WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:32.810 fast. Welcome to the emergency room. 45 minutes 00:00:32.810 --> 00:00:47.829 of CPR. We can stop CPR. Welcome back to The 00:00:47.829 --> 00:00:51.049 Deep Dive. We are shifting gears today. A little 00:00:51.049 --> 00:00:53.770 bit of a different focus. Yeah, exactly. Usually 00:00:53.770 --> 00:00:56.170 when we talk about emergency medicine or, you 00:00:56.170 --> 00:00:58.509 know, critical care and pediatrics, everyone 00:00:58.509 --> 00:01:01.219 wants to talk about the high drama organs. The 00:01:01.219 --> 00:01:03.340 heart, the lungs, the brain. Oh, absolutely, 00:01:03.460 --> 00:01:05.359 the glamorous stuff. The glamorous stuff that 00:01:05.359 --> 00:01:07.260 beeps on the monitor. They certainly get all 00:01:07.260 --> 00:01:09.299 the glory in the textbooks. Everyone wants to 00:01:09.299 --> 00:01:11.579 interpret the ECG or manage the ventilator. So, 00:01:11.579 --> 00:01:14.400 so lately. But today, we are focusing on the 00:01:14.400 --> 00:01:18.579 unsung hero, the body's largest organ, the skin. 00:01:19.120 --> 00:01:22.480 And honestly, for a lot of nursing students and 00:01:22.480 --> 00:01:25.939 even experienced nurses, the skin is, well, it's 00:01:25.939 --> 00:01:27.920 an afterthought. It's seen as just the wrapper. 00:01:28.060 --> 00:01:30.200 It's just the wrapper, right, until it isn't. 00:01:30.239 --> 00:01:32.480 I've heard it described as the check engine light 00:01:32.480 --> 00:01:35.739 of pediatric nursing. That is a perfect analogy, 00:01:35.840 --> 00:01:38.219 but I'd take it a step further. It's not just 00:01:38.219 --> 00:01:41.379 a light. It's the entire dashboard. The dashboard. 00:01:41.739 --> 00:01:44.799 I like that. In pediatrics, the skin is often 00:01:44.799 --> 00:01:48.459 your first clue, sometimes your only clue, that 00:01:48.459 --> 00:01:50.719 there is a systemic issue, a raging infection, 00:01:50.980 --> 00:01:54.500 or a severe trauma occurring. If you ignore the 00:01:54.500 --> 00:01:56.430 check engine light, the car breaks down. And 00:01:56.430 --> 00:01:58.670 if you ignore the skin findings in a child, the 00:01:58.670 --> 00:02:01.810 child crashes. It's that simple. So here is the 00:02:01.810 --> 00:02:04.150 setup for today. We are treating this deep dive 00:02:04.150 --> 00:02:07.989 as a specialized exam cram session. But I don't 00:02:07.989 --> 00:02:10.310 want the superficial flash card version. I really 00:02:10.310 --> 00:02:12.930 want the why. The deep mechanics of it. Yes. 00:02:13.389 --> 00:02:15.569 We are imagining our listener is stepping into 00:02:15.569 --> 00:02:17.830 the shoes of a nursing student right before finals 00:02:17.830 --> 00:02:20.870 or a nurse prepping for their pediatric certification. 00:02:21.259 --> 00:02:24.219 We need to be rigorous. And we are going to cut 00:02:24.219 --> 00:02:25.580 through the noise. We're going to look at Chapter 00:02:25.580 --> 00:02:28.180 23, integumentary disorders and the drug protocols. 00:02:28.400 --> 00:02:30.960 But we aren't just reading the list. We are applying 00:02:30.960 --> 00:02:33.699 the Pareto principle, the 80 -20 rule. Which 00:02:33.699 --> 00:02:36.719 means we are identifying the 20 % of skin concepts 00:02:36.719 --> 00:02:39.659 that show up on 80 % of exams and are critical 00:02:39.659 --> 00:02:42.500 for safety. I'll play the role of the ambitious 00:02:42.500 --> 00:02:45.099 student who wants the cheat codes but also demands 00:02:45.099 --> 00:02:47.199 to understand the mechanics. I'm not just going 00:02:47.199 --> 00:02:49.599 to nod along. I want to know why the physiology 00:02:49.599 --> 00:02:52.099 works the way it does. and I will play the clinical 00:02:52.099 --> 00:02:55.620 educator. My job is to filter the list, focus 00:02:55.620 --> 00:02:58.580 on safety, assessment priorities, and explain 00:02:58.580 --> 00:03:01.120 the path of physiology so you don't have to memorize 00:03:01.120 --> 00:03:04.819 it by rote. OK, let's dive in. Section A, the 00:03:04.819 --> 00:03:07.990 master 80 -20 map. When you look at the integumentary 00:03:07.990 --> 00:03:10.409 system in kids, it can feel like a laundry list 00:03:10.409 --> 00:03:13.050 of weird Latin names, teneavus, dermatitis, that. 00:03:13.389 --> 00:03:15.729 How do we organize this into big buckets so we 00:03:15.729 --> 00:03:17.669 don't lose our minds? You have to categorize 00:03:17.669 --> 00:03:20.550 them or you will get overwhelmed. In the source 00:03:20.550 --> 00:03:22.509 material we have today, everything really falls 00:03:22.509 --> 00:03:24.849 into four distinct patterns. If you can recognize 00:03:24.849 --> 00:03:27.129 the pattern, you can predict the test question 00:03:27.129 --> 00:03:29.509 and the clinical intervention. Okay, lay out 00:03:29.509 --> 00:03:31.969 the four buckets for me. Bucket one is infectious 00:03:31.969 --> 00:03:34.490 patterns. This is your biological warfare section, 00:03:34.770 --> 00:03:37.379 bacteria versus fungus. Think impetigo versus 00:03:37.379 --> 00:03:41.219 ringworm. The exam priority here is almost always 00:03:41.219 --> 00:03:43.520 contagion control. How do I stop this from spreading? 00:03:44.099 --> 00:03:46.520 And of course, identifying the rash by its visual 00:03:46.520 --> 00:03:49.099 description. Contagion and description. Got it. 00:03:49.139 --> 00:03:51.759 Bucket two. Inflammatory and allergic patterns. 00:03:52.020 --> 00:03:54.300 This is where the body attacks itself or overreacts 00:03:54.300 --> 00:03:57.379 to the environment. Eczema and dioper dermatitis 00:03:57.379 --> 00:03:59.740 are the big ones here. And the priority there 00:03:59.740 --> 00:04:02.770 isn't so much life or death. Not in the immediate 00:04:02.770 --> 00:04:05.210 sense, no. It's symptom management, comfort, 00:04:05.330 --> 00:04:07.469 and a huge amount of parent education. Right. 00:04:07.750 --> 00:04:10.469 Okay, what's bucket three? Hormonal and developmental 00:04:10.469 --> 00:04:14.150 patterns. This is primarily acne vulgaris. Now, 00:04:14.150 --> 00:04:16.329 you might roll your eyes and think acne is low 00:04:16.329 --> 00:04:20.129 stakes, but the exam priority here is the psychosocial 00:04:20.129 --> 00:04:22.389 impact on the adolescent and medication safety. 00:04:22.589 --> 00:04:24.430 Medication. Specifically, there are some very 00:04:24.430 --> 00:04:26.889 dangerous drugs used for severe acne that show 00:04:26.889 --> 00:04:28.829 up on exams constantly. We have to know them 00:04:28.829 --> 00:04:31.339 inside and out. And the fourth bucket. I'm guessing 00:04:31.339 --> 00:04:33.779 this is the scary one. This is the scary one. 00:04:34.379 --> 00:04:37.199 Trauma and emergency patterns. This is burns. 00:04:37.540 --> 00:04:40.139 This is the highest stakes bucket. This is where 00:04:40.139 --> 00:04:42.600 skin issues become life -threatening airway and 00:04:42.600 --> 00:04:44.620 circulation issues. So if I'm looking at this 00:04:44.620 --> 00:04:47.139 stack of papers and I'm panicking because my 00:04:47.139 --> 00:04:49.959 exam is tomorrow, what is the can't miss list? 00:04:50.089 --> 00:04:53.370 What absolutely must I know to be safe? OK, cut 00:04:53.370 --> 00:04:55.949 to the chase. If you remember nothing else from 00:04:55.949 --> 00:04:58.589 today, you must master the management of burns, 00:04:59.050 --> 00:05:01.149 specifically the prioritization of airway and 00:05:01.149 --> 00:05:03.449 fluid volume, and you must master the safety 00:05:03.449 --> 00:05:06.569 protocols for severe acne medication, specifically 00:05:06.569 --> 00:05:10.050 isotrenilin or acucaine. Burns and acutane. Those 00:05:10.050 --> 00:05:12.730 are the two areas where a wrong answer or a missed 00:05:12.730 --> 00:05:15.209 assessment leads to significant harm or death. 00:05:15.569 --> 00:05:18.069 Full stop. OK. Burns and Accutane are the heavy 00:05:18.069 --> 00:05:20.149 hitters. We will definitely spend a significant 00:05:20.149 --> 00:05:22.310 amount of time on those. But let's start with 00:05:22.310 --> 00:05:24.310 the stuff that you see every single day in the 00:05:24.310 --> 00:05:26.509 clinic. Let's go to that first bucket, infectious 00:05:26.509 --> 00:05:29.569 pattern. Let's do it. Topic one, Empedigo. Even 00:05:29.569 --> 00:05:31.410 the name sounds unpleasant. It sounds like something 00:05:31.410 --> 00:05:33.810 a goblin would have. It is unpleasant. It's the 00:05:33.810 --> 00:05:36.870 classic bacterial skin infection in kids. It's 00:05:36.870 --> 00:05:39.350 incredibly common. Give me the one -liner, the 00:05:39.350 --> 00:05:41.209 thing I should immediately think of when I see 00:05:41.209 --> 00:05:43.689 the word Empedigo. The honey -crusted contagion. 