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 --> 00:00:46.689 fast. Welcome to the emergency room. Welcome 00:00:46.689 --> 00:00:49.859 back to the Deep Dive. Today, we are walking 00:00:49.859 --> 00:00:53.179 into what is, I think, arguably the most intimidating 00:00:53.179 --> 00:00:55.439 room in the pediatric hospital. Oh, absolutely. 00:00:55.700 --> 00:00:57.740 We're tackling the beast. And when I say beast, 00:00:57.840 --> 00:01:00.179 I mean the one unit that seems to strike absolute 00:01:00.179 --> 00:01:03.320 fear into the hearts of nursing students, new 00:01:03.320 --> 00:01:06.700 grads, and even seasoned nurses more than any 00:01:06.700 --> 00:01:08.560 other system in the body. We are talking about 00:01:08.560 --> 00:01:11.219 the heart. We are talking about the heart, specifically 00:01:11.219 --> 00:01:15.420 chapter 19. the child with an alteration in cardiovascular 00:01:15.420 --> 00:01:18.000 status. Now, I've got to be honest with you. 00:01:18.060 --> 00:01:20.140 When I first looked at this stack of slides, 00:01:20.340 --> 00:01:22.680 the textbooks, the ATI notes, all the stuff you 00:01:22.680 --> 00:01:25.439 sent over, I felt my own blood pressure go up. 00:01:25.579 --> 00:01:28.540 I believe it. You've got defects with names that 00:01:28.540 --> 00:01:31.079 sound like, I don't know... complex spells from 00:01:31.079 --> 00:01:33.340 Harry Potter to Trilogy of Fallot, Transposition 00:01:33.340 --> 00:01:35.599 of the Great Arteries. You've got hemodynamics, 00:01:35.879 --> 00:01:38.159 you've got physics, you've got medications with 00:01:38.159 --> 00:01:40.400 therapeutic windows so narrow they're practically 00:01:40.400 --> 00:01:42.900 invisible. It is intimidating. I think for a 00:01:42.900 --> 00:01:45.340 lot of learners, the cardiovascular system, it 00:01:45.340 --> 00:01:48.500 just feels like a maze. You turn one corner and 00:01:48.500 --> 00:01:50.319 you're dealing with electrical conduction, you 00:01:50.319 --> 00:01:53.980 turn another and it's plumbing and pressure gradients. 00:01:53.980 --> 00:01:56.260 Right. And unlike, say, the skin or the bones, 00:01:56.400 --> 00:01:58.680 you can't see what's happening. It's all hidden 00:01:58.680 --> 00:02:01.890 inside. So if you don't have a map, you get lost 00:02:01.890 --> 00:02:05.390 very, very quickly. And in pediatrics, getting 00:02:05.390 --> 00:02:08.789 lost can have, well, catastrophic consequences. 00:02:09.210 --> 00:02:11.710 Things happen fast. Oh, fast. Exactly. And the 00:02:11.710 --> 00:02:13.729 stakes, they couldn't be higher. We're talking 00:02:13.729 --> 00:02:15.710 about the engine of the body, keeping the blood 00:02:15.710 --> 00:02:19.150 moving, keeping the brain oxygenated. So here 00:02:19.150 --> 00:02:22.310 is our mission for today's deep dive. We are 00:02:22.310 --> 00:02:24.189 not just going to read the textbook to you. We 00:02:24.189 --> 00:02:28.069 are going to adopt a persona. Ah! Today, we are 00:02:28.069 --> 00:02:30.689 the pediatric nursing exam coach. I like that 00:02:30.689 --> 00:02:34.189 the exam coach. Yeah, right We are gonna cross 00:02:34.189 --> 00:02:36.370 reference all these sources and we are going 00:02:36.370 --> 00:02:39.330 to find the Pareto principle the 80 -20 rule 00:02:39.330 --> 00:02:41.930 we want to identify the 20 % of the material 00:02:41.930 --> 00:02:44.750 that is going to answer 80 % of the exam questions 00:02:44.750 --> 00:02:47.409 and you know more importantly the 20 % of the 00:02:47.409 --> 00:02:48.889 concepts that are actually gonna save a life 00:02:48.889 --> 00:02:51.009 at the bedside that's the only way to do it because 00:02:51.009 --> 00:02:52.990 you can't memorize everything if you try to memorize 00:02:52.990 --> 00:02:55.490 every single anatomical variation you'll just 00:02:55.789 --> 00:02:58.449 You'll drown. You will. That is the perfect way 00:02:58.449 --> 00:03:00.069 to approach this, because if you try to memorize 00:03:00.069 --> 00:03:02.710 every single anatomical variation of every single 00:03:02.710 --> 00:03:05.169 defect, you will burn out before you even get 00:03:05.169 --> 00:03:07.650 to the acquired heart diseases. You need a framework. 00:03:07.909 --> 00:03:10.229 You need a map. A map. Yeah. If you understand 00:03:10.229 --> 00:03:14.189 the why, the what becomes obvious. So lay out 00:03:14.189 --> 00:03:17.090 the roadmap for us. How do we conquer this beast? 00:03:17.830 --> 00:03:19.669 OK, so we're going to break this down into four 00:03:19.669 --> 00:03:23.219 main... kill zones or priority areas. First, 00:03:23.300 --> 00:03:25.280 we're going to build the master map. This is 00:03:25.280 --> 00:03:28.139 the physics. If you understand pressure gradients 00:03:28.139 --> 00:03:31.060 and the transition from fetal to newborn circulation, 00:03:31.340 --> 00:03:33.860 that critical switch, you don't need to memorize 00:03:33.860 --> 00:03:36.560 half the defects. You'll be able to predict the 00:03:36.560 --> 00:03:39.409 symptoms just by, well... Just by logic. I love 00:03:39.409 --> 00:03:42.849 that. Physics over memorization. Exactly. Second, 00:03:43.110 --> 00:03:45.409 we're going to tackle the defects themselves. 00:03:45.789 --> 00:03:47.610 But we aren't going alphabetically. That's a 00:03:47.610 --> 00:03:50.090 huge mistake. OK. We are going to categorize 00:03:50.090 --> 00:03:52.949 them by blood flow. Is the lungs getting too 00:03:52.949 --> 00:03:55.909 much blood? Too little. Is the plumbing kinked? 00:03:56.009 --> 00:03:58.750 That organizes the chaos. I like that. Grouping 00:03:58.750 --> 00:04:01.810 them. Third, we have the acquired conditions, 00:04:01.969 --> 00:04:03.990 things that happen after birth, like Kawasaki 00:04:03.990 --> 00:04:06.689 disease and rheumatic fever. And finally, we 00:04:06.689 --> 00:04:09.770 have the nursing safety kill zones. These are 00:04:09.770 --> 00:04:12.110 the medications like digoxin and procedures like 00:04:12.110 --> 00:04:13.909 cardiac cath, where if you don't know your stuff, 00:04:13.969 --> 00:04:16.209 you can do serious harm. And throughout all of 00:04:16.209 --> 00:04:18.730 this, because this is pediatrics, we have to 00:04:18.730 --> 00:04:20.449 keep one question in the back of our minds, right? 00:04:20.550 --> 00:04:23.970 Always. How does this heart problem stop a child 00:04:23.970 --> 00:04:27.480 from being a child? Precisely. A heart defect 00:04:27.480 --> 00:04:30.579 in a 40 -year -old is a medical problem. A heart 00:04:30.579 --> 00:04:32.860 defect in a four -month -old, that's a developmental 00:04:32.860 --> 00:04:36.360 crisis. It affects feeding, growth, play, I mean, 00:04:36.379 --> 00:04:38.660 everything. We have to look at the patient, not 00:04:38.660 --> 00:04:41.259 just the pump. OK, let's unpack this. Part one. 00:04:41.319 --> 00:04:44.500 Yeah. The master 80 -20 map. You mentioned pressure 00:04:44.500 --> 00:04:46.459 gradients. I feel like I need a refresher on 00:04:46.459 --> 00:04:49.759 high school physics here. Why is this the absolute 00:04:49.759 --> 00:04:53.290 need to know? Concept because blood is lazy. 00:04:53.290 --> 00:04:55.110 That's the golden rule. You have to write down 00:04:55.110 --> 00:04:57.170 blood is lazy Okay, if you write nothing else 00:04:57.170 --> 00:05:00.329 down today write this blood will always always 00:05:00.329 --> 00:05:02.449 flow from an area of high pressure to an area 00:05:02.449 --> 00:05:04.670 of low pressure It follows the path of least 00:05:04.670 --> 00:05:06.990 resistance. It doesn't want to work hard. It's 00:05:06.990 --> 00:05:09.519 like water flowing downhill Simple as that. Okay. 00:05:09.740 --> 00:05:11.540 Blood is lazy. I can relate to that. So let's 00:05:11.540 --> 00:05:14.040 look at a normal healthy adult or child after 00:05:14.040 --> 00:05:16.379 they're born. The heart has two sides. The left 00:05:16.379 --> 00:05:18.680 side is the powerhouse. The left ventricle has 00:05:18.680 --> 00:05:20.779 to pump blood all the way to your toes, your 00:05:20.779 --> 00:05:23.839 brain, your fingertips against gravity. It has 00:05:23.839 --> 00:05:25.480 to overcome the resistance of the whole body, 00:05:25.699 --> 00:05:28.279 the systemic vascular resistance. So it's working 00:05:28.279 --> 00:05:30.699 hard. It's working very hard. So the left side 00:05:30.699 --> 00:05:32.959 is high pressure. Left is high. Got it. That's 00:05:32.959 --> 00:05:35.439 the heavy lifter. The right side, well, it has 00:05:35.439 --> 00:05:37.600 a much easier job. It only has to pump blood 00:05:37.600 --> 00:05:40.079 next door to the lungs. The lungs are spongy. 