Welcome to the bed. We'll go ahead and give you
the story. This is all going to happen super
fast. Welcome to the emergency room. Welcome
back to the deep dive. Today we are wading into
what I think is fair to call the high stakes
end of the pool. Oh, absolutely. The deep end.
We are tackling pediatric neurology. Yeah. And,
you know, looking at the stack of research we
have here, we've got chapter 16 on intracranial
regulation, some really heavy hitting drug guides,
those dense seizure tables. It's easy to get
overwhelmed. It is a lot. And the reason it feels
so heavy is because the stakes are just incredibly
high. Right. When we talk about a child's brain,
we aren't just talking about keeping them alive.
We're talking about preserving who they are going
to become. The margin for error is it's razor
thin. That's a great way to put it. If you mess
up a dose of, say, Tylenol, usually it's a manageable
problem. Right. But if you miss a subtle sign
of increasing intracranial pressure, the consequences
are they're permanent. They're profound. But
our mission today isn't to memorize every single
cranial nerve or turn ourselves into neurosurgeons.
That's for the anatomy lab. Today, we're building
what we call the master 80 -20 map. I love applying
the Pareto principle here. It's really the only
way to survive in a clinical setting, or on an
exam for that matter. The 80 -20 rule. Yeah.
We need to identify that 20 % of neurological
concepts that are going to help you answer 80
% of the tough exam questions. And more importantly.
More importantly, catch 80 % of the catastrophic
errors before they happen at the bedside. So
before we jump into the specific diseases, the
seizures, meningitis, all of that, we have to
start with the why. Because reading through this
intro material, my biggest takeaway was kids
are not just small adults. Not even close. Their
heads are literally built differently. They are.
And that structural difference is the key to
everything we're going to talk about today. If
you treat a child's neuro symptoms like an adult's,
or if you expect them to show the same signs,
You will miss the warnings every single time.
Okay, so break that down for us. What is the
fundamental difference? Well, think of an adult's
skull. It's a fused, rigid bone box. Right. It
doesn't move. It doesn't give. If pressure builds
up inside an adult's head, say from a bleed or
a tumor, that pressure has absolutely nowhere
to go. So it compresses the brain tissue. Immediately.
And the adult gets symptoms very, very fast.
But an infant, their skull is dynamic. It's a
completely different system. Because of the fontanels,
the soft spots. The fontanels and the sutures.
The seams between the skull bones aren't fused
yet. This is a critical point. It allows the
head to actually expand if the pressure inside
starts to rise. Which on the surface sounds like
a good thing, right? The built -in safety valve.
In theory, yes. It buys you a little bit of time.
But clinically, it's a huge double -edged sword.
Oh, so. because that ability to expand can mask
the early signs of pressure. An infant can accommodate
a significantly larger volume of fluid or blood
before they start showing those classic adult
signs of crashing. So the problem is getting
worse on the inside. Right. The head is getting
bigger. The brain is under stress. But the baby
might just look a little fussy, a little irritable.
And if you're waiting for them to act like a
sick adult who's complaining of a crushing headache,
you might be waiting until it's far, far too
late. Wow. OK. That sets the stage perfectly.
We have a dynamic system that hides its secrets.
So let's get into this master 80 -20 map. You've
categorized the chaos of neuro into four distinct
patterns that seem to govern almost all pediatric
neuroemergencies. Right. And if you can recognize
these four patterns, you can pretty much handle
anything they throw at you on an exam or in the
ER. OK, let's run through them. Pattern number
one. We're calling it the pressure cooker. This
is everything related to increased intracranial
pressure, or ICP, and hydrotephyllus. OK. The
pressure cooker. Got it. Pattern number two.
The electrical storm. All things seizures and
epilepsy. Makes sense. Pattern number three.
The invader. This is infection, specifically
the big one, meningitis. And the last one, pattern
number four. The physical trauma. This covers
structural defects like spina bifida, but also
head injuries and the very dark, but very necessary
topic of non -accidental trauma. Okay. Pressure,
electricity, infection, and trauma. That is a
really solid framework. Let's dive into the first
one. The pressure cooker. Increased ICP. Let's
do it. So you mentioned the Monroe -Kelly doctrine
earlier. It's a core concept in this section.
It really is the foundation for understanding
pressure. It sounds super technical, but it's
basically just physics, right? It is. Just imagine
the skull as that rigid box we talked about,
or in the infant's case, a semi -rigid box. OK.
Inside that box, you only have room for three
things. Brain tissue, which makes up about 80%.
The brain itself? Right. Then you have blood,
which is about 10%. And finally, cerebrospinal
fluid, or CSF, which is the last 10%. And that's
it. It all adds up to 100. That's it. There is
no empty space. It's not like there's air in
there. So it's a zero -sum game. Precisely. If
you add something new, like a tumor or blood
from a hemorrhage, or if you have too much of
one of the existing things, like too much CSF
and hydrocephalus, something else has to give.