00:05:43.970 --> 00:05:46.129 Okay. Honey -crusted. That's the visual cue. 00:05:46.449 --> 00:05:48.430 Let's unpack the pathet here. I don't want just 00:05:48.430 --> 00:05:50.709 the visual yet. What is happening at the cellular 00:05:50.709 --> 00:05:54.069 level? So you're usually dealing with Staphylococcus 00:05:54.069 --> 00:05:57.970 aureus or Streptococcus pyogenes. These are bacteria 00:05:57.970 --> 00:06:00.029 that naturally colonize our skin. They hang out 00:06:00.029 --> 00:06:02.670 on the surface and cause zero problems. They're 00:06:02.670 --> 00:06:04.910 just part of the normal flora. Exactly. They're 00:06:04.910 --> 00:06:07.310 fine. Until there's a breach. The breach being 00:06:07.310 --> 00:06:09.439 the key. We aren't just talking about a massive 00:06:09.439 --> 00:06:11.519 cut, right? This isn't from falling off a bike. 00:06:11.699 --> 00:06:15.000 No, and that's the exam trap. The breach is microscopic. 00:06:15.300 --> 00:06:17.720 It's a mosquito bite the kid scratched. It's 00:06:17.720 --> 00:06:20.000 a runny nose where the tissue got raw from constant 00:06:20.000 --> 00:06:23.420 wiping. It's a little patch of eczema. The bacteria 00:06:23.420 --> 00:06:25.740 finds that opening, dives into the epidermis, 00:06:25.879 --> 00:06:28.600 and releases toxins. And those toxins are what 00:06:28.600 --> 00:06:30.279 caused the blistering. Is that the mechanism? 00:06:30.519 --> 00:06:33.220 That's it, exactly. The toxins break down the 00:06:33.220 --> 00:06:36.000 proteins that hold skin cells together, specifically 00:06:36.000 --> 00:06:38.949 the desmosomes. So the skin literally starts 00:06:38.949 --> 00:06:42.089 to separate. Fluid leaks out. That's your vesicle. 00:06:42.430 --> 00:06:44.649 And when that vesicle pops, the serum dries up. 00:06:45.389 --> 00:06:48.290 Ah, so that's the honey. That dried serum is 00:06:48.290 --> 00:06:51.089 what gives you that classic golden honey -colored 00:06:51.089 --> 00:06:53.389 crust. Okay, that makes the honey description 00:06:53.389 --> 00:06:55.449 surprisingly grosser when you know it's dried 00:06:55.449 --> 00:06:58.990 serum. But distinguishing this on an exam, is 00:06:58.990 --> 00:07:01.629 it always crested or are there different types 00:07:01.629 --> 00:07:03.740 I need to watch for? Great question. because 00:07:03.740 --> 00:07:05.639 you can get tripped up here. There are two types, 00:07:06.000 --> 00:07:08.720 non -bullis and bullis. The honey crust is the 00:07:08.720 --> 00:07:11.339 non -bullis type. That's the most common, maybe 00:07:11.339 --> 00:07:14.439 70 % of cases. OK, so what is bullis and pedigo? 00:07:14.660 --> 00:07:17.439 Bullis is exactly what it sounds like. Big, fluid 00:07:17.439 --> 00:07:20.850 -filled, glisters bully. These don't always crust 00:07:20.850 --> 00:07:23.629 immediately. They look like shiny, raw, red circles 00:07:23.629 --> 00:07:26.329 after they pop. It's often caused by specific 00:07:26.329 --> 00:07:28.509 toxin -producing staph. I feel like that's a 00:07:28.509 --> 00:07:30.649 critical distinction, because if a student is 00:07:30.649 --> 00:07:33.149 only hunting for the keyword crust, they might 00:07:33.149 --> 00:07:35.810 miss a case study describing a shiny, denuded 00:07:35.810 --> 00:07:39.870 red area on an infant. Precisely. If you see 00:07:39.870 --> 00:07:43.069 bulo, or varnish -like crust, you still need 00:07:43.069 --> 00:07:45.730 to be thinking in pedigo. It's the same family 00:07:45.730 --> 00:07:47.870 of infection, just a different presentation. 00:07:48.050 --> 00:07:51.009 And where do we usually see this? Anatomically? 00:07:51.490 --> 00:07:53.730 Off and around the nose and mouth. Think about 00:07:53.730 --> 00:07:56.329 toddlers. They're constantly wiping their noses, 00:07:56.350 --> 00:07:58.250 touching their faces. They create little micro 00:07:58.250 --> 00:08:00.910 abrasions. The bacteria gets in, and boom, honey 00:08:00.910 --> 00:08:02.709 crusts. So what's the need to know treatment? 00:08:02.870 --> 00:08:05.329 How do we fix this? If it's mild and localized, 00:08:05.790 --> 00:08:08.610 just a few spots. We use a topical bacterial 00:08:08.610 --> 00:08:11.509 ointment. like muperosin. We just put the medicine 00:08:11.509 --> 00:08:14.089 right on the lesions. But before you apply it, 00:08:14.250 --> 00:08:16.430 there is a nursing step that people often forget. 00:08:16.649 --> 00:08:18.689 Oh, this sounds like a good test question. What 00:08:18.689 --> 00:08:20.689 is it? You have to remove the crust. Really? 