephrine. And this timing 00:15:28.360 --> 00:15:32.039 is a critical nursing pearl. In the VFPVT arm, 00:15:32.240 --> 00:15:36.340 epinephrine 0 .01 milligrams per kilo IVIO is 00:15:36.340 --> 00:15:38.059 administered after the second shock is found 00:15:38.059 --> 00:15:40.740 to be unsuccessful. The priority is electricity 00:15:40.740 --> 00:15:43.759 first, then chemical support. And we repeat EPI 00:15:43.759 --> 00:15:45.480 every three to five minutes after that. That 00:15:45.480 --> 00:15:48.080 timing distinction is so crucial. When do we 00:15:48.080 --> 00:15:50.779 finally escalate the shock energy? In step seven. 00:15:51.350 --> 00:15:54.450 If the rhythm persists after shock two and after 00:15:54.450 --> 00:15:57.029 epinephrine has been given, you then escalate 00:15:57.029 --> 00:15:59.529 the energy dose for shock three to four joules 00:15:59.529 --> 00:16:02.210 per kilogram. Double it. You double it. And you 00:16:02.210 --> 00:16:04.830 can continue escalating up to 10 joules per kilo 00:16:04.830 --> 00:16:07.929 or the adult max dose for subsequent shocks. 00:16:08.149 --> 00:16:10.629 And again, two minutes of high quality CPR follows 00:16:10.629 --> 00:16:13.629 immediately. OK, so if we reach step eight, we 00:16:13.629 --> 00:16:17.129 are now dealing with shock refractory VFPVT, 00:16:17.149 --> 00:16:19.750 and that requires antiarrhythmics. We've got 00:16:19.750 --> 00:16:23.139 amiodrone. Right. This is where we try to stabilize 00:16:23.139 --> 00:16:26.620 that irritable myocardium chemically. We use 00:16:26.620 --> 00:16:28.940 either amiodarone, which is five milligrams per 00:16:28.940 --> 00:16:32.279 kilo, ivyobolus, or lidocaine at one milligram 00:16:32.279 --> 00:16:35.019 per kilo, ivyobolus. Is one preferred? Clinically, 00:16:35.159 --> 00:16:37.139 amiodarone is often preferred. It has a more 00:16:37.139 --> 00:16:39.220 complex mechanism. It affects multiple channels, 00:16:39.279 --> 00:16:41.659 which gives it, you know, broader antiarrhythmic 00:16:41.659 --> 00:16:43.679 effectiveness. But remember, if you identified 00:16:43.679 --> 00:16:45.700 torsades earlier, you have to stop the sequence 00:16:45.700 --> 00:16:47.720 and immediately give magnesium sulfate. Right. 00:16:47.860 --> 00:16:51.000 That's 25 to 50 milligrams per kilo, ivyobolus. 00:16:51.240 --> 00:16:53.360 OK, let's pivot to the right side of the algorithm. 00:16:53.980 --> 00:16:57.200 Asystole and PEA. This is the more common, yet 00:16:57.200 --> 00:17:00.080 much tougher, road for pediatric resuscitation 00:17:00.080 --> 00:17:02.480 because it represents that systemic collapse. 00:17:03.059 --> 00:17:04.920 Let's start with identifying them on the monitor. 00:17:05.180 --> 00:17:08.380 A cystally is. It's straightforward. It's a flat 00:17:08.380 --> 00:17:11.240 electrical line. No electrical activity, no pulses, 00:17:11.359 --> 00:17:14.180 no life. And the protocol. Nursing protocol here. 00:17:14.680 --> 00:17:16.500 Always confirm this on multiple leads. Don't 00:17:16.500 --> 00:17:19.339 waste critical time on a disconnected or a faulty 00:17:19.339 --> 00:17:23.170 lead reading. And PEA, Pulseless Electrical Activity. 00:17:23.569 --> 00:17:26.009 This is the ultimate deceiver because the monitor 00:17:26.009 --> 00:17:28.309 looks like it's organized, but the patient is 00:17:28.309 --> 00:17:31.029 dead. Exactly. PEA means the heart's electrical 00:17:31.029 --> 00:17:33.329 system is still working. You see P waves, you 00:17:33.329 --> 00:17:35.950 see QRS complexes, maybe even a rhythm. But the 00:17:35.950 --> 00:17:38.089 mechanical pumping action has failed to generate 00:17:38.089 --> 00:17:40.289 a palpable pulse or sufficient blood pressure. 00:17:40.569 --> 00:17:43.289 This is the end stage of that hypoxic decline. 00:17:43.529 --> 00:17:46.009 It is. It's fundamentally a mechanical or a metabolic 00:17:46.009 --> 00:17:48.230 problem, not a primary electrical one. And because 00:17:48.230 --> 00:17:50.049 it's not an electrical problem, we do not shock. 00:17:50.549 --> 00:17:52.549 So what's the immediate priority in stack nine? 00:17:52.720 --> 00:17:55.920 Continuous, uninterrupted, high -quality CPR 00:17:55.920 --> 00:18:00.079 in immediate establishment of IVRIO access. We 00:18:00.079 --> 00:18:02.839 are trying to mechanically perfuse the coronaries 00:18:02.839 --> 00:18:05.799 in the brain, just buying time to figure out 00:18:05.799 --> 00:18:08.099 and reverse the root cause. And unlike the shockable 00:18:08.099 --> 00:18:10.140 arm, epinephrine is introduced immediately in 00:18:10.140 --> 00:18:13.069 step 10. Why the urgency here? Because the heart 00:18:13.069 --> 00:18:16.250 muscle is profoundly weak and vasodilated. Ebenephrine 00:18:16.250 --> 00:18:20.609 at 0 .01 milligram per kilo G IVIO is given immediately 00:18:20.609 --> 00:18:23.069 and repeated every three to five minutes. Its 00:18:23.069 --> 00:18:26.329 primary goal through alpha edrenergic stimulation 00:18:26.329 --> 00:18:29.609 is powerful vasoconstriction. This raises the 00:18:29.609 --> 00:18:31.710 aortic diastolic pressure, which is absolutely 00:18:31.710 --> 00:18:33.769 critical for increasing that coronary perfusion 00:18:33.769 --> 00:18:36.210 pressure in a flaccid, non -pumping heart. In 00:18:36.210 --> 00:18:38.750 PEA and a systole, chemical support is the first 00:18:38.750 --> 00:18:40.549 line of advanced intervention right after... 