The pressure just goes up. And that brings us
back to your earlier point about the infant skull
expanding. This feels like our first major clinical
decision point. How does the presentation of
the pressure cooker differ by age? It's night
and day. In an infant, because the skull can
literally expand, The signs are physical. You
can see it and you can feel it. You can literally
measure the change. Yes. The head circumference
grows rapidly. This is why we measure head circumference
at every single well -tiled check. And what are
you looking for? A slow, steady growth. You want
them to track along their percentile curve. But
if a baby jumps from, say, the 50th percentile
to the 95th percentile in head size over a month
or two. That's a huge red flag. A massive red
flag. Something is making that head grow too
fast. You'll also feel the fontanels. Those soft
spots will be tense and bulging outward. They
shouldn't be sunken or flat. They feel tight
like a drum. And the source material mentions
a really specific eye sign. Sunset eyes. Yeah,
this is a classic exam visual and a bedside oh
no moment. Describe what that looks like. The
pressure inside the skull is so high that it
pushes down on the orbital plates of the skull,
which forces the eyeballs downward. So when you
look at the baby, you can see the squarer, the
white part of the eye visible above the iris.
It looks exactly like the sun setting over the
horizon of the lower eyelid. If you see that,
are we in the early warning phase anymore? No,
not at all. If you see sunset eyes, the pressure
is critically high. You're behind the curve.
What else might you hear? You might hear a very
distinct cry. It's high -pitched, almost a shriek.
We call it a neuro -cry. It's not the I'm hungry
cry or the I need a diaper change cry. It's a
piercing, irritable sound that is really hard
to console. OK, so that's the baby. Physical
signs. Bulging fontanel, growing head, sunset
eyes, neuro -cry. But what about a 10 -year -old?
Their sutures are closed. Their box is fixed.
Right. So they can't expand. Their presentation
is going to be based on subjective complaints,
much more like an adult. The classic one being
a headache. A headache, yes. But you have to
dig deeper on the history. It's not just any
headache. It's a headache that is characteristically
worse in the morning or worse when lying down.
OK. Why is it worse in the morning? That's such
a specific detail. It's all about gravity. When
you're upright, walking around during the day,
gravity helps drain venous blood and CSF from
the head down into the spine. Like a natural
drainage system. Exactly. But when you lay flat
to sleep for eight hours, that drainage slows
down. The fluid pools slightly and the pressure
gradually builds overnight, so they wake up with
this pounding, intense headache. And then it
might get better as they move around. Yes. Often,
after they've been up for an hour or so, it improves.
So parents might think, oh, he's just trying
to get out of school. But that specific pattern
is a huge clue. And what about vomiting? Yes.
But again, it's a specific kind. It's often vomiting
without nausea. That's the key. I'm a stomach
bug? Not at all. With a stomach bug, you feel
sick, you get queasy, you feel awful for hours,
and then you throw up. With increased ICP, the
pressure just directly hits the vomiting center
in the brainstem, and boom, sudden, often projectile
vomiting with no warning. So we have the symptoms,
physical signs in babies, headache and vomiting
in older kids. But let's get to the 80 -20 core.
What is the absolute need to know? assessment
here. If you can only check one thing to see
if your patient is getting worse, what is it?
Level of consciousness. LOC. This is the holy
grail of neuroassessment. It is the most sensitive
indicator. For the vitals change. Long before.
The LOC is the earliest indicator of neurological
improvement or deterioration. Before the pupils
blow, before the heart rate tanks, the child
will just become different. And parents are often
the experts on different. They are your number
one resource. If a mom says he's just not acting
like himself, or she's really hard to wake up
today, or he's just staring off into space, you
listen. You take that seriously. And how do we
quantify that? You use the Pediatric Glasgow
Coma Scale. You have to verify what the parents
are telling you. Which is different from the
adult GCS, right? I can't ask a six -month -old
to state their name in the current year. Exactly.
It has to be adapted for pre -verbal children.
So instead of oriented to time and place, you're
looking for things like, does the baby coo or
babble? Do they smile at mom? Do they cry? But
are they consolable? So you're looking for their
normal interaction. Right. Or are they agitated
and inconsolable? That's a lower... score. If
they're just lying there moaning or withdrawing
from your touch, that's a very low score. You're
assessing their interaction with their environment.
Let's talk about the worst case scenario, the
crash, the thing we are all trying to prevent,
herniation. This is the absolute nightmare scenario.
