WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:47.310 fast. Welcome to the emergency room. Welcome 00:00:47.310 --> 00:00:50.609 back to the deep dive. Today we are wading into 00:00:50.609 --> 00:00:54.609 what I think it's fair to call the deep end of 00:00:54.609 --> 00:00:56.270 the nursing home. Oh, absolutely the deep end. 00:00:56.479 --> 00:00:58.799 We're standing at the bedside of a patient who 00:00:58.799 --> 00:01:01.159 weighs maybe seven pounds, has a heart the size 00:01:01.159 --> 00:01:04.420 of a walnut. And inside that walnut, the plumbing 00:01:04.420 --> 00:01:07.799 is, well, it's trying to compromise their ability 00:01:07.799 --> 00:01:11.219 to breathe and grow. We are talking about pediatric 00:01:11.219 --> 00:01:13.579 cardiac nursing. It is the ultimate high -stakes 00:01:13.579 --> 00:01:16.079 environment. I mean, I have seen seasoned nurses, 00:01:16.640 --> 00:01:19.719 people who can handle a chaotic ER on a Saturday 00:01:19.719 --> 00:01:22.569 night just... freeze up when they have to deal 00:01:22.569 --> 00:01:25.049 with a congenital heart defect. And why is that? 00:01:25.049 --> 00:01:27.030 What's the core of that fear? Because the margin 00:01:27.030 --> 00:01:29.890 for error with a neonate is, it's effectively 00:01:29.890 --> 00:01:33.030 zero. And unlike an adult who can grab their 00:01:33.030 --> 00:01:35.329 chest and say, hey, I'm in pain, a baby tells 00:01:35.329 --> 00:01:37.750 you nothing. Right. They just stop eating. or 00:01:37.750 --> 00:01:40.230 they sweat, or they turn a color that human beings 00:01:40.230 --> 00:01:42.969 simply are not supposed to be. Exactly. And I've 00:01:42.969 --> 00:01:45.930 got to be honest, looking at the stack of materials 00:01:45.930 --> 00:01:48.430 we have for this deep dive, I mean, textbook 00:01:48.430 --> 00:01:51.750 chapters on congenital defects, specific clinical 00:01:51.750 --> 00:01:55.370 guides for beta blockers, diagrams of fetal circulation 00:01:55.370 --> 00:01:58.010 that look like subway maps drawn by someone in 00:01:58.010 --> 00:02:00.730 a fever dream. It is intimidating. It really 00:02:00.730 --> 00:02:05.569 is. It's a soup of acronyms. VSD, ASD, PDA, TGA, 00:02:05.989 --> 00:02:08.830 HLHS. It feels like you need a degree in fluid 00:02:08.830 --> 00:02:10.830 dynamics just to read the chart. It absolutely 00:02:10.830 --> 00:02:13.349 feels that way. But that is exactly why we're 00:02:13.349 --> 00:02:15.110 here. We're not just going to read the slides 00:02:15.110 --> 00:02:17.289 to you. We're going to decode the logic behind 00:02:17.289 --> 00:02:19.169 it all. A survival guide. We're calling this 00:02:19.169 --> 00:02:21.550 the Pediatric Cardiac Power Hour. But yeah, it's 00:02:21.550 --> 00:02:23.770 a survival guide. We are going to apply the Pareto 00:02:23.770 --> 00:02:26.310 principle, the 80 -20 rule. I love the 80 -20 00:02:26.310 --> 00:02:28.150 rule. So for the listener who's maybe staring 00:02:28.150 --> 00:02:30.229 at a textbook right now and panicking, break 00:02:30.229 --> 00:02:33.050 that down for us. It's simple, really. In pediatric 00:02:33.050 --> 00:02:35.409 cardiac nursing, about 20 % of the concepts, 00:02:35.669 --> 00:02:37.150 and specifically we're talking about the core 00:02:37.150 --> 00:02:38.870 patterns of blood flow and pressure gradients, 00:02:39.389 --> 00:02:42.250 that 20 % will answer 80 % of your exam questions. 00:02:42.389 --> 00:02:44.930 OK, that's good for the test. But more importantly, 00:02:45.330 --> 00:02:48.250 it will help you catch 80 % of the life -threatening 00:02:48.250 --> 00:02:50.659 issues at the bedside. If you understand the 00:02:50.659 --> 00:02:53.400 physics of why blood moves the way it does, you 00:02:53.400 --> 00:02:55.860 don't have to memorize a list of 20 symptoms 00:02:55.860 --> 00:02:58.860 for 20 different defects. You can figure it out. 00:02:58.900 --> 00:03:00.979 You can derive them. You can predict them. That 00:03:00.979 --> 00:03:03.259 is the promise we are making today. We are going 00:03:03.259 --> 00:03:06.800 to give you that 20%. We're drawing heavily from 00:03:06.800 --> 00:03:11.560 chapter 19 on alterations in perfusion and a 00:03:11.560 --> 00:03:14.860 very specific clinical guide on propranol. Yes, 00:03:14.860 --> 00:03:17.219 that one's crucial. We're going to map out the 00:03:17.219 --> 00:03:19.879 transition from the womb to the room. the specific 00:03:19.879 --> 00:03:21.979 defects that flood the lungs versus the ones 00:03:21.979 --> 00:03:24.400 that starve them and the acquired diseases that 00:03:24.400 --> 00:03:27.139 can strike later like Kawasaki. And we absolutely 00:03:27.139 --> 00:03:29.520 cannot forget the pharmacology. That clinical 00:03:29.520 --> 00:03:32.580 guide on propranolol is just full of red flags. 00:03:32.960 --> 00:03:35.819 One wrong instruction to a parent about how to 00:03:35.819 --> 00:03:37.699 handle that bottle. And what could happen? You 00:03:37.699 --> 00:03:39.680 could crash a baby's blood sugar. You could cause 00:03:39.680 --> 00:03:42.139 a seizure. It is that specific. So let's start 00:03:42.139 --> 00:03:44.240 with that big picture. Before we get into the 00:03:44.240 --> 00:03:47.300 weeds of, you know, ventricles and valves, what 00:03:47.300 --> 00:03:50.060 is the fundamental shift we absolutely need to 00:03:50.060 --> 00:03:53.319 understand. The fundamental shift is the transition 00:03:53.319 --> 00:03:57.000 from fetal circulation to neonatal circulation. 00:03:57.819 --> 00:04:00.479 Everything and I mean everything hinges on that 00:04:00.479 --> 00:04:03.400 first breath. Okay. You have to remember in the 00:04:03.400 --> 00:04:07.919 womb the fetus is well it's under water. The 00:04:07.919 --> 00:04:10.879 lungs are effectively solid organ tissue because 00:04:10.879 --> 00:04:13.020 they're filled with fluid. They are a high pressure 00:04:13.020 --> 00:04:15.360 zone. You can't pump blood through them easily. 00:04:15.379 --> 00:04:17.139 And you don't need to, right? Because the placenta 00:04:17.139 --> 00:04:19.160 is doing all the breathing. Correct. The placenta 00:04:19.160 --> 00:04:21.699 is the lung. It's the kidney. It's the gut. It 00:04:21.699 --> 00:04:24.680 does everything. So the fetal heart is designed 00:04:24.680 --> 00:04:27.060 with what I like to call bypass roads. Bypass 00:04:27.060 --> 00:04:29.439 roads. I like that. It knows lungs are closed 00:04:29.439 --> 00:04:32.019 for business. So it uses two specific shortcuts 00:04:32.019 --> 00:04:34.360 to route blood around them. And let's name these 00:04:34.360 --> 00:04:36.480 shortcuts because I'm guessing if they don't 00:04:36.480 --> 00:04:39.019 close later, they become the defects we have 00:04:39.019 --> 00:04:41.860 to treat. That's exactly it. The first is the 00:04:41.860 --> 00:04:44.319 foreman oval. Foreman oval. This is a literal 00:04:44.319 --> 00:04:47.519 hole, or well, more like a flap, between the 00:04:47.519 --> 00:04:50.459 right atrium and the left atrium. Blood comes 00:04:50.459 --> 00:04:52.740 into the right side, it hits that high resistance 00:04:52.740 --> 00:04:54.959 from the fluid -filled lungs, and it basically 00:04:54.959 --> 00:04:56.980 says, no thanks. About going that way. And it 00:04:56.980 --> 00:04:59.379 just slips through this side door that form an 00:04:59.379 --> 00:05:02.000 ovale directly into the left atrium to get pumped 00:05:02.000 --> 00:05:05.259 out to the body. Efficient. Very efficient. And 00:05:05.259 --> 00:05:07.399 the second one. The second one is the ductus 00:05:07.399 --> 00:05:10.079 arteriosus. This connects a pulmonary artery 00:05:10.079 --> 00:05:12.959 directly to the aorta. Another bypass. Exactly. 