WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:46.910 fast. Welcome to the emergency room. Welcome 00:00:46.910 --> 00:00:51.770 back to the deep dive. Today we are wading into 00:00:51.770 --> 00:00:54.250 what I think is fair to call the high stakes 00:00:54.250 --> 00:00:56.509 end of the pool. Oh, absolutely. The deep end. 00:00:56.649 --> 00:00:59.750 We are tackling pediatric neurology. Yeah. And, 00:00:59.829 --> 00:01:01.549 you know, looking at the stack of research we 00:01:01.549 --> 00:01:03.609 have here, we've got chapter 16 on intracranial 00:01:03.609 --> 00:01:06.849 regulation, some really heavy hitting drug guides, 00:01:07.129 --> 00:01:11.189 those dense seizure tables. It's easy to get 00:01:11.189 --> 00:01:13.790 overwhelmed. It is a lot. And the reason it feels 00:01:13.790 --> 00:01:16.450 so heavy is because the stakes are just incredibly 00:01:16.450 --> 00:01:18.930 high. Right. When we talk about a child's brain, 00:01:19.049 --> 00:01:20.689 we aren't just talking about keeping them alive. 00:01:20.769 --> 00:01:23.170 We're talking about preserving who they are going 00:01:23.170 --> 00:01:27.310 to become. The margin for error is it's razor 00:01:27.310 --> 00:01:29.290 thin. That's a great way to put it. If you mess 00:01:29.290 --> 00:01:32.150 up a dose of, say, Tylenol, usually it's a manageable 00:01:32.150 --> 00:01:34.430 problem. Right. But if you miss a subtle sign 00:01:34.430 --> 00:01:37.349 of increasing intracranial pressure, the consequences 00:01:37.349 --> 00:01:40.370 are they're permanent. They're profound. But 00:01:40.370 --> 00:01:42.450 our mission today isn't to memorize every single 00:01:42.450 --> 00:01:44.549 cranial nerve or turn ourselves into neurosurgeons. 00:01:44.750 --> 00:01:46.750 That's for the anatomy lab. Today, we're building 00:01:46.750 --> 00:01:50.030 what we call the master 80 -20 map. I love applying 00:01:50.030 --> 00:01:52.750 the Pareto principle here. It's really the only 00:01:52.750 --> 00:01:55.810 way to survive in a clinical setting, or on an 00:01:55.810 --> 00:01:58.450 exam for that matter. The 80 -20 rule. Yeah. 00:01:58.849 --> 00:02:02.090 We need to identify that 20 % of neurological 00:02:02.090 --> 00:02:04.409 concepts that are going to help you answer 80 00:02:04.409 --> 00:02:07.469 % of the tough exam questions. And more importantly. 00:02:07.510 --> 00:02:10.069 More importantly, catch 80 % of the catastrophic 00:02:10.069 --> 00:02:13.000 errors before they happen at the bedside. So 00:02:13.000 --> 00:02:15.740 before we jump into the specific diseases, the 00:02:15.740 --> 00:02:18.180 seizures, meningitis, all of that, we have to 00:02:18.180 --> 00:02:21.479 start with the why. Because reading through this 00:02:21.479 --> 00:02:25.439 intro material, my biggest takeaway was kids 00:02:25.439 --> 00:02:27.879 are not just small adults. Not even close. Their 00:02:27.879 --> 00:02:30.080 heads are literally built differently. They are. 00:02:30.340 --> 00:02:32.539 And that structural difference is the key to 00:02:32.539 --> 00:02:34.460 everything we're going to talk about today. If 00:02:34.460 --> 00:02:38.000 you treat a child's neuro symptoms like an adult's, 00:02:38.000 --> 00:02:40.539 or if you expect them to show the same signs, 00:02:40.879 --> 00:02:43.539 You will miss the warnings every single time. 00:02:43.800 --> 00:02:45.340 Okay, so break that down for us. What is the 00:02:45.340 --> 00:02:47.360 fundamental difference? Well, think of an adult's 00:02:47.360 --> 00:02:50.699 skull. It's a fused, rigid bone box. Right. It 00:02:50.699 --> 00:02:54.139 doesn't move. It doesn't give. If pressure builds 00:02:54.139 --> 00:02:57.479 up inside an adult's head, say from a bleed or 00:02:57.479 --> 00:03:00.340 a tumor, that pressure has absolutely nowhere 00:03:00.340 --> 00:03:02.960 to go. So it compresses the brain tissue. Immediately. 00:03:03.199 --> 00:03:05.539 And the adult gets symptoms very, very fast. 00:03:05.979 --> 00:03:09.099 But an infant, their skull is dynamic. It's a 00:03:09.099 --> 00:03:12.020 completely different system. Because of the fontanels, 00:03:12.599 --> 00:03:15.039 the soft spots. The fontanels and the sutures. 00:03:15.379 --> 00:03:17.879 The seams between the skull bones aren't fused 00:03:17.879 --> 00:03:20.860 yet. This is a critical point. It allows the 00:03:20.860 --> 00:03:24.060 head to actually expand if the pressure inside 00:03:24.060 --> 00:03:26.840 starts to rise. Which on the surface sounds like 00:03:26.840 --> 00:03:28.580 a good thing, right? The built -in safety valve. 00:03:28.879 --> 00:03:31.520 In theory, yes. It buys you a little bit of time. 00:03:31.800 --> 00:03:34.060 But clinically, it's a huge double -edged sword. 00:03:34.259 --> 00:03:37.340 Oh, so. because that ability to expand can mask 00:03:37.340 --> 00:03:40.360 the early signs of pressure. An infant can accommodate 00:03:40.360 --> 00:03:43.199 a significantly larger volume of fluid or blood 00:03:43.199 --> 00:03:45.479 before they start showing those classic adult 00:03:45.479 --> 00:03:47.180 signs of crashing. So the problem is getting 00:03:47.180 --> 00:03:49.400 worse on the inside. Right. The head is getting 00:03:49.400 --> 00:03:51.639 bigger. The brain is under stress. But the baby 00:03:51.639 --> 00:03:54.099 might just look a little fussy, a little irritable. 00:03:54.159 --> 00:03:56.379 And if you're waiting for them to act like a 00:03:56.379 --> 00:03:58.900 sick adult who's complaining of a crushing headache, 00:03:58.960 --> 00:04:01.520 you might be waiting until it's far, far too 00:04:01.520 --> 00:04:04.330 late. Wow. OK. That sets the stage perfectly. 00:04:04.789 --> 00:04:06.770 We have a dynamic system that hides its secrets. 00:04:07.370 --> 00:04:10.590 So let's get into this master 80 -20 map. You've 00:04:10.590 --> 00:04:14.389 categorized the chaos of neuro into four distinct 00:04:14.389 --> 00:04:17.670 patterns that seem to govern almost all pediatric 00:04:17.670 --> 00:04:20.470 neuroemergencies. Right. And if you can recognize 00:04:20.470 --> 00:04:22.310 these four patterns, you can pretty much handle 00:04:22.310 --> 00:04:24.689 anything they throw at you on an exam or in the 00:04:24.689 --> 00:04:27.029 ER. OK, let's run through them. Pattern number 00:04:27.029 --> 00:04:29.480 one. We're calling it the pressure cooker. This 00:04:29.480 --> 00:04:32.040 is everything related to increased intracranial 00:04:32.040 --> 00:04:35.779 pressure, or ICP, and hydrotephyllus. OK. The 00:04:35.779 --> 00:04:37.759 pressure cooker. Got it. Pattern number two. 00:04:37.920 --> 00:04:40.480 The electrical storm. All things seizures and 00:04:40.480 --> 00:04:42.379 epilepsy. Makes sense. Pattern number three. 00:04:42.540 --> 00:04:45.420 The invader. This is infection, specifically 00:04:45.420 --> 00:04:47.800 the big one, meningitis. And the last one, pattern 00:04:47.800 --> 00:04:50.269 number four. The physical trauma. This covers 00:04:50.269 --> 00:04:53.029 structural defects like spina bifida, but also 00:04:53.029 --> 00:04:56.569 head injuries and the very dark, but very necessary 00:04:56.569 --> 00:05:00.569 topic of non -accidental trauma. Okay. Pressure, 00:05:00.670 --> 00:05:04.189 electricity, infection, and trauma. That is a 00:05:04.189 --> 00:05:06.829 really solid framework. Let's dive into the first 00:05:06.829 --> 00:05:09.870 one. The pressure cooker. Increased ICP. Let's 00:05:09.870 --> 00:05:12.449 do it. So you mentioned the Monroe -Kelly doctrine 00:05:12.449 --> 00:05:14.889 earlier. It's a core concept in this section. 00:05:15.069 --> 00:05:18.269 It really is the foundation for understanding 00:05:18.269 --> 00:05:20.939 pressure. It sounds super technical, but it's 00:05:20.939 --> 00:05:22.800 basically just physics, right? It is. Just imagine 00:05:22.800 --> 00:05:25.040 the skull as that rigid box we talked about, 00:05:25.040 --> 00:05:27.540 or in the infant's case, a semi -rigid box. OK. 00:05:27.759 --> 00:05:29.699 Inside that box, you only have room for three 00:05:29.699 --> 00:05:32.879 things. Brain tissue, which makes up about 80%. 