What's happening? The pressure gets so high inside
the skull that the brain tissue itself is physically
forced downward through the hole at the base
of the skull, the form in magnum. This process
directly compresses the brainstem. And the brainstem
controls all the basic life functions. Breathing,
heart rate. Correct. If you compress the brainstem,
the patient stops breathing. They die. And the
warning sign for this, the siren that goes off
right before it happens, is Cushing's Triad.
You need to burn this into your memory. Every
nursing student, every nurse has to know this.
Cushing's Triad is the physiological opposite
of shock. OK, let's walk through that comparison.
In shock -like, if a kid is bleeding out, I expect
a high heart rate. So tachycardia. Right. And
eventually low blood pressure or hypotension.
Exactly. The heart beats faster to try to compensate
for the lost volume. But in increased ICP with
Cushing's triad, you see the complete reverse.
You see bradycardia, a slow heart rate. Why does
the heart slow down when the brain is in trouble?
That seems counterintuitive. It's a reflex. The
pressure in the brain is so critically high that
the body's last -ditch effort is to shove blood
up there by massively increasing the systemic
blood pressure so you get severe hypertension.
So blood pressure goes way up. Way up. The baroreceptors
in the aortic arch and carotid arteries sense
this extreme hypertension and they send a signal
to the heart saying, whoa, pressure is way too
high, slow down. So you get hypertension paired
with bradycardia. And the third part of the triad
is the pulse pressure widening. Yes. The systolic
number, the top number, goes way up to fight
the pressure in the brain. But the diastolic,
the bottom number, stays about the same or even
drops. So the gap between the two numbers widens
significantly. And the final sign is the breathing
pattern. Irregular respirations. Often you'll
see something called chain stokes breathing,
which is this pattern of rapid deep breaths followed
by periods of apnea where they stop breathing
entirely. So if you see that triad, slow heart
rate, high blood pressure with a wide pulse pressure
and weird breathing. The child is minutes, maybe
seconds away from herniation and respiratory
arrest. This is a call a code moment. OK, so
let's talk interventions. We're in the pressure
cooker. The alarm is going off. How do we turn
down the heat and prevent that crash? Positioning
is your first, fastest, and cheapest move. Elevate
the head of the bed, the HOB, to about 15 to
30 degrees. Why not 90 degrees? Why not sit them
all the way up? That's a great question and a
common mistake. If you sit them up too high,
you can actually cause the blood pressure to
drop in the brain and compromise cerebral perfusion.
30 degrees is the sweet spot. What's it doing?
It uses gravity to promote venous drainage from
the head without fighting too hard against arterial
blood flow going up to the brain. But here is
the nuance that catches people on exams. Keep
the head midline. Midline. Why is that so important?
Think of the jugular veins in the neck as the
main drain pipes for the head. If you turn the
head to the side, you twist the neck, and you
can compress or kink the jugular vein. You're
blocking the drain pipe. You've kinked the drain
pipe. Blood can't get out of the brain efficiently,
and the pressure spikes even higher. You need
to keep their nose aligned with their belly button.
Use towel rolls or sandbags if you have to. That
makes perfect sense. What about things we do
at the bedside, like suctioning? Minimize it
at all costs. coughing, straining, suctioning,
even vigorous crying, all of those things increase
intra -thoracic pressure. That pressure pushes
back up the venous system and directly increases
intracranial pressure. If you absolutely have
to suction to clear a blocked airway, do it quickly
for less than 10 seconds and pre -oxygenate them.
But never do it routinely just because it's on
a schedule. And treat pain and agitation. Aggressively.
A crying, screaming, agitated child has a higher
ICP. A calm, quiet, dimly lit environment is
therapeutic. Before we leave this pattern, I
want to touch on shunts. Because hydrocephalus,
which is simply too much CSF, is often treated
with a VP shunt. So ventricular peritoneal shunt,
yeah. It's basically a piece of plumbing. It's
a thin tube that runs from the ventricle in the
brain, punnels under the skin, and drains down
into the peritoneal cavity in the belly. The
belly. Yep, in the abdomen. The fluid just drains
there and gets reabsorbed by the body. So it's
a plumbing fix. But plumbing breaks. What's the
need to know on shunts? The two big scary words
are infection and malfunction. This is a massive
exam tip and a critical clinical rule. If a child
with a known VP shunt comes into your ER with
a fever, vomiting, lethargy, headache, or is
just not acting right. You have to assume it's
the shunt. You must assume the shunt is broken
or infected until proven otherwise. Even if their
brother has the stomach flu and the symptoms
look identical. It does not matter. You rule
out the life -threatening shunt problem first.
because if that shunt is blocked, ICP is rising
rapidly and they can crash. If it's infected,
that's meningitis waiting to happen. So what's
the workup? They need a CT scan of the head to
look for ventricle size changes and a shunt series,
which is a set of x -rays to see if the tubing
is intact immediately. Okay, pattern one, pressure
cooker. Done, a lot there. Let's move to pattern
two, the electrical storm, seizures. This is
another huge topic, but again we need to simplify
it for our AD20 map. A seizure is, at its core,
an uncontrolled chaotic electrical discharge
in the brain. It's a short circuit. And as with
pressure, age matters. The presentation varies
wildly. Let's start with the infants. The source
material really highlights infantile spasms.
