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 --> 00:00:32.810 fast. Welcome to the emergency room. 45 minutes 00:00:32.810 --> 00:00:47.710 of CPR. We can stop CPR. Welcome back to the 00:00:47.710 --> 00:00:51.130 deep dive today. We are shifting gears a little 00:00:51.130 --> 00:00:53.229 bit. Usually we take a really broad topic You 00:00:53.229 --> 00:00:55.890 know tech history philosophy and we just unravel 00:00:55.890 --> 00:00:58.210 it, right? But today we're doing something very 00:00:58.210 --> 00:01:00.750 specific and honestly something I really wish 00:01:00.750 --> 00:01:04.269 I had access to back when I was like Drowning 00:01:04.269 --> 00:01:06.769 in highlighter fluid and caffeine. I know that 00:01:06.769 --> 00:01:09.049 feeling we're calling this the nursing school 00:01:09.049 --> 00:01:12.189 crash course edition But before you tune out 00:01:12.189 --> 00:01:14.890 if you are a nurse just hold on even if you're 00:01:14.890 --> 00:01:18.349 just a curious learner a parent or I don't know 00:01:18.349 --> 00:01:20.650 someone who wants to Understand how the medical 00:01:20.650 --> 00:01:23.599 world actually thinks pull up a chair We're turning 00:01:23.599 --> 00:01:26.780 this deep dive into what I like to call a clinical 00:01:26.780 --> 00:01:29.459 coffee break. It's good to be here. And I really 00:01:29.459 --> 00:01:32.140 like that framing, a clinical coffee break. Yeah. 00:01:32.359 --> 00:01:34.659 Yeah, because usually when you're learning this 00:01:34.659 --> 00:01:37.579 stuff, it feels less like a coffee break and 00:01:37.579 --> 00:01:40.239 more like a firehose to the face. Exactly. Oh 00:01:40.239 --> 00:01:42.859 my gosh, the panic is real. So. Specifically, 00:01:42.959 --> 00:01:44.780 who are we talking to today? Who is the learner 00:01:44.780 --> 00:01:47.879 for this session? We are looking at the listener 00:01:47.879 --> 00:01:50.540 who is maybe, you know, prepping for the NCLEX, 00:01:50.780 --> 00:01:52.859 getting ready for a pediatric shelf exam, or 00:01:52.859 --> 00:01:55.140 maybe they're about to start a rotation in the 00:01:55.140 --> 00:01:57.799 PICU, the Pediatric Intensive Care Unit, and 00:01:57.799 --> 00:02:01.019 they are just, well, they're terrified of missing 00:02:01.019 --> 00:02:03.099 something critical. Right. You know that feeling 00:02:03.099 --> 00:02:04.640 where you've read the textbook but you don't 00:02:04.640 --> 00:02:06.459 actually know what it looks like in real life? 00:02:06.650 --> 00:02:08.889 Yes. That's who we are helping today. I know 00:02:08.889 --> 00:02:10.689 that feeling so well. You have the knowledge, 00:02:10.770 --> 00:02:14.009 but you don't have the wisdom yet. So we've pulled 00:02:14.009 --> 00:02:16.629 a massive stack of materials here to bridge that 00:02:16.629 --> 00:02:20.289 gap. We're talking textbook excerpts, clinical 00:02:20.289 --> 00:02:25.389 guidelines, vaccine protocols, epidemiology reports, 00:02:25.689 --> 00:02:28.389 all focused on one specific and frankly terrifying 00:02:28.389 --> 00:02:31.270 beast, Pertussis. Also known as whooping cough. 00:02:31.789 --> 00:02:35.250 Right. And we are going to apply the Pareto principle 00:02:35.250 --> 00:02:38.069 here, the 80 -20 rule. The classic efficiency 00:02:38.069 --> 00:02:39.849 hack. I love it. Right. We aren't going to read 00:02:39.849 --> 00:02:42.449 the textbook to you page by page. I mean, that 00:02:42.449 --> 00:02:44.550 just puts people to sleep. It does. We're going 00:02:44.550 --> 00:02:46.750 to extract the 20 % of the information that is 00:02:46.750 --> 00:02:48.610 going to answer 80 % of your exam questions. 00:02:48.810 --> 00:02:51.129 And more importantly, keep your patients safe 00:02:51.129 --> 00:02:53.469 when it really matters most. I love that. Cut 00:02:53.469 --> 00:02:56.310 the fluff. Give us the meat. So help me map this 00:02:56.310 --> 00:02:59.430 out. If we have, let's say, 60 minutes to become 00:02:59.430 --> 00:03:02.969 experts on pertussis, what's the roadmap? Okay, 00:03:03.009 --> 00:03:05.509 so we have four main stops on this journey. First, 00:03:05.590 --> 00:03:07.710 we're gonna build the master 80 -20 map. This 00:03:07.710 --> 00:03:10.069 is all about clinical pattern recognition for 00:03:10.069 --> 00:03:12.550 infectious respiratory distress. If you can spot 00:03:12.550 --> 00:03:15.069 the pattern, you pass the exam. Second, we're 00:03:15.069 --> 00:03:17.469 doing the deep dive into pertussis itself, but 00:03:17.469 --> 00:03:20.830 we're going deep into the mechanics, the pathophysiology, 00:03:21.030 --> 00:03:24.000 the assessment, the interventions. Third, we're 00:03:24.000 --> 00:03:26.580 running the vaccine gauntlet. The vaccine gauntlet. 00:03:26.939 --> 00:03:28.960 I assume that means clearing up the absolute 00:03:28.960 --> 00:03:32.000 alphabet soup of like DTAP, DTAP, DTP. Exactly. 00:03:32.139 --> 00:03:34.379 It confuses everyone. We are going to fix that 00:03:34.379 --> 00:03:37.039 permanently. And finally, fourth, we'll look 00:03:37.039 --> 00:03:39.379 at the developmental impacts. Because a disease 00:03:39.379 --> 00:03:42.039 like this, it changes a child's trajectory and 00:03:42.039 --> 00:03:44.680 we need to understand the fallout beyond just 00:03:44.680 --> 00:03:47.300 the infection. OK, let's unpack this. Start us 00:03:47.300 --> 00:03:50.340 off with that Master 8020 map. When we talk about 00:03:50.340 --> 00:03:53.280 the pattern for pertussis, what are we actually 00:03:53.280 --> 00:03:55.159 looking for? Because in my head, I just hear 00:03:55.159 --> 00:03:58.520 a cough. See, that's the trap. If you only look 00:03:58.520 --> 00:04:01.419 for a cough, you are going to miss the most dangerous 00:04:01.419 --> 00:04:04.340 cases. We are looking for what I call the wolf 00:04:04.340 --> 00:04:06.639 in sheep's clothing. OK. That is the pattern 00:04:06.639 --> 00:04:09.280 for pertussis. In the source material, there's 00:04:09.280 --> 00:04:12.199 this massive discrepancy that exam writers absolutely 00:04:12.199 --> 00:04:14.800 love to exploit. Which is? You have a disease 00:04:14.800 --> 00:04:17.459 that in an adult or an adolescent looks like 00:04:17.459 --> 00:04:20.610 nothing, just a nagging annoying cold, but in 00:04:20.610 --> 00:04:23.129 an infant, it's a killer. So the pattern isn't 00:04:23.129 --> 00:04:25.889 just symptoms, it's symptoms relative to age. 00:04:26.250 --> 00:04:28.970 Precisely. And this leads us to the key decision 00:04:28.970 --> 00:04:31.449 point. If you're sitting for an exam or you're 00:04:31.449 --> 00:04:33.990 triaging a patient in the ER, the decision point 00:04:33.990 --> 00:04:36.410 is differentiating between respiratory distress 00:04:36.410 --> 00:04:39.610 and respiratory failure. Okay, distress versus 00:04:39.610 --> 00:04:41.509 failure. Now here's the exam writer tip, and 00:04:41.509 --> 00:04:44.170 I want you to underline this mentally. In pertussis, 00:04:44.279 --> 00:04:46.920 The presenting sign in infants often isn't the 00:04:46.920 --> 00:04:49.860 cough. It's not the cough. It's apnea. Apnea. 