00:08:20.829 --> 00:08:22.649 You have to pick it off? You do. The crust is 00:08:22.649 --> 00:08:25.170 a barrier. It's like a shield. If you put ointment 00:08:25.170 --> 00:08:27.389 on top of a hard scab, it doesn't get to the 00:08:27.389 --> 00:08:29.230 bacteria underneath. You need to soak it with 00:08:29.230 --> 00:08:31.920 warm water and gently scrub it off. Gently being 00:08:31.920 --> 00:08:33.899 the operative word, you're not trying to make 00:08:33.899 --> 00:08:36.840 it bleed. No, not at all. Just soften and de 00:08:36.840 --> 00:08:39.200 -bride that superficial layer so the medication 00:08:39.200 --> 00:08:41.639 can penetrate. OK, so that's for mild cases. 00:08:41.799 --> 00:08:44.200 What if it's severe, like it's all over their 00:08:44.200 --> 00:08:46.700 body? If it's widespread, or if there is fever 00:08:46.700 --> 00:08:49.500 and lymphadenopathy, swollen lymph nodes, we 00:08:49.500 --> 00:08:52.899 move to oral antibiotics, usually a syphilis 00:08:52.899 --> 00:08:55.759 warren or a moxacillin clavulinate, something 00:08:55.759 --> 00:08:58.360 that gives good staph and strep coverage. And 00:08:58.360 --> 00:09:00.929 for the parents? Because I imagine they freak 00:09:00.929 --> 00:09:03.549 out when they see this scabbing all over their 00:09:03.549 --> 00:09:07.230 kid's face. What's the key education point? The 00:09:07.230 --> 00:09:10.169 biggest parent education point is hygiene. This 00:09:10.169 --> 00:09:13.309 is highly contagious. If that kid touches the 00:09:13.309 --> 00:09:15.750 crust and then touches another kid or touches 00:09:15.750 --> 00:09:18.570 a toy that another kid touches, it spreads. What's 00:09:18.570 --> 00:09:20.570 that term for when they spread it on themselves? 00:09:20.929 --> 00:09:23.529 Auto -inoculation. They scratch their nose, then 00:09:23.529 --> 00:09:25.409 scratch their arm, and suddenly they have a new 00:09:25.409 --> 00:09:27.429 spot on their arm. Right. So hand washing is 00:09:27.429 --> 00:09:29.190 paramount. Keep the child's fingernail short 00:09:29.190 --> 00:09:31.370 so they can't scratch and spread it. They need 00:09:31.370 --> 00:09:33.750 to stay home from daycare or school for the first 00:09:33.750 --> 00:09:36.649 24 hours after starting antibiotics. Is there 00:09:36.649 --> 00:09:39.490 any good news for the parents? Something to calm 00:09:39.490 --> 00:09:44.169 them down? Yes. A common fear is scarring. Parents 00:09:44.169 --> 00:09:46.750 see these nasty scabs on their beautiful baby's 00:09:46.750 --> 00:09:49.750 face and worry it's permanent. You can reassure 00:09:49.750 --> 00:09:52.519 them. Empedigo is superficial. It sits in the 00:09:52.519 --> 00:09:55.379 epidermis. It tends to heal without scarring. 00:09:55.659 --> 00:09:57.620 It looks worse than it is. That's a huge relief 00:09:57.620 --> 00:10:00.740 for them, I'm sure. Okay, let's move from bacteria 00:10:00.740 --> 00:10:05.299 to fungus. Topic two. Fungal skin infections. 00:10:05.740 --> 00:10:08.100 The tiniest. We call them the tiniest. It's a 00:10:08.100 --> 00:10:10.539 fungus among us, differentiated by location. 00:10:10.960 --> 00:10:13.299 I feel like ringworm is the term everyone knows, 00:10:13.299 --> 00:10:15.019 but it's kind of a misnomer, right? It's not 00:10:15.019 --> 00:10:17.480 a worm. Completely. There is no worm. It's a 00:10:17.480 --> 00:10:19.700 dermatophyto, a fungus that feeds on keratin. 00:10:19.840 --> 00:10:22.519 Keratin is the protein in your hair, skin, and 00:10:22.519 --> 00:10:24.799 nails. So it's literally eating the skin. It 00:10:24.799 --> 00:10:27.019 is, and it grows in a circle, expanding outward 00:10:27.019 --> 00:10:29.480 as it eats the keratin in your skin. The center 00:10:29.480 --> 00:10:31.679 clears up because the fungus has moved on to 00:10:31.679 --> 00:10:34.279 fresher pastures at the edge, creating that classic 00:10:34.279 --> 00:10:37.500 ring. That is disturbingly evocative, fresher 00:10:37.500 --> 00:10:39.740 pastures. Let's run down the anatomy lesson because 00:10:39.740 --> 00:10:41.600 the Latin names tell you exactly where it is. 00:10:41.679 --> 00:10:44.399 Right, so if you see tinea caddis on an exam. 00:10:44.480 --> 00:10:47.419 Epitetus means head, so scalp. Correct, tinea 00:10:47.419 --> 00:10:51.590 cruus. Cruus. Sounds like crutch, groin, jock 00:10:51.590 --> 00:10:55.289 itch. Exactly, tinea pedis. Pedis is foot, athlete's 00:10:55.289 --> 00:10:59.850 foot. Easy enough. Tinea corporis. Corporis means 00:10:59.850 --> 00:11:03.809 body, so arms, legs, trunk. Yes, that's your 00:11:03.809 --> 00:11:06.169 classic ringworm presentation, the circular patch 00:11:06.169 --> 00:11:09.370 on the arm. And then tinea versicolor is specifically 00:11:09.370 --> 00:11:12.110 on the trunk and extremities, often looking like 00:11:12.110 --> 00:11:14.549 discolored patches, either lighter or darker 00:11:14.549 --> 00:11:16.750 than the surrounding skin. Okay, let's talk treatment. 