This is a can't -miss diagnosis. It's so tricky
because it doesn't look like a seizure you see
in the movies. The baby isn't shaking violently
on the floor. It's often called a jackknife seizure.
Can you describe that motion? The baby will suddenly
and violently flex their neck and arms, crunching
forward like a little jackknife. Then they relax.
Then a few seconds later they do it again and
again. It happens in clusters, often when they're
waking up or falling asleep. And I can see how
a parent might just think that's colic or a stomach
cramp. Exactly. Oh, his tummy hurts. He's crunching
up. But the reason this is so critical and why
it's on her 80 -20 list is that infantile spasms
are highly correlated with developmental regression.
Regression, you mean losing skills they already
had. Yes. If you don't treat this aggressively
and stop the spasms, the child can stop developing
or even lose skills like smiling or rolling over.
And often, they never gain them back. It is a
true developmental emergency. Moving up the age
bracket, febrile seizures, every parent's worst
nightmare. Extremely common in toddlers, and
while terrifying to watch, they are usually benign.
The trigger is a rapid spike in temperature.
It's the speed of the spike, not the absolute
height of the fever. That's the key point. A
child can have a 104 fever and be fine if it
climbed slowly. But going from 98 .6 to 103 in
20 minutes can trigger it. It's the velocity
of the change that causes the brain's electrical
system to short circuit. And then we have absence
seizures in school -age kids. The daydreaming
seizure. The kid just checks out for five or
ten seconds. They're falling, no shaking? Nope.
just a blank stare. They stop talking mid -sentence.
Teachers are often the first to notice and flag
it as ADHD or not paying attention. So how do
you tell the difference? If a kid is just daydreaming
and you touch their shoulder or call their name,
they'll snap out of it. With an absent seizure,
they are completely unresponsive during the event.
You might also see subtle motor signs like lip
smacking or eyelid fluttering. And then they're
just back. And they have no memory of the last
time. They just pick up where they left off.
OK, let's talk management. You're at the bedside.
A child goes into a full tonic -clonic seizure.
Stiffening, jerking, maybe foaming at the mouth.
What is your absolute number one priority? Safety
and airway. But you manage the airway primarily
through positioning. turn them on to their side.
The recovery position. Why the side? Gravity
again. You want any saliva or vomit to drain
out of the mouth, not down into the lungs. Aspiration
pneumonia is a huge risk during a seizure. And
what do we absolutely not do? This seems to be
a favorite exam topic. Do not put anything in
their mouth. No tongue blades, no spoons, no
fingers. That is a dangerous old myth. Why is
it so dangerous? You'll break their teeth, you'll
injure their gums, or worse, you'll push the
tongue back and completely block their airway.
The jaw can clench with incredible force. And
secondly, do not restrain them. Don't hold them
down. You can fracture bones trying to hold a
seizing child down. Your job is to protect them
from the environment. So clear the arimu furniture,
put a soft pillow or jacket under their head,
and just let the seizure run its course and time
it. Unless it doesn't stop. Right. And that brings
us to status epilepticus. What is the definition?
A seizure lasting more than five minutes or a
series of seizures where the child doesn't regain
consciousness in between. Why is five minutes
the magic number? Because after about five minutes
of continuous seizing, the brain's demand for
oxygen and glucose skyrockets and exceeds what
the body can supply. Neurons start to die from
metabolic exhaustion. The brain is literally
cooking itself. This is a medical emergency.
So we need medications. And this is a key synthesis
point from our sources. Rescue versus maintenance
meds. We need to be crystal clear here. A huge
distinction. If a child is seizing right now
in front of you, you need a rescue medication.
That is always a benzodiazepine. Like diazepam
or lorazepam. Right. Valium or Etivan. And if
they don't have an IV line, it's pretty hard
to start an IV on a seizing child. It's nearly
impossible. So we use other routes. Rectal diazepam,
which comes in a gel form called diastat, is
the classic home rescue med, or more commonly
now intranasal midazolam. You just use a syringe
to squirt it up the nose. And it absorbs that
quickly? Instantly across the nasal mucosa. It's
incredibly effective. But you would not try to
give them a pill to swallow? Never. Absolutely
not. Aspiration's steady. Obviously. OK, so that's
rescue. But for preventing seizures... Tomorrow
or next week, we use maintenance meds. We'll
get to those in the drug module, but these are
things like carbamazepine or gabapentin. They're
taken daily. Exactly. And a maintenance med will
not stop an active seizure. It won't work fast
enough. Two different drug classes for two different
jobs. One last thing on seizures from the source,
the keto diet. I feel like this is a wait what
moment for a lot of people who just associate
keto with weight loss influencers on Instagram.