00:18:40.400 --> 00:18:43.200 CPR starts. So step 11 is this never -ending 00:18:43.200 --> 00:18:46.900 cycle of CPR, EPI, and the crucial step, treating 00:18:46.900 --> 00:18:50.099 reversible causes. Correct. If the rhythm stays 00:18:50.099 --> 00:18:52.619 non -shockable after two minutes, you resume 00:18:52.619 --> 00:18:55.619 CPR and immediately, simultaneously, you begin 00:18:55.619 --> 00:18:58.299 that deep diagnostic workup known as the H's 00:18:58.299 --> 00:19:01.839 and T's. The prognosis for PEA and a systole 00:19:01.839 --> 00:19:04.200 rests entirely on how quickly and effectively 00:19:04.200 --> 00:19:06.319 you can address that underlying physiological 00:19:06.319 --> 00:19:08.680 insult. And what if that rhythm suddenly shifts? 00:19:08.940 --> 00:19:11.819 What if a systole suddenly becomes V fib? You 00:19:11.819 --> 00:19:13.859 have to recognize that switch immediately. If 00:19:13.859 --> 00:19:16.200 the rhythm becomes shockable, the non -shockable 00:19:16.200 --> 00:19:18.559 algorithm is abandoned, and you jump directly 00:19:18.559 --> 00:19:20.799 to the shockable arm, typically starting at step 00:19:20.799 --> 00:19:23.779 seven, to deliver that four joule per kilo shock 00:19:23.779 --> 00:19:26.559 without any delay. This is where the ER nurse's 00:19:26.559 --> 00:19:29.279 ability to multitask and think critically is 00:19:29.279 --> 00:19:31.759 tested the most. When you're running a PEA code, 00:19:31.920 --> 00:19:33.640 you're not just following a timeline, you're 00:19:33.640 --> 00:19:35.839 an investigator. Let's spend some time on the 00:19:35.839 --> 00:19:38.000 H's and T's, not just listing them, but talking 00:19:38.000 --> 00:19:40.559 about how a nurse identifies them rapidly in 00:19:40.559 --> 00:19:43.299 a chaotic code. Exactly. The differential diagnosis 00:19:43.299 --> 00:19:45.539 has to happen concurrently with compressions. 00:19:45.980 --> 00:19:47.940 If you don't treat the cause, the heart is never 00:19:47.940 --> 00:19:50.079 going to stay restarted. Let's focus on the H's 00:19:50.079 --> 00:19:54.240 first, the metabolic and volume issues. Hypovolemia 00:19:54.240 --> 00:19:56.519 is high on the list, especially in a traumatic 00:19:56.519 --> 00:19:59.960 or septic child. Right. Signs of severe hypovolemia 00:19:59.960 --> 00:20:02.079 are often evident from, you know, pre -arrival 00:20:02.079 --> 00:20:05.380 data or your initial assessment. Flat neck veins, 00:20:05.799 --> 00:20:08.779 a history of vomiting or diarrhea or known hemorrhage. 00:20:08.940 --> 00:20:11.019 And the diagnostic tool. The rapid diagnostic 00:20:11.019 --> 00:20:13.160 tool here is the fluid challenge. If you think 00:20:13.160 --> 00:20:16.000 the patient is hypovolemic, you give rapid boluses 00:20:16.000 --> 00:20:19.559 of isotonic crystalloid 20 ml per kilo. If the 00:20:19.559 --> 00:20:21.599 vital signs transiently improve, you've pretty 00:20:21.599 --> 00:20:24.019 much confirmed the cause. If the patient has 00:20:24.019 --> 00:20:26.359 known trauma, you move immediately to blood products. 00:20:26.859 --> 00:20:29.279 Next is hypoxia, which, as we know, is the most 00:20:29.279 --> 00:20:32.220 common killer. Hypoxia demands the absolute highest 00:20:32.220 --> 00:20:35.220 priority in every pediatric code. You have to 00:20:35.220 --> 00:20:38.240 ensure optimal ventilation and oxygenation. If 00:20:38.240 --> 00:20:41.299 the oxygen saturation isn't 100 % and the ETC 00:20:41.299 --> 00:20:43.759 show is low, you are not adequately delivering 00:20:43.759 --> 00:20:46.160 oxygen. So what do you check? This means checking 00:20:46.160 --> 00:20:48.720 the advanced airway, ensuring a proper bag valve 00:20:48.720 --> 00:20:51.680 mask seal, and confirming ET tube placement with 00:20:51.680 --> 00:20:53.740 everything you've got. Then we have the electrolyte 00:20:53.740 --> 00:20:57.960 and acid base issues. Hydrogen ion, so acidosis, 00:20:58.819 --> 00:21:02.130 hyperkalemia, and hypothermia. Acidosis is almost 00:21:02.130 --> 00:21:04.509 always present in cardiac arrest, but unless 00:21:04.509 --> 00:21:06.970 it's severe or the arrest is prolonged, bicarb 00:21:06.970 --> 00:21:10.750 isn't routine. Hyperkalemia or severe acidosis, 00:21:10.809 --> 00:21:13.009 that usually requires an emergent point -of -care 00:21:13.009 --> 00:21:15.490 blood -gas analysis. And if you suspect high 00:21:15.490 --> 00:21:18.650 potassium? If hyperkalemia is suspected, maybe 00:21:18.650 --> 00:21:21.390 in a child with renal failure, you have to prepare 00:21:21.390 --> 00:21:23.930 calcium chloride or sodium bicarbonate immediately 00:21:23.930 --> 00:21:26.589 to stabilize the myocardium and shift that potassium. 00:21:26.829 --> 00:21:29.309 For hypothermia, if the core temperature is below 00:21:29.309 --> 00:21:31.789 30 degrees Celsius, the heart is often refractory 00:21:31.789 --> 00:21:34.690 to all drugs and electricity. You must initiate 00:21:34.690 --> 00:21:37.529 active rewarming efforts concurrently. OK, now 00:21:37.529 --> 00:21:40.369 for the T's, the structural and mechanical issues. 00:21:40.869 --> 00:21:43.130 Tension pneumothorax and tamponade. These are 00:21:43.130 --> 00:21:45.730 obstructive causes of shock. A tension pneumothorax 00:21:45.730 --> 00:21:47.549 is suspected if there's a history of trauma, 00:21:48.109 --> 00:21:50.250 marked asymmetry of breath sounds, and it's really 00:21:50.250 --> 00:21:52.670 difficult to ventilate. This needs rapid intervention. 