00:04:50.339 --> 00:04:53.259 Meaning they just... They stop breathing. They 00:04:53.259 --> 00:04:55.519 stop breathing, complete cessation of airflow. 00:04:55.759 --> 00:04:58.319 The sources are very, very specific about this. 00:04:58.839 --> 00:05:01.319 Infants under six months, and especially those 00:05:01.319 --> 00:05:04.220 under two months, they often lack the muscular 00:05:04.220 --> 00:05:06.639 strength to produce that classic whoop sound. 00:05:06.699 --> 00:05:09.660 Wow. They don't have the intercostal muscle development 00:05:09.660 --> 00:05:12.319 to force air against the glottis like that. So 00:05:12.319 --> 00:05:14.939 if you're waiting for the whoop to diagnose pertussis 00:05:14.939 --> 00:05:17.399 in a newborn, you've waited way too long. So 00:05:17.399 --> 00:05:19.379 what do they present with instead? They present 00:05:19.379 --> 00:05:23.819 with gagging, gasping, That's a slow heart rate 00:05:23.819 --> 00:05:26.839 and apnea. That is terrifying. Because if I'm 00:05:26.839 --> 00:05:29.360 a new nurse and a parent brings in a baby who 00:05:29.360 --> 00:05:32.759 is just acting funny or looks a little pale but 00:05:32.759 --> 00:05:35.339 isn't coughing, pertussis might not even be on 00:05:35.339 --> 00:05:37.920 my radar. And that is the trap. That is exactly 00:05:37.920 --> 00:05:40.300 why it's the wolf in sheep's clothing. The baby 00:05:40.300 --> 00:05:42.379 looks fine, looks fine, looks fine, and then 00:05:42.379 --> 00:05:44.819 suddenly turns blue and stops breathing. Wow. 00:05:45.139 --> 00:05:47.420 So if I'm at the bedside, what is my priority 00:05:47.420 --> 00:05:49.319 assessment cue? What's the very first thing I'm 00:05:49.319 --> 00:05:51.920 looking for visually and auditorily? Visually, 00:05:52.139 --> 00:05:54.660 you are looking for cyanosis during feeding or 00:05:54.660 --> 00:05:57.959 coughing. If a baby turns dusky or blue around 00:05:57.959 --> 00:05:59.680 the lips when they're trying to suck on a bottle, 00:05:59.939 --> 00:06:02.240 that is a massive red flag. Why? What does that 00:06:02.240 --> 00:06:04.360 mean? It means they can't coordinate breathing 00:06:04.360 --> 00:06:07.220 and swallowing because their airway is so compromised. 00:06:08.139 --> 00:06:10.939 Auditorily, in that young infant, you're listening 00:06:10.939 --> 00:06:13.439 for the silence. The silence. The absence of 00:06:13.439 --> 00:06:16.480 breath sounds. You might hear a gasp and then... 00:06:16.680 --> 00:06:19.180 Just nothing that is the can't miss item here. 00:06:19.180 --> 00:06:21.560 Okay, the source material highlights a statistic 00:06:21.560 --> 00:06:23.279 that honestly gave me chills when I reviewed 00:06:23.279 --> 00:06:27.819 it 84 % of pertussis related deaths occur in 00:06:27.819 --> 00:06:31.240 infants younger than two months old 84 % almost 00:06:31.240 --> 00:06:33.939 all the mortality is in that group that is too 00:06:33.939 --> 00:06:36.180 young to be Vaccinated and too weak to cough 00:06:36.180 --> 00:06:39.040 effectively. They're completely vulnerable. So 00:06:39.040 --> 00:06:41.699 knowing that what is our first line nursing action? 00:06:42.519 --> 00:06:45.519 The minute we suspect this pattern the wolf and 00:06:45.519 --> 00:06:48.600 sheep's clothing What do we do? Droplet precautions. 00:06:48.800 --> 00:06:50.899 Immediately. You don't wait for the lab result. 00:06:50.959 --> 00:06:52.879 You don't wait for the doctor to come confirm 00:06:52.879 --> 00:06:56.220 it. You mask up and you isolate the patient. 00:06:57.000 --> 00:06:59.399 Standard droplet precautions mean a mask within 00:06:59.399 --> 00:07:02.240 three feet of the patient. Okay. And simultaneously 00:07:02.240 --> 00:07:04.600 you're initiating airway support. That means 00:07:04.600 --> 00:07:08.459 suctioning and oxygen. Because remember this 00:07:08.459 --> 00:07:12.439 is a disease of thick sticky mucus. If you don't 00:07:12.439 --> 00:07:15.560 clear the airway Oxygen can't get in. OK, that 00:07:15.560 --> 00:07:17.860 really sets the scene. We know the stakes. We 00:07:17.860 --> 00:07:19.540 know we aren't just dealing with a bad cold. 00:07:20.279 --> 00:07:23.819 So now let's go into the system by system lecture. 00:07:24.500 --> 00:07:26.660 Let's really get into the wheeze of Pertusis. 00:07:27.139 --> 00:07:29.660 The history books call it the 100 Day Cough, 00:07:29.959 --> 00:07:31.740 which sounds like something from a Stephen King 00:07:31.740 --> 00:07:33.579 novel. It really does. Give me the one liner 00:07:33.579 --> 00:07:36.209 identifier. OK, here's the hook. Pertussis is 00:07:36.209 --> 00:07:39.350 a toxin -mediated bacterial infection that paralyzes 00:07:39.350 --> 00:07:42.110 the respiratory cleanup crew. The cleanup crew. 00:07:42.269 --> 00:07:44.290 The cilia. OK, let's pause there. I feel like 00:07:44.290 --> 00:07:46.649 we learn about cilia in biology class, the little 00:07:46.649 --> 00:07:49.170 hairs, and then we just forget about them. Why 00:07:49.170 --> 00:07:52.050 are they so critical here? So imagine your trachea 00:07:52.050 --> 00:07:54.670 and your bronchi are lined with a shag carpet. 00:07:54.990 --> 00:07:57.730 That carpet is made of billions of microscopic 00:07:57.730 --> 00:08:00.470 hairs called cilia, and they aren't just sitting 00:08:00.470 --> 00:08:04.220 there, they're beading. constantly in these rhythmic 00:08:04.220 --> 00:08:06.860 waves pushing mucus up and out of your lungs. 