00:05:32.879 --> 00:05:35.139 The brain itself? Right. Then you have blood, 00:05:35.180 --> 00:05:38.819 which is about 10%. And finally, cerebrospinal 00:05:38.819 --> 00:05:42.480 fluid, or CSF, which is the last 10%. And that's 00:05:42.480 --> 00:05:44.860 it. It all adds up to 100. That's it. There is 00:05:44.860 --> 00:05:46.980 no empty space. It's not like there's air in 00:05:46.980 --> 00:05:49.959 there. So it's a zero -sum game. Precisely. If 00:05:49.959 --> 00:05:52.939 you add something new, like a tumor or blood 00:05:52.939 --> 00:05:55.980 from a hemorrhage, or if you have too much of 00:05:55.980 --> 00:05:57.899 one of the existing things, like too much CSF 00:05:57.899 --> 00:06:00.579 and hydrocephalus, something else has to give. 00:06:00.600 --> 00:06:02.500 The pressure just goes up. And that brings us 00:06:02.500 --> 00:06:04.699 back to your earlier point about the infant skull 00:06:04.699 --> 00:06:08.000 expanding. This feels like our first major clinical 00:06:08.000 --> 00:06:10.720 decision point. How does the presentation of 00:06:10.720 --> 00:06:13.660 the pressure cooker differ by age? It's night 00:06:13.660 --> 00:06:16.339 and day. In an infant, because the skull can 00:06:16.339 --> 00:06:18.980 literally expand, The signs are physical. You 00:06:18.980 --> 00:06:21.220 can see it and you can feel it. You can literally 00:06:21.220 --> 00:06:23.600 measure the change. Yes. The head circumference 00:06:23.600 --> 00:06:26.839 grows rapidly. This is why we measure head circumference 00:06:26.839 --> 00:06:29.420 at every single well -tiled check. And what are 00:06:29.420 --> 00:06:32.319 you looking for? A slow, steady growth. You want 00:06:32.319 --> 00:06:35.120 them to track along their percentile curve. But 00:06:35.120 --> 00:06:38.959 if a baby jumps from, say, the 50th percentile 00:06:38.959 --> 00:06:42.439 to the 95th percentile in head size over a month 00:06:42.439 --> 00:06:44.959 or two. That's a huge red flag. A massive red 00:06:44.959 --> 00:06:46.899 flag. Something is making that head grow too 00:06:46.899 --> 00:06:49.540 fast. You'll also feel the fontanels. Those soft 00:06:49.540 --> 00:06:51.779 spots will be tense and bulging outward. They 00:06:51.779 --> 00:06:53.879 shouldn't be sunken or flat. They feel tight 00:06:53.879 --> 00:06:55.879 like a drum. And the source material mentions 00:06:55.879 --> 00:06:58.910 a really specific eye sign. Sunset eyes. Yeah, 00:06:58.970 --> 00:07:01.810 this is a classic exam visual and a bedside oh 00:07:01.810 --> 00:07:04.589 no moment. Describe what that looks like. The 00:07:04.589 --> 00:07:07.610 pressure inside the skull is so high that it 00:07:07.610 --> 00:07:09.990 pushes down on the orbital plates of the skull, 00:07:10.350 --> 00:07:13.410 which forces the eyeballs downward. So when you 00:07:13.410 --> 00:07:15.250 look at the baby, you can see the squarer, the 00:07:15.250 --> 00:07:17.410 white part of the eye visible above the iris. 00:07:17.529 --> 00:07:19.769 It looks exactly like the sun setting over the 00:07:19.769 --> 00:07:22.209 horizon of the lower eyelid. If you see that, 00:07:22.209 --> 00:07:25.129 are we in the early warning phase anymore? No, 00:07:25.329 --> 00:07:28.339 not at all. If you see sunset eyes, the pressure 00:07:28.339 --> 00:07:30.040 is critically high. You're behind the curve. 00:07:30.220 --> 00:07:32.680 What else might you hear? You might hear a very 00:07:32.680 --> 00:07:35.959 distinct cry. It's high -pitched, almost a shriek. 00:07:36.000 --> 00:07:39.019 We call it a neuro -cry. It's not the I'm hungry 00:07:39.019 --> 00:07:42.120 cry or the I need a diaper change cry. It's a 00:07:42.120 --> 00:07:45.160 piercing, irritable sound that is really hard 00:07:45.160 --> 00:07:48.000 to console. OK, so that's the baby. Physical 00:07:48.000 --> 00:07:52.180 signs. Bulging fontanel, growing head, sunset 00:07:52.180 --> 00:07:54.959 eyes, neuro -cry. But what about a 10 -year -old? 00:07:55.069 --> 00:07:57.189 Their sutures are closed. Their box is fixed. 00:07:57.470 --> 00:07:59.490 Right. So they can't expand. Their presentation 00:07:59.490 --> 00:08:01.350 is going to be based on subjective complaints, 00:08:01.430 --> 00:08:03.290 much more like an adult. The classic one being 00:08:03.290 --> 00:08:06.269 a headache. A headache, yes. But you have to 00:08:06.269 --> 00:08:08.649 dig deeper on the history. It's not just any 00:08:08.649 --> 00:08:11.370 headache. It's a headache that is characteristically 00:08:11.370 --> 00:08:13.970 worse in the morning or worse when lying down. 00:08:14.350 --> 00:08:16.889 OK. Why is it worse in the morning? That's such 00:08:16.889 --> 00:08:19.930 a specific detail. It's all about gravity. When 00:08:19.930 --> 00:08:22.389 you're upright, walking around during the day, 00:08:22.730 --> 00:08:26.089 gravity helps drain venous blood and CSF from 00:08:26.089 --> 00:08:28.069 the head down into the spine. Like a natural 00:08:28.069 --> 00:08:30.790 drainage system. Exactly. But when you lay flat 00:08:30.790 --> 00:08:33.350 to sleep for eight hours, that drainage slows 00:08:33.350 --> 00:08:36.389 down. The fluid pools slightly and the pressure 00:08:36.389 --> 00:08:38.549 gradually builds overnight, so they wake up with 00:08:38.549 --> 00:08:41.289 this pounding, intense headache. And then it 00:08:41.289 --> 00:08:43.950 might get better as they move around. Yes. Often, 00:08:44.210 --> 00:08:46.509 after they've been up for an hour or so, it improves. 00:08:46.750 --> 00:08:48.070 So parents might think, oh, he's just trying 00:08:48.070 --> 00:08:50.649 to get out of school. But that specific pattern 00:08:50.649 --> 00:08:53.649 is a huge clue. And what about vomiting? Yes. 00:08:53.909 --> 00:08:56.330 But again, it's a specific kind. It's often vomiting 00:08:56.330 --> 00:08:58.509 without nausea. That's the key. I'm a stomach 00:08:58.509 --> 00:09:01.620 bug? Not at all. With a stomach bug, you feel 00:09:01.620 --> 00:09:04.080 sick, you get queasy, you feel awful for hours, 00:09:04.179 --> 00:09:07.200 and then you throw up. With increased ICP, the 00:09:07.200 --> 00:09:09.740 pressure just directly hits the vomiting center 00:09:09.740 --> 00:09:13.000 in the brainstem, and boom, sudden, often projectile 00:09:13.000 --> 00:09:15.419 vomiting with no warning. So we have the symptoms, 00:09:15.919 --> 00:09:18.620 physical signs in babies, headache and vomiting 00:09:18.620 --> 00:09:21.799 in older kids. But let's get to the 80 -20 core. 00:09:22.200 --> 00:09:26.039 What is the absolute need to know? assessment 00:09:26.039 --> 00:09:28.519 here. If you can only check one thing to see 00:09:28.519 --> 00:09:30.379 if your patient is getting worse, what is it? 00:09:30.580 --> 00:09:34.240 Level of consciousness. LOC. This is the holy 00:09:34.240 --> 00:09:36.759 grail of neuroassessment. It is the most sensitive 00:09:36.759 --> 00:09:38.940 indicator. For the vitals change. Long before. 00:09:39.240 --> 00:09:41.940 The LOC is the earliest indicator of neurological 00:09:41.940 --> 00:09:44.659 improvement or deterioration. Before the pupils 00:09:44.659 --> 00:09:46.519 blow, before the heart rate tanks, the child 00:09:46.519 --> 00:09:48.600 will just become different. And parents are often 00:09:48.600 --> 00:09:50.440 the experts on different. They are your number 00:09:50.440 --> 00:09:52.700 one resource. If a mom says he's just not acting 00:09:52.700 --> 00:09:54.299 like himself, or she's really hard to wake up 00:09:54.299 --> 00:09:57.320 today, or he's just staring off into space, you 00:09:57.320 --> 00:09:59.440 listen. You take that seriously. And how do we 00:09:59.440 --> 00:10:02.009 quantify that? You use the Pediatric Glasgow 00:10:02.009 --> 00:10:04.889 Coma Scale. You have to verify what the parents 00:10:04.889 --> 00:10:06.409 are telling you. Which is different from the 00:10:06.409 --> 00:10:09.230 adult GCS, right? I can't ask a six -month -old 00:10:09.230 --> 00:10:12.309 to state their name in the current year. Exactly. 00:10:12.330 --> 00:10:14.330 It has to be adapted for pre -verbal children. 00:10:14.610 --> 00:10:17.649 So instead of oriented to time and place, you're 00:10:17.649 --> 00:10:20.110 looking for things like, does the baby coo or 00:10:20.110 --> 00:10:23.210 babble? Do they smile at mom? Do they cry? But 00:10:23.210 --> 00:10:25.149 are they consolable? So you're looking for their 00:10:25.149 --> 00:10:28.049 normal interaction. Right. Or are they agitated 00:10:28.049 --> 00:10:30.389 and inconsolable? That's a lower... score. If 00:10:30.389 --> 00:10:33.409 they're just lying there moaning or withdrawing 00:10:33.409 --> 00:10:35.769 from your touch, that's a very low score. You're 00:10:35.769 --> 00:10:38.090 assessing their interaction with their environment. 00:10:38.409 --> 00:10:41.070 Let's talk about the worst case scenario, the 00:10:41.070 --> 00:10:44.009 crash, the thing we are all trying to prevent, 00:10:44.629 --> 00:10:47.570 herniation. This is the absolute nightmare scenario. 