00:21:52.930 --> 00:21:55.460 Needle decompression. Immediate needle decompression, 00:21:55.660 --> 00:21:58.359 second intercostal space, mid -clavicular line, 00:21:58.619 --> 00:22:01.779 followed by a tube thoracostomy. Cardiac tamponade 00:22:01.779 --> 00:22:04.059 is suspected with a rapid drop in blood pressure 00:22:04.059 --> 00:22:07.220 and jugular venous distension. A rapid bedside 00:22:07.220 --> 00:22:09.640 ultrasound is the fastest way to confirm this, 00:22:09.859 --> 00:22:12.619 and that requires an urgent pericardiacentesis. 00:22:13.200 --> 00:22:15.799 And finally, toxins and thrombosis. Toxins can 00:22:15.799 --> 00:22:17.720 often be identified from the patient history 00:22:17.720 --> 00:22:21.099 or toxicology screens. For example, a tricyclic 00:22:21.099 --> 00:22:24.569 antidepressant overdose requires bicarb. Thrombosis 00:22:24.569 --> 00:22:27.109 pulmonary or coronary is really difficult to 00:22:27.109 --> 00:22:29.609 diagnose rapidly but it's a consideration in 00:22:29.609 --> 00:22:32.009 children with underlying risk factors like congenital 00:22:32.009 --> 00:22:34.329 heart disease or central lines. So the takeaway 00:22:34.329 --> 00:22:37.029 is? The key message is during a non -shockable 00:22:37.029 --> 00:22:39.730 arrest the nurse must constantly prompt the team 00:22:39.730 --> 00:22:42.950 leader what H or T are we treating next and be 00:22:42.950 --> 00:22:44.869 ready to prepare that necessary intervention. 00:22:45.369 --> 00:22:47.410 Okay so medications are only as effective as 00:22:47.410 --> 00:22:50.240 their delivery system. As the nurse, you are 00:22:50.240 --> 00:22:53.220 the gatekeeper of vascular access. Let's review 00:22:53.220 --> 00:22:55.420 the hierarchy and the non -negotiable step for 00:22:55.420 --> 00:22:57.880 drug delivery in a code. The hierarchy is simple. 00:22:58.140 --> 00:23:00.799 Intravenous IV is primary. If you can't get a 00:23:00.799 --> 00:23:03.220 good peripheral IV quickly, you transition immediately 00:23:03.220 --> 00:23:05.640 to the secondary route. Intraosseous access. 00:23:05.839 --> 00:23:08.460 I .O. The I .O. route provides drug and fluid 00:23:08.460 --> 00:23:11.240 delivery that's comparable to central venous 00:23:11.240 --> 00:23:14.079 access, and you can establish it in any age group, 00:23:14.240 --> 00:23:17.589 often in under 60 seconds. This is vastly preferred 00:23:17.589 --> 00:23:20.849 over the third and final choice, the endotracheal 00:23:20.849 --> 00:23:24.450 or ET route. Why is the ET route so universally 00:23:24.450 --> 00:23:27.369 disfavored now, especially for epinephrine? It's 00:23:27.369 --> 00:23:29.849 problematic because drug absorption is just highly 00:23:29.849 --> 00:23:32.769 unreliable and unpredictable. It results in significantly 00:23:32.769 --> 00:23:35.869 lower and often subtherapeutic blood concentrations. 00:23:36.670 --> 00:23:38.529 Furthermore, some studies suggest that the lower 00:23:38.529 --> 00:23:40.710 concentration of epi delivered this way can cause 00:23:40.710 --> 00:23:43.089 a transient beta adrenergic effect without the 00:23:43.089 --> 00:23:45.529 desired alpha constriction. And that can lead 00:23:45.529 --> 00:23:48.269 to detrimental hypotension rather than the beneficial 00:23:48.269 --> 00:23:50.670 coronary perfusion you're looking for. It should 00:23:50.670 --> 00:23:53.210 only be used as a last resort until you get IV 00:23:53.210 --> 00:23:56.279 or IO access. This brings us to probably the 00:23:56.279 --> 00:23:58.700 most important nursing parole regarding drug 00:23:58.700 --> 00:24:02.380 administration via peripheral IV or IO, the saline 00:24:02.380 --> 00:24:05.839 flush. What is the clinical consequence of skipping 00:24:05.839 --> 00:24:09.180 that flush? If you skip the saline flush, the 00:24:09.180 --> 00:24:11.660 medication, epinephrine, amutorone, whatever 00:24:11.660 --> 00:24:14.660 it is, it just sits there. It's static in the 00:24:14.660 --> 00:24:17.140 peripheral vein or the IO space. It's just hanging 00:24:17.140 --> 00:24:19.609 out? It's just hanging out. If you're giving, 00:24:19.609 --> 00:24:23.589 say, half an ml of epi into a peripheral IV without 00:24:23.589 --> 00:24:25.970 a flush, it might take several circulation times 00:24:25.970 --> 00:24:28.230 to even reach the central circulation where the 00:24:28.230 --> 00:24:31.789 heart is. By using a five to 10 ml normal saline 00:24:31.789 --> 00:24:34.309 flush, you create a bolus effect. You force the 00:24:34.309 --> 00:24:36.109 drug immediately into the central circulation 00:24:36.109 --> 00:24:38.869 during those ongoing chest compressions, guaranteeing 00:24:38.869 --> 00:24:41.069 rapid delivery and maximizing the drug's impact 00:24:41.069 --> 00:24:43.829 within that critical three to five minute dosing 00:24:43.829 --> 00:24:46.430 window. So skipping the flush is like? Skipping 00:24:46.430 --> 00:24:48.230 the flush is equivalent to delaying the dose 00:24:48.230 --> 00:24:50.849 by 30 to 60 seconds. It's a critical error. And 00:24:50.849 --> 00:24:53.210 just for reference, if we are absolutely forced 00:24:53.210 --> 00:24:55.970 to use the ET route for epinephrine, the dose 00:24:55.970 --> 00:24:58.789 adjustment is massive. It is. The recommended 00:24:58.789 --> 00:25:03.150 ET dose of epi is 10 times the IVIO dose, recognizing 00:25:03.150 --> 00:25:05.950 that 90 % of