It is. But we are not talking about weight loss
here. For children with refractory epilepsy,
that's seizures that multiple medications can't
control. A strict, medically supervised ketogenic
diet is a valid and sometimes very effective
treatment. Well, it's a very high fat, very low
carb, adequate protein diet. It forces the body
and specifically the brain to shift its primary
fuel source from glucose, which is sugar, to
ketones, which are derived from fat. And that
helped. For reasons we don't fully understand,
burning ketones for fuel seems to have a stabilizing
effect on neurons. It raises the seizure threshold.
It calms the electrical storm. But it's not just
cutting carbs like a typical diet, is it? No.
It is incredibly rigorous. You have to weigh
every single gram of food. The ratios have to
be precise. You cannot cheat. What happens if
you do? One cookie or even a dose of liquid Tylenol
that has a sugary syrup base can throw them out
of ketosis and trigger a cluster of seizures
instantly. It requires a massive family commitment
and dietitian support. Wow. Okay, fascinating.
Let's move to pattern three, the invader, meningitis.
This is the one that keeps pediatricians and
ER docs up at night, specifically bacterial meningitis.
This is an inflammation of the meninges, the
protective covering of the brain and spinal cord.
Yeah. What are the main pathogens we are worried
about? In the post -vaccine era, it's mainly
streptococcus pneumonia, naceria, meningitis,
and in unvaccinated kids, haemophilus influenza
type B, or Hib, these are the big bads. They
invade the CSF and cause massive, purulent inflammation.
What does the patient look like? In an older
child, you get the classic triad, high fever,
a severe headache, and neutral rigidity. A stiff
neck. Let's talk about the stiff neck. Why does
that happen? Because the meninges are a continuous
sheath that goes from the brain all the way down
the spinal cord. When you try to bend your neck
forward, you stretch those inflamed angry tissues,
and it causes excruciating pain. The muscles
in the neck spasm to prevent that motion. They
might also have photophobia, right? Light sensitivity.
Yes. Light hurts their eyes. And the other terrifying
sign is the rash. The purple rash. If you see
a purple, patechial, or purpuric rash that doesn't
blanch, meaning it doesn't fade when you press
on it with a glass, that is meningocosemia. What
does that mean? It means the bacteria, Neisseria,
are in the bloodstream causing DIC septic shock.
It is a run -don't -walk, life -threatening emergency.
But infants, as always, are vague and confusing.
Always, you won't get a complaint of a headache.
You get poor feeding, a weak cry, vomiting, maybe
a bulging fontanel. But there is a specific posture
to watch for. Opistotinose. Opistotinose. That's
a mouthful. It is. The baby arches their back
and neck backward rigidly. It looks incredibly
uncomfortable. They do it because the meninges
are so inflamed that curling up into a ball,
flexing, stretches them and hurts. Arching back
relieves the tension on that inflamed spinal
cord. Okay, we have two classic assessment signs
here that appear on every nursing exam. Kornig's
and Brudzinski's. Can you clarify them in a simple
way? Absolutely. For Kornig's sign, think K for
knee. You lay the child down, flex their hip
to 90 degrees, and then you try to straighten
the leg at the knee. If it causes severe pain
in their back or resistance because of hamstring
spasm, That's a positive kernings. The meningial
irritation is causing that reflex. And Brzezinski's.
For Brzezinski's sign, think B for brain or back
of the head. You lay them flat and you passively
lift their head off the bed, flexing their neck
toward their chest. And what happens? If their
knees and hips automatically buckle and flex
up toward their body, that's a positive Brzezinski's.
It's an involuntary reflex to try and relieve
that painful stretch on the spine. So you suspect
meningitis. You see the stiff neck. Maybe a positive
Brzezinski's. What is the very first thing you
do before anything else? Isolate. Put them on
droplet precautions immediately. Mask on the
patient. Gown, gloves, mask for you. You do this
before you call the doctor, before you go for
the lumbar puncture. You don't wait for lab confirmation.
Do not wait. If it is bacterial, it spreads through
respiratory droplets. You have to protect the
other patients on the unit and the staff. Then
you get the orders for an LP, a lumbar puncture.
You get the CSF fluid. What are we looking for
to confirm our suspicion? The main goal of the
LP is to differentiate bacterial from viral meningitis.
Bacterial is the emergency. Viral or aseptic
is usually self -limiting. So what does bacterial
fluid look like? In bacterial meningitis, the
fluid will often be cloudy, almost milky. The
white blood cell count will be very high, mostly
neutrophils. Protein will also be high because
of all the bacteria and dead cells floating around.