00:05:40.120 --> 00:05:43.139 They're low resistance organs. So the right side 00:05:43.139 --> 00:05:45.720 is low pressure. So left is high, right is low. 00:05:45.740 --> 00:05:47.800 That's our baseline. That's normal. Correct. 00:05:48.139 --> 00:05:50.439 Now imagine someone punches a hole in the wall 00:05:50.439 --> 00:05:53.000 between the left and right side, a septal defect. 00:05:53.220 --> 00:05:55.800 Which way does the blood go? Well, if the left 00:05:55.800 --> 00:05:58.839 is high pressure and the right is low and blood 00:05:58.839 --> 00:06:02.699 is lazy, the blood is going to get pushed from 00:06:02.699 --> 00:06:05.060 the left to the right. Boom. You just solved 00:06:05.060 --> 00:06:07.319 50 % of the exam questions. I'm not kidding. 00:06:07.920 --> 00:06:10.399 If there is a simple halt, like a ventricular 00:06:10.399 --> 00:06:13.100 septal defect, a VSD or an atrial septal defect, 00:06:13.399 --> 00:06:16.220 an ASD blood flows left to right. OK. And what 00:06:16.220 --> 00:06:18.319 does that mean for the body? It means oxygenated 00:06:18.319 --> 00:06:21.079 blood that should be going to the body is leaking 00:06:21.079 --> 00:06:23.279 back into the right side and going to the lungs 00:06:23.279 --> 00:06:26.019 again. It's doing an extra lap. An unnecessary 00:06:26.019 --> 00:06:29.259 and damaging extra lap. The lungs get flooded. 00:06:29.480 --> 00:06:32.199 They're overworked. And the body, well, it gets 00:06:32.199 --> 00:06:34.779 less blood than it should. But the blood going 00:06:34.779 --> 00:06:37.360 to the body is still pink, right? It's oxygenated. 00:06:37.980 --> 00:06:40.240 Exactly. That's the key distinction. In a left 00:06:40.240 --> 00:06:42.459 -to -right shunt, the blood that makes it out 00:06:42.459 --> 00:06:45.040 to the body has plenty of oxygen. The kid is 00:06:45.040 --> 00:06:47.899 pink. They aren't blue. OK. But their lungs are 00:06:47.899 --> 00:06:51.100 wet. We call this pink but wet, or asianotic 00:06:51.100 --> 00:06:53.480 but with signs of congestive heart failure. Pink 00:06:53.480 --> 00:06:55.720 but wet. That's a great visual. Now flip the 00:06:55.720 --> 00:06:59.019 script for me. What if something blocks the lungs. 00:06:59.319 --> 00:07:01.639 OK, good question. Let's say the path to the 00:07:01.639 --> 00:07:04.459 lungs is tight. We call that pulmonary stenosis. 00:07:04.899 --> 00:07:07.720 The door to the lungs is narrowed. So the pressure 00:07:07.720 --> 00:07:09.959 on the right side starts to build up because 00:07:09.959 --> 00:07:11.920 the blood can't get out. It's a traffic jam. 00:07:11.980 --> 00:07:14.100 It's a traffic jam. It's pushing against a closed 00:07:14.100 --> 00:07:17.319 door. Eventually the right side pressure gets 00:07:17.319 --> 00:07:19.800 higher than the left. Now which way does the 00:07:19.800 --> 00:07:21.660 blood go through that hole? It would have to 00:07:21.660 --> 00:07:23.860 reverse. It would go right to left. What kind 00:07:23.860 --> 00:07:26.540 of blood is on the right side? Deoxygenated blue 00:07:26.540 --> 00:07:29.480 blood. And now you're pumping that blue blood 00:07:29.480 --> 00:07:32.620 across the hole and out to the body. That child 00:07:32.620 --> 00:07:36.000 is cyanotic. that child is blue. That's the fundamental 00:07:36.000 --> 00:07:38.699 trick. Left to right is wet, right to left is 00:07:38.699 --> 00:07:41.459 blue. That simplifies it so much. I don't have 00:07:41.459 --> 00:07:44.079 to just memorize a lift of symptoms for every 00:07:44.079 --> 00:07:46.279 single defect if I can just stop and ask, where 00:07:46.279 --> 00:07:48.639 is the pressure higher? That's the master map. 00:07:49.160 --> 00:07:51.199 Now, before we apply this to the specific defects, 00:07:51.259 --> 00:07:53.199 we have to talk about the switch because babies 00:07:53.199 --> 00:07:55.199 don't just pop out with adult circulation. This 00:07:55.199 --> 00:07:57.560 is where fetal circulation trips everybody up. 00:07:57.899 --> 00:08:00.790 Right. In the womb. The fetus is basically underwater. 00:08:00.949 --> 00:08:03.189 They aren't breathing air. Exactly. The lungs 00:08:03.189 --> 00:08:05.910 are filled with fluid. They are clamped down, 00:08:06.050 --> 00:08:08.470 high pressure. They are closed for business. 00:08:08.769 --> 00:08:11.230 Mom is doing all the breathing work via the placenta. 00:08:11.329 --> 00:08:13.970 So the body needs to work around. It has these 00:08:13.970 --> 00:08:16.730 special shortcut shunts to bypass the lungs. 00:08:16.810 --> 00:08:18.709 Because why send blood to the lungs if they aren't 00:08:18.709 --> 00:08:21.509 doing anything? These are the famous Latin names. 00:08:22.290 --> 00:08:26.189 Foramen, oval, and ductus arteriosus. Think of 00:08:26.189 --> 00:08:29.139 them as escape hatches. The foramen oval is a 00:08:29.139 --> 00:08:32.220 little flap, a hole between the atria. It lets 00:08:32.220 --> 00:08:34.720 blood skip the right ventricle and go straight 00:08:34.720 --> 00:08:38.039 to the left side. And the ductus arteriosus is 00:08:38.039 --> 00:08:40.700 a little vessel connecting the pulmonary artery 00:08:40.700 --> 00:08:43.360 directly to the aorta. It's like a highway bypass. 00:08:43.480 --> 00:08:45.519 It says, hey, don't go to the lungs. It's a dead 00:08:45.519 --> 00:08:48.519 end. Just go straight to the body. So in utero, 00:08:48.799 --> 00:08:51.090 bypassing the lungs is good. It's necessary. 00:08:51.490 --> 00:08:53.330 The right side pressure is high because the lungs 00:08:53.330 --> 00:08:56.210 are clamped shut. So blood flows right to left 00:08:56.210 --> 00:08:58.629 through these shunts. Correct. But then the baby 00:08:58.629 --> 00:09:02.009 is born. The cord is cut. The baby takes that 00:09:02.009 --> 00:09:04.830 first big breath. Wow. What happens in that moment? 00:09:04.970 --> 00:09:07.230 I assume the lungs open up, like really open 00:09:07.230 --> 00:09:10.690 up. That first breath is magic. It's an incredible 00:09:10.690 --> 00:09:13.570 physiological event. The lungs expand with air. 00:09:13.850 --> 00:09:15.929 The resistance in the pulmonary vessels drops 00:09:15.929 --> 00:09:18.330 like a rock. Suddenly the right side becomes 00:09:18.330 --> 00:09:20.820 the low pressure side. the left side. Well at 00:09:20.820 --> 00:09:22.960 the same time the cord is clamped so the systemic 00:09:22.960 --> 00:09:25.019 resistance goes way up. The left side becomes 00:09:25.019 --> 00:09:27.940 high pressure. This dramatic pressure shift slams 00:09:27.940 --> 00:09:31.100 those doors shut. The foramen ovale closes. The 00:09:31.100 --> 00:09:33.940 ductus arteriosus starts to constrict and close 00:09:33.940 --> 00:09:36.179 over the next few hours or days. It's like a 00:09:36.179 --> 00:09:37.700 complete plumbing renovation that happens in 00:09:37.700 --> 00:09:40.440 seconds. The walls go up, the doors lock. Ideally. 00:09:40.720 --> 00:09:43.419 But this is the exam writer favorite section. 00:09:43.919 --> 00:09:46.860 You need to know two medications regarding these 00:09:46.860 --> 00:09:49.429 shunts. Because sometimes the door stays open 00:09:49.429 --> 00:09:52.070 when we want it closed, or sometimes, and this 00:09:52.070 --> 00:09:55.389 is critical, we need to force it open to save 00:09:55.389 --> 00:09:57.789 a life. Okay, hit me. Let's start with closing 00:09:57.789 --> 00:09:59.690 the door. When do we need to do that? Let's say 00:09:59.690 --> 00:10:02.490 the ductus arteriosus stays open when it shouldn't. 00:10:02.490 --> 00:10:05.840 We call that a PDA. A patent ductus arteriosus. 00:10:06.139 --> 00:10:08.759 It's now acting like a left to right shunt flooding 00:10:08.759 --> 00:10:10.820 the lungs. Because the pressure has switched. 00:10:11.039 --> 00:10:13.460 Left is now high. Exactly. So we want to close 00:10:13.460 --> 00:10:16.519 it. We give a drug called indomethacin. Indomethacin. 00:10:16.539 --> 00:10:20.019 That's an NSAAD, right? Like a super strong ibuprofen. 