00:11:16.870 --> 00:11:19.190 This seems straightforward. Is it just put cream 00:11:19.190 --> 00:11:21.529 on it for all of them? This is the exam trap, 00:11:21.769 --> 00:11:25.830 and it's a big one. For most tinea, you know, 00:11:25.970 --> 00:11:28.669 like tinea corporeis on the arm or tinea pedis 00:11:28.669 --> 00:11:31.450 on the foot, yes, you use a topical anti -fungal 00:11:31.450 --> 00:11:34.330 cream like clitrimazole or miconazole. And there's 00:11:34.330 --> 00:11:36.350 a specific way to apply it, right? Yes, you apply 00:11:36.350 --> 00:11:38.590 it an inch past the border to catch the spreading 00:11:38.590 --> 00:11:40.389 fungus. You're trying to create a firewall. Why? 00:11:40.610 --> 00:11:43.149 I hear a butt coming. But tinea capitis on the 00:11:43.149 --> 00:11:45.490 head is different. Think about the anatomy. The 00:11:45.490 --> 00:11:47.769 fungus isn't just on the skin, it's down inside 00:11:47.769 --> 00:11:50.149 the hair follicle. Oh, so a topical cream isn't 00:11:50.149 --> 00:11:51.830 going to reach it? It can't get down that deep? 00:11:52.149 --> 00:11:55.049 Correct. Creams can't penetrate deep enough into 00:11:55.049 --> 00:11:57.929 the follicle bulb. So if a child has tinea capitis, 00:11:58.309 --> 00:12:01.149 we usually need oral systemic medication. Grizzle 00:12:01.149 --> 00:12:04.039 fulvin is the gold standard here. Oral meds for 00:12:04.039 --> 00:12:06.500 a scalp rash? That's a massive distinction. So 00:12:06.500 --> 00:12:09.240 if you pick topical nystatin for tinnacupitis 00:12:09.240 --> 00:12:12.200 on an exam, you are wrong. You are wrong, and 00:12:12.200 --> 00:12:14.919 the patient won't get better. And clinically, 00:12:15.320 --> 00:12:17.460 tinnacupapetus can cause permanent hair loss 00:12:17.460 --> 00:12:20.799 if it causes a carrion. a big, boggy inflamed 00:12:20.799 --> 00:12:22.919 abscess. So we treat it aggressively from the 00:12:22.919 --> 00:12:25.360 inside out. Okay, that's a huge clinical pearl. 00:12:25.700 --> 00:12:27.779 Oral meds for the head, topical for the body. 00:12:27.919 --> 00:12:30.000 And sometimes we add a special shampoo, like 00:12:30.000 --> 00:12:32.159 selenium sulfide shampoo, to help decrease the 00:12:32.159 --> 00:12:34.700 fungal load on the scalp. But the shampoo alone 00:12:34.700 --> 00:12:37.000 is not enough. It's an adjunct to the oral therapy. 00:12:37.139 --> 00:12:40.240 Got it. Okay, moving on to Book It 2. Inflammatory 00:12:40.240 --> 00:12:44.139 patterns. Topic 3 is a big one. Eczema. Or atopic 00:12:44.139 --> 00:12:47.220 dermatitis. The itch that rashes. Wait, don't 00:12:47.220 --> 00:12:50.169 you mean the rash that itches? No. And that's 00:12:50.169 --> 00:12:52.769 a crucial distinction in pediatrics. We call 00:12:52.769 --> 00:12:55.029 it the itch that rashes, because the itching 00:12:55.029 --> 00:12:58.210 often comes first. The child feels this intense, 00:12:58.490 --> 00:13:01.750 pruritus itching, and they scratch. The scratching 00:13:01.750 --> 00:13:04.509 damages the skin barrier, and then the rash flares 00:13:04.509 --> 00:13:07.269 up. It's an allergic cycle. Scratching leads 00:13:07.269 --> 00:13:09.509 to rash, which leads to more itching. That's 00:13:09.509 --> 00:13:11.950 a paradigm shift for me. So the itching is the 00:13:11.950 --> 00:13:14.509 cause, not the symptom. In many ways, yes. The 00:13:14.509 --> 00:13:16.730 primary sensation is the pruritus. Let's talk 00:13:16.730 --> 00:13:19.429 about the atopic triad. I see this term everywhere. 00:13:19.750 --> 00:13:22.029 What is it and why does it matter? This is essential 00:13:22.029 --> 00:13:25.129 for history taking. Eczema rarely travels alone. 