But the key differentiator is the glucose level.
What happens to the glucose? It drops. It's significantly
low. And why is that? Because the bacteria are
alive and they are hungry. They are literally
eating the sugar in the cerebrospinal fluid for
energy to replicate. So it's a great mnemonic.
Bacteria eat sugar. Low sugar in the CSF means
it's probably bacterial. Exactly. In viral meningitis,
the glucose is usually normal because viruses
don't metabolize sugar in the same way. And if
it is bacterial, the treatment is? You start
high -dose IV antibiotics immediately. Even before
the final culture comes back, you start broad
spectrum coverage. Time is brain. Every minute
you delay treatment increases the risk of permanent
damage. Speaking of damage, what's the long -term
impact here? The number one most common long
-term complication of bacterial meningitis is
sensorineural hearing loss. Yes. The inflammation
can directly damage the auditory nerve. So every
single child who recovers from meningitis needs
a formal hearing screen before they are discharged
from the hospital. Why is that so important?
You don't want to send them home and have the
parents realize six months later that their child
has a speech delay because they haven't been
able to hear properly. It's a preventable secondary
problem. OK. That's a fantastic clinical pearl.
Let's move to our last pattern, pattern four.
Physical trauma and neural tube defects. Let's
focus on spina bifida first, specifically myelomeningosal.
This is a congenital defect. It's a failure of
the neural tube to close completely during the
first month of pregnancy. It's heavily linked
to folic acid deficiency. And the baby is born
with what? They're born with a sac protruding
from their back, usually the lower back, and
inside that sac are the meninges, CSF, and exposed
spinal nerves. The need to know from the sources
here is very heavily focused on the preoperative
period. You have a newborn with essentially an
open wound on their back that connects to their
brain. Infection is the number one enemy. You
have to protect that sac at all costs. If that
sac ruptures, bacteria have a direct highway
into the spinal cord and the brain. It's a setup
for meningitis. So how do we position them? Pwn
only. They lie on their belly, no lying on the
back, no side lying. All care diaper changes,
feeding has to happen with them on their belly.
And how do we care for the sack itself? You have
to cover it with a sterile, saline -soaked dressing.
It must be kept moist at all times. Why moist?
If the sack dries out, the delicate tissue can
crack and rupture. So you're constantly applying
these warm, sterile, wet dressings, often under
a warmer, to prevent heat loss. Now, there's
a really specific allergy we have to mention
with these kids. It's a weird food connection
that always seems to show up on board exams.
Ah, yes, the latex fruit syndrome. Tell us about
that. Why these kids? Children with spina bifida
undergo multiple surgeries starting from birth.
They also often require daily bladder catheterizations
for their entire lives. So they have a massive
exposure to latex. Massive lifelong exposure
to latex products. Gloves, catheters, balloons.
As a result, they almost universally develop
a severe latex allergy or sensitivity. You must
treat every child with spina bifida as if they
have a latex allergy. So a completely latex -free
environment in the hospital. Strictly. Kicker
for the exam question. Because of protein cross
-reactivity, people who are allergic to latex
are also often allergic to certain foods that
share similar protein structures. And which foods
are those? The big ones are bananas, avocados,
kiwi, and chestnuts. So if you're working the
pediatric floor and the lunch tray comes up with
a banana for the spina bifida patient in room
204. You send it back immediately. That is a
critical safety catch. Giving them that banana
could trigger anaphylaxis. Let's pivot now to
head trauma. The sources differentiate between
epidural and subdural hematomas. I think a lot
of us get these mixed up. The easiest way to
remember is to think about the plumbing. An epidural
hematoma is an arterial bleed. It happens between
the skull and the dura mater. And arteries are
high pressure. Very high pressure. So this bleeds
fast. The classic presentation is what they call
talk and die. Talk and die. That is incredibly
grim. It is. A child gets hit in the head, maybe
a baseball to the temple, which is a classic
location. They might pass out for a second, but
then they wake up and seem totally fine. They're
talking, they're walking around. That's the lucid
interval. That's the lucid interval. So parents
think, oh, thank God he's OK. But meanwhile,
that torn artery is pumping blood into that space.
The pressure builds rapidly. Suddenly, they lose
consciousness, a pupil blows, and they crash.
It requires immediate emergency surgery. And
a subdural hematoma? Subdural is a venous bleed.
It's a bleed under the dura. Veins are low pressure,
so this is a slower, oozing bleed. The symptoms
can develop over hours or even days, and it's
much more common in infants, especially in the
context of our next topic, non -accidental trauma.
Shaken baby syndrome? This is where the nurse
has to be both a clinician, a detective, and
a fierce advocate for the child. What's the mechanism
of injury? It's a combination of an infant's
anatomy. They have a weak neck, they can't support
their head well, and their head is disproportionately
large and heavy. When an infant is shaken violently,
the brain slams back and forth inside the skull.