that drug may be lost to absorption 00:25:05.950 --> 00:25:08.329 variability. Okay, let's detail the pharmacology 00:25:08.329 --> 00:25:11.289 of the key PALS agents, starting with the alpha 00:25:11.289 --> 00:25:14.529 -edrenergic powerhouse. Epinephrine. It's a vasopressor 00:25:14.529 --> 00:25:17.210 used in all arrest rhythms. Its mechanism is 00:25:17.210 --> 00:25:19.589 multifaceted, but it's really centered on that 00:25:19.589 --> 00:25:21.950 alpha -edrenergic stimulation causing powerful 00:25:21.950 --> 00:25:24.769 vasoconstriction to increase aortic diastolic 00:25:24.769 --> 00:25:27.640 pressure and consequently coronary perfusion 00:25:27.640 --> 00:25:30.279 pressure. And the beta effects. Its beta adrenergic 00:25:30.279 --> 00:25:32.940 effects are secondary. They promote contractility 00:25:32.940 --> 00:25:35.480 and heart rate, but it's the alpha effect we're 00:25:35.480 --> 00:25:38.319 after in a code. The indication is cardiac arrest, 00:25:38.359 --> 00:25:42.319 a systole, PEA, and VFTVT after the second shock. 00:25:42.779 --> 00:25:46.740 Dose is 0 .01 milligram per kilo G IVIO bolus, 00:25:46.819 --> 00:25:49.180 repeated every three to five minutes. And a nursing 00:25:49.180 --> 00:25:51.279 note here. Be meticulous about using the correct 00:25:51.279 --> 00:25:54.380 concentration. It's 1 to 10 ,000 for IVI use, 00:25:54.579 --> 00:25:56.559 which often requires careful dilution if your 00:25:56.559 --> 00:25:59.119 code card only stocks 1 to 1 ,000. For the shock 00:25:59.119 --> 00:26:01.660 refractory rhythms, we rely on the antiarrhythmics. 00:26:01.779 --> 00:26:05.160 Let's compare amiodurone and lidocaine. Amiodurone 00:26:05.160 --> 00:26:08.039 is a potent antiarrhythmic. It affects sodium, 00:26:08.220 --> 00:26:10.799 potassium, and calcium channels, prolonging the 00:26:10.799 --> 00:26:13.039 action potential duration and the refractory 00:26:13.039 --> 00:26:17.289 period. Indication. shock refractory VF or PVT. 00:26:17.890 --> 00:26:22.210 The dose is five milligram per kilo G IVIO bolus. 00:26:22.529 --> 00:26:24.690 What's the risk with amyloid run? It must be 00:26:24.690 --> 00:26:26.750 administered slowly or diluted if you're giving 00:26:26.750 --> 00:26:29.910 it as an infusion post ROSC because rapid boluses 00:26:29.910 --> 00:26:32.849 can cause significant hypotension. And the alternative? 00:26:33.170 --> 00:26:35.809 Lidocaine. It's a simpler sodium channel blocker 00:26:35.809 --> 00:26:38.349 that suppresses ventricular arrhythmias and decreases 00:26:38.349 --> 00:26:41.900 automaticity. Indication. Alternative to amiodarone 00:26:41.900 --> 00:26:45.579 for shock refractory VF -PVT, the dose is one 00:26:45.579 --> 00:26:48.500 milligram per kilo G IVIO bolus. And the risk 00:26:48.500 --> 00:26:50.880 there? You need to monitor for signs of leadocaine 00:26:50.880 --> 00:26:53.960 toxicity post -ROSC, which can include seizures, 00:26:54.420 --> 00:26:56.400 altered mental status, and even cardiovascular 00:26:56.400 --> 00:26:58.460 collapse. Okay, let's move outside the core arrest 00:26:58.460 --> 00:27:01.359 sequence to drugs for specific indications. First, 00:27:01.559 --> 00:27:04.190 for symptomatic bradycardia. Atropine. It's an 00:27:04.190 --> 00:27:06.130 anticholinergic that increases heart rate by 00:27:06.130 --> 00:27:07.930 blocking the effects of the vagus nerve on the 00:27:07.930 --> 00:27:10.069 heart. It's indicated for bradycardia caused 00:27:10.069 --> 00:27:13.150 by excessive vagal tone or a primary AV block. 00:27:13.230 --> 00:27:15.569 But not for everything. Not for routine use in 00:27:15.569 --> 00:27:18.529 cardiac arrest, no. Especially if the bradycardia 00:27:18.529 --> 00:27:21.769 is due to hypoxia. Treating the hypoxia is the 00:27:21.769 --> 00:27:23.970 primary goal there. If you do use it, the dose 00:27:23.970 --> 00:27:28.279 is 0 .02 milligram per kilo G IVIO. and the crucial 00:27:28.279 --> 00:27:31.059 agent for torsades de pointes. Magnesium sulfate. 00:27:31.279 --> 00:27:34.259 This is for arrhythmias associated with hypomagnesemia. 00:27:34.539 --> 00:27:37.460 Indication is torsades de points. Dose is 25 00:27:37.460 --> 00:27:40.839 to 50 milligrams per kilo G IVI bolus. You'll 00:27:40.839 --> 00:27:43.339 want to monitor deep tendon reflexes and for 00:27:43.339 --> 00:27:46.160 signs of hypermagnesemia, especially if renal 00:27:46.160 --> 00:27:48.180 function is impaired. Finally, the drug that 00:27:48.180 --> 00:27:50.720 is now highly restricted, sodium bicarbonate. 00:27:50.839 --> 00:27:53.059 Yeah. Sodium bicarb is used to increase serum 00:27:53.059 --> 00:27:56.119 pH, which can help treat severe acidosis or decrease 00:27:56.119 --> 00:27:58.240 potassium concentrations. Its indications are 00:27:58.240 --> 00:28:01.079 very limited now. Severe hyperkalemia, prolonged 00:28:01.079 --> 00:28:03.200 cardiac arrest that's refractory to other treatments, 00:28:03.480 --> 00:28:06.599 or specific poisonings like a triceclic antidepressant 00:28:06.599 --> 00:28:09.160 overdose. And if it is indicated. The dose is 00:28:09.160 --> 00:28:11.740 one milli -equivalent per kilogram IVIO, and 00:28:11.740 --> 00:28:14.180 the nursing note is critical. Bicarbonate is 00:28:14.180 --> 00:28:16.980 an alkaline solution and should never ever be 00:28:16.980 --> 00:28:18.740 administered in the same line as calcium because 00:28:18.740 --> 00:28:21.319 it will precipitate. It turns to chalk. Pediatric 00:28:21.319 --> 00:28:24.259 arrest is primarily a hypoxic event, yet we have 00:28:24.259 --> 00:28:26.700 these firm guidelines telling us to avoid excessive 00:28:26.700 --> 00:28:29.829 ventilation. That sounds like a contradiction. 