00:10:47.710 --> 00:10:49.990 What's happening? The pressure gets so high inside 00:10:49.990 --> 00:10:52.429 the skull that the brain tissue itself is physically 00:10:52.429 --> 00:10:54.590 forced downward through the hole at the base 00:10:54.590 --> 00:10:57.720 of the skull, the form in magnum. This process 00:10:57.720 --> 00:11:00.559 directly compresses the brainstem. And the brainstem 00:11:00.559 --> 00:11:03.580 controls all the basic life functions. Breathing, 00:11:03.799 --> 00:11:06.639 heart rate. Correct. If you compress the brainstem, 00:11:06.820 --> 00:11:09.679 the patient stops breathing. They die. And the 00:11:09.679 --> 00:11:11.519 warning sign for this, the siren that goes off 00:11:11.519 --> 00:11:14.080 right before it happens, is Cushing's Triad. 00:11:14.179 --> 00:11:16.740 You need to burn this into your memory. Every 00:11:16.740 --> 00:11:19.179 nursing student, every nurse has to know this. 00:11:19.759 --> 00:11:22.539 Cushing's Triad is the physiological opposite 00:11:22.539 --> 00:11:25.129 of shock. OK, let's walk through that comparison. 00:11:25.669 --> 00:11:29.149 In shock -like, if a kid is bleeding out, I expect 00:11:29.149 --> 00:11:32.230 a high heart rate. So tachycardia. Right. And 00:11:32.230 --> 00:11:33.970 eventually low blood pressure or hypotension. 00:11:34.169 --> 00:11:37.230 Exactly. The heart beats faster to try to compensate 00:11:37.230 --> 00:11:40.529 for the lost volume. But in increased ICP with 00:11:40.529 --> 00:11:43.029 Cushing's triad, you see the complete reverse. 00:11:43.169 --> 00:11:46.350 You see bradycardia, a slow heart rate. Why does 00:11:46.350 --> 00:11:48.389 the heart slow down when the brain is in trouble? 00:11:48.450 --> 00:11:50.809 That seems counterintuitive. It's a reflex. The 00:11:50.809 --> 00:11:53.049 pressure in the brain is so critically high that 00:11:53.049 --> 00:11:55.389 the body's last -ditch effort is to shove blood 00:11:55.389 --> 00:11:58.210 up there by massively increasing the systemic 00:11:58.210 --> 00:12:00.529 blood pressure so you get severe hypertension. 00:12:00.929 --> 00:12:04.809 So blood pressure goes way up. Way up. The baroreceptors 00:12:04.809 --> 00:12:07.850 in the aortic arch and carotid arteries sense 00:12:07.850 --> 00:12:10.649 this extreme hypertension and they send a signal 00:12:10.649 --> 00:12:13.610 to the heart saying, whoa, pressure is way too 00:12:13.610 --> 00:12:16.759 high, slow down. So you get hypertension paired 00:12:16.759 --> 00:12:19.019 with bradycardia. And the third part of the triad 00:12:19.019 --> 00:12:22.480 is the pulse pressure widening. Yes. The systolic 00:12:22.480 --> 00:12:25.039 number, the top number, goes way up to fight 00:12:25.039 --> 00:12:27.019 the pressure in the brain. But the diastolic, 00:12:27.039 --> 00:12:29.580 the bottom number, stays about the same or even 00:12:29.580 --> 00:12:32.440 drops. So the gap between the two numbers widens 00:12:32.440 --> 00:12:35.259 significantly. And the final sign is the breathing 00:12:35.259 --> 00:12:37.629 pattern. Irregular respirations. Often you'll 00:12:37.629 --> 00:12:39.470 see something called chain stokes breathing, 00:12:39.870 --> 00:12:42.950 which is this pattern of rapid deep breaths followed 00:12:42.950 --> 00:12:45.210 by periods of apnea where they stop breathing 00:12:45.210 --> 00:12:47.750 entirely. So if you see that triad, slow heart 00:12:47.750 --> 00:12:50.070 rate, high blood pressure with a wide pulse pressure 00:12:50.070 --> 00:12:53.809 and weird breathing. The child is minutes, maybe 00:12:53.809 --> 00:12:56.690 seconds away from herniation and respiratory 00:12:56.690 --> 00:12:59.029 arrest. This is a call a code moment. OK, so 00:12:59.029 --> 00:13:00.590 let's talk interventions. We're in the pressure 00:13:00.590 --> 00:13:03.110 cooker. The alarm is going off. How do we turn 00:13:03.110 --> 00:13:06.049 down the heat and prevent that crash? Positioning 00:13:06.049 --> 00:13:09.889 is your first, fastest, and cheapest move. Elevate 00:13:09.889 --> 00:13:12.570 the head of the bed, the HOB, to about 15 to 00:13:12.570 --> 00:13:15.870 30 degrees. Why not 90 degrees? Why not sit them 00:13:15.870 --> 00:13:18.450 all the way up? That's a great question and a 00:13:18.450 --> 00:13:21.330 common mistake. If you sit them up too high, 00:13:21.490 --> 00:13:23.690 you can actually cause the blood pressure to 00:13:23.690 --> 00:13:27.350 drop in the brain and compromise cerebral perfusion. 00:13:28.210 --> 00:13:30.539 30 degrees is the sweet spot. What's it doing? 00:13:30.960 --> 00:13:33.740 It uses gravity to promote venous drainage from 00:13:33.740 --> 00:13:36.360 the head without fighting too hard against arterial 00:13:36.360 --> 00:13:39.200 blood flow going up to the brain. But here is 00:13:39.200 --> 00:13:41.720 the nuance that catches people on exams. Keep 00:13:41.720 --> 00:13:44.259 the head midline. Midline. Why is that so important? 00:13:44.440 --> 00:13:46.659 Think of the jugular veins in the neck as the 00:13:46.659 --> 00:13:49.419 main drain pipes for the head. If you turn the 00:13:49.419 --> 00:13:51.919 head to the side, you twist the neck, and you 00:13:51.919 --> 00:13:54.379 can compress or kink the jugular vein. You're 00:13:54.379 --> 00:13:56.240 blocking the drain pipe. You've kinked the drain 00:13:56.240 --> 00:13:58.730 pipe. Blood can't get out of the brain efficiently, 00:13:58.909 --> 00:14:01.190 and the pressure spikes even higher. You need 00:14:01.190 --> 00:14:03.210 to keep their nose aligned with their belly button. 00:14:03.590 --> 00:14:06.309 Use towel rolls or sandbags if you have to. That 00:14:06.309 --> 00:14:08.250 makes perfect sense. What about things we do 00:14:08.250 --> 00:14:10.769 at the bedside, like suctioning? Minimize it 00:14:10.769 --> 00:14:14.340 at all costs. coughing, straining, suctioning, 00:14:14.500 --> 00:14:17.559 even vigorous crying, all of those things increase 00:14:17.559 --> 00:14:20.340 intra -thoracic pressure. That pressure pushes 00:14:20.340 --> 00:14:23.139 back up the venous system and directly increases 00:14:23.139 --> 00:14:25.399 intracranial pressure. If you absolutely have 00:14:25.399 --> 00:14:28.080 to suction to clear a blocked airway, do it quickly 00:14:28.080 --> 00:14:30.899 for less than 10 seconds and pre -oxygenate them. 00:14:31.279 --> 00:14:33.340 But never do it routinely just because it's on 00:14:33.340 --> 00:14:36.240 a schedule. And treat pain and agitation. Aggressively. 00:14:36.980 --> 00:14:40.379 A crying, screaming, agitated child has a higher 00:14:40.379 --> 00:14:45.379 ICP. A calm, quiet, dimly lit environment is 00:14:45.379 --> 00:14:47.740 therapeutic. Before we leave this pattern, I 00:14:47.740 --> 00:14:50.240 want to touch on shunts. Because hydrocephalus, 00:14:50.240 --> 00:14:53.100 which is simply too much CSF, is often treated 00:14:53.100 --> 00:14:55.860 with a VP shunt. So ventricular peritoneal shunt, 00:14:56.039 --> 00:14:57.799 yeah. It's basically a piece of plumbing. It's 00:14:57.799 --> 00:15:00.059 a thin tube that runs from the ventricle in the 00:15:00.059 --> 00:15:02.659 brain, punnels under the skin, and drains down 00:15:02.659 --> 00:15:04.860 into the peritoneal cavity in the belly. The 00:15:04.860 --> 00:15:07.120 belly. Yep, in the abdomen. The fluid just drains 00:15:07.120 --> 00:15:09.080 there and gets reabsorbed by the body. So it's 00:15:09.080 --> 00:15:11.480 a plumbing fix. But plumbing breaks. What's the 00:15:11.480 --> 00:15:14.080 need to know on shunts? The two big scary words 00:15:14.080 --> 00:15:17.759 are infection and malfunction. This is a massive 00:15:17.759 --> 00:15:20.879 exam tip and a critical clinical rule. If a child 00:15:20.879 --> 00:15:23.820 with a known VP shunt comes into your ER with 00:15:23.820 --> 00:15:26.600 a fever, vomiting, lethargy, headache, or is 00:15:26.600 --> 00:15:28.919 just not acting right. You have to assume it's 00:15:28.919 --> 00:15:31.019 the shunt. You must assume the shunt is broken 00:15:31.019 --> 00:15:33.379 or infected until proven otherwise. Even if their 00:15:33.379 --> 00:15:35.039 brother has the stomach flu and the symptoms 00:15:35.039 --> 00:15:37.519 look identical. It does not matter. You rule 00:15:37.519 --> 00:15:39.500 out the life -threatening shunt problem first. 