00:13:25.509 --> 00:13:28.129 It travels with two friends, asthma and allergic 00:13:28.129 --> 00:13:31.289 rhinitis or hay fever. If a kid comes in with 00:13:31.289 --> 00:13:33.870 severe eczema, you could be asking about breathing 00:13:33.870 --> 00:13:36.070 issues and allergies. So if you see one, you 00:13:36.070 --> 00:13:37.370 should be looking for the others. You should 00:13:37.370 --> 00:13:40.210 have a high index of suspicion. It's all the 00:13:40.210 --> 00:13:43.299 same underlying hypersensitivity. an overactive 00:13:43.299 --> 00:13:45.600 immune system. Pathologically, what is wrong 00:13:45.600 --> 00:13:47.799 with their skin? Why is it so dry? It's often 00:13:47.799 --> 00:13:50.120 a genetic defect in a protein called filigrin. 00:13:50.679 --> 00:13:53.220 Filigrin? Imagine your skin cells are bricks. 00:13:54.539 --> 00:13:56.419 Filigrin is the mortar that holds them together 00:13:56.419 --> 00:13:58.899 and keeps moisture in. In eczema, the mortar 00:13:58.899 --> 00:14:02.139 is crumbly. Water evaporates out. We call that 00:14:02.139 --> 00:14:04.600 transepidermal water loss. Yeah. And allergens 00:14:04.600 --> 00:14:08.450 get in. So the skin is literally leaky? The barrier 00:14:08.450 --> 00:14:12.009 is compromised from birth. Yes. It's dry, cracked, 00:14:12.309 --> 00:14:14.409 and defenseless against the environment. So what 00:14:14.409 --> 00:14:16.850 is our priority intervention? If the problem 00:14:16.850 --> 00:14:19.870 is dry, itchy skin, how do we fix it? What's 00:14:19.870 --> 00:14:22.570 the 80 -20 here? Hydration and moisture preservation. 00:14:22.730 --> 00:14:25.399 That is the number one goal. We have to seal 00:14:25.399 --> 00:14:27.580 the barrier. How do we do that? The source material 00:14:27.580 --> 00:14:30.059 explicitly names some products here. Yes, it 00:14:30.059 --> 00:14:33.039 mentions aquaphor and Cetaphil. We need heavy, 00:14:33.259 --> 00:14:35.340 thick emollients. We are not talking about watery 00:14:35.340 --> 00:14:37.600 lotions that smell like vanilla. Why not? Lotions 00:14:37.600 --> 00:14:39.580 seem like a good idea. Lotions have high water 00:14:39.580 --> 00:14:41.799 content and can actually dry the skin more as 00:14:41.799 --> 00:14:44.059 they evaporate. It's counterintuitive. We need 00:14:44.059 --> 00:14:47.460 ointments, grease, petroleum -based products 00:14:47.460 --> 00:14:49.740 that create an occlusive barrier. So grease them 00:14:49.740 --> 00:14:52.610 up. Grease them up. Especially right after a 00:14:52.610 --> 00:14:55.129 bath, when the skin is still damp. We call it 00:14:55.129 --> 00:14:57.990 the soak and seal method. A short, lukewarm bath, 00:14:58.230 --> 00:15:00.590 pat dry, and then immediately slather on the 00:15:00.590 --> 00:15:03.009 ointment to trap that moisture. What about medications? 00:15:03.549 --> 00:15:05.909 If the moisturizing isn't enough? We attack the 00:15:05.909 --> 00:15:08.389 two problems. The inflammation and the itch. 00:15:08.960 --> 00:15:11.700 For inflammation, we use topical steroids during 00:15:11.700 --> 00:15:14.120 flare -ups. Now, parents are often terrified 00:15:14.120 --> 00:15:17.419 of steroids, steroid phobia. They think it will 00:15:17.419 --> 00:15:20.100 stump the kid's growth or thin their skin instantly. 00:15:20.519 --> 00:15:23.200 How do you counsel them? And that's a valid concern 00:15:23.200 --> 00:15:26.759 is misused. But as the nurse, you educate. We 00:15:26.759 --> 00:15:29.000 use the lowest potency that works only on the 00:15:29.000 --> 00:15:31.100 affected areas and only for short bursts like 00:15:31.100 --> 00:15:33.340 one to two weeks. We don't slather high -dose 00:15:33.340 --> 00:15:35.519 steroids on the face for months. It's about appropriate 00:15:35.519 --> 00:15:38.960 use. So low and slow. And there's a mention of 00:15:38.960 --> 00:15:41.299 immunomodulators like tacrolimus. What's their 00:15:41.299 --> 00:15:43.720 role? Right. Those are non -steroidal options. 00:15:43.879 --> 00:15:45.960 We use them specifically for sensitive areas 00:15:45.960 --> 00:15:48.460 like the face or eyelids where you want to avoid 00:15:48.460 --> 00:15:51.500 long -term steroid use. Or we use them for maintenance 00:15:51.500 --> 00:15:54.039 to prevent flares. And what about the itch? How 00:15:54.039 --> 00:15:57.029 do we stop that cycle we talked about? Antihistamines. 