00:10:20.340 --> 00:10:23.679 It is. It works by blocking prostaglandins. Prostaglandins 00:10:23.679 --> 00:10:25.600 are the chemical that keeps the ductus open in 00:10:25.600 --> 00:10:27.779 the room. So if we block them with indomethacin, 00:10:27.840 --> 00:10:30.000 the door closes. Indomethacin closes the door. 00:10:30.240 --> 00:10:32.679 Got it. But, and here's where it gets really 00:10:32.679 --> 00:10:35.399 interesting and really high stakes. Sometimes 00:10:35.399 --> 00:10:38.120 a baby is born with a horrible defect where the 00:10:38.120 --> 00:10:40.440 plumbing is totally messed up. Maybe the aorta 00:10:40.440 --> 00:10:42.740 is connected to the wrong side. The only way 00:10:42.740 --> 00:10:45.360 that baby survives is if some blood can mix through 00:10:45.360 --> 00:10:47.899 that fetal shunt. So if the ductus closes? The 00:10:47.899 --> 00:10:50.879 baby dies. because there is no other way for 00:10:50.879 --> 00:10:53.379 oxygen to get to the body. So in that case, we 00:10:53.379 --> 00:10:55.320 want to reverse nature. We want to keep that 00:10:55.320 --> 00:10:57.679 fetal door propped open. Exactly. We need to 00:10:57.679 --> 00:10:59.700 keep the fetal shunts open until the surgeon 00:10:59.700 --> 00:11:02.500 can get there. For that, we give prostaglandins, 00:11:02.580 --> 00:11:06.059 specifically a drug called alprazodadol. Prostaglandins 00:11:06.059 --> 00:11:08.320 keep the ductus open. Okay, so I need a mnemonic 00:11:08.320 --> 00:11:11.179 for this. Indomethacin sounds like, in comes 00:11:11.179 --> 00:11:15.139 the door closing it, and prostaglandins... Well, 00:11:15.159 --> 00:11:17.620 P for prostaglandin, P for propidopen. I usually 00:11:17.620 --> 00:11:20.879 say prostaglandins provide a path, but propidopen 00:11:20.879 --> 00:11:24.080 is great, whatever works. Just remember, NSAIDs 00:11:24.080 --> 00:11:26.700 like endomethacin close, prostaglandins open. 00:11:27.019 --> 00:11:29.799 If you mix those up on a test or in real life, 00:11:29.960 --> 00:11:32.139 you've killed the patient. It's that serious. 00:11:32.299 --> 00:11:33.779 All right, we have the physics, we have the fetal 00:11:33.779 --> 00:11:36.139 switch. Now, let's walk into the patient's room, 00:11:36.360 --> 00:11:39.039 part two. Assessment red flags. You're looking 00:11:39.039 --> 00:11:41.299 at a six -week -old baby. What is the number 00:11:41.299 --> 00:11:44.320 one absolute Can't miss sign of cardiac disease. 00:11:44.519 --> 00:11:46.799 Sweating during feeds. Sweating. Not chest pain. 00:11:47.279 --> 00:11:49.639 Not clutching the arm. Infants don't clutch their 00:11:49.639 --> 00:11:52.230 chest. And they don't run on treadmills. Their 00:11:52.230 --> 00:11:54.690 stress test is eating. That's a great way to 00:11:54.690 --> 00:11:56.649 put it. Feeding takes a huge amount of energy 00:11:56.649 --> 00:11:59.129 for a baby. They have to suck, swallow, breathe, 00:11:59.309 --> 00:12:01.750 coordinate, all of that. If a baby has heart 00:12:01.750 --> 00:12:03.750 failure, their heart just can't keep up with 00:12:03.750 --> 00:12:06.250 that demand. So the sympathetic nervous system 00:12:06.250 --> 00:12:09.009 kicks in fight or flight. They start sweating, 00:12:09.110 --> 00:12:10.909 usually on the salp and forehead, while they 00:12:10.909 --> 00:12:13.289 nurse or take a bottle. That is such a vivid 00:12:13.289 --> 00:12:15.529 image. We have a case study in the source material, 00:12:15.549 --> 00:12:18.669 Logan, six weeks old. His parent says he falls 00:12:18.669 --> 00:12:21.159 asleep while feeding. but he never finishes the 00:12:21.159 --> 00:12:23.480 bottle and his little head is always wet with 00:12:23.480 --> 00:12:27.360 sweat. That is a classic textbook clinical one 00:12:27.360 --> 00:12:30.360 -liner. Diaphoresis plus fatigue during feeding 00:12:30.360 --> 00:12:33.259 equals early heart failure. If you see that on 00:12:33.259 --> 00:12:36.559 an exam or in triage, alarm bells, flashing red 00:12:36.559 --> 00:12:38.240 lights, everything should be going off in your 00:12:38.240 --> 00:12:40.440 head. And why is that so bad? Because that child 00:12:40.440 --> 00:12:42.519 is not gaining weight. They are burning all their 00:12:42.519 --> 00:12:44.639 calories just trying to breathe and circulate 00:12:44.639 --> 00:12:47.600 blood. We call it failure to thrive, but really 00:12:47.600 --> 00:12:50.100 it's the heart failing to support growth. So 00:12:50.100 --> 00:12:52.480 developmentally, this child is just completely 00:12:52.480 --> 00:12:54.720 stalling out. Exactly. The calories are going 00:12:54.720 --> 00:12:57.879 to survival, not to growing the brain or the 00:12:57.879 --> 00:13:00.700 bones or hitting milestones. What about vital 00:13:00.700 --> 00:13:03.120 signs? I know kids aren't just small adults. 00:13:03.259 --> 00:13:05.299 The numbers are totally different. They are drastically 00:13:05.299 --> 00:13:07.159 different. And you have to know the ranges. The 00:13:07.159 --> 00:13:08.940 younger the child, the faster the heart rate 00:13:08.940 --> 00:13:11.279 and the lower the blood pressure. A newborn might 00:13:11.279 --> 00:13:15.259 have a heart rate of 140 or 150, even 160. That's 00:13:15.259 --> 00:13:17.980 perfectly normal. And if you saw 150 in an adult. 00:13:18.220 --> 00:13:20.419 You're grabbing the crash cart. Yeah. But in 00:13:20.419 --> 00:13:23.480 a newborn, you document it as normal. An adolescent, 00:13:23.500 --> 00:13:25.000 on the other hand, might have a heart rate of 00:13:25.000 --> 00:13:27.720 70, just like an adult. And blood pressure. This 00:13:27.720 --> 00:13:30.179 is the trap. In an infant, a normal BP is something 00:13:30.179 --> 00:13:34.080 like 80 over 55. If you see 80, 55 in an adult, 00:13:34.500 --> 00:13:37.000 they are hypotensive and you're worried. In a 00:13:37.000 --> 00:13:39.539 baby, you're happy. You have to know the age 00:13:39.539 --> 00:13:42.289 -specific norms. They're not intuitive. And the 00:13:42.289 --> 00:13:44.909 source material mentions a specific trap about 00:13:44.909 --> 00:13:47.990 when to assess these vitals. Yes, this is huge. 00:13:48.490 --> 00:13:51.450 If a baby is crying, screaming, or fighting you, 00:13:51.809 --> 00:13:54.590 their heart rate and BP will be sky high. You 00:13:54.590 --> 00:13:57.389 cannot interpret that data. It's useless. A crying 00:13:57.389 --> 00:13:59.690 baby might have a heart rate of 200 just from 00:13:59.690 --> 00:14:02.009 rage. It doesn't mean they have SVT. It means 00:14:02.009 --> 00:14:04.049 they're mad. You have to measure vitals when 00:14:04.049 --> 00:14:07.399 the infant is calm or, ideally, sleeping. Quiet 00:14:07.399 --> 00:14:09.559 exam. It is a skill. You have to learn to be 00:14:09.559 --> 00:14:12.000 a ninja. You enter the room. You listen to the 00:14:12.000 --> 00:14:13.659 heart and lungs before you stick the thermometer 00:14:13.659 --> 00:14:16.419 in or put the cold cuff on. Do the least invasive 00:14:16.419 --> 00:14:19.840 things first. Once they cry, your good data is 00:14:19.840 --> 00:14:21.960 gone. One last assessment piece before we move 00:14:21.960 --> 00:14:24.919 on. Clubbing and polycythemia. These sound like 00:14:24.919 --> 00:14:27.759 old timey pirate terms. They kind of do and they 00:14:27.759 --> 00:14:30.299 go together. If a child has a defect where they 00:14:30.299 --> 00:14:33.820 are chronically hypoxic, low oxygen for months 00:14:33.820 --> 00:14:36.769 or years, the body tries to compensate. Two things 00:14:36.769 --> 00:14:39.889 happen. One, the tips of the fingers and toes 00:14:39.889 --> 00:14:42.509 get wide and round. The nail bed gets spongy. 00:14:42.549 --> 00:14:44.889 That's clubbing. It's a sign of chronic long 00:14:44.889 --> 00:14:47.429 -term oxygen deprivation. You will not see this 00:14:47.429 --> 00:14:49.870 in a newborn. It takes time to develop. OK, so 00:14:49.870 --> 00:14:51.490 clubbing tells me this has been going on for 00:14:51.490 --> 00:14:53.129 a while. It's a history lesson on their fingertips. 00:14:53.570 --> 00:14:56.460 What about polysthythemia? Poly means many, cythemia 00:14:56.460 --> 00:14:59.240 means cells in the blood. The kidneys sense low 00:14:59.240 --> 00:15:01.679 oxygen and they scream at the bone marrow, send 00:15:01.679 --> 00:15:04.820 more red blood cells. We need more oxygen carriers. 00:15:05.399 --> 00:15:08.980 So the body produces a ton of RBCs. That's polycythemia. 00:15:09.240 --> 00:15:11.000 More red blood cells sounds good though, right? 00:15:11.259 --> 00:15:13.460 More oxygen carriers. It's a double -edged sword. 00:15:13.740 --> 00:15:16.139 It's a good intention with a bad outcome. Yes, 00:15:16.179 --> 00:15:18.519 you have more carriers, but your blood becomes 00:15:18.519 --> 00:15:20.779 thick. like a milkshake instead of water. Oh, 00:15:20.820 --> 00:15:23.740 I see. And thick blood moves slowly. It can clot. 00:15:24.100 --> 00:15:26.559 So these kids are at a huge risk for strokes. 00:15:26.600 --> 00:15:28.519 That's why hydration is so critical for them 00:15:28.519 --> 00:15:31.299 to keep that thick blood moving. If a polycythemic 00:15:31.299 --> 00:15:34.899 kid gets dehydrated from, say, vomiting or diarrhea, 00:15:35.360 --> 00:15:37.659 their blood can turn to sludge. It's a medical 00:15:37.659 --> 00:15:40.639 emergency. Fascinating. OK. OK. Let's move to 00:15:40.639 --> 00:15:43.019 the meat of the episode, part three, the defects. 