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 --> 00:00:46.870 fast. Welcome to the emergency room. Welcome 00:00:46.870 --> 00:00:48.670 back to The Deep Dive. I'm really glad you're 00:00:48.670 --> 00:00:50.630 here with us. Today, we're doing something a 00:00:50.630 --> 00:00:53.100 little bit different. Usually... You know, we 00:00:53.100 --> 00:00:55.299 take a topic and sort of wander through the philosophy 00:00:55.299 --> 00:00:59.159 or the tech trends, but today we have a very 00:00:59.159 --> 00:01:02.079 specific, very tactical mission. We do. We're 00:01:02.079 --> 00:01:04.859 taking this massive stack of sources, I mean, 00:01:04.859 --> 00:01:07.519 clinical overviews, pathogenesis papers, CDC 00:01:07.519 --> 00:01:10.579 protocols, nursing textbooks, and we're going 00:01:10.579 --> 00:01:15.620 to transform those dry, dense pages into what 00:01:15.620 --> 00:01:18.340 we're calling the pediatric nursing exam cram. 00:01:18.439 --> 00:01:21.000 It's a really specialized session. We're essentially 00:01:21.000 --> 00:01:24.010 building the ultimate study guide for a disease 00:01:24.010 --> 00:01:25.769 that, quite honestly, a lot of people, a lot 00:01:25.769 --> 00:01:27.829 of students think belongs in a history book. 00:01:27.849 --> 00:01:29.709 Right. But if you actually look at the data, 00:01:30.569 --> 00:01:32.049 and well, certainly if you look at the nursing 00:01:32.049 --> 00:01:34.790 board exams, this topic is very, very much alive. 00:01:35.150 --> 00:01:37.609 We're talking about measles. Or to get clinical 00:01:37.609 --> 00:01:39.969 about it. Or to be clinically precise, rubeola. 00:01:40.129 --> 00:01:42.650 Rubeola. And before you, the listener, tune out 00:01:42.650 --> 00:01:44.569 thinking, oh, I know what measles is. It's just 00:01:44.569 --> 00:01:47.590 a rash. Hold on. Because this is the exam writers, 00:01:47.829 --> 00:01:49.959 darling. It really is. Oh, absolutely. The sources 00:01:49.959 --> 00:01:52.260 we looked at make it so clear that this disease 00:01:52.260 --> 00:01:54.859 is a favorite for testing critical thinking. 00:01:55.299 --> 00:01:58.340 Oh, 100%. If I'm writing a test question for 00:01:58.340 --> 00:02:01.079 the NCLE -X or for a pediatric board exam, I 00:02:01.079 --> 00:02:03.560 love measles. That sounds just a little bit sadistic. 00:02:03.819 --> 00:02:06.319 Why do you love it? Because it tests everything 00:02:06.319 --> 00:02:08.400 it wants. I mean, in a single clinical scenario, 00:02:08.620 --> 00:02:11.909 a kid with a fever and a rash. I can test your 00:02:11.909 --> 00:02:14.889 knowledge of isolation precautions. I can test 00:02:14.889 --> 00:02:17.889 you on vaccine schedules. I can test your ability 00:02:17.889 --> 00:02:20.590 to spot contraindications. I can test you on 00:02:20.590 --> 00:02:23.729 public health reporting. It's the perfect storm. 00:02:24.069 --> 00:02:27.509 It forces you to integrate safety, pharmacology, 00:02:27.669 --> 00:02:31.009 and pathophysiology, all in one go. OK, so our 00:02:31.009 --> 00:02:32.889 goal today is to make you bulletproof on this 00:02:32.889 --> 00:02:35.169 topic. Whether you're prepping for a final, the 00:02:35.169 --> 00:02:37.430 NCLE -X, or you just want to be the sharpest 00:02:37.430 --> 00:02:39.250 clinician on the unit, we're going to break this 00:02:39.250 --> 00:02:41.319 down. Here's the roadmap. We're going to start 00:02:41.319 --> 00:02:44.020 with what we call the master 80 -20 map. These 00:02:44.020 --> 00:02:46.020 are the patterns you need to recognize instantly. 00:02:46.659 --> 00:02:50.000 Then we're going much deeper than a cheat sheet 00:02:50.000 --> 00:02:52.360 into the system by system lecture. We'll look 00:02:52.360 --> 00:02:56.360 at the Trojan horse, pathophysiology, the presentation, 00:02:56.659 --> 00:02:58.860 and the management. And we can't forget the developmental 00:02:58.860 --> 00:03:01.240 impacts. I mean, that's huge. Dealing with a 00:03:01.240 --> 00:03:04.139 measles patient who is two years old is completely 00:03:04.139 --> 00:03:07.199 different from dealing with one who is 10. We'll 00:03:07.199 --> 00:03:09.379 cover how to handle the isolation psychologically. 00:03:09.900 --> 00:03:12.379 Yes. And finally, we will wrap up with the nice 00:03:12.379 --> 00:03:15.400 to know history and some tricky differentiations 00:03:15.400 --> 00:03:18.099 to keep you from getting fooled by other, you 00:03:18.099 --> 00:03:21.159 know, rash diseases on an exam. It's a full agenda. 00:03:21.360 --> 00:03:24.020 It is. So let's jump right in. Section A, the 00:03:24.020 --> 00:03:26.919 master 80 -20 map. If a student or a nurse only 00:03:26.919 --> 00:03:29.039 retains about five minutes of this entire deep 00:03:29.039 --> 00:03:31.379 dive, what is the one pattern they need to burn 00:03:31.379 --> 00:03:33.939 into their brain? What's the measles signature? 00:03:34.199 --> 00:03:36.789 OK, the signature pattern is this. A high fever 00:03:36.789 --> 00:03:39.590 prodrome plus a descending rash. You'd have both 00:03:39.590 --> 00:03:42.469 of those components. High fever prodrome, descending 00:03:42.469 --> 00:03:45.689 rash. Yes. So if you see a question description 00:03:45.689 --> 00:03:48.270 of a child who is just absolutely miserable, 00:03:48.530 --> 00:03:50.889 toxic looking, with a high fever, we're talking 00:03:50.889 --> 00:03:55.409 103, 104, even 105 degrees Fahrenheit. Wow. And 00:03:55.409 --> 00:03:58.669 then, and only then, a rash starts on the head 00:03:58.669 --> 00:04:03.689 and moves down. You stop. Do not pass go you 00:04:03.689 --> 00:04:05.870 have to think measles until it's proven otherwise 00:04:05.870 --> 00:04:07.750 I want to stick on that descending part for a 00:04:07.750 --> 00:04:09.590 second because you know a lot of rashes spread 00:04:09.590 --> 00:04:12.289 What makes this one so unique? It's the gravity 00:04:12.289 --> 00:04:15.349 of it It literally starts at the hairline behind 00:04:15.349 --> 00:04:17.850 the ears and it just washes down the body like 00:04:17.850 --> 00:04:20.250 you poured a bucket of paint over the kid's head 00:04:20.250 --> 00:04:22.990 That's a great it hits the face then the neck 00:04:22.990 --> 00:04:25.790 then the trunk then the extremities It doesn't 00:04:25.790 --> 00:04:28.069 pop up randomly on the belly first or on the 00:04:28.069 --> 00:04:31.509 legs. It is a top -down invasion. Okay, so High 00:04:31.509 --> 00:04:34.129 fever first, rash later, moving down. Got it. 00:04:34.449 --> 00:04:36.370 Now let's talk about the safety decision point. 00:04:36.509 --> 00:04:39.350 This is the can't miss item. If you suspect this 00:04:39.350 --> 00:04:41.529 pattern, what is the absolute first thing you 00:04:41.529 --> 00:04:43.490 do before you even take a temperature, before 00:04:43.490 --> 00:04:46.970 you call the doctor? You isolate them immediately. 00:04:47.560 --> 00:04:50.800 But this is where people fail the exam, and frankly, 00:04:50.920 --> 00:04:52.639 this is where they endanger the entire unit. 00:04:52.759 --> 00:04:55.300 You don't just put them in a private room. Right. 00:04:55.519 --> 00:04:57.699 You need airborne precautions. OK, this was the 00:04:57.699 --> 00:04:59.240 part of the research that honestly terrified 00:04:59.240 --> 00:05:01.500 me. The sources mentioned something called the 00:05:01.500 --> 00:05:04.220 two -hour rule. Can we unpack that? Because airborne 00:05:04.220 --> 00:05:07.339 sounds like a buzzword, but the physics of it 00:05:07.339 --> 00:05:10.139 are genuinely scary. It is scary. and you're 00:05:10.139 --> 00:05:13.459 right to be. So most respiratory bugs, like say 00:05:13.459 --> 00:05:16.680 the flu or RSV, they travel on droplets. You 00:05:16.680 --> 00:05:19.420 cough, a heavy wet droplet flies out about three 00:05:19.420 --> 00:05:21.699 feet, and then gravity just pulls it to the floor. 