00:15:58.090 --> 00:16:00.470 Especially at night. Something like diffenhydramine 00:16:00.470 --> 00:16:03.730 or hydroxazine can help break the cycle by reducing 00:16:03.730 --> 00:16:06.049 the itch and helping the child sleep. I want 00:16:06.049 --> 00:16:09.230 to pause on the developmental impact here. Because 00:16:09.230 --> 00:16:11.929 eczema sounds annoying, but is it really a developmental 00:16:11.929 --> 00:16:14.870 issue? Hugely. Imagine you were a two -year -old. 00:16:15.389 --> 00:16:18.190 Your main job is to sleep and grow. But your 00:16:18.190 --> 00:16:20.970 skin feels like it's on fire. You itch constantly. 00:16:21.049 --> 00:16:23.190 You can't sleep. And if you don't sleep? If you 00:16:23.190 --> 00:16:25.700 don't sleep, you don't... release growth hormone 00:16:25.700 --> 00:16:28.419 properly. You are irritable. You aren't playing. 00:16:28.659 --> 00:16:31.960 You aren't learning. Severe eczema can be a major 00:16:31.960 --> 00:16:34.340 disruptor to infant and toddler development, 00:16:34.740 --> 00:16:36.860 strictly due to sleep hygiene and chronic discomfort. 00:16:37.139 --> 00:16:39.000 It affects the whole family dynamic. That puts 00:16:39.000 --> 00:16:42.000 it in perspective. It's not just dry skin. quality 00:16:42.000 --> 00:16:44.740 of life issue that has real developmental consequences. 00:16:45.220 --> 00:16:47.340 Exactly. Let's slide down to the other inflammatory 00:16:47.340 --> 00:16:50.039 issue. Diaper dermatitis versus candidiasis. 00:16:50.240 --> 00:16:52.399 This is the battle of the diaper rashes. The 00:16:52.399 --> 00:16:54.980 common versus the east. Every parent deals with 00:16:54.980 --> 00:16:56.899 this at some point. How do I tell them apart 00:16:56.899 --> 00:17:00.139 visually? What's the key finding? Standard diaper 00:17:00.139 --> 00:17:03.159 dermatitis is usually erythema redness on the 00:17:03.159 --> 00:17:05.599 convex surfaces. Convex, so the parts that stick 00:17:05.599 --> 00:17:07.779 out. Exactly. The parts of the butt that touch 00:17:07.779 --> 00:17:11.299 the diaper. The cheeks. It spares the folds. 00:17:11.819 --> 00:17:14.740 Wait, it spares the folds? That seems odd. Usually, 00:17:14.900 --> 00:17:17.420 yes, because it's caused by friction and irritation 00:17:17.420 --> 00:17:20.140 from urine and stool. The folds are tucked away 00:17:20.140 --> 00:17:22.559 and protected from that direct contact. OK, so 00:17:22.559 --> 00:17:25.119 redness on the cheeks, but the creases look fine. 00:17:25.799 --> 00:17:28.180 And the treatment? Varioidments. We need to put 00:17:28.180 --> 00:17:30.779 a wall between the skin and the diaper. Zinc 00:17:30.779 --> 00:17:35.079 oxide, vitamin A, D, E, petrolatum. You slather 00:17:35.079 --> 00:17:37.220 it on like frosting on a cupcake. I like that 00:17:37.220 --> 00:17:39.769 visual. And you don't wipe it all off. You don't 00:17:39.769 --> 00:17:42.089 scrub it off fully with every change. You just 00:17:42.089 --> 00:17:44.329 clean the soiled part and add more frosting. 00:17:44.970 --> 00:17:47.690 Protect that barrier at all costs. Air time is 00:17:47.690 --> 00:17:49.930 also great. Let them run around without a diaper 00:17:49.930 --> 00:17:53.230 for a bit. OK, what about candidiasis, the yeast? 00:17:53.349 --> 00:17:55.490 How does that look different? Candidiasis loves 00:17:55.490 --> 00:17:58.490 the folds. It loves warm, dark, moist places. 00:17:58.869 --> 00:18:01.150 So if the redness is deep in the inguinal folds, 00:18:01.630 --> 00:18:03.910 you should suspect yeast. So it's the opposite 00:18:03.910 --> 00:18:06.500 of the standard rash. Exactly. And what's the 00:18:06.500 --> 00:18:08.839 hallmark visual finding? This sounds like a test 00:18:08.839 --> 00:18:12.079 question. It is. Satellite lesions. This is the 00:18:12.079 --> 00:18:14.519 buzzword. You have the main beefy red rash and 00:18:14.519 --> 00:18:16.579 then a little red dot scattered outside the main 00:18:16.579 --> 00:18:20.619 border. Like satellites orbiting a planet. If 00:18:20.619 --> 00:18:23.960 you see satellite lesions, it's yeast. And barrier 00:18:23.960 --> 00:18:26.880 cream won't fix yeast. Correct. You're just trapping 00:18:26.880 --> 00:18:28.859 the yeast under a layer of ointment. You need 00:18:28.859 --> 00:18:33.049 an antifungal. Neustatin or Clotrimazole. The 00:18:33.049 --> 00:18:35.349 source explicitly separates these because the 00:18:35.349 --> 00:18:37.549 treatment path is totally different. If you treat 00:18:37.549 --> 00:18:40.309 yeast with zinc oxide, it won't go away and the 00:18:40.309 --> 00:18:42.650 parents will be back in two days. Got it. Okay, 00:18:42.670 --> 00:18:45.289 let's graduate from babies to teenagers. Bucket 00:18:45.289 --> 00:18:50.210 three, hormonal patterns. Topic five, acne vulgaris. 