00:05:13.160 --> 00:05:15.740 So if any blood does sneak past the first door 00:05:15.740 --> 00:05:18.259 and gets into the pulmonary artery, instead of 00:05:18.259 --> 00:05:19.990 fighting its way into the aorta, lungs it takes 00:05:19.990 --> 00:05:22.129 this little off -ramp straight into the aorta. 00:05:22.430 --> 00:05:23.949 Okay so just to get this straight in my head 00:05:23.949 --> 00:05:27.209 in a fetus right to left flow bypassing the lungs 00:05:27.209 --> 00:05:30.089 that's normal it's actually necessary. It's essential 00:05:30.089 --> 00:05:33.930 for survival on the womb but then birth happens. 00:05:33.949 --> 00:05:36.470 The big moment. The cord is clamped the placenta 00:05:36.470 --> 00:05:40.410 is gone suddenly systemic resistance the pressure 00:05:40.410 --> 00:05:43.430 of the body skyrockets and the baby takes that 00:05:43.430 --> 00:05:46.649 first massive, life -changing breaths. And that 00:05:46.649 --> 00:05:49.089 one breath changes all the physics. Completely. 00:05:49.790 --> 00:05:52.430 The lungs inflate with air. The fluid is pushed 00:05:52.430 --> 00:05:55.089 out. All of a sudden, the lungs go from being 00:05:55.089 --> 00:05:57.870 a high -pressure brick to a low -pressure sponge. 00:05:58.170 --> 00:06:01.769 Wow. Blood just rushes into the lungs. And that 00:06:01.769 --> 00:06:04.589 massive rush of oxygenated blood returns to the 00:06:04.589 --> 00:06:07.089 left atrium, which increases the pressure there. 00:06:07.370 --> 00:06:09.990 And that pressure does what? It slams the foreman 00:06:09.990 --> 00:06:13.610 ovals shut, like a trapdoor. And the ductus arteriosus. 00:06:13.720 --> 00:06:16.259 that other bypass. The rise in oxygen levels 00:06:16.259 --> 00:06:18.860 from breathing signals the smooth muscle in that 00:06:18.860 --> 00:06:21.540 vessel to clamp down. It constricts and closes. 00:06:22.040 --> 00:06:24.180 So within a few days, those bypass roads should 00:06:24.180 --> 00:06:26.160 be gone. And you're left with a normal circuit. 00:06:26.379 --> 00:06:28.720 You are now running on a series circuit, lungs 00:06:28.720 --> 00:06:31.399 then body, lungs then body, over and over. But 00:06:31.399 --> 00:06:33.920 when they don't close, or if, you know, the walls 00:06:33.920 --> 00:06:35.459 weren't built right in the first place, that's 00:06:35.459 --> 00:06:37.920 where we get congenital heart defects. Exactly. 00:06:38.120 --> 00:06:40.600 Congenital means born with it. And this brings 00:06:40.600 --> 00:06:43.529 us right to our master 80 -20 map. Instead of 00:06:43.529 --> 00:06:46.170 memorizing 50 different defects, we look for 00:06:46.170 --> 00:06:48.189 patterns. I love patterns. What's pattern number 00:06:48.189 --> 00:06:50.730 one? Pattern number one is the hemodynamic shunt. 00:06:50.990 --> 00:06:53.569 Blood going the wrong way. Just blood going the 00:06:53.569 --> 00:06:55.410 wrong way. And this is all about pressure gradients, 00:06:55.490 --> 00:06:58.310 right? High to low, always. Always. Blood flows 00:06:58.310 --> 00:07:00.209 like water downhill from high pressure to low 00:07:00.209 --> 00:07:03.680 pressure. The left side of the heart is the powerhouse. 00:07:04.279 --> 00:07:06.019 It pumps to the whole body, so it's high pressure. 00:07:06.379 --> 00:07:09.120 The right side is the low pressure pump, just 00:07:09.120 --> 00:07:11.480 for the lungs. So pattern 1A, I'm guessing, is 00:07:11.480 --> 00:07:14.079 when blood flows from left to right? Correct. 00:07:14.720 --> 00:07:16.660 High pressure on the left leaks into the low 00:07:16.660 --> 00:07:19.300 pressure on the right. And where does the right 00:07:19.300 --> 00:07:21.779 side go? To the lungs. So this floods the lungs. 00:07:22.259 --> 00:07:24.459 These are your pink kids with wet lungs. And 00:07:24.459 --> 00:07:27.259 kids with wet lungs, okay. And 1B? That's the 00:07:27.259 --> 00:07:29.600 reverse. If the right side is blocked for some 00:07:29.600 --> 00:07:32.279 reason, the pressure builds up there and it forces 00:07:32.279 --> 00:07:34.939 unoxygenated blue blood over to the left side 00:07:34.939 --> 00:07:37.100 and out to the body. These are your blue kids. 00:07:37.199 --> 00:07:39.720 Okay, so right there, that's a huge clue. If 00:07:39.720 --> 00:07:41.660 I'm taking an exam and the question describes 00:07:41.660 --> 00:07:45.560 a cyanotic or, you know, a blue baby, I immediately 00:07:45.560 --> 00:07:47.980 know I'm looking for a defect that pushes blood 00:07:47.980 --> 00:07:51.019 right to left. Precisely. You have just eliminated 00:07:51.019 --> 00:07:53.660 half the possible answer choices. That is the 00:07:53.660 --> 00:07:55.579 kind of shortcut we need. That's the 80 -20 in 00:07:55.579 --> 00:07:57.870 action. What about pattern number two? Pattern 00:07:57.870 --> 00:08:00.709 number two is the failing heart, or heart failure, 00:08:00.870 --> 00:08:05.189 HF. But here is the critical can't miss takeaway. 00:08:06.269 --> 00:08:09.050 Heart failure in a baby does not look like heart 00:08:09.050 --> 00:08:12.569 failure in an adult. Okay, how so? An adult clutches 00:08:12.569 --> 00:08:15.129 their chest. An adult says, I have an elephant 00:08:15.129 --> 00:08:19.269 on my chest. A baby. A baby can't do that. So 00:08:19.269 --> 00:08:22.189 what do they do instead? They stop growing. The 00:08:22.189 --> 00:08:24.949 absolute classic assessment cue is sweating during 00:08:24.949 --> 00:08:28.779 feeds. Sweating during feeds. That is such a 00:08:28.779 --> 00:08:33.139 specific and kind of strange image. It is. But 00:08:33.139 --> 00:08:35.580 imagine you had to run a marathon while trying 00:08:35.580 --> 00:08:37.600 to drink a milkshake through a coffee stirrer. 00:08:37.779 --> 00:08:40.100 Impossible. That is what breastfeeding feels 00:08:40.100 --> 00:08:42.360 like for a baby in heart failure. Their metabolic 00:08:42.360 --> 00:08:45.019 rate is just through the roof. So pattern two 00:08:45.019 --> 00:08:47.799 is failure to thrive plus respiratory distress 00:08:47.799 --> 00:08:49.899 plus that key feeding difficulty. You got it. 00:08:50.000 --> 00:08:52.019 And pattern three, what's that one? Pattern three 00:08:52.019 --> 00:08:54.179 is the inflammatory storm. This is the acquired 00:08:54.179 --> 00:08:55.840 stuff. This isn't plumbing you're born with. 00:08:55.899 --> 00:08:58.440 This is something that happens later. Think Kawasaki 00:08:58.440 --> 00:09:01.799 and rheumatic fever. The danger here isn't usually 00:09:01.799 --> 00:09:04.120 the initial plumbing. It's the immune system 00:09:04.120 --> 00:09:06.240 attacking the heart structures like the valves 00:09:06.240 --> 00:09:09.220 or the coronary arteries. And the final pattern. 00:09:09.580 --> 00:09:13.009 Pattern four. Pharmacology safety. Specifically, 00:09:13.230 --> 00:09:15.629 they can't miss rules for beta blockers, like 00:09:15.629 --> 00:09:18.509 propranolol. Knowing when to hold the med is 00:09:18.509 --> 00:09:21.190 just as important, if not more important, than 00:09:21.190 --> 00:09:24.100 knowing when to give it. All right, let's go 00:09:24.100 --> 00:09:25.960 deeper. Let's do the system -by -system breakdown. 