00:05:22.220 --> 00:05:24.220 If I'm standing six feet away, I'm generally 00:05:24.220 --> 00:05:27.220 safe. Measles is completely different. How so? 00:05:27.639 --> 00:05:29.860 Weasels travels on what are called droplet nuclei. 00:05:30.160 --> 00:05:32.839 So imagine the droplet comes out of the person's 00:05:32.839 --> 00:05:34.660 mouth, but the water in it evaporates almost 00:05:34.660 --> 00:05:37.839 instantly. What's left behind is this microscopic, 00:05:38.279 --> 00:05:41.209 lightweight, viral core. So it's not wet anymore. 00:05:41.569 --> 00:05:44.370 No, it's dry. And because it's so light, it doesn't 00:05:44.370 --> 00:05:46.790 fall. It floats. It just rides the air currents 00:05:46.790 --> 00:05:50.069 in the room. It's like dust motes you see floating 00:05:50.069 --> 00:05:52.910 in a sunbeam. So it's just hanging there. Exactly. 00:05:53.209 --> 00:05:55.569 And the source data is really explicit on this. 00:05:56.189 --> 00:05:59.829 These viral nuclei remain viable and infectious 00:05:59.829 --> 00:06:02.470 in the air for up to two hours after the infected 00:06:02.470 --> 00:06:05.569 person has left the room. Two hours. OK, I want 00:06:05.569 --> 00:06:07.310 to role play a scenario because this really drives 00:06:07.310 --> 00:06:09.420 it home for me. Let's say a mom brings her kid 00:06:09.420 --> 00:06:13.379 into the ER. He's coughing, looks sick. You triage 00:06:13.379 --> 00:06:16.100 him. You think maybe it's the flu. You put him 00:06:16.100 --> 00:06:18.680 in exam room three. He's there for 20 minutes. 00:06:18.860 --> 00:06:21.560 Then he leaves. OK, following. An hour later, 00:06:22.040 --> 00:06:24.459 so 60 minutes have passed. The room is empty. 00:06:24.939 --> 00:06:27.100 I'm a nurse. I walk into exam room three to clean 00:06:27.100 --> 00:06:28.740 it or stock supplies. I'm not wearing a mask 00:06:28.740 --> 00:06:31.180 because, well, the room is empty. Am I in trouble? 00:06:31.319 --> 00:06:33.500 You are in serious trouble. If you are not immune 00:06:33.500 --> 00:06:37.540 to measles, there is a 90 % statistical probability, 00:06:37.660 --> 00:06:40.300 that's the attack rate, that you will contract 00:06:40.300 --> 00:06:42.980 the disease just by breathing that air. A 90 00:06:42.980 --> 00:06:45.639 % chance from an empty room. You're walking into 00:06:45.639 --> 00:06:48.000 a cloud of invisible virus that is still just 00:06:48.000 --> 00:06:51.019 waiting for a host. That is sci -fi horror movie 00:06:51.019 --> 00:06:53.199 stuff. It's like catching a disease from a ghost. 00:06:53.560 --> 00:06:55.759 It is. And that is why the isolation protocol 00:06:55.759 --> 00:06:58.240 is so incredibly strict. It has to be a negative 00:06:58.240 --> 00:07:00.560 pressure room, which... actively sucks the air 00:07:00.560 --> 00:07:02.579 out and filters it so it can't drift into the 00:07:02.579 --> 00:07:05.459 hallway. Right. And you, the provider, must wear 00:07:05.459 --> 00:07:08.639 an N95 mask, which is fitted to seal against 00:07:08.639 --> 00:07:11.579 your face. A standard surgical mask has gaps 00:07:11.579 --> 00:07:14.060 on the sides. Those little nuclei will float 00:07:14.060 --> 00:07:16.699 right in. So the takeaway for the 80 -20 map? 00:07:17.569 --> 00:07:20.470 If you even suspect measles, you don't wait for 00:07:20.470 --> 00:07:22.689 the lab result. If the clinical picture fits, 00:07:23.050 --> 00:07:25.850 you isolate airborne immediately. Correct. It's 00:07:25.850 --> 00:07:28.730 a guilty until proven innocent situation when 00:07:28.730 --> 00:07:30.970 it comes to isolation. You cannot risk it. Okay, 00:07:31.089 --> 00:07:32.850 we have the isolation down. What about the assessment 00:07:32.850 --> 00:07:35.050 queue? If I'm looking at this kid... Besides 00:07:35.050 --> 00:07:37.850 the super high fever, what are the specific signs 00:07:37.850 --> 00:07:40.689 that scream measles? You are looking for the 00:07:40.689 --> 00:07:43.509 three C's. I love a good mnemonic. It saves lives 00:07:43.509 --> 00:07:46.170 on exams, I swear. It's a classic for a reason. 00:07:46.610 --> 00:07:49.769 It's cough, choriza. and conjunctivitis. OK, 00:07:49.769 --> 00:07:51.589 let's break those down because cough is pretty 00:07:51.589 --> 00:07:53.889 generic. A lot of things cause a cough. That's 00:07:53.889 --> 00:07:56.110 true. But the text describe it very specifically 00:07:56.110 --> 00:07:58.790 as a hacking cough. This isn't a polite little 00:07:58.790 --> 00:08:01.870 clear your throat cough. It is deep. It is harsh. 00:08:02.029 --> 00:08:04.370 And it just sounds exhausting, like the kid can't 00:08:04.370 --> 00:08:06.529 catch their breath. And cordyceps, that's a fancy 00:08:06.529 --> 00:08:09.350 word. It is. It's just medical speak for inflammation 00:08:09.350 --> 00:08:12.470 of the mucous membranes in the nose. So basically, 00:08:13.230 --> 00:08:16.050 a profoundly runny nose. They're just dripping 00:08:16.050 --> 00:08:19.689 constantly. Got it. And the last C conjunctivitis. 00:08:19.970 --> 00:08:22.170 Pink eye. But it's usually bilateral in both 00:08:22.170 --> 00:08:26.149 eyes. They're red, watery, really irritated eyes. 00:08:27.009 --> 00:08:29.350 And often this is a key symptom. They are photophobic. 00:08:29.550 --> 00:08:32.289 Meaning light hurts them. Light physically hurts 00:08:32.289 --> 00:08:35.210 their eyes. So you have this kid who is hacking 00:08:35.210 --> 00:08:38.590 snotty with red. weepy eyes, and they're miserable 00:08:38.590 --> 00:08:40.509 with a fever, and they want the lights turned 00:08:40.509 --> 00:08:43.250 off. That's a very specific picture. It is. And 00:08:43.250 --> 00:08:44.789 then there's the smoking gun, the thing that 00:08:44.789 --> 00:08:46.870 shows up before the rash on the body. The ananthem, 00:08:47.110 --> 00:08:49.769 the spots inside the mouth. Couplic spots. Couplic 00:08:49.769 --> 00:08:52.190 spots. Yes. We'll detail the appearance in a 00:08:52.190 --> 00:08:53.549 little bit, but if you look in the mouth and 00:08:53.549 --> 00:08:56.450 you see these specific spots, you have your diagnosis. 00:08:56.909 --> 00:08:58.529 You don't even need to wait for the rash on the 00:08:58.529 --> 00:09:01.370 face to appear. And the last item on our 80 -20 00:09:01.370 --> 00:09:04.259 map, the can't miss safety item. This surprised 00:09:04.259 --> 00:09:06.080 me when I was reading the sources. It wasn't 00:09:06.080 --> 00:09:08.679 an antibiotic or some fancy antiviral. It was 00:09:08.679 --> 00:09:11.559 a vitamin. Vitamin A? Why? Is this just, you 00:09:11.559 --> 00:09:14.200 know, holistic nursing? Take some vitamins and 00:09:14.200 --> 00:09:16.700 feel better? No, no, this is hardcore physiology. 00:09:17.120 --> 00:09:20.059 The measles virus is brutal on epithelial cells. 00:09:20.480 --> 00:09:22.580 The lining of your gut, your lungs, and especially 00:09:22.580 --> 00:09:25.740 your eyes. It rapidly depletes the body's store 00:09:25.740 --> 00:09:28.240 of vitamin A. Okay, and when vitamin A levels 00:09:28.240 --> 00:09:30.960 drop the immune response weakens and the risk 00:09:30.960 --> 00:09:33.580 of blindness skyrocket blindness for measles 00:09:33.580 --> 00:09:37.179 Yes corneal scarring the virus directly attacks 00:09:37.179 --> 00:09:39.360 the eye and without enough vitamin A to help 00:09:39.360 --> 00:09:41.879 prepare that delicate tissue the damage becomes 00:09:41.879 --> 00:09:45.279 permanent so high dose vitamin A is a standard 00:09:45.279 --> 00:09:48.159 medical order for severe measles to prevent blindness 00:09:48.159 --> 00:09:51.659 and Actually to reduce overall mortality. So 00:09:51.659 --> 00:09:54.480 to recap the 80 -20 map before we go deeper high 00:09:54.480 --> 00:09:57.379 fever plus a descending rash Airborne isolation, 00:09:57.580 --> 00:09:59.759 immediately remember the two hour ghost rule. 00:10:00.379 --> 00:10:03.580 Look for the three C's and coplic spots. And 00:10:03.580 --> 00:10:06.299 keep vitamin A in the front of your mind as a 00:10:06.299 --> 00:10:08.740 treatment priority. That's the cheat sheet. If 00:10:08.740 --> 00:10:12.320 you know that, you are safe in the room. Now 00:10:12.320 --> 00:10:14.240 let's get into the weeds. OK, let's do it. Let's 00:10:14.240 --> 00:10:17.039 move to section B, the system by system lecture. 