00:28:30.609 --> 00:28:32.809 Why must we be so restrictive with our breaths? 00:28:32.930 --> 00:28:35.710 It's a very delicate balance. The contradiction 00:28:35.710 --> 00:28:38.650 exists because hyperventilation is actively harmful. 00:28:38.829 --> 00:28:41.509 How so? Excessive ventilation, whether it's too 00:28:41.509 --> 00:28:44.430 fast or too forceful, significantly increases 00:28:44.430 --> 00:28:46.890 your intra -thoracic pressure. When that pressure 00:28:46.890 --> 00:28:50.329 rises, it pinches the vena cava, which impedes 00:28:50.329 --> 00:28:53.230 venous return to the heart. Less blood returns, 00:28:53.369 --> 00:28:55.470 less blood is pushed out during compressions, 00:28:55.470 --> 00:28:58.220 and your coronary perfusion pressure drops dramatically. 00:28:58.599 --> 00:29:00.880 You're fighting your own compressions. So we 00:29:00.880 --> 00:29:03.480 need to provide just enough oxygen but not so 00:29:03.480 --> 00:29:05.519 much pressure that we compromise cardiac output. 00:29:06.019 --> 00:29:08.279 What are the specific ventilation rates once 00:29:08.279 --> 00:29:10.619 an advanced airway is in place? With an advanced 00:29:10.619 --> 00:29:13.500 airway like an ET tube or a supraglottic airway 00:29:13.500 --> 00:29:16.759 secured, compressions become continuous at 100 00:29:16.759 --> 00:29:20.480 to 120 per minute and ventilation shifts to asynchronous. 00:29:20.880 --> 00:29:23.299 The rate is strictly one breath every six seconds. 00:29:23.400 --> 00:29:25.940 Which is 10 breaths a minute. 10 breaths per 00:29:25.940 --> 00:29:29.079 minute, and use only the volume necessary to 00:29:29.079 --> 00:29:32.180 cause visible chest rise, avoiding gastric distension. 00:29:32.559 --> 00:29:35.099 And a quick note on cricoid pressure, which often 00:29:35.099 --> 00:29:38.279 seems to slow down intubation attempts. The guidelines 00:29:38.279 --> 00:29:40.980 are pretty clear. Routine use of cricord pressure 00:29:40.980 --> 00:29:43.720 is discouraged. It has not been shown to prevent 00:29:43.720 --> 00:29:46.759 aspiration, and it often interferes with successful 00:29:46.759 --> 00:29:49.839 placement of the ET tube or even effective bag 00:29:49.839 --> 00:29:52.559 mask ventilation. We often think of n -tidal 00:29:52.559 --> 00:29:56.019 carbon dioxide, or ETKO, primarily as a tool 00:29:56.019 --> 00:29:59.119 for confirming correct ET tube placement. But 00:29:59.119 --> 00:30:01.680 in a cardiac arrest setting, its significance 00:30:01.680 --> 00:30:03.759 just explodes. It becomes your most reliable 00:30:03.759 --> 00:30:06.279 real -time monitor of resuscitation quality. 00:30:06.430 --> 00:30:10.150 The so what of ETCO is that it directly correlates 00:30:10.150 --> 00:30:12.130 to pulmonary blood flow. OK, break that down. 00:30:12.349 --> 00:30:14.170 Since the lungs are being ventilated constantly, 00:30:14.549 --> 00:30:17.369 the only way ETCO gets exhaled is if blood flow. 00:30:17.809 --> 00:30:19.849 Your cardiac output carries it from the tissues 00:30:19.849 --> 00:30:23.390 to the lungs. Therefore, ETCO provides an immediate, 00:30:23.470 --> 00:30:26.329 indirect measure of cardiac output and lung perfusion 00:30:26.329 --> 00:30:29.250 during CPR. So how does the nurse use this number 00:30:29.250 --> 00:30:32.000 to guide compression quality? During high quality 00:30:32.000 --> 00:30:35.559 CPR, your initial ET caro target should be between 00:30:35.559 --> 00:30:38.799 10 and 15 millimeters of mercury. If your values 00:30:38.799 --> 00:30:41.900 are consistently dropping below 10, that is an 00:30:41.900 --> 00:30:44.019 immediate red flag. What does it tell you? It 00:30:44.019 --> 00:30:45.900 tells the team that their compressions are ineffective, 00:30:46.500 --> 00:30:48.380 blood flow is critically poor, or the patient 00:30:48.380 --> 00:30:50.880 has some severe metabolic derangements. You have 00:30:50.880 --> 00:30:53.200 to immediately adjust compression depth technique 00:30:53.200 --> 00:30:55.720 or positioning until that number improves. And 00:30:55.720 --> 00:30:58.119 what about the clearest, most undeniable sign 00:30:58.119 --> 00:31:00.779 of success, which often precedes the physical 00:31:00.779 --> 00:31:03.839 return of a pulse? That is the abrupt and sustained 00:31:03.839 --> 00:31:07.539 jump in ETKO. A reading that abruptly rises and 00:31:07.539 --> 00:31:10.339 stays elevated, often to a value over 40 millimeters 00:31:10.339 --> 00:31:13.500 of mercury, is the most reliable earliest indicator 00:31:13.500 --> 00:31:17.440 of return of spontaneous circulation, ROSC. Wow. 00:31:17.640 --> 00:31:20.079 That spike signifies a sudden rush of blood flow 00:31:20.079 --> 00:31:22.339 carrying all that metabolic Keo that had been 00:31:22.339 --> 00:31:24.740 backing up in the system. When you see that spike, 00:31:24.880 --> 00:31:27.400 you stop compressions and check for a pulse immediately. 