And that tears the veins. It tears the small
bridging veins that connect the brain to the
dura, causing a subdural hematoma. And there's
a clinical triad for shaken baby syndrome. I
guess. If you see this combination of injuries,
you must suspect abuse. It is retinal hemorrhages,
a subdural hematoma, and cerebral edema, or brain
swelling. And you say the retinal hemorrhages
are key. They are pathognomonic. That means they
are almost exclusively caused by this type of
abusive shaking injury. You do not get retinal
hemorrhages from a simple fall off a couch or
a changing table. The forces just aren't great
enough. And that's the exam tip too, isn't it?
This story doesn't match the injury. Always.
If the parent or caregiver brings in a two -month
-old and says, he rolled off the bed, you have
to stop. A two -month -old cannot roll over.
That is a developmental impossibility. So your
alarm bells go off? Immediately. As a nurse,
you are a mandatory reporter. It's not your job
to prove abuse, but you are legally and ethically
required to report the suspicion to protect the
child. You aren't judging the parent. You are
saving a life. OK. That covers the four patterns.
That was incredibly thorough. Let's shift gears
and move into part C, the medication module,
the safe dosing files. We have some very specific
high -yield drugs here that you really need to
understand deeply. Let's start with a big one,
carbamazepine. Brand name, Tegreckel. This is
a classic anti -convulsant. How does it work?
What's the mechanism of action? It's a sodium
channel blocker. In simple terms, it stabilizes
the gates on nerve cells that let sodium in and
out, which is what creates an electrical impulse.
By blocking these, it stops the repetitive, chaotic
electrical firing that causes a seizure. It tells
the nerves to chill out. Basically, yes. Stop
firing so fast. What are the PD -specific safety
pearls here, the things we need to know for kids?
OK, first, and this is a safety issue for nurses
and parents, it's classified as a hazardous drug
by Neofesh. What does that mean for handling
it? It means if you are a nurse handling the
liquid suspension or crushing a tablet, you need
to wear gloves. Ideally, double chemo gloves.
You don't want to absorb this through your skin
over time. But the big patient safety red flag
involves genetics, specifically for patients
of Asian ancestry. This is huge, and it's a relatively
new understanding in pharmacology. There is a
specific genetic marker, an allele, called HLAB
1502. And people of Asian descent are more likely
to have it. Much more likely. And if they carry
this allele and they take carbamazepine, they
have a ten -fold higher risk of developing Stevens
-Johnson syndrome, or SJS. Which is a horrific,
life -threatening skin reaction. It is. The skin
and mucous membranes blister and peel off. It's
essentially a chemical burn from the inside out.
It's often fatal. So what is the guideline now?
Genetic testing for this allele is recommended
before starting the drug in Asian populations.
If you see an exam question about starting an
Asian child on Tikritol, the correct answer will
involve checking for that allele first. It also
messes with the bone marrow, right? Yes. It can
cause myelo suppression or bone marrow suppression.
It lowers your white blood cells, your red blood
cells, and your platelets. So let's synthesize
that. If you have a child on carbamazepine, who
develops a fever and a sore throat. You cannot
just assume it's a simple case of strep throat.
You have to check a CBC. Is their white blood
cell count zero? A granulocytosis. Has the drug
wiped out their immune system? So a simple cold
could become life -threatening sepsis. Instantly.
You also watch for signs of anemia like fatigue
and pallor from low red cells and signs of bleeding
like bruising or petechiae from low platelets.
Okay, next up in our list, gabapentin. brand
name Neurontin. This one is interesting. Its
name makes you think it works on the GABA system,
and it's structurally related to the neurotransmitter
GABA, but it doesn't actually bind to GABA receptors.
So how does it work? It works on voltage -gated
calcium channels. A different mechanism. In adults,
we often use this for nerve pain, and the classic
side effect is sedation, that Gabapentin fog.
Right. Somnolence, dizziness. It's a huge fall
risk. But in kids, it can have a paradoxical
effect. Meaning it does a complete opposite.
Yes. Instead of chilling them out, it can ramp
them up. It can cause significant behavioral
changes. Hostility, aggression, emotional ability,
hyperkinesia, meaning they're bouncing off the
walls. So a parent might call and say, he's turning
into a monster. Or she's throwing things constantly.
And you have to know that could be the drug.
It's not just the child acting out. So a big
teaching point is to warn parents to watch for
those behavior changes. Exactly. And like all
anticonvulsants, there is a black box warning
for suicidal ideation. It sounds heavy to talk
about in pediatrics, but even in younger kids
and teens, you have to monitor for mood changes,
depression, or self -harming thoughts. Let's
do a quick hit on a couple of others from the
textbook table. Funny Toin. The big one everyone
remembers is gingival hyperplasia. Overgrowth
of the gums. Yes. The gums can literally grow
over the teeth. It's not an infection or poor
hygiene. It's a direct side effect of the drug.