00:10:17.519 --> 00:10:19.659 We always like to start with a one liner. If 00:10:19.659 --> 00:10:21.860 you had to describe measles to a colleague in 00:10:21.860 --> 00:10:24.360 just one sentence, what is it? OK, my one liner 00:10:24.360 --> 00:10:27.460 would be. Measles is an acute, highly contagious 00:10:27.460 --> 00:10:31.159 viral respiratory illness, specifically a paramexovirus 00:10:31.159 --> 00:10:34.139 characterized by a high fever prodrome, a specific 00:10:34.139 --> 00:10:37.720 mouth enanthem called coplic spots, and a generalized 00:10:37.720 --> 00:10:40.960 maculopapular rash. You really emphasize respiratory 00:10:40.960 --> 00:10:43.279 illness again there. I did. But everyone, I mean 00:10:43.279 --> 00:10:45.860 everyone, thinks of it as a skin disease because 00:10:45.860 --> 00:10:48.159 of the rash. That is the single biggest misconception. 00:10:48.360 --> 00:10:50.980 The rash is just the billboard. It's the advertisement 00:10:50.980 --> 00:10:54.110 for the disease. But the disease itself is respiratory. 00:10:54.269 --> 00:10:56.610 The transmission is respiratory. The entry point 00:10:56.610 --> 00:10:59.409 is respiratory. The major complications are respiratory. 00:10:59.710 --> 00:11:01.669 OK, so let's walk through that patho in plain 00:11:01.669 --> 00:11:05.049 language. The virus is the invader. How does 00:11:05.049 --> 00:11:07.370 it get in? You said it's respiratory. You breathe 00:11:07.370 --> 00:11:09.649 it in, those little droplet nuclei we talked 00:11:09.649 --> 00:11:13.240 about. The virus goes down the trachea. into 00:11:13.240 --> 00:11:16.759 the lungs and lands in the alveoli, the tiny 00:11:16.759 --> 00:11:20.500 air sacs. Now usually you have immune cells down 00:11:20.500 --> 00:11:23.039 there called alveolar macrophages patrolling. 00:11:23.259 --> 00:11:26.980 Think of them like the security guards or the 00:11:26.980 --> 00:11:29.419 rooms of the lungs just cleaning up debris. So 00:11:29.419 --> 00:11:32.220 the security guards sees the virus and eats it, 00:11:32.360 --> 00:11:35.480 problem solved. Well, it tries to. But the measles 00:11:35.480 --> 00:11:38.100 virus is incredibly clever. It uses the macrophages 00:11:38.100 --> 00:11:41.220 like a Trojan horse. It actively infects the 00:11:41.220 --> 00:11:43.440 very cell that's supposed to kill it. That's 00:11:43.440 --> 00:11:45.779 insidious. It is. It hijacks the machinery inside 00:11:45.779 --> 00:11:48.019 the macrophage, starts making copies of itself, 00:11:48.320 --> 00:11:50.360 and then it rides that macrophage to the local 00:11:50.360 --> 00:11:52.519 lymph nodes. So it uses the security guard to 00:11:52.519 --> 00:11:54.960 get a free ride into the police station. Exactly. 00:11:55.299 --> 00:11:57.320 That whole process takes about two to three days. 00:11:57.559 --> 00:11:59.879 This is part of the incubation period. The patient 00:11:59.879 --> 00:12:03.360 feels totally fine. But inside, the virus is 00:12:03.360 --> 00:12:05.379 replicating like crazy in those lymph nodes. 00:12:05.860 --> 00:12:08.500 Then it bursts out into the bloodstream. We call 00:12:08.500 --> 00:12:10.559 this primary viremia. And they still don't have 00:12:10.559 --> 00:12:12.779 symptoms. Maybe a little fatigue, but nothing 00:12:12.779 --> 00:12:15.250 specific. The virus then spreads to what's called 00:12:15.250 --> 00:12:18.350 the reticular endothelial system. So the spleen, 00:12:18.409 --> 00:12:21.409 the liver, the bone marrow, it sets up shop there 00:12:21.409 --> 00:12:24.110 and just amplifies. It makes millions upon millions 00:12:24.110 --> 00:12:26.509 of copies of itself. It's building an army. It 00:12:26.509 --> 00:12:29.309 absolutely is. And then around day five to seven, 00:12:29.409 --> 00:12:31.990 after that initial infection, you get secondary 00:12:31.990 --> 00:12:34.769 viremia. This is the massive wave. The dam breaks. 00:12:34.929 --> 00:12:36.529 The virus floods the blood. It goes everywhere. 00:12:36.809 --> 00:12:40.129 Skin, kidneys, the GI tract, and crucially back 00:12:40.129 --> 00:12:42.350 to the lungs in massive numbers. And this is 00:12:42.350 --> 00:12:44.330 when they get sick. This is the prodrome. The 00:12:44.330 --> 00:12:46.629 viral load is peaking. The immune system is freaking 00:12:46.629 --> 00:12:48.950 out. The respiratory lining starts shedding virus 00:12:48.950 --> 00:12:51.750 like crazy. When that kid coughs now, they are 00:12:51.750 --> 00:12:54.649 a biological weapon. They're just spraying aerosolized 00:12:54.649 --> 00:12:56.889 virus everywhere. Let's put this on a timeline, 00:12:57.110 --> 00:13:00.929 because exams love day X questions. So the source 00:13:00.929 --> 00:13:04.029 says incubation is about 11 to 12 days. Right. 00:13:04.049 --> 00:13:06.269 That's the silent period. From the moment they 00:13:06.269 --> 00:13:07.970 breezed it in at the airport or the playground 00:13:07.970 --> 00:13:11.870 to the very first symptom, 11 to 12 days, nothing. 00:13:12.110 --> 00:13:14.309 Then we hit the prodrome. This is the warning 00:13:14.309 --> 00:13:16.389 phase. Yep. And this lasts about two to four 00:13:16.389 --> 00:13:19.730 days. This is where the kid looks toxic. The 00:13:19.730 --> 00:13:22.649 fever spikes in a stepwise fashion. It'll be 00:13:22.649 --> 00:13:26.870 101, then 102, peaking up at 103 to 105 degrees. 00:13:27.009 --> 00:13:30.289 That is a terrifyingly high fever. It is. And 00:13:30.289 --> 00:13:32.809 remember, the rash isn't there yet. It's just 00:13:32.809 --> 00:13:35.460 the fever in the three Cs. This is the most dangerous 00:13:35.460 --> 00:13:37.620 time for transmission because people think, oh, 00:13:37.620 --> 00:13:39.419 it's just a bad cold and they keep the kid in 00:13:39.419 --> 00:13:41.419 school or take them to the grocery store, not 00:13:41.419 --> 00:13:43.659 knowing they are spreading this incredibly contagious 00:13:43.659 --> 00:13:46.799 virus. Right. And then the enanthem appears, 00:13:47.120 --> 00:13:49.460 the coplic spots. Can you describe them exactly 00:13:49.460 --> 00:13:51.340 as they would appear on an exam description? 00:13:51.500 --> 00:13:53.440 I need a really clear visual. OK, the phrase 00:13:53.440 --> 00:13:56.259 you need to look for is grains of salt on a bright 00:13:56.259 --> 00:13:59.879 red background. Grains of salt. Yes. Or another 00:13:59.879 --> 00:14:03.240 description is punctate blue white spots. They 00:14:03.240 --> 00:14:06.600 are very small. And they're on the buccal mucosa. 00:14:06.899 --> 00:14:08.899 That's inside of the cheek, usually right next 00:14:08.899 --> 00:14:11.740 to the molars. Salt on a red background. That's 00:14:11.740 --> 00:14:14.600 very vivid. And remember, they are pathognomonic. 00:14:14.720 --> 00:14:17.559 If you see them, it is measles. There is practically 00:14:17.559 --> 00:14:19.940 nothing else that causes that specific finding. 00:14:20.639 --> 00:14:23.629 But... And here's the catch, they disappear quickly. 