00:08:07.180 --> 00:08:09.360 It's called the mucociliary escalator. I like 00:08:09.360 --> 00:08:11.199 that visual. The escalator takes the trash out. 00:08:11.319 --> 00:08:14.740 It is your lungs janitorial staff. Exactly. Now 00:08:14.740 --> 00:08:17.680 enter Bordetella produsus. The bad guy. The bad 00:08:17.680 --> 00:08:21.509 guy. This is a gram negative rod bacteria. And 00:08:21.509 --> 00:08:24.449 here's the fascinating and really nasty part 00:08:24.449 --> 00:08:27.170 of how it works. It attaches specifically to 00:08:27.170 --> 00:08:29.310 those cilia. It targets them. It targets them. 00:08:29.610 --> 00:08:31.790 Once it latches on, it releases a cocktail of 00:08:31.790 --> 00:08:34.950 toxins. The big ones you need to know are pertussis 00:08:34.950 --> 00:08:38.909 toxin, or PT, and tracheal cytotoxin. Tracheal 00:08:38.909 --> 00:08:40.730 cytotoxin. That name is not subtle. It sounds 00:08:40.730 --> 00:08:42.809 like exactly what it is. Poison for the trachea. 00:08:42.850 --> 00:08:45.470 It is remarkably efficient. Tracheal cytotoxin 00:08:45.470 --> 00:08:47.629 doesn't just irritate the cilia. It paralyzes 00:08:47.629 --> 00:08:50.029 them and eventually shears them right off. It 00:08:50.029 --> 00:08:52.480 literally... kills the ciliated cells so the 00:08:52.480 --> 00:08:54.519 escalator just stops the escalator stops the 00:08:54.519 --> 00:08:57.799 janitors are dead but the mucus production that 00:08:57.799 --> 00:09:00.440 ramps up because of all the inflammation oh no 00:09:00.440 --> 00:09:03.019 so you have more trash than ever and no one to 00:09:03.019 --> 00:09:06.159 take it out precisely you are left with this 00:09:06.159 --> 00:09:09.340 thick ropey glue like mucus just sitting in the 00:09:09.340 --> 00:09:12.049 bottom of the lungs And because the cilia are 00:09:12.049 --> 00:09:14.710 gone, the body has only one mechanism left to 00:09:14.710 --> 00:09:18.149 move it. A cough. A violent, mechanical, sheer 00:09:18.149 --> 00:09:21.330 force cough. It's not a tickle. The body is trying 00:09:21.330 --> 00:09:24.289 to physically blast that glue out of the airway 00:09:24.289 --> 00:09:26.610 using air pressure alone. So that's why it's 00:09:26.610 --> 00:09:28.250 so violent. That's why it's so violent. That's 00:09:28.250 --> 00:09:31.070 why these kids break ribs. They are generating 00:09:31.070 --> 00:09:33.590 massive amounts of pressure to compensate for 00:09:33.590 --> 00:09:36.620 the loss of those microscopic hairs. Wow. That 00:09:36.620 --> 00:09:38.879 makes so much sense. And it explains why the 00:09:38.879 --> 00:09:40.940 cough lasts so long, too. You can't just fix 00:09:40.940 --> 00:09:42.720 the cough. You literally have to wait for the 00:09:42.720 --> 00:09:44.940 carpet to grow back. Exactly. And that takes 00:09:44.940 --> 00:09:47.419 weeks to months. But there's another layer to 00:09:47.419 --> 00:09:50.379 the pathophysiology that is key for exams, and 00:09:50.379 --> 00:09:52.519 just for understanding why these kids get so 00:09:52.519 --> 00:09:55.360 incredibly sick. The bacteria confuses the immune 00:09:55.360 --> 00:09:57.379 system. How so? It promotes something called 00:09:57.379 --> 00:10:00.480 lymphocytosis, which means your white blood cell 00:10:00.480 --> 00:10:02.940 count goes through the roof. A specific kind, 00:10:03.100 --> 00:10:05.730 the lymphocytes. Usually a high white count means 00:10:05.730 --> 00:10:08.289 the body is fighting back. Right. That's a good 00:10:08.289 --> 00:10:12.419 sign. Usually, yes. But here, it's a trap. The 00:10:12.419 --> 00:10:14.340 bacteria triggers the production of all these 00:10:14.340 --> 00:10:17.039 lymphocytes, but it impairs chemotaxis. Okay, 00:10:17.059 --> 00:10:19.779 let's unpack that term, chemotaxis. Chemotaxis 00:10:19.779 --> 00:10:22.860 is the chemical signal that acts like a GPS for 00:10:22.860 --> 00:10:25.840 the immune cells. It tells them, hey, go to the 00:10:25.840 --> 00:10:29.279 lungs, the infection is here. The perticis toxin 00:10:29.279 --> 00:10:32.899 scrambles that GPS. No way. So the body is pumping 00:10:32.899 --> 00:10:35.379 out all these soldiers, the lymphocytes, but 00:10:35.379 --> 00:10:37.080 they don't know where the battle is. They just 00:10:37.080 --> 00:10:39.250 end up floating aimlessly in the blood. That 00:10:39.250 --> 00:10:41.470 is incredibly sneaky. It's like flooding the 00:10:41.470 --> 00:10:43.990 streets with police cars, but cutting the radio 00:10:43.990 --> 00:10:46.129 lines so they don't know where the robbery is 00:10:46.129 --> 00:10:48.750 happening. That is a perfect analogy. And clinically, 00:10:48.830 --> 00:10:51.889 this is a huge diagnostic clue. If you see an 00:10:51.889 --> 00:10:54.269 infant with a cough and a white blood cell count 00:10:54.269 --> 00:10:57.490 of 30 ,000 or 40 ,000, I mean, numbers that usually 00:10:57.490 --> 00:10:59.750 make you think of leukemia. Right. You have to 00:10:59.750 --> 00:11:02.570 think pertussis. It's a classic leukemoid reaction. 00:11:02.889 --> 00:11:05.269 That's a big need -to -know point. High white 00:11:05.269 --> 00:11:08.769 count, scrambled GPS. Now, we talked a bit about 00:11:08.769 --> 00:11:11.190 the infant presentation versus the adult in the 00:11:11.190 --> 00:11:13.549 intro, but I want to break that down systematically 00:11:13.549 --> 00:11:15.929 by age because you said the sources emphasize 00:11:15.929 --> 00:11:19.590 this is a huge exam trap. It's a huge trap. Right. 00:11:19.629 --> 00:11:22.029 Let's start with the infant. Six months, as we 00:11:22.029 --> 00:11:25.549 said. Apnea, gasping, bradycardia, no whoop. 00:11:25.730 --> 00:11:27.870 The exam question will describe a baby who stops 00:11:27.870 --> 00:11:31.159 breathing after a sneeze or a gag. That is pertussis 00:11:31.159 --> 00:11:33.720 until proven otherwise. OK. Then we move up to 00:11:33.720 --> 00:11:35.500 the toddlers and children. This is where you 00:11:35.500 --> 00:11:37.840 see the classic textbook presentation, the high 00:11:37.840 --> 00:11:39.879 -pitched inspiratory whoop. Right. They cough, 00:11:39.919 --> 00:11:42.139 cough, cough in this staccato style until they 00:11:42.139 --> 00:11:44.100 have emptied their lungs completely. They turn 00:11:44.100 --> 00:11:47.080 red or even blue. And then, desperate for air, 00:11:47.200 --> 00:11:49.840 they inhale forcibly against unnarrowed glottis. 00:11:49.899 --> 00:11:52.720 And you hear that whoop. And there's a very specific 00:11:52.720 --> 00:11:54.919 sign associated with this age group, right? Yeah. 00:11:54.960 --> 00:11:58.649 Something messy. Yes. Post -tussive emesis. Vomiting 00:11:58.649 --> 00:12:01.490 after coughing. This is a huge differentiator. 