00:09:26.120 --> 00:09:28.259 We've covered the transition. Now let's talk 00:09:28.259 --> 00:09:30.980 vital signs. I feel like this is a massive trap 00:09:30.980 --> 00:09:33.039 for students who are used to working with adults. 00:09:33.259 --> 00:09:35.600 It is a huge trap. If you walk into a room and 00:09:35.600 --> 00:09:38.860 you see a heart rate of 100 in an adult, you're 00:09:38.860 --> 00:09:40.860 concerned. You're watching them. Sure. In a one 00:09:40.860 --> 00:09:44.179 -month -old infant, a heart rate of 100 is, well, 00:09:44.200 --> 00:09:45.960 it's actually on the low end of normal. Really? 00:09:46.080 --> 00:09:48.860 100 is low? Yes. An infant's heart rate can range 00:09:48.860 --> 00:09:51.659 from 90 all the way up to 160 beats per minute. 00:09:51.919 --> 00:09:53.860 And if they're crying, it can go even higher. 00:09:54.399 --> 00:09:57.320 A resting heart rate of 140 BPM is perfectly 00:09:57.320 --> 00:09:59.779 totally normal. And blood pressure, I assume 00:09:59.779 --> 00:10:02.299 it's the opposite, much lower, maybe around 80 00:10:02.299 --> 00:10:06.080 over 55. As the child ages, the heart rate gradually 00:10:06.080 --> 00:10:07.980 goes down, the blood pressure gradually goes 00:10:07.980 --> 00:10:10.480 up. By the time they're an adolescent, they start 00:10:10.480 --> 00:10:12.759 to reach those adult norms we're all used to. 00:10:12.980 --> 00:10:16.120 OK, so exam tip right there. Do not apply adult 00:10:16.120 --> 00:10:19.059 vital sign standards to a neonate. You will either 00:10:19.059 --> 00:10:22.379 call a code on a perfectly healthy baby, or worse, 00:10:22.659 --> 00:10:25.340 or ignore a crashing one. OK, let's dive into 00:10:25.340 --> 00:10:28.399 that first category of defects, the pink defects, 00:10:29.000 --> 00:10:31.000 the ones with increased pulmonary blood flow. 00:10:31.139 --> 00:10:33.480 These are our left to right shunts. So the main 00:10:33.480 --> 00:10:35.779 players you'll see are atrial septal defect, 00:10:36.139 --> 00:10:39.789 or ASD, ventricular septal defect, VSD. Patent 00:10:39.789 --> 00:10:42.649 ductus arteriosus, PDA, and then a more complex 00:10:42.649 --> 00:10:44.970 one, atrioventricular canal defect. Let's group 00:10:44.970 --> 00:10:47.509 them together. So ASD and VSD are basically holes 00:10:47.509 --> 00:10:49.889 in the walls, right? ASD in the top chambers, 00:10:50.049 --> 00:10:52.269 the atria, and VSD in the bottom, the ventricles. 00:10:52.490 --> 00:10:54.149 Correct. You're just a hole in the septum. And 00:10:54.149 --> 00:10:57.389 PDA, is that leftover fetal vessel staying open? 00:10:57.870 --> 00:10:59.649 Why do we call them pink? What's the logic there? 00:10:59.889 --> 00:11:02.350 It's because oxygenated blood is recirculating. 00:11:02.769 --> 00:11:04.830 The blood has already been to the lungs. It's 00:11:04.830 --> 00:11:07.289 red. It's full of oxygen. It went to the left 00:11:07.289 --> 00:11:09.350 side of the heart. But instead of going out to 00:11:09.350 --> 00:11:12.389 the toes where it's needed, it leaks back through 00:11:12.389 --> 00:11:14.470 the hole to the right side and goes to the lungs 00:11:14.470 --> 00:11:16.830 again. So the body is still getting oxygenated 00:11:16.830 --> 00:11:20.190 blood. The baby isn't blue. They are pink. But 00:11:20.190 --> 00:11:23.090 the lungs are getting double the volume, just 00:11:23.090 --> 00:11:25.610 overwhelmed with blood. Exactly. It's a traffic 00:11:25.610 --> 00:11:28.950 jam in the lungs. This leads directly to pulmonary 00:11:28.950 --> 00:11:32.120 congestion. wet lungs. If you put a stethoscope 00:11:32.120 --> 00:11:34.360 on their chest, you're gonna hear crackles. And 00:11:34.360 --> 00:11:36.320 this brings us right back to that heart failure 00:11:36.320 --> 00:11:39.019 pattern you mentioned. It's a direct line. The 00:11:39.019 --> 00:11:41.539 heart has to pump so much harder to manage this 00:11:41.539 --> 00:11:44.120 chaotic flow, so the right side of the heart 00:11:44.120 --> 00:11:47.019 can enlarge, it gets overworked, and the baby's 00:11:47.019 --> 00:11:49.620 metabolic demand just skyrockets. Let's talk 00:11:49.620 --> 00:11:52.120 about the PDA specifically, the patent ductus 00:11:52.120 --> 00:11:55.200 arteriosus. This one seems to have a very specific 00:11:55.200 --> 00:11:57.899 treatment that exams just love to ask about. 00:11:58.090 --> 00:12:01.009 They do. A PDA is that leftover connection between 00:12:01.009 --> 00:12:03.570 the aorta and the pulmonary artery. Oh. And the 00:12:03.570 --> 00:12:05.889 classic key word you need to listen for is a 00:12:05.889 --> 00:12:08.809 murmur that sounds like a washing machine. A 00:12:08.809 --> 00:12:10.990 continuous machine -like murmur. Washing machine 00:12:10.990 --> 00:12:13.210 murmur. OK, got it. And how do we fix this one? 00:12:13.409 --> 00:12:15.409 Well, surgically, you can ligate it. You can 00:12:15.409 --> 00:12:17.570 tie it off. But before we do that, if it's supposed 00:12:17.570 --> 00:12:19.830 to close and it hasn't, we can try to force it 00:12:19.830 --> 00:12:22.470 close with medication. And we use indomethacin 00:12:22.470 --> 00:12:27.070 or IV ibuprofen. Wait, ibuprofen? You mean like... 00:12:26.840 --> 00:12:30.480 Like Advil? Essentially, yes. They are both NSAIDs 00:12:30.480 --> 00:12:34.279 non -steroidal anti -inflammatory drugs and NSAIDs 00:12:34.279 --> 00:12:36.919 inhibit prostaglandins. And what do prostaglandins 00:12:36.919 --> 00:12:39.320 do? Prostaglandins are the chemical that keeps 00:12:39.320 --> 00:12:41.500 the ductus open in the womb. That's their job. 00:12:42.000 --> 00:12:44.360 So if you block the prostaglandins... You encourage 00:12:44.360 --> 00:12:46.480 the hole to close. You take away the signal that's 00:12:46.480 --> 00:12:49.159 keeping it open. So endomethacin closes the hole. 00:12:49.259 --> 00:12:50.779 I'm repeating that out loud because I have a 00:12:50.779 --> 00:12:52.860 feeling that later on things are going to get 00:12:52.860 --> 00:12:55.960 confusing. Please do. Endomethacin equals a closed 00:12:55.960 --> 00:12:58.789 PDA. Now, let's connect this to the developmental 00:12:58.789 --> 00:13:01.470 impact. This is the need to know for nursing 00:13:01.470 --> 00:13:05.230 care, right? We have a baby who is breathing 00:13:05.230 --> 00:13:07.909 fast to chimney and they're burning calories 00:13:07.909 --> 00:13:09.889 like crazy just to keep their heart beating. 00:13:10.429 --> 00:13:12.629 What does that do to their growth? It stops it. 00:13:12.690 --> 00:13:14.509 This is the definition of failure to thrive. 00:13:15.129 --> 00:13:17.190 These babies, they just fall right off their 00:13:17.190 --> 00:13:20.029 growth curve. So as the nurse, what's the priority 00:13:20.029 --> 00:13:23.529 intervention? Do we just feed them more? You 00:13:23.529 --> 00:13:25.990 can't. You have to completely rethink feeding. 