00:31:27.799 --> 00:31:31.799 When you achieve ROSC, an organized rhythm, palpable 00:31:31.799 --> 00:31:35.019 central pulses, measurable blood pressure, The 00:31:35.019 --> 00:31:37.299 resuscitation hasn't ended. It's just changed 00:31:37.299 --> 00:31:40.200 phase. The goal shifts to optimizing recovery 00:31:40.200 --> 00:31:42.880 and preventing that secondary injury. The post 00:31:42.880 --> 00:31:45.119 -arrest phase is crucial. It often determines 00:31:45.119 --> 00:31:47.799 the neurological outcome. The immediate goals 00:31:47.799 --> 00:31:50.700 are stabilization and optimization. Starting 00:31:50.700 --> 00:31:54.200 with hemodynamics. Yes. We have to maintain blood 00:31:54.200 --> 00:31:58.140 pressure and spontaneous arterial pressure. Hypotension 00:31:58.140 --> 00:32:01.680 post -ROSC is incredibly common and it is devastating. 00:32:01.900 --> 00:32:04.059 So what's the management? It requires aggressive 00:32:04.059 --> 00:32:06.940 management. Initial fluid boluses of isotonic 00:32:06.940 --> 00:32:09.700 crystalloid to treat any residual hypovolemia, 00:32:09.940 --> 00:32:11.980 followed immediately by initiating pressors like 00:32:11.980 --> 00:32:14.539 epinephrine or dopamine if the shock persists, 00:32:14.960 --> 00:32:16.819 were aiming for a systolic blood pressure above 00:32:16.819 --> 00:32:19.039 the fifth percentile for age. And respiratory 00:32:19.039 --> 00:32:21.039 targets. We just spent the whole code worrying 00:32:21.039 --> 00:32:23.440 about getting enough oxygen. Right. Post -ROSE, 00:32:23.519 --> 00:32:26.359 we actually focus on avoiding hyperoxia and hyperventilation. 00:32:26.599 --> 00:32:29.440 We target oxygen saturations between 94 and 99 00:32:29.440 --> 00:32:32.019 percent. 100 percent saturation can actually 00:32:32.019 --> 00:32:34.559 cause reperfusion injury. And ventilation. For 00:32:34.559 --> 00:32:37.940 ventilation, the goal is to maintain normal carbia, 00:32:38.200 --> 00:32:41.799 a PCO of about 35 to 45 millimeters of mercury, 00:32:42.039 --> 00:32:46.359 which you monitor with ET2 and blood gases. Hyperventilation, 00:32:46.519 --> 00:32:49.079 which gives you a low PCOROS, causes cerebral 00:32:49.079 --> 00:32:51.599 vasoconstriction, and that reduces blood flow 00:32:51.599 --> 00:32:53.660 to the recovering brain. Finally, temperature 00:32:53.660 --> 00:32:55.740 management. Targeted temperature management, 00:32:55.900 --> 00:32:58.599 or TTM, is a standard component of post -cardiac 00:32:58.599 --> 00:33:01.160 arrest care, particularly for comatose children 00:33:01.160 --> 00:33:04.660 post -ROSC. While the specific target temperature 00:33:04.660 --> 00:33:07.359 might vary by institution, the goal is always 00:33:07.359 --> 00:33:10.180 to strictly avoid hyperthermia or fever. Why 00:33:10.180 --> 00:33:12.519 is fever so bad here? Because elevated temperature 00:33:12.519 --> 00:33:15.039 significantly increases cerebral metabolic demand 00:33:15.039 --> 00:33:17.140 and it worsens the neurological outcome. The 00:33:17.140 --> 00:33:19.259 nurse must initiate cooling measures or monitor 00:33:19.259 --> 00:33:22.819 closely immediately post R .O .S .C. In the chaos 00:33:22.819 --> 00:33:25.539 of a code, the difference between a smooth operation 00:33:25.539 --> 00:33:28.259 and a disaster is often not pharmacology, but 00:33:28.259 --> 00:33:31.619 choreography. Pay Ellis requires a high -functioning 00:33:31.619 --> 00:33:34.980 team. As an ER nurse, you might be the documenter, 00:33:35.059 --> 00:33:37.420 the medication preparer, or the compressor. What 00:33:37.420 --> 00:33:39.500 are the fundamentals of team dynamics that guarantee 00:33:39.500 --> 00:33:42.099 adherence to the algorithm? Structure and clarity 00:33:42.099 --> 00:33:45.500 are completely non -negotiable. Successful resuscitation 00:33:45.500 --> 00:33:47.880 revolves around rigid adherence to the two -minute 00:33:47.880 --> 00:33:51.119 CPR cycle. This is the clock that guides all 00:33:51.119 --> 00:33:53.700 team tasks. And the most important job to maintain 00:33:53.700 --> 00:33:56.339 quality within that two -minute cycle is the 00:33:56.339 --> 00:33:59.440 compressor. Exactly. Compressor rotation must 00:33:59.440 --> 00:34:02.519 occur every two minutes. or sooner if the compressor 00:34:02.519 --> 00:34:05.980 is visibly fatigued. This rotation ensures that 00:34:05.980 --> 00:34:08.679 depth and quality do not degrade. The leader 00:34:08.679 --> 00:34:10.760 should anticipate the switch and cue the next 00:34:10.760 --> 00:34:13.360 compressor right before the rhythm check so that 00:34:13.360 --> 00:34:15.760 transition is seamless. From the perspective 00:34:15.760 --> 00:34:18.579 of the documenter or the medication nurse, how 00:34:18.579 --> 00:34:21.079 does the team leader use closed -loop communication 00:34:21.079 --> 00:34:23.760 to maintain safety and flow? Closed -loop communication 00:34:23.760 --> 00:34:26.159 prevents critical tasks from being dropped. If 00:34:26.159 --> 00:34:29.079 the leader says, nurse, give 0 .01 milligrams 00:34:29.079 --> 00:34:31.880 per kilo of epinephrine, the nurse must respond, 00:34:32.239 --> 00:34:35.719 I am preparing epinephrine 0 .01 milligrams per 00:34:35.719 --> 00:34:37.920 kilo. And then confirm when it's given. When 00:34:37.920 --> 00:34:39.940 the drug is administered, the nurse confirms 00:34:39.940 --> 00:34:44.199 epinephrine 0 .01 milligrams per kilo given at 00:34:44.199 --> 00:34:48.900 1042 AM, followed by a 10 ml flush. This confirmation 00:34:48.900 --> 00:34:51.079 ensures the message was received, the action 00:34:51.079 --> 00:34:53.340 was performed correctly, and the documentation 00:34:53.340 --> 00:34:56.119 