00:12:01.850 --> 00:12:03.970 If you see an exam question describing a child 00:12:03.970 --> 00:12:05.850 who coughs so hard they throw up, the answer 00:12:05.850 --> 00:12:08.879 is almost always pertussis. Why does that happen? 00:12:09.480 --> 00:12:12.379 Is it just the force? It's the sheer intra -abdominal 00:12:12.379 --> 00:12:15.559 pressure. They are squeezing their core muscles 00:12:15.559 --> 00:12:18.460 so hard to expel the air that they literally 00:12:18.460 --> 00:12:21.179 can crest the stomach. Plus, that thick mucus 00:12:21.179 --> 00:12:24.080 triggers the gag reflex. It's just a miserable 00:12:24.080 --> 00:12:26.259 experience for the child. I can't even imagine. 00:12:26.500 --> 00:12:28.159 And then we have the adolescents and adults. 00:12:28.340 --> 00:12:30.940 Yeah. The reservoir. And this is the dangerous 00:12:30.940 --> 00:12:33.419 group, not for themselves, but for the community. 00:12:33.519 --> 00:12:37.879 OK. In adults, Pertussis often looks like a lingering, 00:12:38.100 --> 00:12:40.539 nagging cough that lasts more than seven days. 00:12:40.879 --> 00:12:42.559 They usually don't whoop because their airways 00:12:42.559 --> 00:12:44.600 are larger and more mature. They just think they 00:12:44.600 --> 00:12:46.879 have a cold. They can't kick. Exactly. They feel 00:12:46.879 --> 00:12:49.080 fine. They go to work. They go to family gatherings. 00:12:49.720 --> 00:12:51.980 But they are shedding bacteria. They are the 00:12:51.980 --> 00:12:55.059 ones giving it to the baby. So if grandma has 00:12:55.059 --> 00:12:57.909 had a bronchitis for three weeks, Keep her away 00:12:57.909 --> 00:13:00.330 from the newborn. 100%. If you take one thing 00:13:00.330 --> 00:13:03.129 away from the epidemiology. Adults are the rector. 00:13:03.330 --> 00:13:05.610 Infants are the victims. Okay, let's get into 00:13:05.610 --> 00:13:08.769 the need to know core. The 80 -20 exam meet. 00:13:09.190 --> 00:13:12.169 The sources outline three distinct stages of 00:13:12.169 --> 00:13:15.730 this disease. And the chronology here is critical, 00:13:15.870 --> 00:13:17.950 isn't it? Because the symptoms change so much 00:13:17.950 --> 00:13:21.049 over time. It is absolutely essential for diagnosis 00:13:21.049 --> 00:13:23.210 and for understanding communicability. Stage 00:13:23.210 --> 00:13:26.460 one is the cataral stage. This lasts about one 00:13:26.460 --> 00:13:28.940 to two weeks. Cut -tarl is one of those medical 00:13:28.940 --> 00:13:31.700 words that just sounds gross. What does it actually 00:13:31.700 --> 00:13:34.529 look like? It looks like a common cold. Runny 00:13:34.529 --> 00:13:36.970 nose rhinorrhea, sneezing, a low -grade fever, 00:13:37.370 --> 00:13:40.809 a mild cough. And here is the kicker. What's 00:13:40.809 --> 00:13:43.649 that? This is the most contagious stage. Of course 00:13:43.649 --> 00:13:45.909 it is. The stage where you look the least sick 00:13:45.909 --> 00:13:48.610 is when you are most dangerous. Exactly. The 00:13:48.610 --> 00:13:50.809 bacterial load in the nose and throat is at its 00:13:50.809 --> 00:13:52.889 absolute peak. But because it looks like a common 00:13:52.889 --> 00:13:55.490 cold, nobody isolates themselves. They go to 00:13:55.490 --> 00:13:57.950 school. They go to daycare. By the time that 00:13:57.950 --> 00:13:59.750 severe cough starts, they've already exposed 00:13:59.750 --> 00:14:02.990 everyone. So diagnosing it here is almost impossible 00:14:02.990 --> 00:14:04.690 unless Unless you know there's an outbreak or 00:14:04.690 --> 00:14:06.429 a known exposure. Correct. Unless you have a 00:14:06.429 --> 00:14:08.809 very high index of suspicion, you're likely to 00:14:08.809 --> 00:14:11.070 miss it in the cataral stage. Then we move to 00:14:11.070 --> 00:14:14.200 stage two. The paroxysmal stage. This can last 00:14:14.200 --> 00:14:16.200 anywhere from one to six weeks, sometimes up 00:14:16.200 --> 00:14:18.639 to 10 weeks. This is where the toxins have done 00:14:18.639 --> 00:14:21.039 their damage to the cilia. The janitors are dead. 00:14:21.100 --> 00:14:23.799 The janitors are dead, and you get the severe 00:14:23.799 --> 00:14:27.500 coughing fits, the paroxysms. The source mentions 00:14:27.500 --> 00:14:30.860 patients can have 15 or more attacks in 24 hours, 00:14:31.139 --> 00:14:33.899 and they are significantly worse at night. This 00:14:33.899 --> 00:14:35.980 is where you see the cyanosis, the exhaustion, 00:14:36.179 --> 00:14:38.399 the vomiting we talked about. Yes, and it's really 00:14:38.399 --> 00:14:40.940 important to visualize this for the exam or the 00:14:40.940 --> 00:14:44.289 bedside. Between attacks, the child might look 00:14:44.289 --> 00:14:46.570 totally normal. Really? Yeah, they might be playing. 00:14:46.909 --> 00:14:48.990 But during the attack, they are fighting for 00:14:48.990 --> 00:14:51.450 their life. Right. It's terrifying for parents 00:14:51.450 --> 00:14:54.250 because the switch is just, it's instant. Wow. 00:14:54.440 --> 00:14:57.379 And finally, stage three. The convalescent stage. 00:14:57.519 --> 00:15:00.200 This is the recovery. It takes weeks to months. 00:15:00.360 --> 00:15:02.940 The cough gradually improves. But a fun fact, 00:15:03.139 --> 00:15:05.139 well, not fun for the patient. From the source, 00:15:05.419 --> 00:15:07.700 the cough can come back. It can come back? Yeah, 00:15:07.720 --> 00:15:10.320 if the child gets a regular cold or another respiratory 00:15:10.320 --> 00:15:13.879 virus months later, that whoop can return briefly 00:15:13.879 --> 00:15:16.120 because the airway is still so hypersensitive 00:15:16.120 --> 00:15:18.820 and it's still healing. That explains the 100 00:15:18.820 --> 00:15:21.860 Day Cough nickname. It really just lingers. It 00:15:21.860 --> 00:15:24.159 does. Let's talk nursing assessments. We're at 00:15:24.159 --> 00:15:26.940 the bedside. What are we prioritizing? Three 00:15:26.940 --> 00:15:29.600 things stand out in all the literature. First, 00:15:30.259 --> 00:15:32.919 respiratory rate and effort. You are watching 00:15:32.919 --> 00:15:35.759 for exhaustion. A baby can only work that hard 00:15:35.759 --> 00:15:37.659 to breathe for so long before they just give 00:15:37.659 --> 00:15:39.379 up. And