00:13:26.269 --> 00:13:28.330 You can't just let them breastfeed for 45 minutes 00:13:28.330 --> 00:13:30.929 straight. They will burn more calories eating 00:13:30.929 --> 00:13:33.129 than they actually get from the milk. So what's 00:13:33.129 --> 00:13:36.149 the strategy? Small frequent feeds. We use high 00:13:36.149 --> 00:13:38.730 calorie formula. We'll even fortify breast milk. 00:13:39.019 --> 00:13:42.000 bumping it up to 24 or even 30 calories per ounce 00:13:42.000 --> 00:13:44.480 instead of the standard 20. And we might even 00:13:44.480 --> 00:13:46.500 need to use a gavage feed. So putting down an 00:13:46.500 --> 00:13:49.759 NG tube. An NG tube, yes. So they can get the 00:13:49.759 --> 00:13:51.440 nutrition without the work of sucking. It lets 00:13:51.440 --> 00:13:53.799 them rest. Rest becomes a medical intervention 00:13:53.799 --> 00:13:56.879 here. Absolutely. Clustering your care is essential. 00:13:57.240 --> 00:13:59.039 Don't go in every 10 minutes to poke and prod 00:13:59.039 --> 00:14:01.559 them. Go in, do the vitals, change the diaper, 00:14:01.720 --> 00:14:03.539 give them medication, and then let them sleep. 00:14:03.940 --> 00:14:06.840 They need that energy to grow heart muscle. Okay, 00:14:06.919 --> 00:14:09.240 let's flip the script. Let's talk about the blue 00:14:09.240 --> 00:14:12.179 defects, the ones with decreased pulmonary blood 00:14:12.179 --> 00:14:15.639 flow. This is our pattern 1b, the right to left 00:14:15.639 --> 00:14:18.980 shunt. Something is blocking the blood from getting 00:14:18.980 --> 00:14:21.080 to the lungs in the first place. An obstruction. 00:14:21.240 --> 00:14:24.059 A major obstruction. So the unoxygenated blue 00:14:24.059 --> 00:14:27.460 blood gets frustrated, it can't go forward, so 00:14:27.460 --> 00:14:30.159 it pushes through a hole, usually a VSD, and 00:14:30.159 --> 00:14:32.320 goes out to the body without ever picking up 00:14:32.320 --> 00:14:36.100 oxygen. Hence, the baby is blue. Cyanotic. Right. 00:14:36.240 --> 00:14:38.840 And the big bad wolf in this category is Tetralogy 00:14:38.840 --> 00:14:41.899 of Fallot. Tetralogy. That means four. So we 00:14:41.899 --> 00:14:44.080 need to memorize these four specific defects. 00:14:44.120 --> 00:14:46.000 You absolutely do. Okay. Walk us through them. 00:14:46.000 --> 00:14:48.440 What's number one? Number one is pulmonic stenosis. 00:14:48.980 --> 00:14:51.320 The valve leading to the lungs is tight and narrow. 00:14:51.379 --> 00:14:53.639 This is the main problem. It's the source of 00:14:53.639 --> 00:14:55.580 the obstruction. Okay. A tight valve. What's 00:14:55.580 --> 00:14:58.559 number two? Number two is a consequence of number 00:14:58.559 --> 00:15:01.960 one. Right ventricular hypertrophy. The muscle 00:15:01.960 --> 00:15:04.259 of the right ventricle gets really thick and 00:15:04.259 --> 00:15:06.480 beefy from trying to push blood against that 00:15:06.480 --> 00:15:09.799 tight stenotic valve. Makes sense. Number three. 00:15:09.980 --> 00:15:13.200 Number three is a VSD, a ventricular septal defect, 00:15:14.000 --> 00:15:16.340 a hole between the bottom two chambers. And the 00:15:16.340 --> 00:15:18.700 last one, number four. Number four is the overriding 00:15:18.700 --> 00:15:22.169 aorta. The aorta, instead of sitting neatly over 00:15:22.169 --> 00:15:25.149 the left ventricle, is shifted over so it sits 00:15:25.149 --> 00:15:27.610 right on top of that VSD. So it's sucking up 00:15:27.610 --> 00:15:29.830 blood from both sides. Exactly. It's getting 00:15:29.830 --> 00:15:31.990 a mix of red blood from the left and blue blood 00:15:31.990 --> 00:15:34.090 from the right. That sounds like a recipe for 00:15:34.090 --> 00:15:37.190 disaster. It is. And it leads to the single most 00:15:37.190 --> 00:15:40.490 famous exam scenario in all of pediatric cardiac 00:15:40.490 --> 00:15:43.850 nursing, the Tet spell. Also known as a hypercyanotic 00:15:43.850 --> 00:15:46.139 spell. Correct. Paint the picture for us. You're 00:15:46.139 --> 00:15:48.220 the nurse. What happens? Usually it's triggered 00:15:48.220 --> 00:15:51.059 by something that increases oxygen demand. So 00:15:51.059 --> 00:15:53.659 the infant is crying or feeding or even just 00:15:53.659 --> 00:15:55.879 having a bowel movement. Suddenly that tight 00:15:55.879 --> 00:15:58.759 pulmonary valve spasms and shuts down even more. 00:15:58.960 --> 00:16:01.720 So even less blood gets to the lungs. Almost 00:16:01.720 --> 00:16:04.820 no blood goes to the lungs. The baby turns profoundly 00:16:04.820 --> 00:16:07.899 blue. They get limp. They might even lose consciousness. 00:16:08.259 --> 00:16:10.740 It is absolutely terrifying for parents to witness. 00:16:10.860 --> 00:16:13.879 And as the nurse, you walk into that room, what 00:16:13.879 --> 00:16:16.720 is your immediate first line do it now action? 00:16:17.000 --> 00:16:20.259 Knee to chest position. Okay, why? Why does shoving 00:16:20.259 --> 00:16:22.659 a baby's knees into their chest help their heart? 00:16:22.759 --> 00:16:25.259 It seems so counterintuitive. It's pure physics. 00:16:26.200 --> 00:16:28.480 By kinking the femoral arteries in their legs, 00:16:28.740 --> 00:16:31.200 which is essentially what you're doing, you dramatically 00:16:31.200 --> 00:16:33.820 increase the systemic vascular resistance, or 00:16:33.820 --> 00:16:36.169 SVR. So you're making it harder for blood to 00:16:36.169 --> 00:16:38.730 go down to the legs. Right. And that back pressure, 00:16:38.850 --> 00:16:41.429 that high pressure in the body, forces the blood 00:16:41.429 --> 00:16:44.070 to choose the other path, the path of least resistance, 00:16:44.549 --> 00:16:46.669 which is now back into the pulmonary artery into 00:16:46.669 --> 00:16:49.570 the lungs. It reverses the shunt temporarily. 00:16:50.009 --> 00:16:52.730 That is brilliant. It's like mechanical shunting 00:16:52.730 --> 00:16:54.929 with your hands. It works. And what's amazing 00:16:54.929 --> 00:16:57.549 is, for an older child with unrepaired tetralogy 00:16:57.549 --> 00:17:00.029 of phallate, you'll see them do this instinctively. 00:17:00.190 --> 00:17:01.860 What do you mean? They'll be running around on 00:17:01.860 --> 00:17:03.519 the playground, they'll get winded, and they 00:17:03.519 --> 00:17:05.680 will suddenly just squat down in the middle of 00:17:05.680 --> 00:17:07.259 playing. They're giving themselves the knee -to 00:17:07.259 --> 00:17:09.640 -chest position. They are self -treating a mild 00:17:09.640 --> 00:17:13.799 tet spell. Wow. So squatting to breathe? That's 00:17:13.799 --> 00:17:16.180 a major developmental red flag if you see it 00:17:16.180 --> 00:17:18.640 in a toddler. It is a huge one. If a parent ever 00:17:18.640 --> 00:17:20.779 tells you, oh, he always squats when he plays 00:17:20.779 --> 00:17:24.920 tag, That kid needs an echocardiogram stat. Aside 00:17:24.920 --> 00:17:26.880 from the squat, what else do we do for a tech 00:17:26.880 --> 00:17:29.339 spell? OK, so after needed chest, you want to 00:17:29.339 --> 00:17:31.599 apply 100 % oxygen, usually by blow by, so you 00:17:31.599 --> 00:17:33.900 don't agitate them more. You want to calm the 00:17:33.900 --> 00:17:37.079 child. Morphine can help relax that spasm and 00:17:37.079 --> 00:17:40.920 reduce the agitation. And then IV fluids. But 00:17:40.920 --> 00:17:43.279 needed chest is always step one. Okay, another 00:17:43.279 --> 00:17:46.440 one of these blue defects is tricuspid atresia. 