00:15:43.320 --> 00:15:44.820 We're going to use your method grouping them 00:15:44.820 --> 00:15:47.559 by hemodynamics, by blood flow. Let's start with 00:15:47.559 --> 00:15:50.299 group A. Increased pulmonary blood flow. The 00:15:50.299 --> 00:15:53.139 wet lungs group. Right. Remember our map. This 00:15:53.139 --> 00:15:55.860 is a left to right shunt. Blood is leaking from 00:15:55.860 --> 00:15:58.340 the high pressure left side back to the low pressure 00:15:58.340 --> 00:16:01.019 right side and going to the lungs again. The 00:16:01.019 --> 00:16:03.220 lungs are over -circulated. They're boggy. They're 00:16:03.220 --> 00:16:06.639 wet. The usual suspects here are ASD, VSD, and 00:16:06.639 --> 00:16:09.919 PDA. So let's break down the VSD first. The source 00:16:09.919 --> 00:16:12.480 says this is the most common congenital anomaly. 00:16:12.840 --> 00:16:16.279 It is. Ventricular septal defect. hole between 00:16:16.279 --> 00:16:18.440 the ventricles. Because the left ventricle is 00:16:18.440 --> 00:16:21.600 the big pumper, it pushes blood forcefully through 00:16:21.600 --> 00:16:24.519 that hole into the right ventricle. This creates 00:16:24.519 --> 00:16:26.500 a lot of turbulence. Which you can hear. Which 00:16:26.500 --> 00:16:28.980 you can hear. So on the exam you are listening 00:16:28.980 --> 00:16:33.320 for a loud harsh murmur at the left sternal border. 00:16:33.399 --> 00:16:36.679 Loud and harsh. Left sternal border and What 00:16:36.679 --> 00:16:38.399 happens to the kid? How do they present? They 00:16:38.399 --> 00:16:40.860 usually aren't blue, so they're asianotic because 00:16:40.860 --> 00:16:42.860 plenty of oxygenated blood is still getting to 00:16:42.860 --> 00:16:45.240 the body. But they are tired. They have pulmonary 00:16:45.240 --> 00:16:47.700 congestion. You'll hear crackles, wet lungs. 00:16:48.039 --> 00:16:50.360 They get respiratory infections constantly. Why 00:16:50.360 --> 00:16:53.200 the constant infections? Wet lungs are a petri 00:16:53.200 --> 00:16:56.879 dish for bacteria. Fluid stasis just breeds infection. 00:16:57.779 --> 00:17:00.659 So, developmentally, this kid is the one who's 00:17:00.659 --> 00:17:02.419 always missing school or daycare because they 00:17:02.419 --> 00:17:04.619 have pneumonia. Again. And they're probably not 00:17:04.619 --> 00:17:06.339 growing well. They're falling off the growth 00:17:06.339 --> 00:17:08.539 chart because they're too tired to eat and they're 00:17:08.539 --> 00:17:11.119 burning all their calories just trying to breathe 00:17:11.119 --> 00:17:14.259 against those wet lungs. The good news is many 00:17:14.259 --> 00:17:17.279 of these close on their own. That's right. Spontaneous 00:17:17.279 --> 00:17:20.039 closure happens in about half of small VSDs by 00:17:20.039 --> 00:17:23.240 age two. So often we just watch and wait. But 00:17:23.240 --> 00:17:25.619 if it's large and causing significant heart failure, 00:17:25.700 --> 00:17:27.740 we have to go in and patch it. Kate, what about 00:17:27.740 --> 00:17:31.839 an ASD, atrial septal defect? a hole between 00:17:31.839 --> 00:17:33.960 the atria. How is that different from a VSD? 00:17:34.170 --> 00:17:36.390 It's still a left to right shunt, so the lungs 00:17:36.390 --> 00:17:38.829 are still getting extra blood, but the pressure 00:17:38.829 --> 00:17:41.069 difference between the atria is much lower than 00:17:41.069 --> 00:17:43.990 between the ventricles. So the murmur is much 00:17:43.990 --> 00:17:47.230 softer. It's not that loud, harsh sound. It's 00:17:47.230 --> 00:17:49.769 often described as a systolic ejection murmur 00:17:49.769 --> 00:17:53.029 with a wide fixed splitting of the second heart 00:17:53.029 --> 00:17:55.890 sound. That sounds very specific. It's an audiophile's 00:17:55.890 --> 00:17:58.869 term. But basically, these kids are often asymptomatic 00:17:58.869 --> 00:18:01.609 for years. They might get diagnosed as a teenager 00:18:01.609 --> 00:18:03.769 when they get tired playing sports. are less 00:18:03.769 --> 00:18:06.069 likely to have that profound heart failure in 00:18:06.069 --> 00:18:08.650 infancy that you see with a big VST. So it's 00:18:08.650 --> 00:18:11.190 a quieter, more subtle version of the same problem. 00:18:11.609 --> 00:18:15.190 In a way, yes. Still wet lungs, but less dramatically 00:18:15.190 --> 00:18:18.549 so in many cases. OK. Next in this group is the 00:18:18.549 --> 00:18:22.009 PDA patent, ductus arteriosus. Yeah. We talked 00:18:22.009 --> 00:18:24.829 about the drugs. Indomithicin closes it. But 00:18:24.829 --> 00:18:26.910 what does it sound like? This is a classic board 00:18:26.910 --> 00:18:31.119 question. PDA has a machine -like murmur. A machine? 00:18:31.259 --> 00:18:33.859 Yeah, it sounds like a washing machine. A continuous, 00:18:34.180 --> 00:18:36.960 churning, hum -like sound right under the left 00:18:36.960 --> 00:18:40.000 clavicle. You'll also feel bounding pulses. Why 00:18:40.000 --> 00:18:42.180 bounding? What causes that? It's because during 00:18:42.180 --> 00:18:44.700 diastole, when the heart is relaxing, blood is 00:18:44.700 --> 00:18:46.880 constantly running off from the aorta through 00:18:46.880 --> 00:18:50.039 the PDA and into the pulmonary artery. This makes 00:18:50.039 --> 00:18:52.400 the diastolic pressure drop. So there's a wide 00:18:52.400 --> 00:18:55.000 gap between the top number, the systolic, and 00:18:55.000 --> 00:18:56.920 the bottom number, the diastolic. A wide pulse 00:18:56.920 --> 00:19:00.349 pressure. Exactly. And that wide pulse pressure 00:19:00.349 --> 00:19:03.250 makes the pulse feel really strong and snappy, 00:19:03.589 --> 00:19:06.049 bounding. Yeah. Machine murmur, bounding pulses 00:19:06.049 --> 00:19:10.509 give endomethacin to close it. Got it. Now, what 00:19:10.509 --> 00:19:12.730 happens if we ignore these defects, if we let 00:19:12.730 --> 00:19:15.710 the lungs stay wet for years and years? That's 00:19:15.710 --> 00:19:18.269 the nightmare scenario. We call it Eisenmenger 00:19:18.269 --> 00:19:20.849 syndrome. Eisenmenger. Eventually, the lungs 00:19:20.849 --> 00:19:24.200 get sick of being flooded. The delicate blood 00:19:24.200 --> 00:19:26.680 vessels in the lungs start to harden and thicken 00:19:26.680 --> 00:19:29.720 to protect themselves. This is called pulmonary 00:19:29.720 --> 00:19:32.099 hypertension. And that increases the pressure 00:19:32.099 --> 00:19:34.299 on the right side of the heart. Exactly. The 00:19:34.299 --> 00:19:36.680 right side now has to pump against this super 00:19:36.680 --> 00:19:39.400 high resistance in the lungs. And if the right 00:19:39.400 --> 00:19:42.400 side pressure gets high enough, it actually exceeds 00:19:42.400 --> 00:19:44.700 the left side pressure. So the shunt. The shunt 00:19:44.700 --> 00:19:47.019 reverses. It goes right to left. The kid turns 00:19:47.019 --> 00:19:49.500 blue. And once that happens, the damage is permanent 00:19:49.500 --> 00:19:51.519 and you're reversible. You can't just fix the 00:19:51.519 --> 00:19:53.940 hole anymore. The lungs are shot. That's why 00:19:53.940 --> 00:19:56.640 we fix these defects early before that permanent 00:19:56.640 --> 00:19:58.920 damage sets in. OK, that makes sense. Let's move 00:19:58.920 --> 00:20:01.839 to group B. The obstructive defects. The kinked 00:20:01.839 --> 00:20:04.799 hose group. Right. So here, the problem isn't 00:20:04.799 --> 00:20:08.039 a hole, it's a blockage. The king of this group, 00:20:08.200 --> 00:20:11.480 the one you'll see on exams the most, is coarctation 00:20:11.480 --> 00:20:14.319 of the aorta. Coarctation just means narrowing, 00:20:14.319 --> 00:20:16.640 right? Exactly. Imagine you have a garden hose 00:20:16.640 --> 00:20:18.900 and you pinch it in the middle. pressure builds 00:20:18.900 --> 00:20:21.819 up behind the pinch and the flow is weak after 00:20:21.819 --> 00:20:24.079 the pinch. And in the aorta, the pinch is usually 00:20:24.079 --> 00:20:26.160 right after the arch after the arteries branch 00:20:26.160 --> 00:20:28.900 off to the head and arms. Exactly. So blood flows 00:20:28.900 --> 00:20:31.359 easily under high pressure to the head and arms. 00:20:31.380 --> 00:20:34.440 That's the high pressure zone. But it can't squeeze 00:20:34.440 --> 00:20:37.859 past that pinch to get to the legs, the gut, 00:20:38.079 --> 00:20:40.420 the kidneys. That's the low pressure zone. This 00:20:40.420 --> 00:20:42.480 leads to the famous four extremity blood pressure 00:20:42.480 --> 00:20:45.440 test. This is the absolute need to know for coarctation. 