that's when they crash. That's when they 00:15:39.379 --> 00:15:42.500 crash and they need intubation. Second, Hydration 00:15:42.500 --> 00:15:45.700 status. If they are vomiting after every cough, 00:15:46.000 --> 00:15:48.179 they are at huge risk for dehydration. Check 00:15:48.179 --> 00:15:50.360 the fontanel, check the mucus membranes, check 00:15:50.360 --> 00:15:53.679 the urine output. Right. Third, oxygen saturation, 00:15:54.220 --> 00:15:56.519 specifically during the coughing spells. They 00:15:56.519 --> 00:15:58.580 might set at 98 % while they're sleeping, but 00:15:58.580 --> 00:16:01.519 drop to 60 % during a paroxysm. You have to be 00:16:01.519 --> 00:16:03.440 there to catch those desaturations. And what 00:16:03.440 --> 00:16:06.019 about labs? We mentioned the white count. Yes. 00:16:07.039 --> 00:16:10.139 Lymphocytosis. An absolute lymphocyte count greater 00:16:10.139 --> 00:16:13.940 than 20 ,000 is a major, major red flag for pertussis 00:16:13.940 --> 00:16:17.059 in infants. If you see a coughing baby with a 00:16:17.059 --> 00:16:20.340 WBC of 30 ,000, alarm bells should be ringing 00:16:20.340 --> 00:16:23.679 in your head. Okay. And for the definitive diagnosis, 00:16:25.059 --> 00:16:27.740 the gold standard. The culture is the gold standard, 00:16:27.779 --> 00:16:30.700 but it is tricky. The bacteria is fastidious. 00:16:30.779 --> 00:16:33.480 It's a picky eater. Okay. It requires special 00:16:33.480 --> 00:16:36.220 media like Reagan Lowe or Bordet Gangu, and here 00:16:36.220 --> 00:16:38.820 is a very specific exam tip regarding the swab 00:16:38.820 --> 00:16:41.100 itself. Oh, I love these technical details. What 00:16:41.100 --> 00:16:44.000 about the swab? You must use a polyester, rayon, 00:16:44.039 --> 00:16:47.399 or nylon swab. Do not use cotton. Why not? Is 00:16:47.399 --> 00:16:49.200 it just about the fibers getting stuck or something? 00:16:49.320 --> 00:16:52.000 No, it's chemistry. Cotton fibers contain fatty 00:16:52.000 --> 00:16:55.000 acids that are actually toxic to Bordetella pertussis. 00:16:55.080 --> 00:16:57.700 You're kidding. No. If you use a standard cotton 00:16:57.700 --> 00:16:59.799 swab, you will kill the bacteria on the stick 00:16:59.799 --> 00:17:01.460 before it ever gets to the lab, and you will 00:17:01.460 --> 00:17:04.519 get a false negative result. Wow. That is a detail 00:17:04.519 --> 00:17:07.480 that just screams test question. Nurse uses cotton 00:17:07.480 --> 00:17:10.140 swab, lab comes back negative, child is still 00:17:10.140 --> 00:17:13.480 sick. What went wrong? Exactly. The other option 00:17:13.480 --> 00:17:16.849 is PCR. It's faster and more sensitive. It's 00:17:16.849 --> 00:17:19.170 good for up to about four weeks of coughing. 00:17:19.569 --> 00:17:21.769 After four weeks, the bacteria are mostly gone, 00:17:21.809 --> 00:17:23.690 even if the cough is still there. So testing 00:17:23.690 --> 00:17:26.410 becomes less useful. OK, let's talk treatment. 00:17:27.210 --> 00:17:29.809 Priority interventions. We already said droplet 00:17:29.809 --> 00:17:32.710 precautions. What about meds? Antibiotics are 00:17:32.710 --> 00:17:36.440 the mainstay. specifically macrolides. So we're 00:17:36.440 --> 00:17:40.019 talking azithromycin, chlorithromycin, erythromycin. 00:17:40.640 --> 00:17:43.319 But there's a massive nuance here regarding timing 00:17:43.319 --> 00:17:46.119 that students often miss. Break down the timing 00:17:46.119 --> 00:17:48.420 for us. This seems important. It's critical. 00:17:48.519 --> 00:17:51.259 If you give the antibiotic in the cataral stage 00:17:51.259 --> 00:17:53.799 so early on. When it just looks like a cold. 00:17:53.960 --> 00:17:56.160 Right. You can actually modify the course of 00:17:56.160 --> 00:17:58.039 the illness. You can make it less severe and 00:17:58.039 --> 00:18:00.559 shorten it. But if you give it in the paroxysmal 00:18:00.559 --> 00:18:02.160 stage. Once the whipping has already started. 00:18:02.380 --> 00:18:05.299 Yes. At that point, it does not stop the cough. 00:18:05.720 --> 00:18:07.279 Wait, so if the kid is already whooping, the 00:18:07.279 --> 00:18:09.420 medicine doesn't fix them? No. The damage to 00:18:09.420 --> 00:18:11.900 the cilia is already done. The toxin has done 00:18:11.900 --> 00:18:14.579 its work. The antibiotic at that point is purely 00:18:14.579 --> 00:18:16.279 for public health. Okay, what does that mean? 00:18:16.480 --> 00:18:19.019 It kills the bacteria so the patient isn't contagious 00:18:19.019 --> 00:18:21.619 anymore. But they are still going to cough until 00:18:21.619 --> 00:18:24.420 those cilio grow back. That is such a critical 00:18:24.420 --> 00:18:26.759 counseling point for parents. I can just imagine 00:18:26.759 --> 00:18:29.359 the frustration. I gave him the medicine for 00:18:29.359 --> 00:18:31.579 five days and he's still coughing. Right. You 00:18:31.579 --> 00:18:33.619 have to set expectations. You have to say, Mrs. 00:18:33.819 --> 00:18:37.259 Jones, this medicine is to protect the baby sister 00:18:37.259 --> 00:18:39.900 and the kids at school. It won't stop the cough 00:18:39.900 --> 00:18:43.200 right away. That will take time. Exam writers 00:18:43.200 --> 00:18:45.319 love to throw distractors in here. What's the 00:18:45.319 --> 00:18:48.430 common tra - regarding medication. Cough suppressants? 00:18:49.250 --> 00:18:52.710 They will ask if you should give codeine or destromethorphin. 00:18:53.029 --> 00:18:56.670 The answer is a hard NO. Why? Wouldn't we want 00:18:56.670 --> 00:18:59.309 to stop this horrible cough? It seems so intuitive, 00:18:59.390 --> 00:19:02.089 but remember the patho. The cough is functional. 