00:14:24.470 --> 00:14:26.789 By the time the body rash is full blown, the 00:14:26.789 --> 00:14:29.990 coplic spots are often gone. They are a fleeting 00:14:29.990 --> 00:14:32.090 critical warning sign. So if you miss them in 00:14:32.090 --> 00:14:34.429 the prodrome, you missed your best chance for 00:14:34.429 --> 00:14:36.909 an early definitive diagnosis. Exactly right. 00:14:37.289 --> 00:14:39.970 Now, the main event. The xanthan, the rash. This 00:14:39.970 --> 00:14:42.690 is usually around day 14 from the initial exposure. 00:14:42.970 --> 00:14:44.730 Around there, yeah. And as we said, it starts 00:14:44.730 --> 00:14:46.809 at the hairline behind the ears. That's a classic 00:14:46.809 --> 00:14:49.389 starting point. And it moves down. The term is 00:14:49.389 --> 00:14:52.610 cephalocodal. Cephalocodal. Down and out, face, 00:14:52.649 --> 00:14:55.970 then trunk, then arms, then legs. Usually takes 00:14:55.970 --> 00:14:58.070 about three days to fully cover the body. What 00:14:58.070 --> 00:15:00.789 does it feel like? Is it smooth? No, it's macula 00:15:00.789 --> 00:15:02.669 papular. That means it has flat parts, which 00:15:02.669 --> 00:15:05.330 are the macules, and raised bumps, the papules. 00:15:05.559 --> 00:15:08.220 So it feels a little bit like sandpaper or velvet, 00:15:08.740 --> 00:15:11.139 depending on the severity. And the source has 00:15:11.139 --> 00:15:14.159 all mentioned that initially, it blanches. Meaning 00:15:14.159 --> 00:15:16.580 if you press it with your thumb, it turns white 00:15:16.580 --> 00:15:20.279 for a second. Yes. But as it progresses, by day 00:15:20.279 --> 00:15:22.820 three or four, it stops blanching. The inflammation 00:15:22.820 --> 00:15:25.899 gets more intense. And in severe cases, the spots 00:15:25.899 --> 00:15:28.820 can run together. We call that confluence, especially 00:15:28.820 --> 00:15:31.120 on the face and the shoulders. The kid just looks 00:15:31.120 --> 00:15:33.460 red and swollen. And then how does it leave? 00:15:33.639 --> 00:15:35.720 Does it just fade away all at once? No, it's 00:15:35.720 --> 00:15:37.539 polite. It leaves in the same order it arrived. 00:15:37.700 --> 00:15:39.440 Oh, that's interesting. Yeah, so the face clears 00:15:39.440 --> 00:15:42.000 up first and the feet clear up last. But here's 00:15:42.000 --> 00:15:43.600 another interesting detail from the clinical 00:15:43.600 --> 00:15:47.100 notes. It often leaves behind a brownish discoloration 00:15:47.100 --> 00:15:49.740 and peeling skin. Like a sunburn that's healing. 00:15:50.080 --> 00:15:53.019 It's a similar look. The technical term is desquamation. 00:15:53.759 --> 00:15:56.100 And the brown color is actually from capillary 00:15:56.100 --> 00:15:58.500 leakage. Tiny little bits of blood cells left 00:15:58.500 --> 00:16:00.820 in the tissue. It fades over a week or so. Okay, 00:16:00.960 --> 00:16:04.240 that is a very, very clear picture of the pathology 00:16:04.240 --> 00:16:07.600 and the timeline. So now let's pivot to the need 00:16:07.600 --> 00:16:10.440 -to -know nursing care. We are at the bedside. 00:16:10.860 --> 00:16:14.100 What are our priority assessments? Number one 00:16:14.100 --> 00:16:17.440 always is respiratory status. Because it enters 00:16:17.440 --> 00:16:19.419 through the lungs and it comes back to the lungs. 00:16:19.600 --> 00:16:21.700 And because pneumonia is the single most common 00:16:21.700 --> 00:16:24.299 cause of death in children with measles, you 00:16:24.299 --> 00:16:26.600 have to understand the virus is damaging the 00:16:26.600 --> 00:16:29.049 lung lining. It's stripping away the defenses. 00:16:29.690 --> 00:16:33.269 That sets the stage for a super infection. OK. 00:16:33.450 --> 00:16:35.830 It could be the measles virus itself causing 00:16:35.830 --> 00:16:39.649 a nasty viral pneumonia, or more commonly, bacteria 00:16:39.649 --> 00:16:42.190 like staph or strep see an opportunity and just 00:16:42.190 --> 00:16:44.330 jump in. So as a nurse, I'm listening to those 00:16:44.330 --> 00:16:46.470 lungs every chance I get. Every chance. Yeah. 00:16:46.590 --> 00:16:48.730 You're watching for retractions, for nasal flaring, 00:16:48.929 --> 00:16:52.309 for digipny, that fast, shallow breathing, and 00:16:52.309 --> 00:16:55.690 a huge red flag. If that fever was starting to 00:16:55.690 --> 00:16:57.629 come down, and then it comes roaring back, you 00:16:57.629 --> 00:16:59.990 have to suspect pneumonia. Good tip. What's priority 00:16:59.990 --> 00:17:02.409 number two? Hydration status. This seems basic, 00:17:02.549 --> 00:17:04.410 but walk me through why it's so critical here. 00:17:04.690 --> 00:17:06.630 Okay, so you have a kid with a fever of 105. 00:17:07.549 --> 00:17:09.750 Their metabolic rate is sky high, so they're 00:17:09.750 --> 00:17:12.190 burning through fluid. They have mouth sores, 00:17:12.369 --> 00:17:14.029 those sculptic spots that hurt, so they don't 00:17:14.029 --> 00:17:16.230 want to drink. And the sources mentioned that 00:17:16.230 --> 00:17:18.410 severe diarrhea is a really common symptom as 00:17:18.410 --> 00:17:20.950 well. So fluids are pouring out and almost none 00:17:20.950 --> 00:17:23.390 are coming in. It's a perfect recipe for rapid 00:17:23.390 --> 00:17:26.970 dehydration and hypovolemic shock. You are monitoring 00:17:26.970 --> 00:17:30.490 intake and output strictly, checking skin turgor, 00:17:30.769 --> 00:17:32.369 checking to see if they're making tears when 00:17:32.369 --> 00:17:35.329 they cry. If they can't drink, they need an IV, 00:17:35.410 --> 00:17:37.730 period. Let's talk diagnostics. We suspected 00:17:37.730 --> 00:17:39.809 it. We've isolated them. Now how do we prove 00:17:39.809 --> 00:17:42.690 it? The gold standard is the RT -PCR. It's usually 00:17:42.690 --> 00:17:46.069 a throat swab or a nasopharyngeal swab. The CDC 00:17:46.069 --> 00:17:48.410 protocol also recommends getting a urine sample. 00:17:48.599 --> 00:17:50.740 as the virus sheds in the urine for quite a while. 00:17:50.940 --> 00:17:52.740 And blood work. For blood work, you're looking 00:17:52.740 --> 00:17:56.380 for IgM antibodies in the serum. The M in IgM, 00:17:56.400 --> 00:17:59.880 you can think of it as miserable or now. It tells 00:17:59.880 --> 00:18:02.980 you there's an active current infection. The 00:18:02.980 --> 00:18:04.640 recommendation is to collect the throat swab 00:18:04.640 --> 00:18:06.960 and the blood sample at the same time for the 00:18:06.960 --> 00:18:09.539 best chance of confirmation. OK, interventions. 00:18:09.839 --> 00:18:12.700 We have hammered isolation, negative pressure 00:18:12.700 --> 00:18:16.660 N95. What about medications? Is there an antiviral? 00:18:17.079 --> 00:18:19.640 Unfortunately, no. It's a virus, so antibiotics 00:18:19.640 --> 00:18:22.680 don't work on the measles itself. It is all supportive 00:18:22.680 --> 00:18:25.240 care. You treat the symptoms to keep the child 00:18:25.240 --> 00:18:28.500 stable while their body fights. So antipyretics 00:18:28.500 --> 00:18:30.980 for the fever acetaminophen or ibuprofen. But 00:18:30.980 --> 00:18:33.920 there is a huge warning here, and it's in every 00:18:33.920 --> 00:18:36.900 single source regarding aspirin. Huge E warning. 00:18:37.880 --> 00:18:40.519 Never, ever, ever give aspirin to a child with 00:18:40.519 --> 00:18:43.119 a viral illness. Why? What happens? It puts them 00:18:43.119 --> 00:18:45.369 at risk for Ray syndrome. This is a life -threatening 00:18:45.369 --> 00:18:47.529 condition that causes massive swelling in the 00:18:47.529 --> 00:18:50.130 liver and the brain. It destroys the mitochondria, 00:18:50.289 --> 00:18:52.809 the powerhouses of the cells. It is absolutely 00:18:52.809 --> 00:18:55.390 catastrophic. Stick to Tylenol or Motrin. And 00:18:55.390 --> 00:18:57.329 even with Motrin, there's an age limit, right? 