00:15:39.370 --> 00:15:42.730 because if that shunt is blocked, ICP is rising 00:15:42.730 --> 00:15:45.509 rapidly and they can crash. If it's infected, 00:15:45.870 --> 00:15:48.090 that's meningitis waiting to happen. So what's 00:15:48.090 --> 00:15:50.789 the workup? They need a CT scan of the head to 00:15:50.789 --> 00:15:53.409 look for ventricle size changes and a shunt series, 00:15:53.830 --> 00:15:55.990 which is a set of x -rays to see if the tubing 00:15:55.990 --> 00:15:59.049 is intact immediately. Okay, pattern one, pressure 00:15:59.049 --> 00:16:02.110 cooker. Done, a lot there. Let's move to pattern 00:16:02.110 --> 00:16:06.059 two, the electrical storm, seizures. This is 00:16:06.059 --> 00:16:08.299 another huge topic, but again we need to simplify 00:16:08.299 --> 00:16:11.480 it for our AD20 map. A seizure is, at its core, 00:16:11.779 --> 00:16:14.100 an uncontrolled chaotic electrical discharge 00:16:14.100 --> 00:16:16.860 in the brain. It's a short circuit. And as with 00:16:16.860 --> 00:16:20.039 pressure, age matters. The presentation varies 00:16:20.039 --> 00:16:23.299 wildly. Let's start with the infants. The source 00:16:23.299 --> 00:16:26.259 material really highlights infantile spasms. 00:16:26.679 --> 00:16:29.629 This is a can't -miss diagnosis. It's so tricky 00:16:29.629 --> 00:16:31.490 because it doesn't look like a seizure you see 00:16:31.490 --> 00:16:34.110 in the movies. The baby isn't shaking violently 00:16:34.110 --> 00:16:36.649 on the floor. It's often called a jackknife seizure. 00:16:36.870 --> 00:16:39.309 Can you describe that motion? The baby will suddenly 00:16:39.309 --> 00:16:42.169 and violently flex their neck and arms, crunching 00:16:42.169 --> 00:16:44.990 forward like a little jackknife. Then they relax. 00:16:45.350 --> 00:16:47.330 Then a few seconds later they do it again and 00:16:47.330 --> 00:16:50.009 again. It happens in clusters, often when they're 00:16:50.009 --> 00:16:52.179 waking up or falling asleep. And I can see how 00:16:52.179 --> 00:16:54.419 a parent might just think that's colic or a stomach 00:16:54.419 --> 00:16:56.840 cramp. Exactly. Oh, his tummy hurts. He's crunching 00:16:56.840 --> 00:16:59.100 up. But the reason this is so critical and why 00:16:59.100 --> 00:17:02.019 it's on her 80 -20 list is that infantile spasms 00:17:02.019 --> 00:17:04.819 are highly correlated with developmental regression. 00:17:05.019 --> 00:17:07.099 Regression, you mean losing skills they already 00:17:07.099 --> 00:17:09.880 had. Yes. If you don't treat this aggressively 00:17:09.880 --> 00:17:12.579 and stop the spasms, the child can stop developing 00:17:12.579 --> 00:17:15.400 or even lose skills like smiling or rolling over. 00:17:15.640 --> 00:17:18.480 And often, they never gain them back. It is a 00:17:18.480 --> 00:17:21.420 true developmental emergency. Moving up the age 00:17:21.420 --> 00:17:24.440 bracket, febrile seizures, every parent's worst 00:17:24.440 --> 00:17:27.160 nightmare. Extremely common in toddlers, and 00:17:27.160 --> 00:17:29.859 while terrifying to watch, they are usually benign. 00:17:30.359 --> 00:17:32.460 The trigger is a rapid spike in temperature. 00:17:32.680 --> 00:17:35.299 It's the speed of the spike, not the absolute 00:17:35.299 --> 00:17:37.700 height of the fever. That's the key point. A 00:17:37.700 --> 00:17:40.779 child can have a 104 fever and be fine if it 00:17:40.779 --> 00:17:45.779 climbed slowly. But going from 98 .6 to 103 in 00:17:45.779 --> 00:17:48.599 20 minutes can trigger it. It's the velocity 00:17:48.599 --> 00:17:51.380 of the change that causes the brain's electrical 00:17:51.380 --> 00:17:54.119 system to short circuit. And then we have absence 00:17:54.119 --> 00:17:56.380 seizures in school -age kids. The daydreaming 00:17:56.380 --> 00:17:58.539 seizure. The kid just checks out for five or 00:17:58.539 --> 00:18:00.339 ten seconds. They're falling, no shaking? Nope. 00:18:00.440 --> 00:18:03.880 just a blank stare. They stop talking mid -sentence. 00:18:04.099 --> 00:18:06.420 Teachers are often the first to notice and flag 00:18:06.420 --> 00:18:09.160 it as ADHD or not paying attention. So how do 00:18:09.160 --> 00:18:11.359 you tell the difference? If a kid is just daydreaming 00:18:11.359 --> 00:18:13.279 and you touch their shoulder or call their name, 00:18:13.380 --> 00:18:15.720 they'll snap out of it. With an absent seizure, 00:18:15.759 --> 00:18:17.819 they are completely unresponsive during the event. 00:18:18.279 --> 00:18:20.480 You might also see subtle motor signs like lip 00:18:20.480 --> 00:18:23.059 smacking or eyelid fluttering. And then they're 00:18:23.059 --> 00:18:25.720 just back. And they have no memory of the last 00:18:25.720 --> 00:18:27.519 time. They just pick up where they left off. 00:18:27.720 --> 00:18:30.740 OK, let's talk management. You're at the bedside. 00:18:31.259 --> 00:18:34.140 A child goes into a full tonic -clonic seizure. 00:18:34.700 --> 00:18:36.839 Stiffening, jerking, maybe foaming at the mouth. 00:18:37.400 --> 00:18:40.559 What is your absolute number one priority? Safety 00:18:40.559 --> 00:18:45.180 and airway. But you manage the airway primarily 00:18:45.180 --> 00:18:48.539 through positioning. turn them on to their side. 00:18:48.640 --> 00:18:50.980 The recovery position. Why the side? Gravity 00:18:50.980 --> 00:18:54.200 again. You want any saliva or vomit to drain 00:18:54.200 --> 00:18:57.359 out of the mouth, not down into the lungs. Aspiration 00:18:57.359 --> 00:19:00.079 pneumonia is a huge risk during a seizure. And 00:19:00.079 --> 00:19:02.220 what do we absolutely not do? This seems to be 00:19:02.220 --> 00:19:05.059 a favorite exam topic. Do not put anything in 00:19:05.059 --> 00:19:07.180 their mouth. No tongue blades, no spoons, no 00:19:07.180 --> 00:19:10.130 fingers. That is a dangerous old myth. Why is 00:19:10.130 --> 00:19:11.950 it so dangerous? You'll break their teeth, you'll 00:19:11.950 --> 00:19:14.069 injure their gums, or worse, you'll push the 00:19:14.069 --> 00:19:16.069 tongue back and completely block their airway. 00:19:16.450 --> 00:19:19.210 The jaw can clench with incredible force. And 00:19:19.210 --> 00:19:21.130 secondly, do not restrain them. Don't hold them 00:19:21.130 --> 00:19:23.750 down. You can fracture bones trying to hold a 00:19:23.750 --> 00:19:26.509 seizing child down. Your job is to protect them 00:19:26.509 --> 00:19:29.269 from the environment. So clear the arimu furniture, 00:19:29.910 --> 00:19:32.109 put a soft pillow or jacket under their head, 00:19:33.009 --> 00:19:35.509 and just let the seizure run its course and time 00:19:35.509 --> 00:19:37.789 it. Unless it doesn't stop. Right. And that brings 00:19:37.789 --> 00:19:40.150 us to status epilepticus. What is the definition? 00:19:40.210 --> 00:19:42.650 A seizure lasting more than five minutes or a 00:19:42.650 --> 00:19:44.369 series of seizures where the child doesn't regain 00:19:44.369 --> 00:19:46.710 consciousness in between. Why is five minutes 00:19:46.710 --> 00:19:49.230 the magic number? Because after about five minutes 00:19:49.230 --> 00:19:51.869 of continuous seizing, the brain's demand for 00:19:51.869 --> 00:19:54.490 oxygen and glucose skyrockets and exceeds what 00:19:54.490 --> 00:19:57.509 the body can supply. Neurons start to die from 00:19:57.509 --> 00:20:00.569 metabolic exhaustion. The brain is literally 00:20:00.569 --> 00:20:03.009 cooking itself. This is a medical emergency. 00:20:03.369 --> 00:20:05.750 So we need medications. And this is a key synthesis 00:20:05.750 --> 00:20:08.650 point from our sources. Rescue versus maintenance 00:20:08.650 --> 00:20:10.930 meds. We need to be crystal clear here. A huge 00:20:10.930 --> 00:20:13.750 distinction. If a child is seizing right now 00:20:13.750 --> 00:20:16.190 in front of you, you need a rescue medication. 00:20:16.549 --> 00:20:19.549 That is always a benzodiazepine. Like diazepam 00:20:19.549 --> 00:20:22.490 or lorazepam. Right. Valium or Etivan. And if 00:20:22.490 --> 00:20:25.690 they don't have an IV line, it's pretty hard 00:20:25.690 --> 00:20:28.049 to start an IV on a seizing child. It's nearly 00:20:28.049 --> 00:20:31.410 impossible. So we use other routes. Rectal diazepam, 00:20:31.490 --> 00:20:34.130 which comes in a gel form called diastat, is 00:20:34.130 --> 00:20:37.430 the classic home rescue med, or more commonly 00:20:37.430 --> 00:20:40.230 now intranasal midazolam. You just use a syringe 00:20:40.230 --> 00:20:42.309 to squirt it up the nose. And it absorbs that 00:20:42.309 --> 00:20:45.029 quickly? Instantly across the nasal mucosa. It's 00:20:45.029 --> 00:20:47.049 incredibly effective. But you would not try to 00:20:47.049 --> 00:20:49.210 give them a pill to swallow? Never. Absolutely 00:20:49.210 --> 00:20:52.789 not. Aspiration's steady. Obviously. OK, so that's 00:20:52.789 --> 00:20:56.069 rescue. But for preventing seizures... Tomorrow 00:20:56.069 --> 00:20:59.150 or next week, we use maintenance meds. We'll 00:20:59.150 --> 00:21:00.910 get to those in the drug module, but these are 00:21:00.910 --> 00:21:03.410 things like carbamazepine or gabapentin. They're 00:21:03.410 --> 00:21:06.269 taken daily. Exactly. And a maintenance med will 00:21:06.269 --> 00:21:08.849 not stop an active seizure. It won't work fast 00:21:08.849 --> 00:21:11.390 enough. Two different drug classes for two different 00:21:11.390 --> 00:21:14.109 jobs. One last thing on seizures from the source, 00:21:14.150 --> 00:21:16.970 the keto diet. I feel like this is a wait what 00:21:16.970 --> 00:21:19.589 moment for a lot of people who just associate 00:21:19.589 --> 00:21:21.910 keto with weight loss influencers on Instagram. 