00:19:02.369 --> 00:19:05.509 Right, the fire hose. Exactly. They need to cough 00:19:05.509 --> 00:19:07.549 to get that thick mucus out because the cilia 00:19:07.549 --> 00:19:10.210 are gone. If you suppress the cough, you trap 00:19:10.210 --> 00:19:12.390 the mucus, you create a petri dish in the lungs, 00:19:12.490 --> 00:19:14.910 and you get pneumonia. Plus, the studies show 00:19:14.910 --> 00:19:16.690 cough suppressants generally don't work on the 00:19:16.690 --> 00:19:20.470 pertussis drive anyway. Got it. No coxer. Let 00:19:20.470 --> 00:19:24.390 it out. Now let's talk complications. The, you 00:19:24.390 --> 00:19:27.250 missed this, the kid crashes list. What kills 00:19:27.250 --> 00:19:29.750 these patients? The number one cause of death 00:19:29.750 --> 00:19:32.329 is secondary bacterial pneumonia. The lungs are 00:19:32.329 --> 00:19:34.930 damaged, the defenses are down, and other bacteria 00:19:34.930 --> 00:19:38.410 move in. If a child with pertussis has been stable 00:19:38.410 --> 00:19:41.009 and suddenly spikes a high fever or gets rapidly 00:19:41.009 --> 00:19:43.950 worse, you have to think pneumonia. And I see 00:19:43.950 --> 00:19:46.450 here neurologic complications are also a big 00:19:46.450 --> 00:19:50.000 risk. Yes. Seizures and encephalopathy. This 00:19:50.000 --> 00:19:52.660 is usually due to the severe hypoxia, the lack 00:19:52.660 --> 00:19:55.279 of oxygen during those coughing fits, or it can 00:19:55.279 --> 00:19:58.079 be from the toxin itself. It's rare, but it is 00:19:58.079 --> 00:19:59.839 devastating when it happens. And then there are 00:19:59.839 --> 00:20:01.640 the mechanical injuries. You mentioned rib fractures 00:20:01.640 --> 00:20:05.059 earlier. The force is just violent. We see pneumothorax 00:20:05.059 --> 00:20:08.400 popped lungs, rib fractures, hernias, rectal 00:20:08.400 --> 00:20:10.400 prolapse. That gives you a real idea of the pressure 00:20:10.400 --> 00:20:12.140 these kids are generating in their chest and 00:20:12.140 --> 00:20:13.880 abdomen. That segues perfectly into our next 00:20:13.880 --> 00:20:16.799 section. development, and milestones. Because 00:20:16.799 --> 00:20:19.519 this isn't just a physical illness, it completely 00:20:19.519 --> 00:20:22.019 disrupts the child's entire world. This is a 00:20:22.019 --> 00:20:24.400 section that often gets skipped in quick reviews, 00:20:24.740 --> 00:20:28.420 but for the deep dive, it's so crucial. Think 00:20:28.420 --> 00:20:30.859 about the energy expenditure. An infant burns 00:20:30.859 --> 00:20:33.680 massive calories just struggling to breathe and 00:20:33.680 --> 00:20:36.660 cough. Right. Combine that with the vomiting, 00:20:37.140 --> 00:20:39.980 the post -tussive emesis, and this leads to rapid 00:20:39.980 --> 00:20:42.240 weight loss and failure to thrive. So you have 00:20:42.240 --> 00:20:45.670 a baby. who is burning a marathon's worth of 00:20:45.670 --> 00:20:48.630 calories and puking up their food. That's just 00:20:48.630 --> 00:20:51.390 a recipe for growth arrest. It's a disaster for 00:20:51.390 --> 00:20:54.210 growth. And for a developing brain, sleep is 00:20:54.210 --> 00:20:56.890 crucial. These kids don't sleep. The paroxysms 00:20:56.890 --> 00:20:59.650 are worse at night. So you have severe sleep 00:20:59.650 --> 00:21:01.690 deprivation, which affects neurodevelopment and 00:21:01.690 --> 00:21:05.000 mood. They become irritable. Inconsolable. And 00:21:05.000 --> 00:21:06.940 let's not overlook the psychological impact of 00:21:06.940 --> 00:21:08.539 feeding. I hadn't even thought of that. Oh, this 00:21:08.539 --> 00:21:11.519 is huge. If every time you eat, you choke, you 00:21:11.519 --> 00:21:13.880 gag, and you vomit, you develop oral aversion, 00:21:14.140 --> 00:21:16.160 you get babies who become terrified of the bottle. 00:21:16.400 --> 00:21:18.819 They associate food with pain and suffocation. 00:21:19.000 --> 00:21:21.180 So as nurses, our role isn't just suctioning 00:21:21.180 --> 00:21:22.859 and giving meds. It's about developmental care. 00:21:23.059 --> 00:21:25.200 Right. We need to cluster care. What does that 00:21:25.200 --> 00:21:28.000 mean? Do all your assessments, your vitals, your 00:21:28.000 --> 00:21:30.940 meds, all at once so the child can have uninterrupted 00:21:30.940 --> 00:21:34.220 periods of rest. For feeding, small frequent 00:21:34.220 --> 00:21:36.180 amounts are better than big bottles. Because 00:21:36.180 --> 00:21:38.319 there's less to throw up. Less to throw up and 00:21:38.319 --> 00:21:41.220 less distension means less pressure on the diaphragm. 00:21:41.460 --> 00:21:43.940 And honestly, a huge part of our job is supporting 00:21:43.940 --> 00:21:46.640 the parents. Watching your baby turn blue and 00:21:46.640 --> 00:21:49.920 stop breathing is traumatic. Parental anxiety 00:21:49.920 --> 00:21:52.660 is through the roof. Absolutely. We are treating 00:21:52.660 --> 00:21:55.099 the family unit, not just the airway. Before 00:21:55.099 --> 00:21:57.319 we move to vaccines, I want to emphasize one 00:21:57.319 --> 00:22:00.799 more developmental red flag, regression. A potty 00:22:00.799 --> 00:22:02.960 -trained toddler might start having accidents. 00:22:03.579 --> 00:22:05.559 A baby who was sleeping through the night stops. 00:22:05.900 --> 00:22:08.740 This is normal during severe illness, but parents 00:22:08.740 --> 00:22:10.920 need to be warned so they don't punish the child. 00:22:11.299 --> 00:22:14.279 That's great advice. OK, let's move to section 00:22:14.279 --> 00:22:16.559 C. The vaccine gauntlet. This is where a lot 00:22:16.559 --> 00:22:19.640 of students get lost in the alphabet soup. TTP, 00:22:19.859 --> 00:22:22.779 PDAP, DTP. Let's clear this up once and for all. 00:22:22.839 --> 00:22:24.599 Let's do it. And to understand the vaccine, we 00:22:24.599 --> 00:22:26.279 have to look at the history because it explains 00:22:26.279 --> 00:22:28.359 why we have the schedule we have today. OK, take 00:22:28.359 --> 00:22:31.839 us back. So in the 1940s, we started using the 00:22:31.839 --> 00:22:35.640 whole cell DTP, diphtheria, tetanus, proteasis. 00:22:36.019 --> 00:22:37.940 Whole cell means exactly what it sounds like. 00:22:38.339 --> 00:22:41.039 They took the entire bordetella bacterium, killed 00:22:41.039 --> 00:22:43.920 it, and put it in the vaccine. That sounds blunt. 00:22:44.180 --> 00:22:46.640 It was crude, but it was really effective. It 00:22:46.640 --> 00:22:48.779 was like showing the immune system the entire 00:22:48.779 --> 00:22:51.460 corpse of the enemy. The immune response was 00:22:51.460 --> 00:22:54.000 massive, and it was long -lasting. Cases dropped 00:22:54.000 --> 00:22:57.539 by 75%. But because it was the whole cell, it 00:22:57.539 --> 00:23:00.259 came with a lot of baggage. It caused high fevers, 00:23:00.579 --> 00:23:03.359 really sore arms, and in rare cases, febrile 00:23:03.359 --> 00:23:05.299 seizures. And I assume parents weren't happy 00:23:05.299 --> 00:23:08.240 about that. They were terrified. In the 1970s 00:23:08.240 --> 00:23:11.079 and 80s, there was a massive backlash. You saw 00:23:11.079 --> 00:23:14.299 reports linking DTP to neurological damage. Now, 00:23:14.299 --> 00:23:16.279 most of those were later disproven, but the fear 00:23:16.279 --> 00:23:18.960 was real. Vaccination rates dropped, and pertussis 00:23:18.960 --> 00:23:20.859 came roaring back. So the medical community had 00:23:20.859 --> 00:23:22.819 to pivot. Right. They developed the Cellular 00:23:22.819 --> 00:23:25.400 Vaccine DTaP. Instead of the whole corpse, they 00:23:25.400 --> 00:23:27.420 just picked out a few specific proteins from 00:23:27.420 --> 00:23:30.059 the bacteria, the mugshot of the bacteria, if 00:23:30.059 --> 00:23:31.819 you will, instead of the body. Much cleaner. 