00:18:57.369 --> 00:18:59.930 That's right. No ibuprofen if they're under six 00:18:59.930 --> 00:19:01.869 months old. The kidneys aren't quite ready to 00:19:01.869 --> 00:19:04.410 metabolize it safely. So you stick to acetaminophen 00:19:04.410 --> 00:19:07.069 or Tylenol for the really tiny ones. Got it. 00:19:07.569 --> 00:19:09.509 Now let's circle back to vitamin A. We mentioned 00:19:09.509 --> 00:19:11.890 it in the 80 -20 map. How do we administer it? 00:19:11.970 --> 00:19:15.180 Is it an IV? No, it's usually an oral dose, a 00:19:15.180 --> 00:19:18.220 high dose liquid or capsule. The WHO protocol 00:19:18.220 --> 00:19:21.480 is two doses given 24 hours apart. And if the 00:19:21.480 --> 00:19:23.799 child have clinical signs of vitamin A deficiency, 00:19:24.700 --> 00:19:28.140 like night blindness or dry eyes, they get a 00:19:28.140 --> 00:19:31.099 third dose weeks later. It's incredibly effective. 00:19:31.299 --> 00:19:33.980 It helps restore the integrity of the epithelial 00:19:33.980 --> 00:19:36.500 barrier in the gut and the eyes. Speaking of 00:19:36.500 --> 00:19:39.900 eyes, the patient has conjunctivitis and photophobia. 00:19:40.119 --> 00:19:42.759 What's the nursing action there? Simple comfort 00:19:42.759 --> 00:19:45.119 care. Keep the room dim. Bright lights are going 00:19:45.119 --> 00:19:47.559 to physically hurt their eyes. And you can gently 00:19:47.559 --> 00:19:49.720 clean the crusty secretions from their eyes with 00:19:49.720 --> 00:19:52.180 a washcloth and warm water. Is there a specific 00:19:52.180 --> 00:19:54.519 technique for that? Because you don't want to 00:19:54.519 --> 00:19:57.440 make it worse. Yeah. You always wipe from the 00:19:57.440 --> 00:19:59.819 inner canthus, the part near the nose, to the 00:19:59.819 --> 00:20:02.019 outer canthus near the ear. And you use a fresh 00:20:02.019 --> 00:20:03.920 part of the cloth for each wipe. You never want 00:20:03.920 --> 00:20:06.210 to push bacteria back into the tear duct. That's 00:20:06.210 --> 00:20:08.470 a great clinical pearl. OK, let's run through 00:20:08.470 --> 00:20:10.430 the crash list. The big scary complications. 00:20:10.589 --> 00:20:13.009 We mentioned pneumonia as the top killer. Pneumonia 00:20:13.009 --> 00:20:15.109 is number one. Yeah. But you also have to be 00:20:15.109 --> 00:20:17.410 watching for encephalitis. Inflammation of the 00:20:17.410 --> 00:20:19.670 brain. Right. This happens in about one in 1 00:20:19.670 --> 00:20:22.329 ,000 cases. So it's not super common, but it's 00:20:22.329 --> 00:20:25.069 devastating. It can cause convulsions, deafness, 00:20:25.430 --> 00:20:28.049 or permanent intellectual disability. If your 00:20:28.049 --> 00:20:30.170 patient suddenly gets very lethargic, confused, 00:20:30.230 --> 00:20:33.130 or has a seizure, that is a neurological emergency. 00:20:33.319 --> 00:20:36.579 What about ear infections? Otitis media is very, 00:20:36.579 --> 00:20:39.059 very common. The virus causes inflammation of 00:20:39.059 --> 00:20:41.680 the Eustachian tubes, which messes with drainage. 00:20:42.000 --> 00:20:44.259 So if the fever spikes again after the rash is 00:20:44.259 --> 00:20:46.440 starting to fade, you have to check the ears. 00:20:46.799 --> 00:20:48.799 It's usually a secondary bacterial infection 00:20:48.799 --> 00:20:51.319 that needs antibiotics. And there is that scary 00:20:51.319 --> 00:20:54.059 long -term one mentioned in the sources, SSPE. 00:20:54.460 --> 00:20:57.990 Subacute sclerosing panencephalitis. It is rare, 00:20:58.089 --> 00:21:00.490 thankfully, but it is the stuff of nightmares. 00:21:01.269 --> 00:21:03.549 It is a fatal degenerative brain disease that 00:21:03.549 --> 00:21:05.670 develops seven to ten years after the initial 00:21:05.670 --> 00:21:07.730 measles infection. Wait, seven years later? So 00:21:07.730 --> 00:21:10.230 the kid completely recovers, grows up, goes to 00:21:10.230 --> 00:21:12.049 elementary school, and then... And then they 00:21:12.049 --> 00:21:14.190 start regressing. They lose coordination. They 00:21:14.190 --> 00:21:16.609 have seizures. They lose cognitive function. 00:21:17.009 --> 00:21:19.490 The virus essentially hit out in the brain tissue, 00:21:19.809 --> 00:21:22.880 mutated, and then reactivated years later. It 00:21:22.880 --> 00:21:27.200 is 100 % fatal. There is no cure. That is just 00:21:27.200 --> 00:21:30.099 heavy. It is. And it really underscores why vaccination 00:21:30.099 --> 00:21:32.740 is the strategy here. You do not want to risk 00:21:32.740 --> 00:21:36.359 natural immunity if the potential cause is SSBE 00:21:36.359 --> 00:21:38.660 a decade later. It's like playing Russian roulette 00:21:38.660 --> 00:21:40.779 with a bullet that moves in slow motion. Wow. 00:21:40.900 --> 00:21:42.960 OK, so let's do a quick parent education segment. 00:21:43.240 --> 00:21:45.880 You're discharging the family. What are the absolute 00:21:45.880 --> 00:21:48.019 critical points, you tell them? First, you tell 00:21:48.019 --> 00:21:50.259 them the contagious period. The child has to 00:21:50.259 --> 00:21:52.789 be kept home from school or daycare. for at least 00:21:52.789 --> 00:21:55.410 four days after the rash appeared. They are still 00:21:55.410 --> 00:21:57.710 shedding virus. Four days after the rash starts, 00:21:57.950 --> 00:22:00.410 okay. And second, you have to talk about siblings. 00:22:00.710 --> 00:22:02.549 If there are vaccinated siblings at home, they 00:22:02.549 --> 00:22:04.509 are in deep trouble. We can try to give them 00:22:04.509 --> 00:22:07.170 the vaccine within 72 hours of exposure to maybe 00:22:07.170 --> 00:22:09.890 prevent it. Sort of post -exposure prophylaxis. 00:22:10.170 --> 00:22:12.170 Exactly. Or we can give something called immune 00:22:12.170 --> 00:22:15.789 globulin, or IG, within six days. But parents 00:22:15.789 --> 00:22:17.390 need to know their other kids are very likely 00:22:17.390 --> 00:22:19.960 incubating it. You have to contact Trace within 00:22:19.960 --> 00:22:22.059 the family and the community. OK, before we leave 00:22:22.059 --> 00:22:24.460 the core clinical section, let's hit the exam 00:22:24.460 --> 00:22:26.559 -writer favorites, the traps that they love to 00:22:26.559 --> 00:22:29.259 set. OK, trap number one, the absolute classic, 00:22:29.839 --> 00:22:32.559 rubeola versus rubella. They sound almost identical. 00:22:32.720 --> 00:22:35.539 It's cruel naming. It is. Rubeola is measles. 00:22:36.599 --> 00:22:39.779 Rubella is German measles. The little trick you 00:22:39.779 --> 00:22:43.009 remember is that rubeola has the ola in it. You 00:22:43.009 --> 00:22:45.789 can think ola equals illa. It makes you much, 00:22:45.789 --> 00:22:48.750 much sicker. Higher fever, worse complications, 00:22:48.950 --> 00:22:51.670 worse outcome. Rubial is illa. I like that. So 00:22:51.670 --> 00:22:54.289 rubella is milder. Yes. My mnemonic for that 00:22:54.289 --> 00:22:56.630 is rubella is a little fella. It's generally 00:22:56.630 --> 00:22:59.329 a milder disease in children. Lower fever, the 00:22:59.329 --> 00:23:02.130 rash fades faster. Now, rubella is incredibly 00:23:02.130 --> 00:23:04.329 dangerous for pregnant women because it's teragenic. 