00:21:22.250 --> 00:21:24.450 It is. But we are not talking about weight loss 00:21:24.450 --> 00:21:26.960 here. For children with refractory epilepsy, 00:21:27.539 --> 00:21:30.079 that's seizures that multiple medications can't 00:21:30.079 --> 00:21:33.500 control. A strict, medically supervised ketogenic 00:21:33.500 --> 00:21:36.880 diet is a valid and sometimes very effective 00:21:36.880 --> 00:21:43.079 treatment. Well, it's a very high fat, very low 00:21:43.079 --> 00:21:45.579 carb, adequate protein diet. It forces the body 00:21:45.579 --> 00:21:48.460 and specifically the brain to shift its primary 00:21:48.460 --> 00:21:51.779 fuel source from glucose, which is sugar, to 00:21:51.779 --> 00:21:54.279 ketones, which are derived from fat. And that 00:21:54.279 --> 00:21:55.740 helped. For reasons we don't fully understand, 00:21:55.980 --> 00:21:58.680 burning ketones for fuel seems to have a stabilizing 00:21:58.680 --> 00:22:01.559 effect on neurons. It raises the seizure threshold. 00:22:01.759 --> 00:22:04.279 It calms the electrical storm. But it's not just 00:22:04.279 --> 00:22:06.599 cutting carbs like a typical diet, is it? No. 00:22:06.660 --> 00:22:08.960 It is incredibly rigorous. You have to weigh 00:22:08.960 --> 00:22:11.220 every single gram of food. The ratios have to 00:22:11.220 --> 00:22:13.380 be precise. You cannot cheat. What happens if 00:22:13.380 --> 00:22:16.200 you do? One cookie or even a dose of liquid Tylenol 00:22:16.200 --> 00:22:18.819 that has a sugary syrup base can throw them out 00:22:18.819 --> 00:22:20.940 of ketosis and trigger a cluster of seizures 00:22:20.940 --> 00:22:23.690 instantly. It requires a massive family commitment 00:22:23.690 --> 00:22:26.950 and dietitian support. Wow. Okay, fascinating. 00:22:27.410 --> 00:22:31.809 Let's move to pattern three, the invader, meningitis. 00:22:32.369 --> 00:22:34.529 This is the one that keeps pediatricians and 00:22:34.529 --> 00:22:37.890 ER docs up at night, specifically bacterial meningitis. 00:22:38.029 --> 00:22:39.910 This is an inflammation of the meninges, the 00:22:39.910 --> 00:22:41.769 protective covering of the brain and spinal cord. 00:22:41.970 --> 00:22:44.269 Yeah. What are the main pathogens we are worried 00:22:44.269 --> 00:22:47.069 about? In the post -vaccine era, it's mainly 00:22:47.069 --> 00:22:49.769 streptococcus pneumonia, naceria, meningitis, 00:22:50.390 --> 00:22:53.769 and in unvaccinated kids, haemophilus influenza 00:22:53.769 --> 00:22:56.650 type B, or Hib, these are the big bads. They 00:22:56.650 --> 00:23:00.309 invade the CSF and cause massive, purulent inflammation. 00:23:00.589 --> 00:23:02.549 What does the patient look like? In an older 00:23:02.549 --> 00:23:05.069 child, you get the classic triad, high fever, 00:23:05.630 --> 00:23:08.349 a severe headache, and neutral rigidity. A stiff 00:23:08.349 --> 00:23:10.210 neck. Let's talk about the stiff neck. Why does 00:23:10.210 --> 00:23:12.630 that happen? Because the meninges are a continuous 00:23:12.630 --> 00:23:14.549 sheath that goes from the brain all the way down 00:23:14.549 --> 00:23:16.529 the spinal cord. When you try to bend your neck 00:23:16.529 --> 00:23:19.509 forward, you stretch those inflamed angry tissues, 00:23:19.789 --> 00:23:22.769 and it causes excruciating pain. The muscles 00:23:22.769 --> 00:23:24.890 in the neck spasm to prevent that motion. They 00:23:24.890 --> 00:23:27.150 might also have photophobia, right? Light sensitivity. 00:23:27.430 --> 00:23:30.289 Yes. Light hurts their eyes. And the other terrifying 00:23:30.289 --> 00:23:33.309 sign is the rash. The purple rash. If you see 00:23:33.309 --> 00:23:37.430 a purple, patechial, or purpuric rash that doesn't 00:23:37.430 --> 00:23:39.589 blanch, meaning it doesn't fade when you press 00:23:39.589 --> 00:23:43.049 on it with a glass, that is meningocosemia. What 00:23:43.049 --> 00:23:45.789 does that mean? It means the bacteria, Neisseria, 00:23:45.950 --> 00:23:49.190 are in the bloodstream causing DIC septic shock. 00:23:49.369 --> 00:23:53.190 It is a run -don't -walk, life -threatening emergency. 00:23:53.569 --> 00:23:56.329 But infants, as always, are vague and confusing. 00:23:56.569 --> 00:23:58.589 Always, you won't get a complaint of a headache. 00:23:58.930 --> 00:24:01.650 You get poor feeding, a weak cry, vomiting, maybe 00:24:01.650 --> 00:24:04.990 a bulging fontanel. But there is a specific posture 00:24:04.990 --> 00:24:09.220 to watch for. Opistotinose. Opistotinose. That's 00:24:09.220 --> 00:24:12.079 a mouthful. It is. The baby arches their back 00:24:12.079 --> 00:24:14.740 and neck backward rigidly. It looks incredibly 00:24:14.740 --> 00:24:16.880 uncomfortable. They do it because the meninges 00:24:16.880 --> 00:24:19.640 are so inflamed that curling up into a ball, 00:24:19.880 --> 00:24:22.740 flexing, stretches them and hurts. Arching back 00:24:22.740 --> 00:24:25.019 relieves the tension on that inflamed spinal 00:24:25.019 --> 00:24:27.220 cord. Okay, we have two classic assessment signs 00:24:27.220 --> 00:24:29.660 here that appear on every nursing exam. Kornig's 00:24:29.660 --> 00:24:32.000 and Brudzinski's. Can you clarify them in a simple 00:24:32.000 --> 00:24:35.039 way? Absolutely. For Kornig's sign, think K for 00:24:35.039 --> 00:24:37.259 knee. You lay the child down, flex their hip 00:24:37.259 --> 00:24:39.359 to 90 degrees, and then you try to straighten 00:24:39.359 --> 00:24:41.940 the leg at the knee. If it causes severe pain 00:24:41.940 --> 00:24:43.960 in their back or resistance because of hamstring 00:24:43.960 --> 00:24:47.059 spasm, That's a positive kernings. The meningial 00:24:47.059 --> 00:24:49.599 irritation is causing that reflex. And Brzezinski's. 00:24:49.640 --> 00:24:52.559 For Brzezinski's sign, think B for brain or back 00:24:52.559 --> 00:24:55.180 of the head. You lay them flat and you passively 00:24:55.180 --> 00:24:57.599 lift their head off the bed, flexing their neck 00:24:57.599 --> 00:24:59.779 toward their chest. And what happens? If their 00:24:59.779 --> 00:25:02.240 knees and hips automatically buckle and flex 00:25:02.240 --> 00:25:05.200 up toward their body, that's a positive Brzezinski's. 00:25:05.220 --> 00:25:07.559 It's an involuntary reflex to try and relieve 00:25:07.559 --> 00:25:10.779 that painful stretch on the spine. So you suspect 00:25:10.779 --> 00:25:13.750 meningitis. You see the stiff neck. Maybe a positive 00:25:13.750 --> 00:25:16.190 Brzezinski's. What is the very first thing you 00:25:16.190 --> 00:25:20.109 do before anything else? Isolate. Put them on 00:25:20.109 --> 00:25:22.869 droplet precautions immediately. Mask on the 00:25:22.869 --> 00:25:26.029 patient. Gown, gloves, mask for you. You do this 00:25:26.029 --> 00:25:27.609 before you call the doctor, before you go for 00:25:27.609 --> 00:25:29.990 the lumbar puncture. You don't wait for lab confirmation. 00:25:30.009 --> 00:25:32.769 Do not wait. If it is bacterial, it spreads through 00:25:32.769 --> 00:25:34.869 respiratory droplets. You have to protect the 00:25:34.869 --> 00:25:36.910 other patients on the unit and the staff. Then 00:25:36.910 --> 00:25:39.329 you get the orders for an LP, a lumbar puncture. 00:25:39.390 --> 00:25:42.950 You get the CSF fluid. What are we looking for 00:25:42.950 --> 00:25:45.329 to confirm our suspicion? The main goal of the 00:25:45.329 --> 00:25:48.230 LP is to differentiate bacterial from viral meningitis. 00:25:48.630 --> 00:25:51.509 Bacterial is the emergency. Viral or aseptic 00:25:51.509 --> 00:25:54.109 is usually self -limiting. So what does bacterial 00:25:54.109 --> 00:25:56.730 fluid look like? In bacterial meningitis, the 00:25:56.730 --> 00:25:59.430 fluid will often be cloudy, almost milky. The 00:25:59.430 --> 00:26:01.910 white blood cell count will be very high, mostly 00:26:01.910 --> 00:26:04.650 neutrophils. Protein will also be high because 00:26:04.650 --> 00:26:07.069 of all the bacteria and dead cells floating around. 00:26:07.650 --> 00:26:10.589 But the key differentiator is the glucose level. 