00:23:32.400 --> 00:23:35.220 Safer. Much safer. The side effects plummeted. 00:23:35.559 --> 00:23:37.779 But there was a trade -off that we didn't see 00:23:37.779 --> 00:23:40.299 coming for about a decade. Which was? Waning 00:23:40.299 --> 00:23:43.079 immunity. It turns out, showing the immune system 00:23:43.079 --> 00:23:45.859 the mugshot doesn't create the same lasting memory 00:23:45.859 --> 00:23:49.339 as showing it the corpse. Interesting. This is 00:23:49.339 --> 00:23:51.180 why we are seeing outbreaks in high schools and 00:23:51.180 --> 00:23:53.700 colleges today. The safety profile is so much 00:23:53.700 --> 00:23:56.380 better, but the durability is worse. And that 00:23:56.380 --> 00:23:59.960 brings us to the booster schedule. We need boosters 00:23:59.960 --> 00:24:02.519 because the protection wears off. OK, so now 00:24:02.519 --> 00:24:04.599 we have D -TAP and T -DAP. How do I remember 00:24:04.599 --> 00:24:06.839 which is which for the exam? Look at the casing 00:24:06.839 --> 00:24:09.079 of the letters. It's a really simple visual mnemonic. 00:24:09.519 --> 00:24:13.660 D -TAP has a capital D and P. Think D for Dababy. 00:24:13.779 --> 00:24:16.619 D for Dababy. I like that. OK. It has a higher 00:24:16.619 --> 00:24:19.160 antigen load. It is for children younger than 00:24:19.160 --> 00:24:22.259 seven years. And Tdap. Tdap has a lowercase D 00:24:22.259 --> 00:24:25.279 and P. Think D for decrease. It has a reduced 00:24:25.279 --> 00:24:27.960 antigen load. It's a booster for older children, 00:24:28.119 --> 00:24:30.579 so 11 and up, and for adults. OK, that makes 00:24:30.579 --> 00:24:34.170 us sk - Now, the schedule. This is exam critical. 00:24:34.430 --> 00:24:36.970 When do we poke them? The primary series is at 00:24:36.970 --> 00:24:39.289 two months, four months, and six months. That's 00:24:39.289 --> 00:24:41.470 the foundation. You need those three doses to 00:24:41.470 --> 00:24:44.509 get decent protection. OK. Then you get a booster 00:24:44.509 --> 00:24:47.549 at 15, 18 months, and another one at four, six 00:24:47.549 --> 00:24:49.430 years, right before kindergarten. And then the 00:24:49.430 --> 00:24:51.910 adolescent booster? At 11, 12 years, they get 00:24:51.910 --> 00:24:54.509 the Tdap. That's the middle school shot. Now, 00:24:54.829 --> 00:24:57.450 there's a very specific recommendation for pregnancy. 00:24:57.849 --> 00:25:00.210 And it confuses people because they think, well, 00:25:00.269 --> 00:25:01.890 I just got a tetanus shot two years ago. Why 00:25:01.890 --> 00:25:03.789 do I need another one? Doesn't matter. The guideline 00:25:03.789 --> 00:25:07.750 is every single pregnancy between 27 and 36 weeks. 00:25:07.809 --> 00:25:10.829 Why every time? Yeah. And why that specific window? 00:25:10.950 --> 00:25:13.589 So this is a concept called cocooning via passive 00:25:13.589 --> 00:25:16.250 immunity. The goal isn't to protect the mom. 00:25:16.490 --> 00:25:19.589 The goal is to maximize antibody transfer to 00:25:19.589 --> 00:25:22.630 the fetus. We know that babies can't be vaccinated 00:25:22.630 --> 00:25:24.569 until two months of age. That is a two month 00:25:24.569 --> 00:25:27.490 window where they are sitting ducks. By vaccinating 00:25:27.490 --> 00:25:30.170 mom in the third trimester, she makes a massive 00:25:30.170 --> 00:25:32.049 amount of antibodies, passes them right through 00:25:32.049 --> 00:25:34.769 the placenta, and the baby is born with the temporary 00:25:34.769 --> 00:25:37.490 shield. That is fascinating. It's literally banking 00:25:37.490 --> 00:25:39.730 immunity for the baby before they're even born. 00:25:39.930 --> 00:25:42.490 It is, and it's the most effective way we have 00:25:42.490 --> 00:25:44.809 to prevent death in those under two -month -olds. 00:25:45.829 --> 00:25:48.950 Now, contraindications. When do we not give the 00:25:48.950 --> 00:25:51.269 vaccine? This is a high -yield exam question 00:25:51.269 --> 00:25:54.509 because people assume any neurologic issue is 00:25:54.509 --> 00:25:57.390 a no -go, and that's just wrong. Okay. The absolute 00:25:57.390 --> 00:25:59.769 contraindication is encephalopathy, so like a 00:25:59.769 --> 00:26:02.490 coma or a prolonged seizure occurring within 00:26:02.490 --> 00:26:06.029 seven days of a previous dose that's not attributable 00:26:06.029 --> 00:26:08.670 to another cause. What about a fever? or a family 00:26:08.670 --> 00:26:12.609 history of seizures, or a kid with, say, cerebral 00:26:12.609 --> 00:26:15.390 palsy. Those are precautions, not contraindications. 00:26:15.509 --> 00:26:17.710 You can usually still give it, or you weigh the 00:26:17.710 --> 00:26:20.670 risk versus the benefit. A stable neurologic 00:26:20.670 --> 00:26:22.789 condition, like cerebral palsy or controlled 00:26:22.789 --> 00:26:26.109 epilepsy, is not a contraindication. Exam writers 00:26:26.109 --> 00:26:28.250 love to trick you with a child who has CP. They 00:26:28.250 --> 00:26:30.210 can and they should get the vaccine. And side 00:26:30.210 --> 00:26:32.369 effects. What's normal? Usually pretty mild, 00:26:32.589 --> 00:26:35.670 local pain, swelling, fever. There is something 00:26:35.670 --> 00:26:39.390 called an arthis -type reaction, which is severe 00:26:39.390 --> 00:26:41.410 local swelling from the shoulder to the elbow. 