00:23:04.690 --> 00:23:07.029 But for the child themselves, rubella is the 00:23:07.029 --> 00:23:09.450 illa one. OK, what's trap number two? The allergy 00:23:09.450 --> 00:23:12.470 trap. The allergy trap. Yeah. So the MMR vaccine 00:23:12.470 --> 00:23:15.170 contains two key components besides the virus, 00:23:15.910 --> 00:23:19.390 gelatin and neomycin. The exam will ask you about 00:23:19.390 --> 00:23:22.390 contraindications. For years and years, people 00:23:22.390 --> 00:23:24.210 thought an egg allergy was a problem because 00:23:24.210 --> 00:23:26.250 the virus used to be grown in a certain way. 00:23:26.630 --> 00:23:29.109 It is not a D. Let me repeat that. So if the 00:23:29.109 --> 00:23:31.329 question says the child has a severe allergy 00:23:31.329 --> 00:23:34.730 to eggs, I can still give the MMR vaccine. Yes. 00:23:35.150 --> 00:23:37.730 Current guidelines are clear. Egg allergy is 00:23:37.730 --> 00:23:40.299 not a contraindication. But if they have a true 00:23:40.299 --> 00:23:42.900 anaphylactic history to gelatin or neomycin, 00:23:43.440 --> 00:23:45.980 that is a hard stop. You do not give the vaccine. 00:23:46.220 --> 00:23:48.819 That's a great catch. Okay, let's move to Section 00:23:48.819 --> 00:23:52.180 5, Development and Milestones Impact. This is 00:23:52.180 --> 00:23:54.559 a requirement for our deep dive because diseases 00:23:54.559 --> 00:23:56.819 don't happen in a vacuum. They happen to grow 00:23:56.819 --> 00:23:59.900 in kids. Exactly. And the impact changes so drastically 00:23:59.900 --> 00:24:02.140 based on the developmental stage. Let's start 00:24:02.140 --> 00:24:04.160 with the infant or the toddler. Okay, let's consider 00:24:04.160 --> 00:24:06.000 the physical impact first. We talked about the 00:24:06.000 --> 00:24:08.589 mouth source. the complex spots. Now imagine 00:24:08.589 --> 00:24:10.390 you're a 14 -month -old who is just learning 00:24:10.390 --> 00:24:13.009 to self -feed with a spoon, or maybe you just 00:24:13.009 --> 00:24:15.210 weaned off the bottle. Now their entire mouth 00:24:15.210 --> 00:24:18.490 is full of painful ulcers. Eating hurts. A lot. 00:24:18.690 --> 00:24:20.829 So they might regress in their feeding skills. 00:24:20.950 --> 00:24:23.230 Almost certainly. They might refuse solids and 00:24:23.230 --> 00:24:25.569 demand a bottle again. Or they might just refuse 00:24:25.569 --> 00:24:28.730 everything. And as a nurse, you have to be patient. 00:24:29.069 --> 00:24:31.349 You don't force the milestones. If they need 00:24:31.349 --> 00:24:33.369 to go back to a bottle for hydration, you let 00:24:33.369 --> 00:24:36.640 them. And what about energy? I mean, a 105 fever 00:24:36.640 --> 00:24:39.220 has to just drain them. A toddler who is usually 00:24:39.220 --> 00:24:41.700 running around everywhere. They'll be completely 00:24:41.700 --> 00:24:44.099 lethargic. They stop playing. And you have to 00:24:44.099 --> 00:24:47.599 remember, for a child, play is their work. It's 00:24:47.599 --> 00:24:50.079 how they learn and develop. When play stops, 00:24:50.559 --> 00:24:52.680 development pauses. They're just in survival 00:24:52.680 --> 00:24:54.880 mode. So now let's layer on the hospitalization. 00:24:55.039 --> 00:24:57.720 We put them in airborne isolation. This is huge 00:24:57.720 --> 00:24:59.710 for the psyche of a little one. Walk us through, 00:24:59.849 --> 00:25:02.809 why is isolation so uniquely hard for a toddler? 00:25:03.170 --> 00:25:05.890 Okay, so separation anxiety peaks around six 00:25:05.890 --> 00:25:08.670 to thirty months. Now imagine you're in a strange 00:25:08.670 --> 00:25:11.910 room, in a strange bed, and the door is always 00:25:11.910 --> 00:25:14.349 closed. The only people who come in look like 00:25:14.349 --> 00:25:17.990 aliens. They're in yellow gowns, gloves, N95 00:25:17.990 --> 00:25:20.809 masks, face shields. They can't see smiles, they 00:25:20.809 --> 00:25:24.670 can't read any facial cues. Exactly. To a toddler, 00:25:25.049 --> 00:25:28.759 a smile is safety. It's reassurance. If I hide 00:25:28.759 --> 00:25:31.700 my smile behind a mask, I am a potential threat. 00:25:32.480 --> 00:25:34.880 So the single most important nursing action is 00:25:34.880 --> 00:25:37.299 rooming in. You need to encourage the parents 00:25:37.299 --> 00:25:40.700 to stay 24 -7. They are the anchor in that storm. 00:25:40.880 --> 00:25:43.460 If the parent leaves, that child's cortisol, 00:25:43.599 --> 00:25:46.160 their stress hormones, spikes, which actually 00:25:46.160 --> 00:25:48.220 suppresses the immune system even further. So 00:25:48.220 --> 00:25:50.420 the parent's presence is literally a medical 00:25:50.420 --> 00:25:52.819 intervention. It is. Now what about the preschooler, 00:25:52.960 --> 00:25:55.160 the three to five -year -old? OK. Their core 00:25:55.160 --> 00:25:58.250 developmental fear is bodily harm. or mutilation. 00:25:58.809 --> 00:26:00.769 And they have magical thinking. If they don't 00:26:00.769 --> 00:26:02.730 understand viruses, they might think the mask 00:26:02.730 --> 00:26:04.609 means you're a monster who's going to hurt them. 00:26:04.670 --> 00:26:07.109 Or more commonly, they think the illness is a 00:26:07.109 --> 00:26:09.369 punishment. As in, I was naughty, so now I have 00:26:09.369 --> 00:26:11.970 spots. Exactly. I didn't share my toys, so now 00:26:11.970 --> 00:26:14.710 I'm sick. It's a very concrete cause and effect 00:26:14.710 --> 00:26:16.769 worldview. You have to verbally reassure them 00:26:16.769 --> 00:26:19.029 you're not being punished. This is just a germ. 00:26:19.170 --> 00:26:21.109 It's not your fault. And how do we help them 00:26:21.109 --> 00:26:24.210 cope with all the scary PPE? Medical play. This 00:26:24.210 --> 00:26:26.970 is absolutely critical. Before you do a procedure, 00:26:27.119 --> 00:26:29.680 or even just when you have a quiet moment, give 00:26:29.680 --> 00:26:32.180 them a mask to play with. Let them put a mask 00:26:32.180 --> 00:26:34.559 on their teddy bear. Let them draw a smiley face 00:26:34.559 --> 00:26:36.759 on the outside of your mask, if your hospital 00:26:36.759 --> 00:26:40.519 protocol allows, or on your isolation gown. Demystify 00:26:40.519 --> 00:26:43.380 the gear. Make it less threatening. Turn the 00:26:43.380 --> 00:26:47.119 scary PPE into a costume. This is my spacesuit 00:26:47.119 --> 00:26:49.819 to keep the germs away from me and to keep my 00:26:49.819 --> 00:26:52.420 germs away from you. Okay, and the school -aged 00:26:52.420 --> 00:26:55.359 kid, the 6 to 12 year old. Their main issue is 00:26:55.359 --> 00:26:57.779 boredom and social isolation from their peers. 00:26:58.440 --> 00:27:00.099 They are missing school, missing their friends, 00:27:00.579 --> 00:27:03.940 and being stuck in one room for days is incredibly 00:27:03.940 --> 00:27:05.900 hard for them. They understand what's going on, 00:27:06.140 --> 00:27:08.559 but they feel trapped. But we have to keep the 00:27:08.559 --> 00:27:11.099 room dim for their eyes because of the photophobia. 00:27:11.259 --> 00:27:13.039 Right. So you can't just fall back on the easy 00:27:13.039 --> 00:27:15.319 solution and say, here's an iPad, watch YouTube 00:27:15.319 --> 00:27:17.940 for eight hours. The screen is too bright. It 00:27:17.940 --> 00:27:19.920 will physically hurt them. So what do you do? 00:27:20.059 --> 00:27:22.599 A bored kid in a dark room sounds like a recipe 00:27:22.599 --> 00:27:25.859 for disaster. Audio stimulation. This is the 00:27:25.859 --> 00:27:28.519 time for audio books, for music, for podcasts 00:27:28.519 --> 00:27:31.940 like this one. Or for storytelling. Get the parents 00:27:31.940 --> 00:27:34.599 to read to them. You have to find ways to engage 00:27:34.599 --> 00:27:36.910 their mind without engaging their eyes. That 00:27:36.910 --> 00:27:39.529 is a fantastic practical tip. Don't just hand 00:27:39.529 --> 00:27:41.910 them the iPad. Not with measles conjunctivitis. 