Can we do anything to prevent it? Meticulous
dental hygiene helps. Using a soft toothbrush,
flossing, regular dental visits. And some studies
show that folic acid supplementation can help
reduce the severity. But you have to warn the
teen cosmetically, this is a very big deal for
them. And the last one, valproic acid or Depakote?
Two big words, hepatotoxicity and pancreatitis.
It can be very rough on the liver and pancreas.
So you're monitoring liver enzymes? Absolutely.
You check LFTs at baseline and regularly thereafter.
If the child develops jaundice, abdominal pain,
nausea, vomiting, or becomes super lethargic,
you have to suspect liver damage and stop the
drug. Okay, this brings us to part D, cross -linking
and synthesis. This is where we connect the dots
between the diseases and the drugs. We've touched
on some of this, but let's explicitly link medications
and development. This is the part that is so
often missed in the rush to treat. We focus so
much on stopping the seizure that we forget about
the cost of the treatment. And what is the cost?
Most anticonvulsants are, by their nature, sedating.
They work by slowing down neuronal firing. Which
means they are literally slowing down the brain.
Right. So if you have a school -aged child who
is seizure -free but so sedated from their medication
that they can't stay awake or pay attention in
class, their grades drop. They might get labeled
as having a learning disability or ADD. But really
they're just over -medicated. They're over -medicated.
The nurse's role here is to be an advocate for
finding that sweet spot. The balance between
seizure control and quality of life. Exactly.
We want the lowest effective dose that controls
seizures while allowing the child to learn and
grow and be a kid. If the kid is a zombie, we
haven't won. We need to work with the neurologist
to adjust the regimen. Let's make another synthesis
point. You talked about hydrocephalus, and you
talked about spina bifida. They are almost always
linked. They are. The vast majority of kids born
with myelomeningozo, that severe form of spina
bifida, also have a congenital brain malformation
called a type 2 Chiari malformation. And what
is that? In simple terms, the brain stem and
cerebellum sit lower than they should, partially
blocking the form in magnum, that hole where
the CSF needs to drink. out of the brain. So
the drain is already partially clogged at birth.
Exactly. So if you were caring for a baby who
just had their spina bifida repair surgery on
their back. You aren't just watching the incision
on their back. You are measuring their head circumference
every single shift. Because once you surgically
close that back defect, the fluid that might
have been leaking out now stays trapped in the
system. And if the drain is blocked by that Chiari
malformation, hydrocephalus can develop explosively.
So you fix the back. But that can break the head,
so to speak. You have to watch both. You have
to watch both. It's all connected. The anatomy,
the pressure, the surgical device, the risk for
infection. That really is the theme of pediatric
neurology, isn't it? Yeah. You can't silo the
systems. You can't just treat the seizure without
thinking about the bone marrow and the behavioral
side effects. And you can't treat the spina bifida
without thinking about the latex allergy and
the risk for hydrocephalus. It's a web of connections.
We have covered a massive amount of ground today.
from the expanding skulls of infants to the sugar
-eating bacteria of meningitis, from the genetic
risks of carbamazepine to the banana allergies
of spina bifida. We've definitely built the 80
-20 map. Before we sign off, I want to leave
our listeners with a final thought about the
future of these kids. We've talked so much about
all these fragilities, the soft skulls, the weak
necks, the susceptibility to toxins, but there
is a kind of superpower in pediatric neurology,
isn't there? There is. It's called neuroplasticity.
The ability of the brain to rewire itself. It's
absolutely incredible. I mean, there are children
with severe intractable epilepsy where one half
of their brain is just constantly seizing and
damaging the other half. And for some of them,
the treatment is a hemispherectomy. A hemispherectomy.
Surgeons literally go in and remove or disconnect
half of their brain. Half the brain. Just gone.
Gone. And because they are so young, the remaining
half of their brain can often take over the functions
of the half that was removed. They can learn
to walk again. They can learn to talk again.
They can go to school and live a functional life
with half a brain. That is just mind -blowing.
An adult brain could never do that. If I lost
half my brain today, I'd be hemiplegic and aphasic
for the rest of my life. But a child's brain
is still being written. The software is still
being installed. And that's why our job. That's
why our job of protecting that brain from pressure,
from infection, from trauma. It's so sacred,
we are guarding their future potential. That
really is the why, when you check that level
of consciousness, you aren't just filling out
a box on a chart. You're protecting the person
they are going to become. Keep your eyes on the
milestones. And we'll catch you on the next Deep
Dive.