00:17:46.579 --> 00:17:49.220 Yes, and the key word here is atresia. It means 00:17:49.220 --> 00:17:52.759 missing or completely closed off. So the tricuspid 00:17:52.759 --> 00:17:54.900 valve. The valve between the right atrium and 00:17:54.900 --> 00:17:57.720 the right ventricle. It just isn't there. It's 00:17:57.720 --> 00:18:00.680 a solid wall of tissue. So no blood can get from 00:18:00.680 --> 00:18:03.059 the right atrium to the right ventricle. Nope. 00:18:03.559 --> 00:18:06.140 It's a dead end. The only way this baby survives 00:18:06.140 --> 00:18:09.400 is if there are other holes, an ASD or a VSD, 00:18:09.599 --> 00:18:12.039 to let that blood escape and mix somewhere else. 00:18:12.269 --> 00:18:15.089 And this brings us to a really important pharmacology 00:18:15.089 --> 00:18:19.529 twist. Yes. In tricuspid atresia, or really any 00:18:19.529 --> 00:18:22.609 severe obstruction to lung flow, the blood flow 00:18:22.609 --> 00:18:25.029 to the lungs might be completely dependent on 00:18:25.029 --> 00:18:27.109 that ductus arteriosus we talked about earlier. 00:18:27.250 --> 00:18:29.690 The one that's supposed to close? The PDA. The 00:18:29.690 --> 00:18:32.069 very same. But in this case, if it closes... 00:18:32.089 --> 00:18:34.990 the baby dies, because that backflow from the 00:18:34.990 --> 00:18:37.329 aorta through the PDA and into the pulmonary 00:18:37.329 --> 00:18:40.009 artery might be the only blood the lungs are 00:18:40.009 --> 00:18:41.849 getting. So we have to keep it open. We must 00:18:41.849 --> 00:18:44.269 keep it open. So what do we give? The opposite 00:18:44.269 --> 00:18:46.829 of what we gave before. Exactly. We give prostaglandins, 00:18:47.009 --> 00:18:50.829 specifically a continuous high V drip of prostaglandin 00:18:50.829 --> 00:18:53.130 E1. And this is the prostaglandin paradox. I 00:18:53.130 --> 00:18:55.190 want to say this clearly. Go for it. For a simple 00:18:55.190 --> 00:18:58.089 PDA where we want it closed, we give endomethacin, 00:18:58.130 --> 00:19:00.759 which is an anti of prostaglandin. Correct. But 00:19:00.759 --> 00:19:02.839 for something like tricuspid atresia, where we 00:19:02.839 --> 00:19:05.920 need it to stay open for survival, we give prostaglandins 00:19:05.920 --> 00:19:08.400 to keep it open. You have to know the defect 00:19:08.400 --> 00:19:11.440 to know the drug. If you give endomethacin to 00:19:11.440 --> 00:19:14.920 a baby with tricuspid atresia, you are effectively 00:19:14.920 --> 00:19:18.119 cutting off their only source of oxygenated blood. 00:19:18.200 --> 00:19:21.619 That is a massive can't miss safety item. Always, 00:19:21.640 --> 00:19:24.279 always check the diagnosis before you even think 00:19:24.279 --> 00:19:26.480 about touching the endomethacin. 100 percent. 00:19:26.779 --> 00:19:29.240 OK, let's shift gears. Let's move to the obstructive 00:19:29.240 --> 00:19:32.930 disorders. the pipes are pitched. Coarctation 00:19:32.930 --> 00:19:35.849 of the aorta is the big one here. Coarctation 00:19:35.849 --> 00:19:38.289 is just a fancy word for narrowing. It usually 00:19:38.289 --> 00:19:40.490 happens in the aortic arch right after the arteries 00:19:40.490 --> 00:19:42.829 branch off to the head and the arms, but before 00:19:42.829 --> 00:19:44.569 the arteries go down to the legs and the rest 00:19:44.569 --> 00:19:47.230 of the body. So if you imagine a kink in a garden 00:19:47.230 --> 00:19:50.349 hose, it's the perfect analogy. Upstream of the 00:19:50.349 --> 00:19:52.390 kink, so the head and the arms, the pressure 00:19:52.390 --> 00:19:55.289 is super high. Downstream of the kink, the legs 00:19:55.289 --> 00:19:58.269 and the kidneys, the pressure is just a trickle. 00:19:58.359 --> 00:20:01.740 And this leads to a very, very specific assessment 00:20:01.740 --> 00:20:04.099 finding, doesn't it? The Hallmark finding. The 00:20:04.099 --> 00:20:06.160 disparity in pulses and blood pressure between 00:20:06.160 --> 00:20:08.579 the upper and lower extremities. You check the 00:20:08.579 --> 00:20:11.140 BP in the right arm and it's high. You feel the 00:20:11.140 --> 00:20:13.359 brachial or radial pulses and they're bounding. 00:20:13.599 --> 00:20:15.380 And then you check the legs. You check the BP 00:20:15.380 --> 00:20:17.690 in the leg and it's low. and you try to feel 00:20:17.690 --> 00:20:20.750 for femoral pulses, and they're weak or maybe 00:20:20.750 --> 00:20:23.250 even absent. And normal physiology says that 00:20:23.250 --> 00:20:25.430 leg BP should be a little bit higher than arm 00:20:25.430 --> 00:20:28.069 BP, right? Correct. So if you find that the leg 00:20:28.069 --> 00:20:30.569 pressure is lower than the arm pressure, you 00:20:30.569 --> 00:20:32.769 have just diagnosed coarctation of the aorta. 00:20:32.970 --> 00:20:35.970 And what's the long -term risk here? Well, you've 00:20:35.970 --> 00:20:39.049 got two problems. Stroke for the brain because 00:20:39.049 --> 00:20:41.230 of that severe hypertension in the upper body, 00:20:41.789 --> 00:20:44.890 and poor perfusion to the gut and the kidneys 00:20:44.890 --> 00:20:48.200 downstream. Developmentally, how might this present 00:20:48.200 --> 00:20:50.660 in a slightly older child who's, you know, walking 00:20:50.660 --> 00:20:52.900 and talking? These kids might complain of leg 00:20:52.900 --> 00:20:55.380 pain or cramping with exercise, that's claudication. 00:20:56.039 --> 00:20:58.240 Or they might have frequent headaches and nosebleeds 00:20:58.240 --> 00:21:00.740 from the high blood pressure in their head. Nosebleeds 00:21:00.740 --> 00:21:02.619 and leg pain, you know, taken separately, those 00:21:02.619 --> 00:21:04.599 sound like typical growing pains. But if you 00:21:04.599 --> 00:21:07.079 put them together... The smartiac red flag. Okay, 00:21:07.099 --> 00:21:09.599 now for the really complex ones, the mixed defects. 00:21:09.960 --> 00:21:12.359 Let's start with transhibition of the great arteries, 00:21:12.680 --> 00:21:15.789 or TGA. This is a plumbing nightmare. The aorta 00:21:15.789 --> 00:21:19.390 and the pulmonary artery are just swapped. They're 00:21:19.390 --> 00:21:21.109 hooked up to the wrong ventricle. What does that 00:21:21.109 --> 00:21:23.109 mean for blood flow? It means the right ventricle 00:21:23.109 --> 00:21:26.069 pumps blue, unoxygenated blood into the aorta, 00:21:26.230 --> 00:21:28.369 which goes out to the body and comes back blue. 00:21:28.569 --> 00:21:31.349 And the left ventricle pumps red, oxygenated 00:21:31.349 --> 00:21:33.390 blood into the pulmonary artery, which goes to 00:21:33.390 --> 00:21:35.710 the lungs and comes back red. You've got two 00:21:35.710 --> 00:21:38.150 completely separate parallel circles that never 00:21:38.150 --> 00:21:41.789 touch. Exactly. The body gets zero oxygen. This 00:21:41.789 --> 00:21:44.269 is incompatible with life unless... Unless there's 00:21:44.269 --> 00:21:46.730 a hole. Right. There has to be a place for the 00:21:46.730 --> 00:21:50.130 blood to mix. We need a PDA or an ASD or a VSD. 00:21:50.390 --> 00:21:52.529 And again, this is a prostaglandin's end -now 00:21:52.529 --> 00:21:55.329 emergency. Keep that ductus open at all costs 00:21:55.329 --> 00:21:57.410 until surgery can switch the vessels back to 00:21:57.410 --> 00:21:59.809 where they belong. And what about hypoplastic 00:21:59.809 --> 00:22:02.930 left heart syndrome, HLHS? Hypoplastic just means 00:22:02.930 --> 00:22:06.630 underdeveloped. So in HLHS, the entire left ventricle, 00:22:06.710 --> 00:22:10.700 the main pump for the body, is tiny. non -functional 00:22:10.700 --> 00:22:12.940 and undeveloped. It can't pump blood to the body. 00:22:13.119 --> 00:22:16.160 This sounds incredibly severe. It is one of the 00:22:16.160 --> 00:22:19.680 most severe. These babies typically require a 