00:20:45.480 --> 00:20:47.640 This is how you find it. If you take a BP in 00:20:47.640 --> 00:20:51.000 the arm, it's high, maybe 30, 30, 80 in a child, 00:20:51.240 --> 00:20:53.279 which is hypertensive. Then you take it in the 00:20:53.279 --> 00:20:56.720 leg and it's low, maybe 80, 50. And the pulses, 00:20:57.039 --> 00:20:58.980 they're bounding in the neck and arms, but they're 00:20:58.980 --> 00:21:01.920 weak or even absent in the feet. Upper body hypertension, 00:21:02.259 --> 00:21:04.240 lower body hypertension. What does the patient 00:21:04.240 --> 00:21:06.539 complain of? If they're older, they might complain 00:21:06.539 --> 00:21:08.980 of leg pain with exercise claudication because 00:21:08.980 --> 00:21:10.440 the muscles just aren't getting enough blood 00:21:10.440 --> 00:21:12.339 flow. And they might get frequent headaches, 00:21:12.619 --> 00:21:14.500 nosebleeds, or dizziness because of the high 00:21:14.500 --> 00:21:16.720 pressure in the head. And the risk here if it's 00:21:16.720 --> 00:21:19.720 not fixed? Stroke from the high pressure upstairs? 00:21:20.460 --> 00:21:23.900 Or, even worse, rupture of the aorta. It's a 00:21:23.900 --> 00:21:25.960 mechanical problem that needs a mechanical fixed 00:21:25.960 --> 00:21:28.700 surgery to cut out the narrowed section or a 00:21:28.700 --> 00:21:31.769 balloon angioplasty to stretch it open. If you 00:21:31.769 --> 00:21:34.509 see a test question about BP disparity between 00:21:34.509 --> 00:21:37.289 upper and lower extremities, you click coarctation 00:21:37.289 --> 00:21:41.609 immediately. Okay. Group C. The scary ones. Decreased 00:21:41.609 --> 00:21:44.269 pulmonary blood flow. The blue group. This is 00:21:44.269 --> 00:21:46.670 the right -to -left shunt. Yes. And the poster 00:21:46.670 --> 00:21:49.130 child for this group is Tetralogy of Fallot. 00:21:49.450 --> 00:21:51.869 Tetralogy means four. You have four distinct 00:21:51.869 --> 00:21:54.089 defects occurring at the same time. I always 00:21:54.089 --> 00:21:58.049 use the mnemonic RAPS to remember them. RAPS. 00:21:58.049 --> 00:22:00.630 That's a good one. R for right ventricular hypertrophy. 00:22:00.779 --> 00:22:04.519 A for aorta overriding, P for pulmonary stenosis, 00:22:04.980 --> 00:22:07.700 and S for septal defect, VSD. That's a great 00:22:07.700 --> 00:22:09.559 mnemonic. Let's break it down so it makes sense. 00:22:10.079 --> 00:22:12.460 The real villain here, the one that causes all 00:22:12.460 --> 00:22:14.759 the other problems, is the pulmonary stenosis. 00:22:15.559 --> 00:22:18.859 The exit to the lungs is extremely tight and 00:22:18.859 --> 00:22:21.480 narrow. So blood can't get out of the right ventricle 00:22:21.480 --> 00:22:23.920 easily. It can't. So the right ventricle has 00:22:23.920 --> 00:22:26.579 to push against this tight door and the muscle 00:22:26.579 --> 00:22:29.559 gets huge. That's your right ventricular hypertrophy. 00:22:29.700 --> 00:22:31.460 So the blood is stuck in the right ventricle. 00:22:31.460 --> 00:22:33.410 Where does it go? It takes the path of least 00:22:33.410 --> 00:22:35.930 resistance. It looks at the tight pulmonary valve 00:22:35.930 --> 00:22:38.470 and says, no thanks. And then it sees this big 00:22:38.470 --> 00:22:40.970 VSD, the hole, and it shoots right through it. 00:22:41.069 --> 00:22:43.769 To the left side. And because the aorta is overriding 00:22:43.769 --> 00:22:46.490 or sitting right on top of that hole, the blue 00:22:46.490 --> 00:22:48.470 blood shoots straight from the right ventricle 00:22:48.470 --> 00:22:50.930 through the VSD and into the aorta and out to 00:22:50.930 --> 00:22:54.029 the body. Bypassing the lungs entirely. The result 00:22:54.029 --> 00:22:56.690 is instant cyanosis. Right. And this leads to 00:22:56.690 --> 00:22:59.490 the most dramatic, terrifying event in pediatric 00:22:59.490 --> 00:23:03.430 cardiology. The Tet spell or hypercyanotic spell. 00:23:03.769 --> 00:23:05.630 Okay, paint the picture for me. You're the nurse. 00:23:05.769 --> 00:23:08.730 You walk into the room. A toddler with known 00:23:08.730 --> 00:23:12.309 tetralogy of fallot is crying because they dropped 00:23:12.309 --> 00:23:15.150 a toy or maybe they're straining to poop. Suddenly 00:23:15.150 --> 00:23:17.529 they turn a deep dark blue. They start gasping. 00:23:17.589 --> 00:23:20.529 They go limp. What is happening physiologically? 00:23:20.950 --> 00:23:24.009 The crying or straining increase their oxygen 00:23:24.009 --> 00:23:28.170 demand. At the same time, the muscle right below 00:23:28.170 --> 00:23:31.490 the pulmonary valve, the infundibulum, goes into 00:23:31.490 --> 00:23:34.589 spasm and clamps down completely. It slams the 00:23:34.589 --> 00:23:36.609 door shut. It slams the door to lungs completely 00:23:36.609 --> 00:23:39.170 shut. Zero blood is going to the lungs. It's 00:23:39.170 --> 00:23:41.190 all shunting right to left and out to the body. 00:23:41.569 --> 00:23:44.170 They are profoundly hypoxic. This is a medical 00:23:44.170 --> 00:23:47.250 emergency. This is a kill zone. What is the number 00:23:47.250 --> 00:23:49.529 one priority nursing action? You have seconds. 00:23:49.970 --> 00:23:52.109 Knee to chest position. Immediately. Explain 00:23:52.109 --> 00:23:54.029 that. Why does shoving their knees up to their 00:23:54.029 --> 00:23:56.369 chest help? It seems so simple. It's physics 00:23:56.369 --> 00:23:58.890 again. When you scrunch the legs up like that, 00:23:58.970 --> 00:24:01.690 you are kinking the femoral arteries. You are 00:24:01.690 --> 00:24:04.109 dramatically increasing the resistance in the 00:24:04.109 --> 00:24:06.049 systemic circulation in the body. You're making 00:24:06.049 --> 00:24:08.970 it harder to pump to the body. Exactly. Remember, 00:24:09.210 --> 00:24:12.039 blood is lazy. If the pressure in the body suddenly 00:24:12.039 --> 00:24:14.220 gets really, really high, the blood in the heart 00:24:14.220 --> 00:24:16.880 says, whoa, it's too hard to go out the aorta 00:24:16.880 --> 00:24:19.680 now. It forces the blood to try the other path 00:24:19.680 --> 00:24:22.099 back into the pulmonary artery and to the lungs, 00:24:22.440 --> 00:24:24.940 even if it's tight. You essentially force the 00:24:24.940 --> 00:24:27.200 blood back to the lungs by making the body a 00:24:27.200 --> 00:24:29.799 harder place to go. You reverse the shunt temporarily. 00:24:29.940 --> 00:24:32.519 It's an incredible, life -saving maneuver. So 00:24:32.519 --> 00:24:35.259 set one, knee to chest, or if they're older, 00:24:35.420 --> 00:24:39.240 have them squat. Step two, 100 % oxygen. Step 00:24:39.240 --> 00:24:43.099 three, morphine. Yes. The oxygen helps with what 00:24:43.099 --> 00:24:45.200 little blood is getting to the lungs. And morphine 00:24:45.200 --> 00:24:48.180 is key. It calms the child, which reduces their 00:24:48.180 --> 00:24:50.700 oxygen demand. But it also has a sedative effect 00:24:50.700 --> 00:24:53.700 that can help relax that cardiac spasm. And developmentally, 00:24:53.759 --> 00:24:55.460 you'll see toddlers doing this on their own, 00:24:55.680 --> 00:24:58.160 right? It's amazing to watch. A tet kid will 00:24:58.160 --> 00:24:59.900 be running on the playground. They'll get tired 00:24:59.900 --> 00:25:01.740 and short of breath. And they will instinctively 00:25:01.740 --> 00:25:03.619 drop into a squat for a few seconds. They're 00:25:03.619 --> 00:25:05.579 self -treating. They are. The teacher might yell, 00:25:05.819 --> 00:25:08.500 get up. Stop being lazy. But the school nurse 00:25:08.500 --> 00:25:11.359 should know to say, let them squat. They are 00:25:11.359 --> 00:25:13.579 increasing their systemic vascular resistance 00:25:13.579 --> 00:25:16.819 and improving their own oxygen saturations. Incredible. 00:25:17.240 --> 00:25:21.019 Nature finds a way. OK, group D mix defects. 00:25:21.480 --> 00:25:24.480 The source material calls this the survival depends 00:25:24.480 --> 00:25:27.589 on mixing group. Right, and the big one here, 00:25:27.690 --> 00:25:29.789 the classic example, is transposition of the 00:25:29.789 --> 00:25:32.549 great arteries, or TGA. The plumbing is crossed. 00:25:32.690 --> 00:25:35.069 Completely swapped. The pulmonary artery leaves 00:25:35.069 --> 00:25:37.869 the left ventricle. The aorta leaves the right 00:25:37.869 --> 00:25:41.250 ventricle. So, wait, let me trace that. The right 00:25:41.250 --> 00:25:44.029 side pumps blue blood out the aorta to the body, 00:25:44.470 --> 00:25:46.549 which comes back blue to the right side and gets 00:25:46.549 --> 00:25:49.069 pumped to the body again. A closed loop of no 00:25:49.069 --> 00:25:52.230 oxygen. Correct. A completely futile deoxygenated 00:25:52.230 --> 00:25:55.289 loop. And the left side pumps red oxygenated 00:25:55.289 --> 00:25:57.250 blood to the lungs, which comes back red to the 00:25:57.250 --> 00:25:58.849 left side and goes right back to the lungs again. 