is exact. And what role does the nurse play in 00:34:56.119 --> 00:34:59.000 minimizing that critical less than 10 -second 00:34:59.000 --> 00:35:01.230 interruption? The nurse is the critical link 00:35:01.230 --> 00:35:03.849 between the decision and the action. For a rhythm 00:35:03.849 --> 00:35:06.170 check, the defibrillator nurse must have the 00:35:06.170 --> 00:35:08.769 pads placed and the required energy to joules 00:35:08.769 --> 00:35:11.710 per kilo or four joules per kilo calculated and 00:35:11.710 --> 00:35:14.130 precharged before compression stop. Be ready 00:35:14.130 --> 00:35:16.750 to go. Be ready. For medication delivery, the 00:35:16.750 --> 00:35:19.150 drug must be drawn up, labeled, and placed right 00:35:19.150 --> 00:35:21.130 next to the line. The only thing that should 00:35:21.130 --> 00:35:23.190 happen during that 10 -second pause is rhythm 00:35:23.190 --> 00:35:26.190 interpretation, shock delivery, or drug administration 00:35:26.190 --> 00:35:29.010 followed by the flush. Any preparation done during 00:35:29.010 --> 00:35:31.849 the pause is a failure of team preparation. We've 00:35:31.849 --> 00:35:33.989 covered the core mechanics. Now let's wrap up 00:35:33.989 --> 00:35:36.909 with the nice -to -know clinical pearls and the 00:35:36.909 --> 00:35:39.809 critical adaptations necessary for special circumstances 00:35:39.809 --> 00:35:43.349 that commonly walk through the ER door. The algorithms 00:35:43.349 --> 00:35:45.750 look so clean on paper, but in the heat of the 00:35:45.750 --> 00:35:49.349 moment, these common errors just emerge. Let's 00:35:49.349 --> 00:35:51.650 revisit that timing error in the shockable arm. 00:35:52.130 --> 00:35:55.090 The major mistake is drug sequence mistakes in 00:35:55.090 --> 00:35:59.079 VFPVT. Because epinephrine is so prominent in 00:35:59.079 --> 00:36:02.219 a systole and PEA, there's this tendency to give 00:36:02.219 --> 00:36:04.739 it too early in the shockable arm. Remember, 00:36:05.179 --> 00:36:09.260 shock one CPR, shock two CPR, then EPI. Electricity 00:36:09.260 --> 00:36:11.320 first. You have to give the electrical therapy 00:36:11.320 --> 00:36:14.320 priority first. Administering EPI too early can 00:36:14.320 --> 00:36:16.980 distract the team and it just violates the principle 00:36:16.980 --> 00:36:19.739 of rapid defibrillation for an electrical problem. 00:36:19.980 --> 00:36:21.900 What about the physical process of drug administration? 00:36:22.190 --> 00:36:25.369 The pitfall here is inadequate flush volume and 00:36:25.369 --> 00:36:27.989 speed. So many providers forget the necessity 00:36:27.989 --> 00:36:31.530 of that 5 to 10 ml rapid saline flush after IV 00:36:31.530 --> 00:36:34.409 or IO drug administration. Right. If you inject 00:36:34.409 --> 00:36:36.449 the drug but don't follow it instantly with a 00:36:36.449 --> 00:36:38.909 rapid flush during compressions, you are essentially 00:36:38.909 --> 00:36:41.250 delaying the drug's effect. Ensure the flush 00:36:41.250 --> 00:36:43.489 is done with the same urgency as the drug administration 00:36:43.489 --> 00:36:46.010 itself. And the recurring issue of overventilation. 00:36:46.389 --> 00:36:48.630 Excessive ventilation rate or volume. You have 00:36:48.630 --> 00:36:51.840 to fight the urge to hyperventilate. The detrimental 00:36:51.840 --> 00:36:54.360 impact of increased intra -thoracic pressure 00:36:54.360 --> 00:36:57.219 on venous return will undermine every single 00:36:57.219 --> 00:36:59.800 high -quality compression you perform. Stick 00:36:59.800 --> 00:37:02.079 rigidly to that one breath every six seconds 00:37:02.079 --> 00:37:04.639 with an advanced airway. Okay, so the core Pallas 00:37:04.639 --> 00:37:07.380 algorithm is built for the average child, but 00:37:07.380 --> 00:37:11.599 the ER sees critical exceptions. How do we adapt 00:37:11.599 --> 00:37:14.780 the framework for trauma arrests? Trauma requires 00:37:14.780 --> 00:37:17.019 immediate recognition of specific reversible 00:37:17.019 --> 00:37:20.960 causes. Arrest and trauma is often due to hypovolemia 00:37:20.960 --> 00:37:23.820 from hemorrhage or obstructive shock, like attention 00:37:23.820 --> 00:37:26.360 pneumothorax or tamponade. So the priority shifts? 00:37:26.460 --> 00:37:29.119 The priority shifts immediately. Maintain C -spine 00:37:29.119 --> 00:37:31.219 control, secure the airway, and for circulation 00:37:31.219 --> 00:37:33.400 you have to move immediately past crystalloids 00:37:33.400 --> 00:37:36.480 if massive hemorrhage is suspected. Rapid transfusion 00:37:36.480 --> 00:37:38.800 of O -negative or type -specific blood products 00:37:38.800 --> 00:37:41.360 is essential. And simultaneously, the team must 00:37:41.360 --> 00:37:43.519 address those structural issues like attention 00:37:43.519 --> 00:37:45.960 pneumothorax with needle decompression. The clock 00:37:45.960 --> 00:37:48.119 is running faster here. How about drowning, which 00:37:48.119 --> 00:37:50.559 is often linked to severe hypothermia? Drowning 00:37:50.559 --> 00:37:53.360 involves severe primary hypoxia and requires 00:37:53.360 --> 00:37:56.159 a full court press on oxygenation and ventilation. 