00:22:19.680 --> 00:22:23.140 series of three palliative surgeries. The Norwood, 00:22:23.720 --> 00:22:26.000 the Glen, and the Fonten, starting in the very 00:22:26.000 --> 00:22:28.680 first week of life, just to survive. The developmental 00:22:28.680 --> 00:22:31.920 impact here must be absolutely massive. It is. 00:22:32.240 --> 00:22:34.460 These children can spend months of their first 00:22:34.460 --> 00:22:37.200 few years in the hospital. They have sternal 00:22:37.200 --> 00:22:39.910 precautions after surgery. meaning you can't 00:22:39.910 --> 00:22:42.589 lift them up under the arms. So their gross motor 00:22:42.589 --> 00:22:45.410 milestones, like rolling over or crawling, are 00:22:45.410 --> 00:22:47.430 often delayed because they're tethered to machines 00:22:47.430 --> 00:22:49.849 or recovering from open heart surgery. And feeding 00:22:49.849 --> 00:22:52.609 has to be a challenge. A huge challenge. Many 00:22:52.609 --> 00:22:54.829 of these babies develop oral aversions. Think 00:22:54.829 --> 00:22:57.230 about it. They've been intubated, suctioned constantly, 00:22:57.750 --> 00:23:00.630 had NG tubes down their nose. They start to associate 00:23:00.630 --> 00:23:02.549 anything near their mouth with pain or discomfort. 00:23:02.809 --> 00:23:04.869 So even after the heart is fixed, you're left 00:23:04.869 --> 00:23:07.730 with a major behavioral feeding issue. Exactly. 00:23:07.809 --> 00:23:09.849 You might be dealing with a toddler who simply 00:23:09.849 --> 00:23:11.990 refuses to eat by mouth. You know, that brings 00:23:11.990 --> 00:23:14.630 us to the soft skills part of the outline, psychosocial 00:23:14.630 --> 00:23:17.490 aspect. But honestly, calling it soft feels wrong. 00:23:17.849 --> 00:23:20.910 It's hard. It's the hardest part. You, the surgeon, 00:23:21.230 --> 00:23:24.029 you fix the hole. But you send home a family 00:23:24.029 --> 00:23:27.410 that is completely terrified. So post -op teaching 00:23:27.410 --> 00:23:29.809 is critical. What's one of the first things parents 00:23:29.809 --> 00:23:32.099 ask? Can I pick them up? Can I hold my baby? 00:23:32.200 --> 00:23:36.079 And the answer is yes, please do. But we have 00:23:36.079 --> 00:23:39.160 to teach them how. You scoop them, support the 00:23:39.160 --> 00:23:40.559 head and the bottom. You just don't lift them 00:23:40.559 --> 00:23:42.940 under the arms because of the stress on that 00:23:42.940 --> 00:23:45.559 fresh sternal incision. Why is that holding so 00:23:45.559 --> 00:23:48.319 important? Because bonding is priority number 00:23:48.319 --> 00:23:50.759 one. If the baby cries, their heart rate goes 00:23:50.759 --> 00:23:52.779 up, their blood pressure goes up, the workload 00:23:52.779 --> 00:23:55.900 on their heart goes up. A comforted baby is a 00:23:55.900 --> 00:23:58.849 hemodynamically stable baby. I love that. A comforted 00:23:58.849 --> 00:24:00.990 baby is a hemodynamically stable baby. Everyone 00:24:00.990 --> 00:24:03.410 listening, write that down. Also, simple things. 00:24:03.769 --> 00:24:05.990 Incision care. Keep it clean, keep it dry. No 00:24:05.990 --> 00:24:08.710 lotions, no powders. And teaching them the signs 00:24:08.710 --> 00:24:11.559 of infection redness, drainage fever. OK, let's 00:24:11.559 --> 00:24:14.940 pivot. We've covered the born with it, the congenital 00:24:14.940 --> 00:24:17.640 defects. Now let's talk about the acquired, that 00:24:17.640 --> 00:24:19.779 inflammatory storm you mentioned, pattern number 00:24:19.779 --> 00:24:22.480 three. Let's start with Kawasaki disease. This 00:24:22.480 --> 00:24:25.220 is a weird one. We still don't know exactly what 00:24:25.220 --> 00:24:28.519 causes it. It's idiopathic, but it's an acute 00:24:28.519 --> 00:24:31.859 systemic vasculitis. So inflammation of all the 00:24:31.859 --> 00:24:34.140 blood vessels. Exactly. All throughout the body. 00:24:34.200 --> 00:24:36.380 And who gets it? What's the typical age group? 00:24:36.839 --> 00:24:39.460 It's almost always toddlers and preschoolers. 00:24:40.289 --> 00:24:42.670 Usually children under five years old. And what 00:24:42.670 --> 00:24:45.089 does it look like? How does it present? It comes 00:24:45.089 --> 00:24:48.170 in phases. The acute phase is the most dramatic. 00:24:48.930 --> 00:24:51.569 The hallmark sign is a high fever, over 102, 00:24:52.150 --> 00:24:55.250 that is unresponsive to Tylenol or Motrin and 00:24:55.250 --> 00:24:58.009 it lasts for five or more days. That's the key. 00:24:58.250 --> 00:25:00.990 A persistent high fever. Plus what else? Plus 00:25:00.990 --> 00:25:04.009 the cream symptoms. It's a mnemonic. Okay, breakdown 00:25:04.009 --> 00:25:07.410 cream for us. C is for conjunctivitis red eyes 00:25:07.410 --> 00:25:10.950 but with no drainage or pus. R is for rash, usually 00:25:10.950 --> 00:25:13.390 all over the trunk. E is for edema swelling of 00:25:13.390 --> 00:25:16.349 the hands and feet and erythema bright red palms 00:25:16.349 --> 00:25:19.210 and soles. A is for adenopathy swollen lymph 00:25:19.210 --> 00:25:21.829 nodes, usually just one in the neck. And M is 00:25:21.829 --> 00:25:23.710 for mucosal changes. And that's where we get 00:25:23.710 --> 00:25:25.730 that classic exam description. The strawberry 00:25:25.730 --> 00:25:28.890 tongue and cracked red bleeding lips. And I've 00:25:28.890 --> 00:25:31.049 heard about peeling skin too. Yes, that comes 00:25:31.049 --> 00:25:33.710 a little later in the subacute phase. The skin 00:25:33.710 --> 00:25:35.769 on their fader tips and toes will start to peel 00:25:35.769 --> 00:25:38.349 off in sheets. Why is this so dangerous? I mean, 00:25:38.430 --> 00:25:40.609 it sounds miserable, like a really bad flu, but 00:25:40.609 --> 00:25:43.329 why is it a cardiac emergency? The danger is 00:25:43.329 --> 00:25:47.190 the heart. The inflammation has a special affinity 00:25:47.190 --> 00:25:50.210 for the coronary arteries. It can cause aneurysms 00:25:50.210 --> 00:25:52.950 weak, ballooning spots in the arteries, which 00:25:52.950 --> 00:25:54.869 can then lead to blood clots and heart attacks 00:25:54.869 --> 00:25:57.009 in a five -year -old. A heart attack in a child? 00:25:57.210 --> 00:26:00.269 That's terrifying. So how do we treat it? This 00:26:00.269 --> 00:26:02.849 brings us to a major pharmacology exception. 00:26:03.069 --> 00:26:05.829 We treat it with two main things. First, a big 00:26:05.829 --> 00:26:08.609 dose of IV intravenous immunoglobulin to calm 00:26:08.609 --> 00:26:11.589 the whole immune system down and high dose aspirin. 00:26:11.640 --> 00:26:13.440 And there should be a siren going off in your 00:26:13.440 --> 00:26:15.880 head right now. Aspirin in kids. Normally, we 00:26:15.880 --> 00:26:17.519 never give aspirin to children because of the 00:26:17.519 --> 00:26:19.420 risk of Ray's syndrome, which causes massive 00:26:19.420 --> 00:26:21.759 liver and brain swelling, especially after a 00:26:21.759 --> 00:26:24.059 viral illness like the flu or chickenpox. But 00:26:24.059 --> 00:26:27.220 this is the exception. Kalesaki is the one time 00:26:27.220 --> 00:26:29.519 the benefit -preventing coronary artery clots 00:26:29.519 --> 00:26:32.220 outweighs the risk. We need that antiplatelet 00:26:32.220 --> 00:26:34.539 effect from the aspirin. So an exam writer's 00:26:34.539 --> 00:26:37.039 favorite question would be, which of these children 00:26:37.039 --> 00:26:39.859 requires a prescription for aspirin? And the 00:26:39.859 --> 00:26:42.240 answer is always the child with Kawasaki disease. 