00:26:41.569 --> 00:26:44.009 That's rare. And it usually happens if boosters 00:26:44.009 --> 00:26:45.950 are given too close together. Basically, you 00:26:45.950 --> 00:26:47.809 have too many antibodies at the site, and they 00:26:47.809 --> 00:26:50.569 react violently to the new injection. Got it. 00:26:50.950 --> 00:26:53.569 OK, section D, cross -linking. We're in the ER. 00:26:53.990 --> 00:26:57.170 A kid is coughing. How do we tell pertussis apart 00:26:57.170 --> 00:26:59.390 from the other respiratory villains? Because 00:26:59.390 --> 00:27:01.670 everything coughs in pediatrics. Everything coughs, 00:27:01.670 --> 00:27:03.930 right. The big three to compare are the common 00:27:03.930 --> 00:27:06.309 cold, asthma, and croup. Start with the cold. 00:27:06.519 --> 00:27:09.019 As we discussed, in the cataral stage, you can't 00:27:09.019 --> 00:27:10.940 tell them apart clinically. It's impossible. 00:27:11.220 --> 00:27:13.180 That's why your suspicion has to be based on 00:27:13.180 --> 00:27:16.000 exposure. Is there an outbreak at daycare? Did 00:27:16.000 --> 00:27:18.700 grandma visit with a bad cough? If yes, you treat 00:27:18.700 --> 00:27:20.819 that runny nose like it could be pertussis. What 00:27:20.819 --> 00:27:23.440 about asthma versus pertussis? Two main things. 00:27:23.660 --> 00:27:27.160 First, the sound. Asthma has a wheeze that's 00:27:27.160 --> 00:27:29.900 usually expiratory, so on the breath out. Pertissus 00:27:29.900 --> 00:27:31.880 has a whoop that's inspiratory on the breath 00:27:31.880 --> 00:27:34.700 in. Second, the response to treatment. Asthma 00:27:34.700 --> 00:27:37.500 response to bronchodilators like albuterol. You 00:27:37.500 --> 00:27:40.559 give the nebulizer, the lungs open up. Pertissus 00:27:40.559 --> 00:27:42.859 does not respond to albuterol. If you give a 00:27:42.859 --> 00:27:45.140 breathing treatment and absolutely nothing changes, 00:27:45.640 --> 00:27:49.019 you need to dig deeper. And finally, croup. They 00:27:49.019 --> 00:27:51.799 both make scary noises. Yes, but different scary 00:27:51.799 --> 00:27:55.799 noises. Croup is a viral infection of the upper 00:27:55.799 --> 00:27:58.900 airway. It causes a barking cough like a seal. 00:27:59.099 --> 00:28:01.299 Right, the seal bark. And it has inspiratory 00:28:01.299 --> 00:28:04.579 stridor, which is a rough, raspy sound. Pertussis 00:28:04.579 --> 00:28:07.339 is staccato coughing, that rapid -fire machine 00:28:07.339 --> 00:28:09.960 gun cough, followed by the high -pitched whoop. 00:28:10.140 --> 00:28:13.299 So, bark versus whoop and albuterol response 00:28:13.299 --> 00:28:16.500 versus no response. That is a really solid diagnostic 00:28:16.500 --> 00:28:18.440 framework. And remember, Krupp usually comes 00:28:18.440 --> 00:28:20.619 with a specific x -ray sign, the steeple sign. 00:28:20.940 --> 00:28:22.900 Pertussis doesn't have a specific x -ray finding, 00:28:23.019 --> 00:28:25.039 other than maybe some haziness or inflammation. 00:28:25.519 --> 00:28:27.980 We have covered a massive amount of ground here. 00:28:28.119 --> 00:28:31.039 We've got the pattern, the d -patho, the cilia, 00:28:31.400 --> 00:28:34.619 and the toxins, the nuances of the vaccine history 00:28:34.619 --> 00:28:37.519 and schedule, and the differential diagnosis. 00:28:37.900 --> 00:28:39.759 Let's wrap this up with our summary takeaways. 00:28:40.279 --> 00:28:42.119 If the listener is driving to the testing center 00:28:42.119 --> 00:28:44.259 right now, what are the four things they need 00:28:44.259 --> 00:28:47.559 to log in? Number one, pertussis kills infants 00:28:47.559 --> 00:28:50.259 via apnea. Don't just wait for the cough. If 00:28:50.259 --> 00:28:52.740 a baby stops breathing, you have to think pertussis. 00:28:52.740 --> 00:28:56.019 OK. Number two, it is highly contagious before 00:28:56.019 --> 00:28:58.380 the whoop starts. The cataral stage is the danger 00:28:58.380 --> 00:29:00.980 zone for spread. Got it. Number three, treatment 00:29:00.980 --> 00:29:03.539 with macrolides treats the patient, Andy, the 00:29:03.539 --> 00:29:06.220 community. It stops the spread, but it doesn't 00:29:06.220 --> 00:29:08.799 stop the cough once it has started. And four. 00:29:09.299 --> 00:29:11.660 Number four, vaccination is the primary prevention, 00:29:12.000 --> 00:29:15.900 but immunity wanes. We need boosters like Tdap 00:29:15.900 --> 00:29:18.339 and pregnancy cocooning to keep infants safe. 00:29:18.859 --> 00:29:20.740 And as we close, let's hit them with that final 00:29:20.740 --> 00:29:22.680 provocative thought you mentioned earlier. We 00:29:22.680 --> 00:29:24.920 talked about adults being the reservoir. Yeah. 00:29:25.150 --> 00:29:27.930 We so often look at pediatric infectious diseases 00:29:27.930 --> 00:29:30.369 and we blame the sick kids at school. We think 00:29:30.369 --> 00:29:33.009 of schools as these little germ factories, but 00:29:33.009 --> 00:29:35.069 the source material points to a completely different 00:29:35.069 --> 00:29:38.029 reality for Pertusis. Adolescents and adults 00:29:38.029 --> 00:29:41.430 are the primary reservoir. It is often the healthy 00:29:41.430 --> 00:29:44.140 grandparent with a nagging cough. Something they 00:29:44.140 --> 00:29:47.420 think is just allergies or a lingering cold who 00:29:47.420 --> 00:29:49.819 unknowingly endangers the newborn. That really 00:29:49.819 --> 00:29:52.000 shifts the responsibility, doesn't it? It challenges 00:29:52.000 --> 00:29:54.859 us to stop looking at adult boosters, the Tdap, 00:29:55.319 --> 00:29:57.900 as just tetanus shots that we get when we step 00:29:57.900 --> 00:30:00.039 on a rusty nail. We need to start viewing them 00:30:00.039 --> 00:30:02.640 as a critical pediatric safety net. This is not 00:30:02.640 --> 00:30:04.730 just for me. It's not just for you. When you 00:30:04.730 --> 00:30:06.609 get your Tdap, you aren't just protecting yourself 00:30:06.609 --> 00:30:09.190 from a cough. You are actively contributing to 00:30:09.190 --> 00:30:12.750 keeping the NICU empty. It's herd immunity in 00:30:12.750 --> 00:30:15.369 action. That is a powerful perspective shift. 00:30:15.549 --> 00:30:17.150 It's not just about you. It's about the most 00:30:17.150 --> 00:30:19.490 vulnerable person in the room. Exactly. And for 00:30:19.490 --> 00:30:22.150 the nurse, that's the job, protecting the vulnerable. 00:30:22.650 --> 00:30:25.309 All right, learner. You have got the tools. You 00:30:25.309 --> 00:30:27.650 know the red flags. You know the exam traps. 00:30:28.069 --> 00:30:30.430 Now go crush that exam or that clinical shift. 00:30:30.650 --> 00:30:32.750 You've got this. Thanks for diving in with us. 00:30:32.769 --> 00:30:33.410 See you next time.