00:37:56.930 --> 00:38:00.050 If hypothermia is present, with a core temp below 00:38:00.050 --> 00:38:03.170 30 degrees Celsius, you have to initiate active 00:38:03.170 --> 00:38:06.230 rewarming measures. Warmed for fluids, forced 00:38:06.230 --> 00:38:08.969 air warming. And their prognosis. Critically, 00:38:09.230 --> 00:38:11.789 CPR should not be terminated early in the severely 00:38:11.789 --> 00:38:14.590 hypothermic patient, as they may have exceptional 00:38:14.590 --> 00:38:17.690 neuroprotection. However, the heart is unlikely 00:38:17.690 --> 00:38:20.190 to respond to defibrillation or pacing until 00:38:20.190 --> 00:38:22.449 that core temperature is raised above 30 degrees 00:38:22.449 --> 00:38:24.510 Celsius. And for anaphylaxis, which involves 00:38:24.510 --> 00:38:27.349 massive vasodilation and airway collapse. Anaphylaxis 00:38:27.349 --> 00:38:29.570 requires immediate attention to the airway, standard 00:38:29.570 --> 00:38:32.230 dose epinephrine, and aggressive volume resuscitation. 00:38:32.769 --> 00:38:35.190 Because that massive histamine release causes 00:38:35.190 --> 00:38:37.909 severe vasodilation, which leads to relative 00:38:37.909 --> 00:38:41.349 hypovolemia, you have to give rapid large volume 00:38:41.349 --> 00:38:43.869 fluid boluses. Not much. We're talking multiple 00:38:43.869 --> 00:38:46.889 20 ml per kiloboluses to restore adequate circulating 00:38:46.889 --> 00:38:49.829 volume and reverse that distributive shock. Steroids 00:38:49.829 --> 00:38:52.610 and H1H2 blockers follow, but volume and epi 00:38:52.610 --> 00:38:54.849 are the immediate lifesavers. Let's end with 00:38:54.849 --> 00:38:57.230 how this internal rhythm translates into professional 00:38:57.230 --> 00:39:00.789 practice. For the nurse designated as the documenter, 00:39:01.150 --> 00:39:03.710 what is the best way to record the code so that 00:39:03.710 --> 00:39:05.710 the notes become a tool for the team leader, 00:39:06.130 --> 00:39:09.170 not just a historical record? Documentation is 00:39:09.170 --> 00:39:12.139 the team's external memory and timekeeper. You 00:39:12.139 --> 00:39:14.579 have to use the pay less rhythm, that two minute 00:39:14.579 --> 00:39:17.400 cycle, as your guide. Every critical action, 00:39:17.599 --> 00:39:19.719 a rhythm check, a shock, a drug administration 00:39:19.719 --> 00:39:22.800 should be time stamped precisely. If compression 00:39:22.800 --> 00:39:25.099 started at 10 .30 a .m., the first rhythm check 00:39:25.099 --> 00:39:28.699 is at 10 .32. If epinephrine is given at 10 .33, 00:39:28.980 --> 00:39:31.440 the team leader immediately knows the next epi 00:39:31.440 --> 00:39:35.340 is due between 10 .36 and 10 .38, which coincides 00:39:35.340 --> 00:39:37.619 with the next rhythm check after that. So the 00:39:37.619 --> 00:39:39.699 notes should actually anticipate the next move. 00:39:39.880 --> 00:39:42.590 Exactly. Clear timestamp records allow the team 00:39:42.590 --> 00:39:44.809 leader to look ahead, to calculate the next shock 00:39:44.809 --> 00:39:47.489 dose, pre -draw the next medication, and ensure 00:39:47.489 --> 00:39:49.809 the team is ready to minimize interruptions. 00:39:50.349 --> 00:39:53.389 Good documentation is predictive, not just reflective. 00:39:54.090 --> 00:39:56.110 This level of organization is what separates 00:39:56.110 --> 00:39:58.530 an experienced critical care team from one that 00:39:58.530 --> 00:40:01.070 struggles. We've taken the PAL -S algorithm and 00:40:01.070 --> 00:40:03.349 just dismantled it, focusing on the clinical 00:40:03.349 --> 00:40:05.730 reasoning that empowers you as the ER nurse. 00:40:05.949 --> 00:40:08.369 We learned that the pediatric heart is usually 00:40:08.369 --> 00:40:11.250 a victim of hypoxia, making early intervention 00:40:11.250 --> 00:40:14.590 and the treatment of H's and T's paramount. We 00:40:14.590 --> 00:40:16.969 detailed the two sides of the algorithm, emphasizing 00:40:16.969 --> 00:40:19.570 the critical timing of efferine and the necessary 00:40:19.570 --> 00:40:22.769 energy escalation for shockable rhythms. Crucially, 00:40:23.289 --> 00:40:25.550 we highlighted the non -negotiable nursing task 00:40:25.550 --> 00:40:28.489 of that 5 to 10 mL saline flush and the power 00:40:28.489 --> 00:40:31.510 of ETCO as your real -time measure of perfusion. 00:40:31.949 --> 00:40:33.710 And here is the final thought for you to carry 00:40:33.710 --> 00:40:36.969 forward. While PELUS provides the map, the real 00:40:36.969 --> 00:40:39.550 skill in the emergency setting is rapid differential 00:40:39.550 --> 00:40:42.030 diagnosis in the face of chaos, particularly 00:40:42.030 --> 00:40:44.949 when you're dealing with PEA. Never stop asking 00:40:44.949 --> 00:40:48.340 why. Was this arrest due to a known cardiac issue? 00:40:48.440 --> 00:40:50.960 Was it trauma? Was it an ingestion? The clock 00:40:50.960 --> 00:40:53.340 on the algorithm is running, but the diagnostic 00:40:53.340 --> 00:40:56.199 investigation has to be running even faster. 00:40:56.739 --> 00:40:59.079 Knowing the nuances of special circumstances, 00:40:59.619 --> 00:41:02.280 the need for blood and trauma, the aggressive 00:41:02.280 --> 00:41:05.199 rewarming and drowning, the massive fluid boluses 00:41:05.199 --> 00:41:07.920 and anaphylaxis, that is what allows you to truly 00:41:07.920 --> 00:41:10.039 master the resuscitation beyond just the basic 00:41:10.039 --> 00:41:16.889 protocol. directly translates into the confidence 00:41:16.889 --> 00:41:19.230 required when a sick child arrives, and that 00:41:19.230 --> 00:41:21.489 confidence saves lives. You are now equipped 00:41:21.489 --> 00:41:22.409 for clinical mastery.