00:26:42.740 --> 00:26:45.119 But you still have to teach the parents to be 00:26:45.119 --> 00:26:48.339 vigilant, to watch for signs of raise, and to 00:26:48.339 --> 00:26:50.940 avoid other viral illnesses because the risk, 00:26:51.019 --> 00:26:54.220 while small, is still there. Next up in the acquired 00:26:54.220 --> 00:26:57.859 category, rheumatic fever. This is another autoimmune 00:26:57.859 --> 00:26:59.980 reaction, but this time we know the trigger. 00:27:00.240 --> 00:27:03.819 It's group A strep. So an untreated case of strep 00:27:03.819 --> 00:27:06.789 throat. Exactly. About two to four weeks after 00:27:06.789 --> 00:27:09.230 a sore throat that wasn't fully treated, the 00:27:09.230 --> 00:27:11.569 child's body develops antibodies that are supposed 00:27:11.569 --> 00:27:13.769 to fight the strep, but they mistakenly attack 00:27:13.769 --> 00:27:15.890 their own heart valves. And which valve is most 00:27:15.890 --> 00:27:18.089 commonly affected? Usually the metral valve. 00:27:18.769 --> 00:27:20.710 But the antibodies can also attack the joints 00:27:20.710 --> 00:27:22.789 in the brain. How do we diagnose it? It sounds 00:27:22.789 --> 00:27:24.869 like it could be vague. We use something called 00:27:24.869 --> 00:27:27.869 the modified Jones criteria. You need evidence 00:27:27.869 --> 00:27:30.579 of a recent strep infection. like a positive 00:27:30.579 --> 00:27:33.619 titer, plus either two major symptoms or one 00:27:33.619 --> 00:27:35.640 major and two minor symptoms. What are the major 00:27:35.640 --> 00:27:38.539 symptoms? The big ones are carditis, which is 00:27:38.539 --> 00:27:41.539 inflammation of the heart, polyarthritis, which 00:27:41.539 --> 00:27:44.200 is a migrating joint pain, it'll be in the knee 00:27:44.200 --> 00:27:47.859 one day, the elbow the next, subcutaneous nodules, 00:27:48.420 --> 00:27:52.940 a specific rash called erythema marginatum, Korea. 00:27:52.960 --> 00:27:55.380 The Korea, that's St. Vitus dance, right? The 00:27:55.380 --> 00:27:58.599 jerky movement. Yes. Sudden, aimless, jerky movements 00:27:58.599 --> 00:28:00.660 of the arms and legs. It can be really scary 00:28:00.660 --> 00:28:02.960 for parents to see. Does it go away? It does 00:28:02.960 --> 00:28:04.880 resolve, but it's very distressing while it's 00:28:04.880 --> 00:28:07.420 happening. But the real priority here is prevention. 00:28:07.660 --> 00:28:09.279 Treat the strep throat. Just treat the strep 00:28:09.279 --> 00:28:11.099 throat. Right. If a kid has a sore throat and 00:28:11.099 --> 00:28:14.130 a fever, get a culture. If it's positive, make 00:28:14.130 --> 00:28:16.049 sure they finish the entire course of antibiotics. 00:28:16.349 --> 00:28:18.470 And if they do get rheumatic fever, what's the 00:28:18.470 --> 00:28:20.630 long -term management? Long -term antibiotics, 00:28:21.289 --> 00:28:24.430 sometimes for years or even into adulthood, to 00:28:24.430 --> 00:28:26.910 prevent a recurrence and to prevent further damage 00:28:26.910 --> 00:28:28.650 to the heart valves. Okay, one more required 00:28:28.650 --> 00:28:31.720 condition, infective endocarditis. This is basically 00:28:31.720 --> 00:28:33.660 bacteria growing on the valves or the lining 00:28:33.660 --> 00:28:36.339 of the heart. It often happens in kids who already 00:28:36.339 --> 00:28:39.819 have a congenital heart defect or who have prosthetic 00:28:39.819 --> 00:28:41.900 valves or central lines. What are some of the 00:28:41.900 --> 00:28:44.599 weird classic signs for this one? The classic 00:28:44.599 --> 00:28:47.940 ones are Osler nodules, which are painful, tender 00:28:47.940 --> 00:28:50.059 bumps on the finger pads. I remember it as oh 00:28:50.059 --> 00:28:53.069 for ouch. Oh for ouch. Good one. And then there 00:28:53.069 --> 00:28:55.730 are Janeway lesions, which are flat, painless 00:28:55.730 --> 00:28:58.309 red spots on the palms of the hands or the soles 00:28:58.309 --> 00:29:01.349 of the feet. And you might also see splinter 00:29:01.349 --> 00:29:03.589 hemorrhages under the fingernails. And what's 00:29:03.589 --> 00:29:06.369 the key to prevention here? Prophylactic antibiotics 00:29:06.369 --> 00:29:09.700 before dental procedures. If you have a high 00:29:09.700 --> 00:29:12.859 -risk kid, one with a prosthetic valve or a history 00:29:12.859 --> 00:29:15.579 of endocarditis, they need a dose of amoxicillin 00:29:15.579 --> 00:29:17.400 before the dentist even cleans their teeth. Because 00:29:17.400 --> 00:29:19.980 the bacteria from the mouth. Love to travel to 00:29:19.980 --> 00:29:22.119 the heart and set up shop on damaged tissue. 00:29:22.359 --> 00:29:24.640 Okay, we are heading into the final stretch. 00:29:24.960 --> 00:29:27.680 Section C, the pharmacology deep dive. We've 00:29:27.680 --> 00:29:30.279 talked aspirin, endomethacin, prostaglandins. 00:29:30.539 --> 00:29:34.119 Now let's talk about a daily driver, propranolol. 00:29:34.539 --> 00:29:38.720 Propranolol. It's a beta blocker, a class 2 antiarrhythmic. 00:29:38.859 --> 00:29:41.220 And the key descriptor here is non -selective. 00:29:41.279 --> 00:29:43.759 What does that mean for us clinically? It means 00:29:43.759 --> 00:29:46.160 it blocks more than one type of beta receptor. 00:29:46.859 --> 00:29:49.240 It blocks beta 1 receptors, which are primarily 00:29:49.240 --> 00:29:51.960 in the heart, and it also blocks beta 2 receptors, 00:29:52.319 --> 00:29:54.559 which are primarily in the lungs. So what's the 00:29:54.559 --> 00:29:57.180 effect? Blocking beta 1 is what we want. It slows 00:29:57.180 --> 00:29:58.720 the heart rate and lowers the blood pressure. 00:29:58.980 --> 00:30:02.759 Good. Blocking beta 2, however, causes bronchoconstriction. 00:30:03.180 --> 00:30:07.970 Bad. So... High caution in any child with a history 00:30:07.970 --> 00:30:10.410 of asthma. Extremely high caution. It can trigger 00:30:10.410 --> 00:30:12.650 a full -blown asthma attack. Now, looking at 00:30:12.650 --> 00:30:15.269 our clinical guide here, propranolol is used 00:30:15.269 --> 00:30:17.970 for arrhythmias, sure, but also for something 00:30:17.970 --> 00:30:21.430 pretty surprising, infantile hemangiomas. Yes, 00:30:21.569 --> 00:30:24.250 those bright red raised strawberry burst marks. 00:30:24.730 --> 00:30:27.150 But Cranwall works wonders to shrink them. The 00:30:27.150 --> 00:30:29.750 brand name for this formulation is often hemangiol. 00:30:29.980 --> 00:30:32.779 And there are some very, very specific administration 00:30:32.779 --> 00:30:35.460 rules for hemangiol in infants. Let's run through 00:30:35.460 --> 00:30:37.819 the need -to -know safety check. Okay, rule number 00:30:37.819 --> 00:30:40.680 one, feedings. You absolutely must give it during 00:30:40.680 --> 00:30:43.039 or immediately after a feeding, never on an empty 00:30:43.039 --> 00:30:45.759 stomach. Okay, why is that so critical? Because 00:30:45.759 --> 00:30:47.940 beta blockers can mask the signs and symptoms 00:30:47.940 --> 00:30:50.819 of hypoglycemia low blood sugar. Normally when 00:30:50.819 --> 00:30:53.519 your blood sugar drops, your body releases adrenaline. 00:30:53.740 --> 00:30:57.400 You get shaky, jittery, your heart races, tachycardia. 