00:25:59.369 --> 00:26:01.390 A closed loop of oxygen that never reaches the 00:26:01.390 --> 00:26:03.890 brain. Right. Two separate serpents that never 00:26:03.890 --> 00:26:06.029 cross. That sounds completely incompatible with 00:26:06.029 --> 00:26:09.099 life. It is, unless, unless there is a connection 00:26:09.099 --> 00:26:11.460 somewhere. This is where we go back to our fetal 00:26:11.460 --> 00:26:14.160 shunts. If that baby is lucky enough to have 00:26:14.160 --> 00:26:17.480 a PDA or a hole in the heart like an ASD or VSD, 00:26:17.759 --> 00:26:20.000 the blood can mix and they can stay alive for 00:26:20.000 --> 00:26:22.319 a few days. So this is a scenario where you are 00:26:22.319 --> 00:26:25.619 literally running to the poxies to grab the prostaglandins. 00:26:25.759 --> 00:26:28.859 You are not walking. You are starting a prostaglandin 00:26:28.859 --> 00:26:32.200 drip immediately. Keep that ductus open. It is 00:26:32.200 --> 00:26:34.680 the only lifeline, the only bridge between those 00:26:34.680 --> 00:26:37.380 two circuits, until the surgeons can go in and 00:26:37.380 --> 00:26:39.400 physically switch the vessels back to where they 00:26:39.400 --> 00:26:42.019 belong. We call it the arterial switch operation. 00:26:42.220 --> 00:26:45.019 And then there's the really tough one. hypoplastic 00:26:45.019 --> 00:26:48.299 left heart syndrome or HLHS. This is one of the 00:26:48.299 --> 00:26:51.619 most severe and complex defects. The entire left 00:26:51.619 --> 00:26:54.140 side of the heart, the main pump, is tiny and 00:26:54.140 --> 00:26:56.460 underdeveloped. It barely exists. How do you 00:26:56.460 --> 00:26:58.759 fix half a heart? You can't fix it in the traditional 00:26:58.759 --> 00:27:01.259 sense. You have to completely rewire the entire 00:27:01.259 --> 00:27:04.220 circulation so the single working right ventricle 00:27:04.220 --> 00:27:06.000 does all the work of pumping to both the lungs 00:27:06.000 --> 00:27:08.480 and the bottom. That sounds incredibly complex. 00:27:08.680 --> 00:27:12.140 It is. It takes a series of three major staged 00:27:12.140 --> 00:27:14.109 open heart surgeries over the first few years 00:27:14.109 --> 00:27:16.130 of life, or the only other option is a heart 00:27:16.130 --> 00:27:19.109 transplant. These are the most fragile babies 00:27:19.109 --> 00:27:22.329 in the entire cardiac ICU. That wraps up the 00:27:22.329 --> 00:27:24.410 congenital defects, the ones they're born with. 00:27:24.789 --> 00:27:27.640 Let's shift gears to part four. acquired heart 00:27:27.640 --> 00:27:30.279 disease, the afterbirth group. These are kids 00:27:30.279 --> 00:27:32.539 who were born with healthy hearts, but then get 00:27:32.539 --> 00:27:34.940 sick. And the scariest one for parents, I think, 00:27:35.059 --> 00:27:37.500 is often Kawasaki disease. Kawasaki, it's an 00:27:37.500 --> 00:27:40.619 acute systemic vasculitis. So inflammation of 00:27:40.619 --> 00:27:42.240 all the blood vessels, what does this kid look 00:27:42.240 --> 00:27:45.180 like? They look miserable. We are talking a high... 00:27:45.549 --> 00:27:48.430 persistent fever 103, 104 that lasts for more 00:27:48.430 --> 00:27:51.130 than five days. And the scary part for parents 00:27:51.130 --> 00:27:53.490 is Tylenol or Motrin doesn't touch it. The fever 00:27:53.490 --> 00:27:55.750 just will not break. They're beside themselves. 00:27:56.529 --> 00:27:58.509 So fever for more than five days, that doesn't 00:27:58.509 --> 00:28:01.190 respond to antipyretics. What else? The diagnostic 00:28:01.190 --> 00:28:04.289 criteria are very visual. The mnemonic is CRH 00:28:04.289 --> 00:28:07.490 and burn. C is for conjunctivitis, red eyes, 00:28:07.529 --> 00:28:11.890 but no goop, no drainage. R is for rash. A is 00:28:11.890 --> 00:28:14.529 for adenopathy, swollen lymph nodes in the neck. 00:28:15.190 --> 00:28:18.130 S is for strawberry tongue, a bright red bumpy 00:28:18.130 --> 00:28:21.390 tongue with red cracked lips. And H is for hands 00:28:21.390 --> 00:28:23.890 and feet, which get red, swollen, and then start 00:28:23.890 --> 00:28:27.299 peeling. The burn is the fever. Serration burn. 00:28:27.400 --> 00:28:29.819 That's a good one. And the real danger here isn't 00:28:29.819 --> 00:28:31.660 the fever itself. It's what the inflammation 00:28:31.660 --> 00:28:34.339 does to the heart. Specifically, the coronary 00:28:34.339 --> 00:28:36.400 arteries. The vessels that feed the heart muscle 00:28:36.400 --> 00:28:39.480 itself can get inflamed and balloon out, forming 00:28:39.480 --> 00:28:41.779 coronary artery aneurysms. And if those burst. 00:28:41.960 --> 00:28:43.839 Or if a clot forms in them, a five -year -old 00:28:43.839 --> 00:28:46.059 can have a massive heart attack. So the treatment 00:28:46.059 --> 00:28:48.539 protocol has a huge exam exception. Yes. This 00:28:48.539 --> 00:28:50.900 is the one time you will see this. We give aspirin. 00:28:51.019 --> 00:28:54.500 Whoa. We are taught in Pediatrics 101, never 00:28:54.500 --> 00:28:56.359 give aspirin to children because of the risk 00:28:56.359 --> 00:28:58.700 of Reye's syndrome, which is liver failure and 00:28:58.700 --> 00:29:00.960 brain swelling. This is the one and only major 00:29:00.960 --> 00:29:04.059 exception. In this case, the risk of the heart 00:29:04.059 --> 00:29:06.940 clotting off and these aneurysms forming far 00:29:06.940 --> 00:29:09.579 outweighs the risk of Reye's syndrome. We give 00:29:09.579 --> 00:29:11.900 high dose aspirin for its anti -inflammatory 00:29:11.900 --> 00:29:14.859 and anti -platelet effects. And what else? Along 00:29:14.859 --> 00:29:18.039 with aspirin, the main treatment is IVH intravenous 00:29:18.039 --> 00:29:20.539 immunoglobulin. It's a blood product that helps 00:29:20.539 --> 00:29:22.960 to calm the whole immune system down and reduce 00:29:22.960 --> 00:29:25.180 the inflammation in the arteries. So if you see 00:29:25.180 --> 00:29:28.039 a test question asking which child gets aspirin, 00:29:28.619 --> 00:29:30.200 you look for the kid with the strawberry tongue 00:29:30.200 --> 00:29:32.559 and the five -day fever. Absolutely. And long 00:29:32.559 --> 00:29:35.660 term, these kids need echocardiograms for years 00:29:35.660 --> 00:29:37.960 to make sure those aneurysms don't develop or 00:29:37.960 --> 00:29:41.619 worsen later in life. Next up, rheumatic fever. 00:29:41.880 --> 00:29:43.779 I feel like this is something out of a Charles 00:29:43.779 --> 00:29:45.779 Dickens novel, but it's still around. It is. 00:29:45.859 --> 00:29:48.519 And it's tragic because it is entirely preventable. 00:29:48.900 --> 00:29:51.460 Rheumatic fever is a delayed autoimmune reaction 00:29:51.460 --> 00:29:53.680 to a group A strip infection's strep throat. 00:29:54.099 --> 00:29:56.279 So a kid gets strep throat, maybe it's untreated, 00:29:56.740 --> 00:29:59.220 or maybe they stop the antibiotics too soon because 00:29:59.220 --> 00:30:01.940 they feel better. Then what happens? Two to four 00:30:01.940 --> 00:30:04.059 weeks later, the immune system gets confused. 00:30:04.579 --> 00:30:07.059 The antibodies that it created to fight the strep 00:30:07.059 --> 00:30:09.960 bacteria start attacking the body's own tissues, 00:30:10.660 --> 00:30:13.859 specifically the heart valves, the joints, and 00:30:13.859 --> 00:30:16.079 the brain. This brings us to the Jones criteria 00:30:16.079 --> 00:30:18.720 for diagnosis. Right, the major criteria. One 00:30:18.720 --> 00:30:20.859 is carditis, inflammation of the heart. Another 00:30:20.859 --> 00:30:24.240 is polyarthritis, swollen, painful joints that 00:30:24.240 --> 00:30:26.480 migrate. One day it's the knee, the next day 00:30:26.480 --> 00:30:28.859 it's the elbow. And then there's the really strange 00:30:28.859 --> 00:30:33.180 one. Korea. Seidenham's Korea. It's involuntary, 00:30:33.339 --> 00:30:36.079 jerky movements of the face and limbs. It looks 00:30:36.079 --> 00:30:38.500 terrifying for parents. The kid starts twitching, 00:30:38.700 --> 00:30:41.099 dropping things, making funny faces. They can't 00:30:41.099 --> 00:30:44.140 control it. And erythema marginatum. the rash 00:30:44.140 --> 00:30:46.539 with red rings on the trunk. Right. The career 00:30:46.539 --> 00:30:49.299 resolves, the rash fades, but the real permanent 00:30:49.299 --> 00:30:51.859 damage is from the carditis. It scars the heart 00:30:51.859 --> 00:30:54.279 valves, especially the mitral valve. That damage 00:30:54.279 --> 00:30:57.039 is for life. So the exam tip here is prevention. 00:30:57.259 --> 00:31:00.039 It's all about prevention. Treat strep throat. 