00:26:10.710 --> 00:26:13.309 What happens to the glucose? It drops. It's significantly 00:26:13.309 --> 00:26:16.190 low. And why is that? Because the bacteria are 00:26:16.190 --> 00:26:18.910 alive and they are hungry. They are literally 00:26:18.910 --> 00:26:21.890 eating the sugar in the cerebrospinal fluid for 00:26:21.890 --> 00:26:24.029 energy to replicate. So it's a great mnemonic. 00:26:24.549 --> 00:26:27.369 Bacteria eat sugar. Low sugar in the CSF means 00:26:27.369 --> 00:26:30.529 it's probably bacterial. Exactly. In viral meningitis, 00:26:30.670 --> 00:26:32.650 the glucose is usually normal because viruses 00:26:32.650 --> 00:26:34.869 don't metabolize sugar in the same way. And if 00:26:34.869 --> 00:26:37.150 it is bacterial, the treatment is? You start 00:26:37.150 --> 00:26:40.029 high -dose IV antibiotics immediately. Even before 00:26:40.029 --> 00:26:41.950 the final culture comes back, you start broad 00:26:41.950 --> 00:26:45.470 spectrum coverage. Time is brain. Every minute 00:26:45.470 --> 00:26:47.829 you delay treatment increases the risk of permanent 00:26:47.829 --> 00:26:50.930 damage. Speaking of damage, what's the long -term 00:26:50.930 --> 00:26:53.650 impact here? The number one most common long 00:26:53.650 --> 00:26:56.210 -term complication of bacterial meningitis is 00:26:56.210 --> 00:27:00.539 sensorineural hearing loss. Yes. The inflammation 00:27:00.539 --> 00:27:03.980 can directly damage the auditory nerve. So every 00:27:03.980 --> 00:27:06.539 single child who recovers from meningitis needs 00:27:06.539 --> 00:27:08.579 a formal hearing screen before they are discharged 00:27:08.579 --> 00:27:10.579 from the hospital. Why is that so important? 00:27:10.779 --> 00:27:12.680 You don't want to send them home and have the 00:27:12.680 --> 00:27:14.619 parents realize six months later that their child 00:27:14.619 --> 00:27:16.480 has a speech delay because they haven't been 00:27:16.480 --> 00:27:19.039 able to hear properly. It's a preventable secondary 00:27:19.039 --> 00:27:21.799 problem. OK. That's a fantastic clinical pearl. 00:27:22.359 --> 00:27:24.380 Let's move to our last pattern, pattern four. 00:27:24.750 --> 00:27:27.849 Physical trauma and neural tube defects. Let's 00:27:27.849 --> 00:27:31.309 focus on spina bifida first, specifically myelomeningosal. 00:27:31.509 --> 00:27:34.289 This is a congenital defect. It's a failure of 00:27:34.289 --> 00:27:36.349 the neural tube to close completely during the 00:27:36.349 --> 00:27:38.509 first month of pregnancy. It's heavily linked 00:27:38.509 --> 00:27:41.130 to folic acid deficiency. And the baby is born 00:27:41.130 --> 00:27:43.730 with what? They're born with a sac protruding 00:27:43.730 --> 00:27:46.089 from their back, usually the lower back, and 00:27:46.089 --> 00:27:49.890 inside that sac are the meninges, CSF, and exposed 00:27:49.890 --> 00:27:53.160 spinal nerves. The need to know from the sources 00:27:53.160 --> 00:27:55.819 here is very heavily focused on the preoperative 00:27:55.819 --> 00:27:59.420 period. You have a newborn with essentially an 00:27:59.420 --> 00:28:01.559 open wound on their back that connects to their 00:28:01.559 --> 00:28:03.519 brain. Infection is the number one enemy. You 00:28:03.519 --> 00:28:06.900 have to protect that sac at all costs. If that 00:28:06.900 --> 00:28:09.420 sac ruptures, bacteria have a direct highway 00:28:09.420 --> 00:28:11.960 into the spinal cord and the brain. It's a setup 00:28:11.960 --> 00:28:15.200 for meningitis. So how do we position them? Pwn 00:28:15.200 --> 00:28:18.720 only. They lie on their belly, no lying on the 00:28:18.720 --> 00:28:21.859 back, no side lying. All care diaper changes, 00:28:22.180 --> 00:28:24.259 feeding has to happen with them on their belly. 00:28:24.980 --> 00:28:27.079 And how do we care for the sack itself? You have 00:28:27.079 --> 00:28:30.180 to cover it with a sterile, saline -soaked dressing. 00:28:30.400 --> 00:28:33.099 It must be kept moist at all times. Why moist? 00:28:33.220 --> 00:28:35.859 If the sack dries out, the delicate tissue can 00:28:35.859 --> 00:28:37.980 crack and rupture. So you're constantly applying 00:28:37.980 --> 00:28:40.940 these warm, sterile, wet dressings, often under 00:28:40.940 --> 00:28:43.680 a warmer, to prevent heat loss. Now, there's 00:28:43.680 --> 00:28:45.519 a really specific allergy we have to mention 00:28:45.519 --> 00:28:47.700 with these kids. It's a weird food connection 00:28:47.700 --> 00:28:49.920 that always seems to show up on board exams. 00:28:50.319 --> 00:28:52.740 Ah, yes, the latex fruit syndrome. Tell us about 00:28:52.740 --> 00:28:55.710 that. Why these kids? Children with spina bifida 00:28:55.710 --> 00:28:58.089 undergo multiple surgeries starting from birth. 00:28:58.410 --> 00:29:01.450 They also often require daily bladder catheterizations 00:29:01.450 --> 00:29:04.250 for their entire lives. So they have a massive 00:29:04.250 --> 00:29:07.509 exposure to latex. Massive lifelong exposure 00:29:07.509 --> 00:29:10.329 to latex products. Gloves, catheters, balloons. 00:29:10.430 --> 00:29:12.710 As a result, they almost universally develop 00:29:12.710 --> 00:29:16.049 a severe latex allergy or sensitivity. You must 00:29:16.049 --> 00:29:18.410 treat every child with spina bifida as if they 00:29:18.410 --> 00:29:21.329 have a latex allergy. So a completely latex -free 00:29:21.329 --> 00:29:23.809 environment in the hospital. Strictly. Kicker 00:29:23.809 --> 00:29:27.069 for the exam question. Because of protein cross 00:29:27.069 --> 00:29:30.069 -reactivity, people who are allergic to latex 00:29:30.069 --> 00:29:32.730 are also often allergic to certain foods that 00:29:32.730 --> 00:29:35.009 share similar protein structures. And which foods 00:29:35.009 --> 00:29:37.890 are those? The big ones are bananas, avocados, 00:29:38.089 --> 00:29:40.150 kiwi, and chestnuts. So if you're working the 00:29:40.150 --> 00:29:42.690 pediatric floor and the lunch tray comes up with 00:29:42.690 --> 00:29:45.210 a banana for the spina bifida patient in room 00:29:45.210 --> 00:29:47.509 204. You send it back immediately. That is a 00:29:47.509 --> 00:29:49.509 critical safety catch. Giving them that banana 00:29:49.509 --> 00:29:51.789 could trigger anaphylaxis. Let's pivot now to 00:29:51.789 --> 00:29:54.359 head trauma. The sources differentiate between 00:29:54.359 --> 00:29:56.960 epidural and subdural hematomas. I think a lot 00:29:56.960 --> 00:29:59.119 of us get these mixed up. The easiest way to 00:29:59.119 --> 00:30:02.000 remember is to think about the plumbing. An epidural 00:30:02.000 --> 00:30:05.539 hematoma is an arterial bleed. It happens between 00:30:05.539 --> 00:30:07.960 the skull and the dura mater. And arteries are 00:30:07.960 --> 00:30:10.200 high pressure. Very high pressure. So this bleeds 00:30:10.200 --> 00:30:12.839 fast. The classic presentation is what they call 00:30:12.839 --> 00:30:16.079 talk and die. Talk and die. That is incredibly 00:30:16.079 --> 00:30:19.750 grim. It is. A child gets hit in the head, maybe 00:30:19.750 --> 00:30:21.730 a baseball to the temple, which is a classic 00:30:21.730 --> 00:30:24.650 location. They might pass out for a second, but 00:30:24.650 --> 00:30:26.670 then they wake up and seem totally fine. They're 00:30:26.670 --> 00:30:29.509 talking, they're walking around. That's the lucid 00:30:29.509 --> 00:30:31.650 interval. That's the lucid interval. So parents 00:30:31.650 --> 00:30:34.470 think, oh, thank God he's OK. But meanwhile, 00:30:34.829 --> 00:30:37.930 that torn artery is pumping blood into that space. 00:30:38.410 --> 00:30:41.450 The pressure builds rapidly. Suddenly, they lose 00:30:41.450 --> 00:30:44.150 consciousness, a pupil blows, and they crash. 00:30:44.480 --> 00:30:47.059 It requires immediate emergency surgery. And 00:30:47.059 --> 00:30:49.819 a subdural hematoma? Subdural is a venous bleed. 00:30:49.960 --> 00:30:53.099 It's a bleed under the dura. Veins are low pressure, 00:30:53.099 --> 00:30:55.700 so this is a slower, oozing bleed. The symptoms 00:30:55.700 --> 00:30:58.160 can develop over hours or even days, and it's 00:30:58.160 --> 00:31:00.359 much more common in infants, especially in the 00:31:00.359 --> 00:31:02.720 context of our next topic, non -accidental trauma. 00:31:03.079 --> 00:31:04.880 Shaken baby syndrome? This is where the nurse 00:31:04.880 --> 00:31:08.000 has to be both a clinician, a detective, and 00:31:08.000 --> 00:31:10.740 a fierce advocate for the child. What's the mechanism 00:31:10.740 --> 00:31:13.759 of injury? It's a combination of an infant's 00:31:13.759 --> 00:31:16.660 anatomy. They have a weak neck, they can't support 00:31:16.660 --> 00:31:19.680 their head well, and their head is disproportionately 00:31:19.680 --> 00:31:23.160 large and heavy. When an infant is shaken violently, 00:31:23.819 --> 00:31:26.599 the brain slams back and forth inside the skull. 