00:30:57.960 --> 00:31:00.140 Beta blockers stop all of that. They stop the 00:31:00.140 --> 00:31:02.259 jitters and they stop the tachycardia. So the 00:31:02.259 --> 00:31:04.799 baby could be dangerously hypoglycemic and you 00:31:04.799 --> 00:31:06.799 would have no idea until they have a seizure. 00:31:07.180 --> 00:31:09.920 That is a critical life -saving teaching point 00:31:09.920 --> 00:31:13.960 for parents. No food equals monolally. Absolutely. 00:31:14.599 --> 00:31:16.319 Which leads to rule number two, the vomiting 00:31:16.319 --> 00:31:19.420 rule. If the child is vomiting or just not eating 00:31:19.420 --> 00:31:22.779 well, hold of the dose. Call the provider. Got 00:31:22.779 --> 00:31:24.660 it. What's rule number three? Rule number three 00:31:24.660 --> 00:31:27.299 is the shake rule. Do not shake the hemangel 00:31:27.299 --> 00:31:30.509 bottle. But why not? Almost every liquid suspension 00:31:30.509 --> 00:31:32.769 tells you to shake well. Because this specific 00:31:32.769 --> 00:31:35.390 one creates a lot of bubbles and foam. If you 00:31:35.390 --> 00:31:37.890 draw up a syringe full of foam, you're not getting 00:31:37.890 --> 00:31:39.910 an accurate amount of medication. You're almost 00:31:39.910 --> 00:31:42.069 certainly going to underdose the child, so you 00:31:42.069 --> 00:31:44.529 just invert the bottle gently a few times. And 00:31:44.529 --> 00:31:47.750 what about the black box warning? Abrupt discontinuation. 00:31:48.009 --> 00:31:50.769 You cannot just stop propranolol cold turkey. 00:31:51.049 --> 00:31:53.289 It can cause a severe rebound effect, rebound 00:31:53.289 --> 00:31:56.549 hypertension, tachycardia, or in adults, even 00:31:56.549 --> 00:31:59.829 a heart attack. You must taper it slowly, usually 00:31:59.829 --> 00:32:02.210 over about two weeks. So if a parent calls the 00:32:02.210 --> 00:32:04.329 clinic and says, oh, we ran out three days ago, 00:32:04.569 --> 00:32:06.950 that is an urgent situation. That is an emergency. 00:32:07.069 --> 00:32:09.930 They need to get a refill immediately. Wow. We've 00:32:09.930 --> 00:32:11.549 covered a massive amount of ground. Let's try 00:32:11.549 --> 00:32:13.769 to synthesize some of this. I want to do a rapid 00:32:13.769 --> 00:32:16.009 fire compare and contrast. Ready? Let's do it. 00:32:16.470 --> 00:32:20.029 Congenital versus acquired. Congenital is structural 00:32:20.029 --> 00:32:22.339 plumbing issues. You're born with it. The main 00:32:22.339 --> 00:32:25.619 problem is hemodynamics, so flow. Acquired is 00:32:25.619 --> 00:32:28.380 inflammatory or infectious, like Kawasaki or 00:32:28.380 --> 00:32:30.880 strep. It happens later. The main problem is 00:32:30.880 --> 00:32:33.299 damage to the vessels or the valves. OK. The 00:32:33.299 --> 00:32:35.779 prostaglandin paradox. A simple PDA. We want 00:32:35.779 --> 00:32:38.500 to close it. We use endomethacin. Complex blue 00:32:38.500 --> 00:32:41.000 baby defects like TGA or trichespid atresia. 00:32:41.519 --> 00:32:43.619 We might need to keep the PDA open for survival. 00:32:44.059 --> 00:32:46.539 We use prostaglandins. Perfect. Fluid overload 00:32:46.539 --> 00:32:49.359 versus cyanosis. Left to right shunt. like a 00:32:49.359 --> 00:32:52.259 VSD or ASD, gives you wet lungs and a pink baby. 00:32:53.019 --> 00:32:55.180 Your priority is monitoring for heart failure. 00:32:55.740 --> 00:32:58.240 Right to left shunt, like Tetralogy of Fallot, 00:32:58.440 --> 00:33:01.059 gives you a blue baby. Your priority is monitoring 00:33:01.059 --> 00:33:04.299 for Tet spells. This really brings us to the 00:33:04.299 --> 00:33:06.900 so -what for the listener. We've given them the 00:33:06.900 --> 00:33:08.940 80 -20. We've given them the patterns. What does 00:33:08.940 --> 00:33:11.740 it all mean at the bedside? The so -what is that 00:33:11.740 --> 00:33:13.799 pediatric cardiac nursing isn't just about the 00:33:13.799 --> 00:33:16.690 heart. It's about the whole child. A heart defect 00:33:16.690 --> 00:33:19.009 affects feeding, which affects growth, which 00:33:19.009 --> 00:33:21.430 affects brain development. It affects the parent's 00:33:21.430 --> 00:33:24.410 ability to bond with their sick infant. So it's 00:33:24.410 --> 00:33:26.549 not just about the monitors. When you walk into 00:33:26.549 --> 00:33:28.450 that room, don't just look at the monitor. Look 00:33:28.450 --> 00:33:30.089 at the baby. Are they sweating when they eat? 00:33:30.210 --> 00:33:32.230 Are they squatting when they play? Are the parents 00:33:32.230 --> 00:33:34.670 terrified to touch them? Your interventions, 00:33:34.789 --> 00:33:36.950 knowing to put their knees to their chest, clustering 00:33:36.950 --> 00:33:39.309 their care to let them rest, teaching parents 00:33:39.309 --> 00:33:41.690 how to do high calorie feeds, those are the things 00:33:41.690 --> 00:33:45.079 that save lives and save brains. And just realizing 00:33:45.079 --> 00:33:47.180 that a normal heart rate for a two -month -old 00:33:47.180 --> 00:33:50.799 is 130 helps you not panic and helps you focus 00:33:50.799 --> 00:33:54.099 on what actually matters. Exactly. Know your 00:33:54.099 --> 00:33:57.400 norms so you can spot the real outliers. We always 00:33:57.400 --> 00:33:59.980 like to end with a provocative thought, something 00:33:59.980 --> 00:34:02.140 for our listeners to chew on after we're done. 00:34:02.259 --> 00:34:04.880 Okay, here's one. We've gotten really, really 00:34:04.880 --> 00:34:07.440 good at saving these kids. The survival rates 00:34:07.440 --> 00:34:10.260 for even the most complex congenital heart disease 00:34:10.260 --> 00:34:13.460 are higher than they have ever been. But that 00:34:13.460 --> 00:34:16.400 means we are creating a brand new patient population 00:34:16.400 --> 00:34:20.039 the adult with congenital heart disease ACHD 00:34:20.039 --> 00:34:22.599 right and a heart that was fixed with a patch 00:34:22.599 --> 00:34:25.780 or a conduit at age 2 isn't a normal heart at 00:34:25.780 --> 00:34:28.809 age 40 They have scar tissue, they have a higher 00:34:28.809 --> 00:34:31.590 risk of rhythm issues, they have different hemodynamic 00:34:31.590 --> 00:34:33.789 pressures. So what's the question? The question 00:34:33.789 --> 00:34:36.309 is, how does lifelong acquired heart disease 00:34:36.309 --> 00:34:38.610 management, things like cholesterol, stress, 00:34:38.929 --> 00:34:41.869 diet, exercise, how does that change for someone 00:34:41.869 --> 00:34:44.090 who was born with a fundamental structural defect? 00:34:44.750 --> 00:34:47.309 We're entering an era where our pediatric cardiac 00:34:47.309 --> 00:34:49.349 patients are outliving their initial repairs. 00:34:50.030 --> 00:34:52.150 What does that long -term nursing care look like? 00:34:52.280 --> 00:34:54.800 That is a fascinating frontier. The pediatric 00:34:54.800 --> 00:34:57.300 patient who is now 45 years old. A whole new 00:34:57.300 --> 00:34:59.920 world of nursing. All right, friends. Take a 00:34:59.920 --> 00:35:02.559 deep breath. Your heart rate should be returning 00:35:02.559 --> 00:35:04.980 to normal. Unless you're an infant, in which 00:35:04.980 --> 00:35:08.780 case, you know, try to stay around 140. Check 00:35:08.780 --> 00:35:10.679 the show notes for our 80 -20 cheat sheet on 00:35:10.679 --> 00:35:12.880 all this. Keep those pressure gradients flowing. 00:35:13.119 --> 00:35:16.019 And remember, never, ever shake the soprano off. 00:35:16.300 --> 00:35:17.440 I'll see you in the next e -talk.