00:27:41.950 --> 00:27:44.190 It hurts way too much. OK, let's move to section 00:27:44.190 --> 00:27:47.269 six, the vaccine protocol. This is the preventative 00:27:47.269 --> 00:27:48.930 core of this whole discussion. It really is. 00:27:48.990 --> 00:27:53.069 The vaccine is the MMR, measles, mumps, rubella, 00:27:53.269 --> 00:27:56.390 and it's a live attenuated virus. Live is the 00:27:56.390 --> 00:27:58.250 key word there. That dictates all the rules. 00:27:58.430 --> 00:28:01.009 Correct. Because it's alive, albeit weakened 00:28:01.009 --> 00:28:04.670 virus, we do not give it to pregnant women. Theoretically, 00:28:04.670 --> 00:28:07.359 it could harm the fetus. and women should be 00:28:07.359 --> 00:28:09.299 advised to avoid getting pregnant for four weeks 00:28:09.299 --> 00:28:11.000 after getting the shot. And we also don't give 00:28:11.000 --> 00:28:13.319 it to the severely immunocompromised. Right. 00:28:13.380 --> 00:28:16.740 Kids on chemotherapy or with advanced HIV with 00:28:16.740 --> 00:28:20.420 very low CD4 counts, their immune system is too 00:28:20.420 --> 00:28:23.460 weak to handle even a weakened virus. It could 00:28:23.460 --> 00:28:25.740 cause the actual disease. What's the standard 00:28:25.740 --> 00:28:28.059 schedule in the U .S.? It's a two -dose series. 00:28:28.460 --> 00:28:30.980 Dose number one is at 12 to 15 months of age, 00:28:31.039 --> 00:28:34.079 and dose number two is at four to six years, 00:28:34.339 --> 00:28:36.329 right before they start kindergarten. I've always 00:28:36.329 --> 00:28:39.029 wondered, why do we wait until 12 months? Why 00:28:39.029 --> 00:28:41.769 not give it at birth, like the hepatitis B vaccine? 00:28:41.930 --> 00:28:44.950 It's all because of mom. The baby gets a full 00:28:44.950 --> 00:28:47.710 set of maternal antibodies transferred through 00:28:47.710 --> 00:28:49.710 the placenta that circulate for the first year 00:28:49.710 --> 00:28:52.809 of life. If you give the vaccine too early, say 00:28:52.809 --> 00:28:56.210 at six months, mom's antibodies see the vaccine 00:28:56.210 --> 00:28:58.829 virus and kill it immediately. So the baby's 00:28:58.829 --> 00:29:00.730 own immune system never gets a chance to see 00:29:00.730 --> 00:29:04.099 it and learn from it. Exactly. The maternal antibodies 00:29:04.099 --> 00:29:06.819 neutralize the lesson before it can be learned. 00:29:07.480 --> 00:29:09.619 We have to wait until those antibodies naturally 00:29:09.619 --> 00:29:11.380 fade, which happens right around the one -year 00:29:11.380 --> 00:29:13.880 mark. That makes perfect sense, but there's an 00:29:13.880 --> 00:29:16.440 exception for travel, right? Yes, because measles 00:29:16.440 --> 00:29:18.640 is still rampant in many other parts of the world. 00:29:18.880 --> 00:29:21.400 If you're traveling internationally with an infant 00:29:21.400 --> 00:29:24.140 who is between 6 and 11 months old, they get 00:29:24.140 --> 00:29:26.839 a dose. But the UT, and this is a classic exam 00:29:26.839 --> 00:29:29.119 point, that dose doesn't count. It's a zero dose. 00:29:29.359 --> 00:29:31.700 Right. It provides some temporary protection 00:29:31.700 --> 00:29:34.259 for the trip. But because maternal antibodies 00:29:34.259 --> 00:29:36.839 might still be interfering, we can't be sure 00:29:36.839 --> 00:29:38.700 they'll get long -term memory from it. So you 00:29:38.700 --> 00:29:40.539 still have to give the regular dose at 12 months 00:29:40.539 --> 00:29:42.980 and the booster at four years. OK, let's talk 00:29:42.980 --> 00:29:45.259 about side effects, because this is what parents 00:29:45.259 --> 00:29:48.039 worry about. And there's one specific thing that 00:29:48.039 --> 00:29:51.700 really freaks them out. The mini measles. Sounds 00:29:51.700 --> 00:29:56.019 cute. I'm guessing it probably isn't. Well, it's 00:29:56.019 --> 00:29:58.500 not a true infection, but because it's a live 00:29:58.500 --> 00:30:00.660 vaccine, it replicates a little bit in the body. 00:30:01.349 --> 00:30:04.309 So, about 5 to 15 percent of kids will get a 00:30:04.309 --> 00:30:07.769 fever and a mild rash. But here is the kicker. 00:30:08.089 --> 00:30:10.910 It happens 7 to 12 days after the shot. That 00:30:10.910 --> 00:30:13.410 is such a long delay. It is. Which means the 00:30:13.410 --> 00:30:14.890 parent has forgotten they even got the shot. 00:30:15.529 --> 00:30:17.730 Then, two weeks later, the kid has a fever and 00:30:17.730 --> 00:30:20.410 a rash. They call the office panicking. My child 00:30:20.410 --> 00:30:22.529 has measles from the vaccine. Right. You need 00:30:22.529 --> 00:30:24.509 to warn them up front. In about a week and a 00:30:24.509 --> 00:30:26.069 half, he might get a little fever and a rash. 00:30:26.450 --> 00:30:28.710 That is a good sign. It means the vaccine is 00:30:28.710 --> 00:30:31.740 working. It is not contagious. That is crucial 00:30:31.740 --> 00:30:34.960 guidance to prevent a frantic ER visit. What 00:30:34.960 --> 00:30:37.380 about the MMRV, the one with Vericello or chicken 00:30:37.380 --> 00:30:41.380 pox added in? It's great for reducing the number 00:30:41.380 --> 00:30:43.920 of pokes a kid has to get. However, the data 00:30:43.920 --> 00:30:46.660 clearly shows a slightly higher risk of febrile 00:30:46.660 --> 00:30:49.559 seizures in toddlers, specifically in the 12 00:30:49.559 --> 00:30:53.319 to 23 month age range, with the combined MMRV 00:30:53.319 --> 00:30:55.539 compared to giving MMR and varicella as separate 00:30:55.539 --> 00:30:59.200 shots. So for that first dose at 12 months? Usually 00:30:59.200 --> 00:31:00.799 the recommendation is to separate them. Give 00:31:00.799 --> 00:31:02.960 the MMR in one leg and the varicella in the other, 00:31:03.200 --> 00:31:05.400 just to lower that already small seizure risk. 00:31:05.700 --> 00:31:07.859 For the four -year -old booster dose, the MMRV 00:31:07.859 --> 00:31:09.809 is fine because the risk of febrile seizures 00:31:09.809 --> 00:31:12.109 naturally drops as they get older. OK, we are 00:31:12.109 --> 00:31:14.009 rounding the corner to the nice to know section. 00:31:14.269 --> 00:31:16.130 Give us some context that might not be on the 00:31:16.130 --> 00:31:18.529 test, but just makes us smarter clinicians. Let's 00:31:18.529 --> 00:31:21.589 look at history. Raises, who was a Persian physician 00:31:21.589 --> 00:31:24.029 back in the 10th century, was the first to really 00:31:24.029 --> 00:31:26.589 describe measles in detail. And he wrote that 00:31:26.589 --> 00:31:29.529 it was more to be dreaded than smallpox. Wow. 00:31:29.630 --> 00:31:32.269 And smallpox was really bad. It shows you how 00:31:32.269 --> 00:31:34.849 devastating measles was. Before the vaccine was 00:31:34.849 --> 00:31:37.990 introduced in 1963, basically everyone got it. 00:31:37.980 --> 00:31:41.039 It was a rite of passage. Three to four million 00:31:41.039 --> 00:31:44.099 cases a year in the U .S. alone. Nurses who worked 00:31:44.099 --> 00:31:47.680 in the 50s remember entire measles wards. Just 00:31:47.680 --> 00:31:50.859 dark rooms filled with rows of coughing miserable 00:31:50.859 --> 00:31:53.839 kids. It was not trivial. It's truly amazing 00:31:53.839 --> 00:31:56.460 how quickly we develop vaccine -induced amnesia. 00:31:56.579 --> 00:31:58.539 It is. Here's another interesting fact about 00:31:58.539 --> 00:32:01.339 the virus itself. It's fragile. But wait, we 00:32:01.339 --> 00:32:03.440 just said it was airborne and terrifying. It 00:32:03.440 --> 00:32:05.779 is highly contagious, but the virus particle 00:32:05.779 --> 00:32:08.400 itself is physically weak. It's an enveloped 00:32:08.400 --> 00:32:10.779 virus. That means it has a fatty outer shell. 