00:31:26.839 --> 00:31:28.859 And that tears the veins. It tears the small 00:31:28.859 --> 00:31:31.000 bridging veins that connect the brain to the 00:31:31.000 --> 00:31:34.000 dura, causing a subdural hematoma. And there's 00:31:34.000 --> 00:31:36.420 a clinical triad for shaken baby syndrome. I 00:31:36.420 --> 00:31:39.140 guess. If you see this combination of injuries, 00:31:39.480 --> 00:31:42.599 you must suspect abuse. It is retinal hemorrhages, 00:31:42.940 --> 00:31:46.420 a subdural hematoma, and cerebral edema, or brain 00:31:46.420 --> 00:31:47.960 swelling. And you say the retinal hemorrhages 00:31:47.960 --> 00:31:50.680 are key. They are pathognomonic. That means they 00:31:50.680 --> 00:31:53.700 are almost exclusively caused by this type of 00:31:53.700 --> 00:31:56.119 abusive shaking injury. You do not get retinal 00:31:56.119 --> 00:31:58.579 hemorrhages from a simple fall off a couch or 00:31:58.579 --> 00:32:01.299 a changing table. The forces just aren't great 00:32:01.299 --> 00:32:03.200 enough. And that's the exam tip too, isn't it? 00:32:03.200 --> 00:32:05.329 This story doesn't match the injury. Always. 00:32:05.730 --> 00:32:08.210 If the parent or caregiver brings in a two -month 00:32:08.210 --> 00:32:10.470 -old and says, he rolled off the bed, you have 00:32:10.470 --> 00:32:13.210 to stop. A two -month -old cannot roll over. 00:32:13.329 --> 00:32:16.009 That is a developmental impossibility. So your 00:32:16.009 --> 00:32:18.230 alarm bells go off? Immediately. As a nurse, 00:32:18.230 --> 00:32:21.069 you are a mandatory reporter. It's not your job 00:32:21.069 --> 00:32:23.769 to prove abuse, but you are legally and ethically 00:32:23.769 --> 00:32:26.269 required to report the suspicion to protect the 00:32:26.269 --> 00:32:28.390 child. You aren't judging the parent. You are 00:32:28.390 --> 00:32:31.450 saving a life. OK. That covers the four patterns. 00:32:31.549 --> 00:32:34.740 That was incredibly thorough. Let's shift gears 00:32:34.740 --> 00:32:37.240 and move into part C, the medication module, 00:32:37.859 --> 00:32:41.019 the safe dosing files. We have some very specific 00:32:41.019 --> 00:32:42.980 high -yield drugs here that you really need to 00:32:42.980 --> 00:32:44.779 understand deeply. Let's start with a big one, 00:32:45.019 --> 00:32:47.619 carbamazepine. Brand name, Tegreckel. This is 00:32:47.619 --> 00:32:49.660 a classic anti -convulsant. How does it work? 00:32:49.740 --> 00:32:51.859 What's the mechanism of action? It's a sodium 00:32:51.859 --> 00:32:54.740 channel blocker. In simple terms, it stabilizes 00:32:54.740 --> 00:32:57.220 the gates on nerve cells that let sodium in and 00:32:57.220 --> 00:32:59.299 out, which is what creates an electrical impulse. 00:32:59.740 --> 00:33:02.559 By blocking these, it stops the repetitive, chaotic 00:33:02.559 --> 00:33:05.000 electrical firing that causes a seizure. It tells 00:33:05.000 --> 00:33:08.019 the nerves to chill out. Basically, yes. Stop 00:33:08.019 --> 00:33:11.119 firing so fast. What are the PD -specific safety 00:33:11.119 --> 00:33:13.140 pearls here, the things we need to know for kids? 00:33:13.579 --> 00:33:16.000 OK, first, and this is a safety issue for nurses 00:33:16.000 --> 00:33:18.779 and parents, it's classified as a hazardous drug 00:33:18.779 --> 00:33:21.200 by Neofesh. What does that mean for handling 00:33:21.200 --> 00:33:23.710 it? It means if you are a nurse handling the 00:33:23.710 --> 00:33:26.670 liquid suspension or crushing a tablet, you need 00:33:26.670 --> 00:33:29.670 to wear gloves. Ideally, double chemo gloves. 00:33:29.930 --> 00:33:32.009 You don't want to absorb this through your skin 00:33:32.009 --> 00:33:35.109 over time. But the big patient safety red flag 00:33:35.109 --> 00:33:38.309 involves genetics, specifically for patients 00:33:38.309 --> 00:33:42.089 of Asian ancestry. This is huge, and it's a relatively 00:33:42.089 --> 00:33:45.319 new understanding in pharmacology. There is a 00:33:45.319 --> 00:33:48.599 specific genetic marker, an allele, called HLAB 00:33:48.599 --> 00:33:51.660 1502. And people of Asian descent are more likely 00:33:51.660 --> 00:33:53.859 to have it. Much more likely. And if they carry 00:33:53.859 --> 00:33:55.880 this allele and they take carbamazepine, they 00:33:55.880 --> 00:33:58.579 have a ten -fold higher risk of developing Stevens 00:33:58.579 --> 00:34:01.619 -Johnson syndrome, or SJS. Which is a horrific, 00:34:01.759 --> 00:34:04.799 life -threatening skin reaction. It is. The skin 00:34:04.799 --> 00:34:07.240 and mucous membranes blister and peel off. It's 00:34:07.240 --> 00:34:09.219 essentially a chemical burn from the inside out. 00:34:09.260 --> 00:34:11.480 It's often fatal. So what is the guideline now? 00:34:11.599 --> 00:34:13.960 Genetic testing for this allele is recommended 00:34:13.960 --> 00:34:16.559 before starting the drug in Asian populations. 00:34:17.340 --> 00:34:19.320 If you see an exam question about starting an 00:34:19.320 --> 00:34:22.199 Asian child on Tikritol, the correct answer will 00:34:22.199 --> 00:34:24.980 involve checking for that allele first. It also 00:34:24.980 --> 00:34:27.820 messes with the bone marrow, right? Yes. It can 00:34:27.820 --> 00:34:30.619 cause myelo suppression or bone marrow suppression. 00:34:31.119 --> 00:34:33.500 It lowers your white blood cells, your red blood 00:34:33.500 --> 00:34:35.920 cells, and your platelets. So let's synthesize 00:34:35.920 --> 00:34:38.449 that. If you have a child on carbamazepine, who 00:34:38.449 --> 00:34:40.849 develops a fever and a sore throat. You cannot 00:34:40.849 --> 00:34:42.849 just assume it's a simple case of strep throat. 00:34:42.889 --> 00:34:45.590 You have to check a CBC. Is their white blood 00:34:45.590 --> 00:34:49.230 cell count zero? A granulocytosis. Has the drug 00:34:49.230 --> 00:34:51.809 wiped out their immune system? So a simple cold 00:34:51.809 --> 00:34:53.949 could become life -threatening sepsis. Instantly. 00:34:54.130 --> 00:34:56.809 You also watch for signs of anemia like fatigue 00:34:56.809 --> 00:34:59.769 and pallor from low red cells and signs of bleeding 00:34:59.769 --> 00:35:03.030 like bruising or petechiae from low platelets. 00:35:03.309 --> 00:35:07.059 Okay, next up in our list, gabapentin. brand 00:35:07.059 --> 00:35:09.860 name Neurontin. This one is interesting. Its 00:35:09.860 --> 00:35:12.199 name makes you think it works on the GABA system, 00:35:12.400 --> 00:35:14.860 and it's structurally related to the neurotransmitter 00:35:14.860 --> 00:35:18.159 GABA, but it doesn't actually bind to GABA receptors. 00:35:18.260 --> 00:35:20.860 So how does it work? It works on voltage -gated 00:35:20.860 --> 00:35:24.000 calcium channels. A different mechanism. In adults, 00:35:24.000 --> 00:35:26.440 we often use this for nerve pain, and the classic 00:35:26.440 --> 00:35:29.739 side effect is sedation, that Gabapentin fog. 00:35:29.920 --> 00:35:32.940 Right. Somnolence, dizziness. It's a huge fall 00:35:32.940 --> 00:35:36.719 risk. But in kids, it can have a paradoxical 00:35:36.719 --> 00:35:38.480 effect. Meaning it does a complete opposite. 00:35:38.900 --> 00:35:40.920 Yes. Instead of chilling them out, it can ramp 00:35:40.920 --> 00:35:43.239 them up. It can cause significant behavioral 00:35:43.239 --> 00:35:46.500 changes. Hostility, aggression, emotional ability, 00:35:46.780 --> 00:35:49.119 hyperkinesia, meaning they're bouncing off the 00:35:49.119 --> 00:35:51.340 walls. So a parent might call and say, he's turning 00:35:51.340 --> 00:35:53.960 into a monster. Or she's throwing things constantly. 00:35:54.059 --> 00:35:55.780 And you have to know that could be the drug. 00:35:55.960 --> 00:35:58.480 It's not just the child acting out. So a big 00:35:58.480 --> 00:36:00.619 teaching point is to warn parents to watch for 00:36:00.619 --> 00:36:03.500 those behavior changes. Exactly. And like all 00:36:03.500 --> 00:36:05.760 anticonvulsants, there is a black box warning 00:36:05.760 --> 00:36:09.239 for suicidal ideation. It sounds heavy to talk 00:36:09.239 --> 00:36:11.639 about in pediatrics, but even in younger kids 00:36:11.639 --> 00:36:14.420 and teens, you have to monitor for mood changes, 00:36:14.880 --> 00:36:17.679 depression, or self -harming thoughts. Let's 00:36:17.679 --> 00:36:19.480 do a quick hit on a couple of others from the 00:36:19.480 --> 00:36:23.389 textbook table. Funny Toin. The big one everyone 00:36:23.389 --> 00:36:26.590 remembers is gingival hyperplasia. Overgrowth 00:36:26.590 --> 00:36:29.010 of the gums. Yes. The gums can literally grow 00:36:29.010 --> 00:36:31.409 over the teeth. It's not an infection or poor 00:36:31.409 --> 00:36:33.809 hygiene. It's a direct side effect of the drug. 00:36:33.989 --> 00:36:36.329 Can we do anything to prevent it? Meticulous 00:36:36.329 --> 00:36:39.150 dental hygiene helps. Using a soft toothbrush, 00:36:39.530 --> 00:36:42.489 flossing, regular dental visits. And some studies 00:36:42.489 --> 00:36:44.550 show that folic acid supplementation can help 00:36:44.550 --> 00:36:47.650 reduce the severity. But you have to warn the 00:36:47.650 --> 00:36:50.369 teen cosmetically, this is a very big deal for 00:36:50.369 --> 00:36:54.510 them. And the last one, valproic acid or Depakote? 