00:31:00.420 --> 00:31:03.119 Take all your penicillin for the full 10 days. 00:31:03.619 --> 00:31:05.359 It's not just about a sore throat. It's about 00:31:05.359 --> 00:31:07.359 saving the heart valve from being destroyed by 00:31:07.359 --> 00:31:09.640 your own immune system 20 years down the road. 00:31:10.059 --> 00:31:14.650 One more in this category. This is an infection 00:31:14.650 --> 00:31:17.289 of the inner lining of the heart. It usually 00:31:17.289 --> 00:31:20.109 affects kids with existing heart defects, artificial 00:31:20.109 --> 00:31:23.390 valves, or central lines. Bacteria usually from 00:31:23.390 --> 00:31:25.569 the mouth gets into the blood and sets up camp, 00:31:26.009 --> 00:31:28.089 colonizing the heart valves. This leads to a 00:31:28.089 --> 00:31:30.400 surprising nursing intervention focus. Dental 00:31:30.400 --> 00:31:33.539 hygiene. It's huge. The dentist is a high -risk 00:31:33.539 --> 00:31:35.400 zone for these kids. Every time you clean teeth, 00:31:35.460 --> 00:31:38.279 you can release bacteria into the blood. So high 00:31:38.279 --> 00:31:41.059 -risk kids, those with artificial valves or certain 00:31:41.059 --> 00:31:44.019 unrepaired defects, need prophylactic antibiotics 00:31:44.019 --> 00:31:46.579 about an hour before any dental procedure. So 00:31:46.579 --> 00:31:48.759 good brushing is actually a cardiac intervention 00:31:48.759 --> 00:31:50.900 for these kids. It really, really is. OK. Let's 00:31:50.900 --> 00:31:53.519 move to part five. Nursing management and safety 00:31:53.519 --> 00:31:56.539 kill zones. We've diagnosed the problem. Now 00:31:56.539 --> 00:31:58.900 we have to treat it. and the drugs we use in 00:31:58.900 --> 00:32:01.440 cardio are not to be messed with. Let's talk 00:32:01.440 --> 00:32:05.119 about digoxin. Digoxin or linoxin. It's an old 00:32:05.119 --> 00:32:07.460 drug derived from the foxglove plant, but we 00:32:07.460 --> 00:32:09.539 still use it a lot. It does two main things. 00:32:10.099 --> 00:32:12.799 It increases contractility, which means it makes 00:32:12.799 --> 00:32:15.640 the heart squeeze harder. A positive inotrope. 00:32:15.819 --> 00:32:18.940 Right. And it decreases the heart rate, a negative 00:32:18.940 --> 00:32:21.480 chronotrope. It gives the heart more time to 00:32:21.480 --> 00:32:23.880 fill between beats. So it makes the pump stronger 00:32:23.880 --> 00:32:26.700 and more efficient, squeeze harder, beat slower. 00:32:26.940 --> 00:32:30.079 but the therapeutic window is tiny. The difference 00:32:30.079 --> 00:32:32.220 between a helping dose and a killing dose is 00:32:32.220 --> 00:32:35.079 microscopic. Which is why the need to know assessment 00:32:35.079 --> 00:32:37.539 is the apical pulse. You cannot just feel the 00:32:37.539 --> 00:32:40.059 wrist. You must put your stethoscope on the apex 00:32:40.059 --> 00:32:42.299 of the heart and listen for one full minute, 00:32:42.660 --> 00:32:46.240 not 15 seconds times four, one full uninterrupted 00:32:46.240 --> 00:32:48.579 minute. And what are the cutoff rules? When do 00:32:48.579 --> 00:32:50.700 we hold the drug? This has to be tattooed on 00:32:50.700 --> 00:32:53.319 your brain. For an infant, if the apical heart 00:32:53.319 --> 00:32:55.599 rate is below 90, you hold the drug and you call 00:32:55.599 --> 00:32:58.359 the provider. For an older child, the cutoff 00:32:58.359 --> 00:33:01.660 is below 70. Less than 90 for a baby. Less than 00:33:01.660 --> 00:33:04.640 70 for a child. Write that down. Now, how do 00:33:04.640 --> 00:33:06.339 I know if the kid is toxic? What's the first 00:33:06.339 --> 00:33:08.720 sign? Just vomiting. Kids vomit all the time. 00:33:09.140 --> 00:33:11.240 This sounds tricky. That's why it's so dangerous. 00:33:11.549 --> 00:33:15.029 But if a cardiac kid on digoxin starts vomiting, 00:33:15.390 --> 00:33:17.349 especially more than once, or they lose their 00:33:17.349 --> 00:33:19.569 appetite completely, do not assume it's the flu. 00:33:20.109 --> 00:33:22.410 Your first thought must be dig toxicity until 00:33:22.410 --> 00:33:26.549 proven otherwise. Other signs are profound bradycardia, 00:33:26.930 --> 00:33:29.490 a very slow heart rate, and dysrhythmias. And 00:33:29.490 --> 00:33:31.269 there's a critical electrolyte connection here, 00:33:31.470 --> 00:33:34.829 right? Potassium. Hypokalemia, or low potassium, 00:33:35.210 --> 00:33:37.880 potentiates digoxin toxicity. It makes the heart 00:33:37.880 --> 00:33:40.759 muscle much more sensitive to the drug. So a 00:33:40.759 --> 00:33:43.359 normal dose of DIG can become a toxic dose if 00:33:43.359 --> 00:33:45.619 your potassium level is low. And what's a common 00:33:45.619 --> 00:33:48.740 drug we give that lowers potassium? Lasix, furosemide, 00:33:49.180 --> 00:33:51.119 the diuretic we give to treat the very heart 00:33:51.119 --> 00:33:53.539 failure we're using the digoxin for. It's a vicious 00:33:53.539 --> 00:33:56.240 cycle. We give Lasix to get the fluid off the 00:33:56.240 --> 00:33:58.640 wet lungs. Lasix makes them pee out potassium. 00:33:59.119 --> 00:34:01.599 Low potassium then makes the digoxin toxic. Which 00:34:01.599 --> 00:34:05.160 is why the nurse has to be a hawk. You are monitoring 00:34:05.160 --> 00:34:08.380 potassium levels daily. You're encouraging potassium 00:34:08.380 --> 00:34:10.699 -rich foods like bananas, spinach, potatoes, 00:34:10.800 --> 00:34:13.260 if they're old enough. If your patient is on 00:34:13.260 --> 00:34:16.239 both DIG and Lasix, you are watching that potassium 00:34:16.239 --> 00:34:18.340 like your license depends on it because it does. 00:34:18.480 --> 00:34:21.420 Okay, let's talk about the big procedure. Cardiac 00:34:21.420 --> 00:34:26.099 catheterization. We thread a long thin catheter 00:34:26.099 --> 00:34:28.940 up the femoral vein or artery into the heart 00:34:28.940 --> 00:34:31.960 to measure pressures, fix a valve or patch a 00:34:31.960 --> 00:34:34.800 hole. The kid comes back to the floor. What is 00:34:34.800 --> 00:34:37.940 the number one kill zone? Post procedure. Hemorrhage. 00:34:38.039 --> 00:34:40.619 We just poked a hole in a major artery or vein 00:34:40.619 --> 00:34:44.179 in the groin. If that clot blows, the kid can 00:34:44.179 --> 00:34:46.139 bleed out into their thigh very, very quickly. 00:34:46.219 --> 00:34:48.599 So how do we assess for that? You check the dressing, 00:34:48.880 --> 00:34:51.239 obviously, for any visible bleeding. But blood 00:34:51.239 --> 00:34:53.280 follows gravity. If the kid is lying on their 00:34:53.280 --> 00:34:54.820 back, the blood might not come out the front. 00:34:54.840 --> 00:34:56.960 It might pool under their leg and buttocks. So 00:34:56.960 --> 00:34:58.639 you have to physically slide your hand under 00:34:58.639 --> 00:35:00.940 them. If you feel wetness, check your glove. 00:35:01.119 --> 00:35:02.960 Is it blood? And you have to check the pulses 00:35:02.960 --> 00:35:05.920 below the site. Absolutely. Check the pedal pulses 00:35:05.920 --> 00:35:08.159 in the foot on the affected side. If that leg 00:35:08.159 --> 00:35:10.739 is cool, pale, and the pulse is weak or gone, 00:35:11.099 --> 00:35:13.280 you may have thrown a clot that's blocking the 00:35:13.280 --> 00:35:15.420 femoral artery. That is a medical emergency. 00:35:15.639 --> 00:35:18.500 The leg could die. What's the main nursing intervention 00:35:18.500 --> 00:35:21.800 to prevent bleeding? Keep the affected leg completely 00:35:21.800 --> 00:35:24.960 straight. No bending at the hip. For four to 00:35:24.960 --> 00:35:27.420 eight hours, depending on the protocol. Have 00:35:27.420 --> 00:35:29.400 you ever tried to keep a two -year -old's leg 00:35:29.400 --> 00:35:32.659 straight for six hours? It is a special kind 00:35:32.659 --> 00:35:34.800 of nursing nightmare. This is where pediatric 00:35:34.800 --> 00:35:37.320 nursing becomes an art form. You use soft knee 00:35:37.320 --> 00:35:39.340 immobilizers, you use iPads, you read books, 00:35:39.400 --> 00:35:42.139 you have parents literally hold the leg, but 00:35:42.139 --> 00:35:44.500 they cannot sit up because sitting up flexes 00:35:44.500 --> 00:35:47.099 the hip, puts pressure on that groin site, and 00:35:47.099 --> 00:35:49.860 can pop the clot. And if you see active bleeding, 00:35:50.300 --> 00:35:52.460 if the dressing suddenly becomes soaked with 00:35:52.460 --> 00:35:55.500 blood. Direct, firm pressure, but not just on 00:35:55.500 --> 00:35:57.719 the little bandaid. You apply pressure with your 00:35:57.719 --> 00:36:00.440 gloved hand about one inch above the insertion 00:36:00.440 --> 00:36:03.269 site. You're trying to compress the artery proximally 00:36:03.269 --> 00:36:05.190 to stop the flow coming from the heart. And you 00:36:05.190 --> 00:36:07.070 hold it, and you yell for help. You do not leave 00:36:07.070 --> 00:36:10.289 that room. OK. We've covered the drugs, the procedures. 