00:32:11.339 --> 00:32:13.980 Soap destroys it instantly. Sunlight, UV light 00:32:13.980 --> 00:32:17.059 kills it. Acid kills it. Heat kills it. So it's 00:32:17.059 --> 00:32:18.640 a weird irony. It's one of the most contagious 00:32:18.640 --> 00:32:20.900 viruses we know, but it's a complete wimp outside 00:32:20.900 --> 00:32:23.839 the human body. A total wimp. It relies entirely 00:32:23.839 --> 00:32:26.500 on speed and stealth to get from one person to 00:32:26.500 --> 00:32:28.980 another before the environment can kill it. Okay, 00:32:29.259 --> 00:32:31.160 Section C, crosslinking and differentiation. 00:32:31.539 --> 00:32:33.339 This is for when the exam gives you two very 00:32:33.339 --> 00:32:36.000 similar looking options. How do you tell rubeola, 00:32:36.180 --> 00:32:38.380 or measles, apart from the common cold? It's 00:32:38.380 --> 00:32:41.420 the toxic factor. A kid with a cold runs around, 00:32:41.519 --> 00:32:43.160 they wipe their nose on their sleeve, maybe they 00:32:43.160 --> 00:32:45.559 have a hundred degree fever. A kid with measles 00:32:45.559 --> 00:32:47.640 is miserable. They have that super high fever, 00:32:47.859 --> 00:32:50.220 the photophobia, the hacking costs. They look 00:32:50.220 --> 00:32:52.680 visibly ill. They just want to lay there in a 00:32:52.680 --> 00:32:55.059 dark room. And of course, the progression to 00:32:55.059 --> 00:32:58.559 the rash is the final clincher. What about measles 00:32:58.559 --> 00:33:01.980 versus chickenpox or varicella? The rash is the 00:33:01.980 --> 00:33:05.279 key. Measles is maculopapular, a mix of flat 00:33:05.279 --> 00:33:09.109 areas and bumps. It's red. Chicken pox is vesicular. 00:33:09.289 --> 00:33:11.990 They're fluid -filled blisters. The classic description 00:33:11.990 --> 00:33:14.450 is a dew drop on a rose petal. If it looks like 00:33:14.450 --> 00:33:16.829 a blister, it's chicken pox. If it's red and 00:33:16.829 --> 00:33:19.569 bumpy, think measles. And the trickiest one of 00:33:19.569 --> 00:33:22.970 all, measles versus rosiola. Yes. This is the 00:33:22.970 --> 00:33:25.210 classic timeline differentiation question. You 00:33:25.210 --> 00:33:26.650 have to look at the relationship between the 00:33:26.650 --> 00:33:28.690 fever and the rash. It's everything. OK, layout 00:33:28.690 --> 00:33:31.710 for us. In measles, the fever is high, and it 00:33:31.710 --> 00:33:33.890 is ongoing when the rash appears. They happen 00:33:33.890 --> 00:33:35.710 together. You have a high fever end to your rash 00:33:35.710 --> 00:33:38.240 at the same time in rosiola. The child has a 00:33:38.240 --> 00:33:41.579 super high fever, maybe 104, for three days with 00:33:41.579 --> 00:33:44.099 no other symptoms. Then the fever breaks. It 00:33:44.099 --> 00:33:46.160 goes away completely. And then after the fever 00:33:46.160 --> 00:33:49.279 is gone, the rash pops out. So fever gone, rash 00:33:49.279 --> 00:33:52.700 on equals roseola. Fever high EH with rash equals 00:33:52.700 --> 00:33:55.359 measles. That is a perfect summary. That distinction 00:33:55.359 --> 00:33:57.779 is on almost every single pediatric board exam. 00:33:57.940 --> 00:34:00.440 We have covered a massive amount of ground. Let's 00:34:00.440 --> 00:34:02.880 head to the outro and synthesize this all into 00:34:02.880 --> 00:34:05.599 a safe bedside approach. OK, so you are in the 00:34:05.599 --> 00:34:08.579 clinic or the ER. A sick kid comes in. Step one. 00:34:08.780 --> 00:34:12.619 Step one. Suspect it. Especially in an unvaccinated 00:34:12.619 --> 00:34:15.139 child or a child who has recently traveled. Step 00:34:15.139 --> 00:34:18.139 two. Step two. Isolate immediately. Airborne. 00:34:18.320 --> 00:34:20.780 Get that N95 on. Get them into a negative pressure 00:34:20.780 --> 00:34:22.760 room. Do not let them sit in the waiting room 00:34:22.760 --> 00:34:25.059 breathing on people. Step three. Step three. 00:34:25.539 --> 00:34:28.280 Assess. Look for the three C's cough. Corriaza 00:34:28.280 --> 00:34:31.000 conjunctivitis, and get out your pen light and 00:34:31.000 --> 00:34:33.019 check the buccal mucosa for those complex spots. 00:34:33.099 --> 00:34:35.559 And step four. Step four, treat. It's supportive 00:34:35.559 --> 00:34:37.400 care, it's pushing hydration, and it's getting 00:34:37.400 --> 00:34:39.760 that order for vitamin A from the provider. And 00:34:39.760 --> 00:34:42.699 report it, right? Yes, absolutely. It is a nationally 00:34:42.699 --> 00:34:45.360 reportable disease. The health department needs 00:34:45.360 --> 00:34:47.500 to know immediately so they can begin contact 00:34:47.500 --> 00:34:50.500 tracing and prevent an outbreak. OK, now I want 00:34:50.500 --> 00:34:52.440 to end with that provocative thought we teased 00:34:52.440 --> 00:34:55.039 in the intro. We talk about how the virus enters 00:34:55.039 --> 00:34:58.130 the immune cells. But there's new research, really, 00:34:58.190 --> 00:35:00.489 in just the last few years about something called 00:35:00.489 --> 00:35:03.769 immune amnesia. This is fascinating and absolutely 00:35:03.769 --> 00:35:06.369 terrifying. We used to think that measles just 00:35:06.369 --> 00:35:08.170 suppressed the immune system while you were sick. 00:35:08.869 --> 00:35:11.789 But new studies, using some really advanced techniques, 00:35:12.329 --> 00:35:15.170 show that the measles virus actively hunts down 00:35:15.170 --> 00:35:18.349 and destroys your memory B cells and memory T 00:35:18.349 --> 00:35:20.829 cells. The cells that remember how to fight off 00:35:20.829 --> 00:35:23.030 all the other diseases you've ever had. Yes. 00:35:23.230 --> 00:35:25.750 It kills them. It essentially wipes the hard 00:35:25.750 --> 00:35:28.550 drive of your acquired immunity. So if you had 00:35:28.550 --> 00:35:30.949 the flu last year, and your body built up a strong 00:35:30.949 --> 00:35:33.250 immunity, gone. If you had chickenpox as a kid, 00:35:33.789 --> 00:35:35.889 you might lose that immunity and become susceptible 00:35:35.889 --> 00:35:38.469 again. So it literally resets your immune system 00:35:38.469 --> 00:35:41.750 to a naive, almost baby -like state. Exactly. 00:35:42.250 --> 00:35:44.809 For months, or even two to three years after 00:35:44.809 --> 00:35:47.690 recovering from measles, that child is statistically 00:35:47.690 --> 00:35:50.070 more vulnerable to everything else. The flu, 00:35:50.369 --> 00:35:53.239 strep, pneumonia. because their body forgot how 00:35:53.239 --> 00:35:55.739 to fight them effectively. So the real cost of 00:35:55.739 --> 00:35:57.860 getting measles isn't just the two weeks of the 00:35:57.860 --> 00:36:01.000 rash and the fever. It's years of increased vulnerability. 00:36:01.179 --> 00:36:04.559 It is. Which is why the idea of natural immunity 00:36:04.559 --> 00:36:07.260 parties, where parents intentionally expose their 00:36:07.260 --> 00:36:10.480 kids to get it over with, is so clinically dangerous. 00:36:10.719 --> 00:36:12.559 You aren't just giving them measles. You might 00:36:12.559 --> 00:36:15.159 be taking away their protection against every 00:36:15.159 --> 00:36:17.670 other germ they've ever fought off. That is a 00:36:17.670 --> 00:36:20.389 powerful, powerful takeaway. Measles is a big 00:36:20.389 --> 00:36:22.909 deal. It's the sentinel disease for public health, 00:36:23.230 --> 00:36:25.409 and it's a critical thinking test for every nurse. 00:36:25.849 --> 00:36:27.650 Absolutely. So the next time you see a runny 00:36:27.650 --> 00:36:29.530 nose and a fever, don't just assume it's a cold. 00:36:29.849 --> 00:36:32.150 Check the mouth. Ask about travel. Ask about 00:36:32.150 --> 00:36:35.130 vaccines. Be the detective. Thank you for listening 00:36:35.130 --> 00:36:38.050 to this deep dive. Go crush that exam, and more 00:36:38.050 --> 00:36:40.150 importantly, go keep those kids safe. See you 00:36:40.150 --> 00:36:40.570 next time.