00:36:54.869 --> 00:36:58.650 Two big words, hepatotoxicity and pancreatitis. 00:36:58.849 --> 00:37:00.869 It can be very rough on the liver and pancreas. 00:37:00.929 --> 00:37:03.289 So you're monitoring liver enzymes? Absolutely. 00:37:03.429 --> 00:37:06.349 You check LFTs at baseline and regularly thereafter. 00:37:06.769 --> 00:37:09.130 If the child develops jaundice, abdominal pain, 00:37:09.489 --> 00:37:11.409 nausea, vomiting, or becomes super lethargic, 00:37:11.789 --> 00:37:14.070 you have to suspect liver damage and stop the 00:37:14.070 --> 00:37:17.219 drug. Okay, this brings us to part D, cross -linking 00:37:17.219 --> 00:37:19.500 and synthesis. This is where we connect the dots 00:37:19.500 --> 00:37:21.960 between the diseases and the drugs. We've touched 00:37:21.960 --> 00:37:25.260 on some of this, but let's explicitly link medications 00:37:25.260 --> 00:37:27.699 and development. This is the part that is so 00:37:27.699 --> 00:37:30.340 often missed in the rush to treat. We focus so 00:37:30.340 --> 00:37:33.219 much on stopping the seizure that we forget about 00:37:33.219 --> 00:37:35.289 the cost of the treatment. And what is the cost? 00:37:35.670 --> 00:37:38.989 Most anticonvulsants are, by their nature, sedating. 00:37:39.570 --> 00:37:43.050 They work by slowing down neuronal firing. Which 00:37:43.050 --> 00:37:45.769 means they are literally slowing down the brain. 00:37:45.869 --> 00:37:48.710 Right. So if you have a school -aged child who 00:37:48.710 --> 00:37:52.550 is seizure -free but so sedated from their medication 00:37:52.550 --> 00:37:54.909 that they can't stay awake or pay attention in 00:37:54.909 --> 00:37:57.590 class, their grades drop. They might get labeled 00:37:57.590 --> 00:38:00.590 as having a learning disability or ADD. But really 00:38:00.590 --> 00:38:02.530 they're just over -medicated. They're over -medicated. 00:38:02.809 --> 00:38:05.530 The nurse's role here is to be an advocate for 00:38:05.530 --> 00:38:07.769 finding that sweet spot. The balance between 00:38:07.769 --> 00:38:10.409 seizure control and quality of life. Exactly. 00:38:10.670 --> 00:38:13.010 We want the lowest effective dose that controls 00:38:13.010 --> 00:38:15.469 seizures while allowing the child to learn and 00:38:15.469 --> 00:38:18.150 grow and be a kid. If the kid is a zombie, we 00:38:18.150 --> 00:38:20.880 haven't won. We need to work with the neurologist 00:38:20.880 --> 00:38:23.260 to adjust the regimen. Let's make another synthesis 00:38:23.260 --> 00:38:24.820 point. You talked about hydrocephalus, and you 00:38:24.820 --> 00:38:27.539 talked about spina bifida. They are almost always 00:38:27.539 --> 00:38:30.119 linked. They are. The vast majority of kids born 00:38:30.119 --> 00:38:32.860 with myelomeningozo, that severe form of spina 00:38:32.860 --> 00:38:36.280 bifida, also have a congenital brain malformation 00:38:36.280 --> 00:38:39.179 called a type 2 Chiari malformation. And what 00:38:39.179 --> 00:38:41.940 is that? In simple terms, the brain stem and 00:38:41.940 --> 00:38:44.639 cerebellum sit lower than they should, partially 00:38:44.639 --> 00:38:47.219 blocking the form in magnum, that hole where 00:38:47.219 --> 00:38:49.480 the CSF needs to drink. out of the brain. So 00:38:49.480 --> 00:38:51.599 the drain is already partially clogged at birth. 00:38:51.820 --> 00:38:54.139 Exactly. So if you were caring for a baby who 00:38:54.139 --> 00:38:57.059 just had their spina bifida repair surgery on 00:38:57.059 --> 00:38:58.900 their back. You aren't just watching the incision 00:38:58.900 --> 00:39:01.559 on their back. You are measuring their head circumference 00:39:01.559 --> 00:39:04.559 every single shift. Because once you surgically 00:39:04.559 --> 00:39:07.139 close that back defect, the fluid that might 00:39:07.139 --> 00:39:09.219 have been leaking out now stays trapped in the 00:39:09.219 --> 00:39:12.000 system. And if the drain is blocked by that Chiari 00:39:12.000 --> 00:39:15.719 malformation, hydrocephalus can develop explosively. 00:39:15.900 --> 00:39:18.929 So you fix the back. But that can break the head, 00:39:19.030 --> 00:39:20.550 so to speak. You have to watch both. You have 00:39:20.550 --> 00:39:22.750 to watch both. It's all connected. The anatomy, 00:39:22.909 --> 00:39:25.469 the pressure, the surgical device, the risk for 00:39:25.469 --> 00:39:27.869 infection. That really is the theme of pediatric 00:39:27.869 --> 00:39:29.849 neurology, isn't it? Yeah. You can't silo the 00:39:29.849 --> 00:39:32.250 systems. You can't just treat the seizure without 00:39:32.250 --> 00:39:35.130 thinking about the bone marrow and the behavioral 00:39:35.130 --> 00:39:37.750 side effects. And you can't treat the spina bifida 00:39:37.750 --> 00:39:39.949 without thinking about the latex allergy and 00:39:39.949 --> 00:39:42.670 the risk for hydrocephalus. It's a web of connections. 00:39:43.090 --> 00:39:45.570 We have covered a massive amount of ground today. 00:39:45.719 --> 00:39:49.300 from the expanding skulls of infants to the sugar 00:39:49.300 --> 00:39:51.599 -eating bacteria of meningitis, from the genetic 00:39:51.599 --> 00:39:54.780 risks of carbamazepine to the banana allergies 00:39:54.780 --> 00:39:57.559 of spina bifida. We've definitely built the 80 00:39:57.559 --> 00:39:59.380 -20 map. Before we sign off, I want to leave 00:39:59.380 --> 00:40:01.239 our listeners with a final thought about the 00:40:01.239 --> 00:40:04.000 future of these kids. We've talked so much about 00:40:04.000 --> 00:40:06.460 all these fragilities, the soft skulls, the weak 00:40:06.460 --> 00:40:09.119 necks, the susceptibility to toxins, but there 00:40:09.119 --> 00:40:11.460 is a kind of superpower in pediatric neurology, 00:40:11.539 --> 00:40:13.900 isn't there? There is. It's called neuroplasticity. 00:40:14.059 --> 00:40:16.699 The ability of the brain to rewire itself. It's 00:40:16.699 --> 00:40:18.599 absolutely incredible. I mean, there are children 00:40:18.599 --> 00:40:23.079 with severe intractable epilepsy where one half 00:40:23.079 --> 00:40:25.679 of their brain is just constantly seizing and 00:40:25.679 --> 00:40:27.820 damaging the other half. And for some of them, 00:40:28.019 --> 00:40:30.460 the treatment is a hemispherectomy. A hemispherectomy. 00:40:30.739 --> 00:40:33.519 Surgeons literally go in and remove or disconnect 00:40:33.519 --> 00:40:36.420 half of their brain. Half the brain. Just gone. 00:40:36.679 --> 00:40:39.659 Gone. And because they are so young, the remaining 00:40:39.659 --> 00:40:42.059 half of their brain can often take over the functions 00:40:42.059 --> 00:40:44.239 of the half that was removed. They can learn 00:40:44.239 --> 00:40:46.119 to walk again. They can learn to talk again. 00:40:46.219 --> 00:40:49.059 They can go to school and live a functional life 00:40:49.059 --> 00:40:51.219 with half a brain. That is just mind -blowing. 00:40:51.719 --> 00:40:54.159 An adult brain could never do that. If I lost 00:40:54.159 --> 00:40:57.199 half my brain today, I'd be hemiplegic and aphasic 00:40:57.199 --> 00:41:00.000 for the rest of my life. But a child's brain 00:41:00.000 --> 00:41:02.099 is still being written. The software is still 00:41:02.099 --> 00:41:04.739 being installed. And that's why our job. That's 00:41:04.739 --> 00:41:07.599 why our job of protecting that brain from pressure, 00:41:07.860 --> 00:41:11.260 from infection, from trauma. It's so sacred, 00:41:11.460 --> 00:41:13.639 we are guarding their future potential. That 00:41:13.639 --> 00:41:15.519 really is the why, when you check that level 00:41:15.519 --> 00:41:17.679 of consciousness, you aren't just filling out 00:41:17.679 --> 00:41:20.480 a box on a chart. You're protecting the person 00:41:20.480 --> 00:41:22.639 they are going to become. Keep your eyes on the 00:41:22.639 --> 00:41:25.059 milestones. And we'll catch you on the next Deep 00:41:25.059 --> 00:41:25.460 Dive.