Clinical Tips
Quick and practical tips for your nursing practice
🚨 Flash Cap Refill Is NOT Good Perfusion
Cap refill <1 second looks reassuring. It is not. In warm shock, extreme vasodilation causes flash refill — the blood
🧠 The 60-Second Shock Phenotype Check
Four findings. Under one minute. Every reassessment. 1. Cap refill at STERNUM — firm 5s press, count return >2s = cold
❌ Myth: "Start dopamine — it's the go-to first-line vasopressor in pediatric shock"
Reality: 2 RCTs show epinephrine outperforms dopamine. Dopamine is no longer first-line Canadian Paediatric Society, 2
👤 Marcus, 14, looks "fine" at triage
Warm flushed skin. Bounding pulses. Cap refill instant. BP 85/40. "Good perfusion" — right? Wrong. Pulse pressure: 45
💡 Wrong Vasopressor = Worse Outcomes
Norepinephrine in cold shock: Increases afterload on an already failing heart → cardiac output drops further. You squee
👤 Jaylen, 2, pale and listless
HR 180. BP 70/50. Pale, mottled skin. Cap refill 4 seconds. Cool to mid-calf. Pulse pressure: 20 mmHg narrow. Weak thr
💡 Two Mnemonics. Two Drugs. Zero Confusion.
"COLD needs the HEAT" Cold shock → Epinephrine Beta-1 inotropy warms cardiac output + alpha-1 maintains vascular tone D
📊 Both high AND low BP cause harm in acute stroke
The U-shaped curve: aggressive lowering starves the brain. Uncontrolled elevation causes hemorrhage. For every 10mmHg
🧠 BP SAFE: Your Stroke BP Protocol (2025)
Before reperfusion: <185/110 or no tPA Post-reperfusion: tPA → 130-140 | EVT → 140-180 Spike = Stop and scan possible
📋 IV Antihypertensive Protocol (AHA)
Labetalol: 10-20mg IV push, repeat x1, then infusion 2-8 mg/min Nicardipine: Start 5 mg/h, ↑ 2.5 mg/h q5-15min, max 15
🚨 Sudden BP Spike Post-tPA = Hemorrhage Until Proven Otherwise
New SBP >180-230 or sudden change from baseline + headache, vomiting, or decreased consciousness? Immediate actions: 1
❌ Myth: "All post-reperfusion patients need BP <140"
Reality: Post-EVT target is 140-180 mmHg Two RCTs ENCHANTED2/MT, OPTIMAL-BP stopped early because intensive control <