00:36:10.750 --> 00:36:12.570 Let's touch on the day -to -day management of 00:36:12.570 --> 00:36:16.429 congestive heart failure, or CHF. The goal is 00:36:16.429 --> 00:36:19.130 to decrease the workload on the heart. How do 00:36:19.130 --> 00:36:21.190 we feed these babies? Right. We mentioned the 00:36:21.190 --> 00:36:23.909 sweating. Feeding is work. It's a marathon for 00:36:23.909 --> 00:36:25.909 them. So we need to make it as easy as possible. 00:36:26.170 --> 00:36:30.070 How do we do that? A few key ways. One. Small, 00:36:30.389 --> 00:36:32.750 frequent feeds. Don't overfill their stomach 00:36:32.750 --> 00:36:35.010 because a full stomach pushes up on the diaphragm 00:36:35.010 --> 00:36:37.210 and makes it even harder to breathe. Every three 00:36:37.210 --> 00:36:41.210 hours is standard. Two, high calorie formula. 00:36:41.690 --> 00:36:44.449 Standard formula is 20 kilocalories per ounce. 00:36:44.670 --> 00:36:46.590 We might fortify it with extra powder to make 00:36:46.590 --> 00:36:49.809 it 24 or even 30 kilocal per ounce. The goal 00:36:49.809 --> 00:36:52.630 is more energy and less volume. And what about 00:36:52.630 --> 00:36:55.500 the mechanics of eating? Three. Use a soft nipple 00:36:55.500 --> 00:36:57.440 with a slightly larger hole. We don't want them 00:36:57.440 --> 00:36:59.360 working hard to suck. The milk should almost 00:36:59.360 --> 00:37:01.400 drip into their mouth with minimal effort. And 00:37:01.400 --> 00:37:04.000 if they take longer than, say, 20 or 30 minutes 00:37:04.000 --> 00:37:06.559 to finish a bottle? You stop. If they are still 00:37:06.559 --> 00:37:08.340 trying to eat after 30 minutes, they are burning 00:37:08.340 --> 00:37:09.960 more calories than they are taking in. It's a 00:37:09.960 --> 00:37:12.480 net loss. At that point, you have to prioritize 00:37:12.480 --> 00:37:15.420 growth over the skill of eating. You drop an 00:37:15.420 --> 00:37:17.599 NG tube and you gavage feed the rest of the formula. 00:37:17.940 --> 00:37:21.159 It's about conserving every last calorie. And 00:37:21.159 --> 00:37:23.630 what about positioning? Keep them in a semi -fowler's 00:37:23.630 --> 00:37:25.750 position, even in the car seat. Keep their head 00:37:25.750 --> 00:37:28.510 up. It allows for maximal chest expansion and 00:37:28.510 --> 00:37:30.570 makes the work of breathing a little bit easier. 00:37:30.849 --> 00:37:33.510 Part 6. Psychosocial and family. We can't forget 00:37:33.510 --> 00:37:36.409 the parents. They are terrified. They are grieving. 00:37:36.730 --> 00:37:39.210 They expected a perfect healthy baby and now 00:37:39.210 --> 00:37:42.130 they are in the ICU surrounded by tubes and wires 00:37:42.130 --> 00:37:44.909 and beeping machines. They often feel intense 00:37:44.909 --> 00:37:47.349 guilt like they did something wrong. And they 00:37:47.349 --> 00:37:49.389 live with the constant fear that the child will 00:37:49.389 --> 00:37:52.889 die. So what's our role? Our role is to be a 00:37:52.889 --> 00:37:55.690 calm, clear educator. You need to explain things 00:37:55.690 --> 00:37:58.389 simply. Get a whiteboard. Draw pictures of the 00:37:58.389 --> 00:38:00.469 heart. Here is the hole. Here's the patch the 00:38:00.469 --> 00:38:03.010 surgeon will put in. Empower them with knowledge. 00:38:03.329 --> 00:38:05.650 Let them participate in care bathing, changing 00:38:05.650 --> 00:38:08.730 diapers, to restore some sense of normalcy and 00:38:08.730 --> 00:38:10.789 control. And what about activity restrictions 00:38:10.789 --> 00:38:13.250 for older kids? The kid with a big scar on their 00:38:13.250 --> 00:38:15.250 chest who wants to go play soccer. What do we 00:38:15.250 --> 00:38:18.110 tell them? For most repaired defects, we generally 00:38:18.110 --> 00:38:20.719 tell them to self -limit. The child knows their 00:38:20.719 --> 00:38:23.380 body better than anyone. If they get tired, they 00:38:23.380 --> 00:38:25.800 will stop and rest. We don't usually have to 00:38:25.800 --> 00:38:28.039 bench them from sports unless it's a specific 00:38:28.039 --> 00:38:30.739 arrhythmia condition or they're on anticoagulants. 00:38:31.139 --> 00:38:33.380 But there is a very specific safety rule for 00:38:33.380 --> 00:38:35.980 kids who have had recent open -heart surgery, 00:38:36.239 --> 00:38:38.960 the sternotomy care. Yes, this is a big one. 00:38:39.340 --> 00:38:41.579 After open -heart surgery, their sternum is wired 00:38:41.579 --> 00:38:44.000 shut. It takes about six to eight weeks to heal. 00:38:44.380 --> 00:38:47.219 You absolutely cannot lift that child up under 00:38:47.219 --> 00:38:49.360 the arms. Why not? If you pick them up by the 00:38:49.360 --> 00:38:51.860 armpits, you can pull on that healing bone, pop 00:38:51.860 --> 00:38:54.280 the wires, and destabilize their entire chest. 00:38:54.360 --> 00:38:56.780 It's incredibly painful and dangerous. So you 00:38:56.780 --> 00:38:59.099 have to teach parents to scoop the butt, not 00:38:59.099 --> 00:39:02.780 pull the arms. Good tip. Okay, we have covered 00:39:02.780 --> 00:39:05.440 a massive amount of ground, from pressure gradients 00:39:05.440 --> 00:39:07.599 to strawberry tongues to keeping legs straight. 00:39:07.980 --> 00:39:09.980 Let's wrap this up with our big three takeaways. 00:39:10.920 --> 00:39:13.099 If our listener is walking into an exam tomorrow, 00:39:13.619 --> 00:39:16.159 what are the three things they absolutely must 00:39:16.159 --> 00:39:19.230 have locked in? Okay, number one, hemodynamics 00:39:19.230 --> 00:39:22.670 is king. Don't just memorize defects. Understand 00:39:22.670 --> 00:39:25.429 the flow. Left to right is wet and pink. Right 00:39:25.429 --> 00:39:27.989 to lad is blue and cyanotic. If you know the 00:39:27.989 --> 00:39:30.030 pressure, you know the symptoms. Okay, number 00:39:30.030 --> 00:39:32.989 two. Number two, safety first. Know the Dagoxin 00:39:32.989 --> 00:39:35.710 hold parameters, less than 90 for infants, and 00:39:35.710 --> 00:39:37.769 always watch the potassium. And know the tech 00:39:37.769 --> 00:39:39.550 spell drill. Knee chest position immediately. 00:39:39.929 --> 00:39:41.730 Those are life or death concepts that will be 00:39:41.730 --> 00:39:43.869 on the test. And number three. Number three. 00:39:43.980 --> 00:39:47.179 Assessment nuance. A sweating baby is a failing 00:39:47.179 --> 00:39:49.840 heart. A crying infant gives you bad data, so 00:39:49.840 --> 00:39:51.619 get your vitals when they're quiet. Trust your 00:39:51.619 --> 00:39:54.019 eyes and your hands, not just the monitor. Brilliant. 00:39:54.519 --> 00:39:56.420 And as we close, I want to leave our listeners 00:39:56.420 --> 00:39:59.440 with a provocative thought. We spend so much 00:39:59.440 --> 00:40:01.960 time and energy fixing the pump, the plumbing, 00:40:02.179 --> 00:40:04.219 the valves, the pressure. But what about the 00:40:04.219 --> 00:40:06.599 computer that the pump serves? That is the new 00:40:06.599 --> 00:40:08.559 frontier of research in this field right now. 00:40:08.639 --> 00:40:12.039 We are saving these kids' hearts with amazing 00:40:12.039 --> 00:40:15.179 surgeries. Mortality is way down. But we are 00:40:15.179 --> 00:40:17.699 now finding that children with significant congenital 00:40:17.699 --> 00:40:20.820 heart disease have much higher rates of neurodevelopmental 00:40:20.820 --> 00:40:23.139 delays, ADHD, and learning disabilities later 00:40:23.139 --> 00:40:25.920 in life. Is it the time on the heart -long bypass 00:40:25.920 --> 00:40:29.110 machine during surgery? the periods of low oxygen 00:40:29.110 --> 00:40:31.550 before they get fixed? It's likely a mix of all 00:40:31.550 --> 00:40:33.869 of the above. The brain is incredibly sensitive 00:40:33.869 --> 00:40:36.650 to perfusion and oxygenation, especially in those 00:40:36.650 --> 00:40:39.050 first few years. So as nurses, our job doesn't 00:40:39.050 --> 00:40:41.469 end when the incision heals. We need to be screening 00:40:41.469 --> 00:40:43.309 these kids for developmental delays. We need 00:40:43.309 --> 00:40:45.630 to be pushing for early intervention. We fix 00:40:45.630 --> 00:40:47.590 the hardware, now we have to protect the software. 00:40:47.849 --> 00:40:50.630 We fix the hardware, now we have to protect the 00:40:50.630 --> 00:40:53.769 software. That is a powerful place to end. to 00:40:53.769 --> 00:40:55.590 all the nursing students and nurses out there 00:40:55.590 --> 00:40:58.889 tackling this unit. You can do this. Blood is 00:40:58.889 --> 00:41:01.570 lazy. Follow the flow. You've got this. We've 00:41:01.570 --> 00:41:03.369 got this. Thanks for diving deep with us. See 00:41:03.369 --> 00:41:03.829 you next time.