00:18:50.390 --> 00:18:52.849 The adolescent rite of passage. The source material 00:18:52.849 --> 00:18:55.069 emphasizes that this is exclusively discussed 00:18:55.069 --> 00:18:57.329 in the context of adolescence. Which makes sense 00:18:57.329 --> 00:19:00.559 physiologically. Puberty hits, androgens, the 00:19:00.559 --> 00:19:02.740 male hormones, surge in both boys and girls. 00:19:03.240 --> 00:19:05.039 Those androgens tell the sebaceous glands to 00:19:05.039 --> 00:19:08.200 go into overdrive and you get acne. And developmentally, 00:19:08.279 --> 00:19:10.460 this is massive. This isn't just a cosmetic issue. 00:19:10.759 --> 00:19:14.019 It is absolutely not. Adolescence is all about 00:19:14.019 --> 00:19:17.279 identity formation, body image, and peer acceptance. 00:19:17.990 --> 00:19:20.509 Acne strikes right at the center of their vulnerability. 00:19:21.069 --> 00:19:23.049 A bad breakout can lead to social withdrawal, 00:19:23.269 --> 00:19:25.730 depression, anxiety. It's never just a pimple 00:19:25.730 --> 00:19:28.369 to a teenager. So how do we treat it? I see a 00:19:28.369 --> 00:19:30.250 treatment ladder here in the outline. Think of 00:19:30.250 --> 00:19:33.470 it as steps. We start mild and get heavier. Step 00:19:33.470 --> 00:19:36.890 one is hygiene. Gentle cleansing. Twice a day. 00:19:37.109 --> 00:19:40.269 The text says mild cleanser. Why not scrub it? 00:19:40.349 --> 00:19:42.549 I feel like the instinct is to scrub the grease 00:19:42.549 --> 00:19:44.730 off. That's the wrong instinct and it's a common 00:19:44.730 --> 00:19:47.390 mistake. Scrubbing irritates the skin, causes 00:19:47.390 --> 00:19:49.490 more inflammation, and can actually stimulate 00:19:49.490 --> 00:19:52.190 more oil production as a rebound effect. We want 00:19:52.190 --> 00:19:54.589 gentle cleansing to remove the surface oil without 00:19:54.589 --> 00:19:56.910 destroying the skin's natural barrier. Okay, 00:19:57.009 --> 00:20:00.329 so no harsh scrubs. Step two on the ladder. Topicals. 00:20:00.529 --> 00:20:02.529 We use retinoids like tretinoin to help turn 00:20:02.529 --> 00:20:05.410 over skin cells so pores don't clog, or benzoyl 00:20:05.410 --> 00:20:07.670 peroxide, which is an antibacterial agent, to 00:20:07.670 --> 00:20:10.109 kill the P. acnes bacteria that contributes to 00:20:10.109 --> 00:20:12.470 inflammation. So you're unclogging and killing 00:20:12.470 --> 00:20:15.069 bacteria at the same time. Ideally, yes. Sometimes 00:20:15.069 --> 00:20:17.789 we use them in combination. Step three. What 00:20:17.789 --> 00:20:20.150 if the topicals don't work? If topicals don't 00:20:20.150 --> 00:20:23.390 work, we add systemic antibiotics, the sourceless 00:20:23.390 --> 00:20:26.970 tetracycline. This is an oral pill to fight the 00:20:26.970 --> 00:20:28.829 infection and inflammation from the inside out. 00:20:29.089 --> 00:20:31.470 And if all that fails, the kid is still miserable, 00:20:31.690 --> 00:20:34.029 they're getting scars, we bring in the big guns. 00:20:35.150 --> 00:20:37.319 Isotretinoin. Brand name Accutane, though there 00:20:37.319 --> 00:20:40.819 are many generics now. This is reserved for severe, 00:20:41.119 --> 00:20:44.119 nodulacistic acne that is scarring and resistant 00:20:44.119 --> 00:20:46.039 to everything else. Alright, let's climb the 00:20:46.039 --> 00:20:48.140 ladder to the top rung. We've tried the special 00:20:48.140 --> 00:20:50.059 soaps, we've tried the creams, we've even done 00:20:50.059 --> 00:20:52.279 the oral antibiotics. The kid is still suffering. 00:20:52.500 --> 00:20:54.880 We bring in the nuclear option. Isotretinoin 00:20:54.880 --> 00:20:56.980 is a miracle drug for acne. I mean, it really 00:20:56.980 --> 00:20:59.299 can be life -changing. But it is the highest 00:20:59.299 --> 00:21:01.519 maintenance drug in dermatology. The source material 00:21:01.519 --> 00:21:05.599 highlights box 23 .2 for Accutane. Whenever a 00:21:05.599 --> 00:21:07.440 textbook puts a black box around something, I 00:21:07.440 --> 00:21:10.259 pay attention. What is the absolute red flag 00:21:10.259 --> 00:21:13.339 do not pass go risk here? Teratogenicity. Meaning 00:21:13.339 --> 00:21:16.759 birth defects. Severe life altering birth defects. 00:21:17.500 --> 00:21:20.319 If a female patient takes this drug while pregnant 00:21:20.319 --> 00:21:23.660 or becomes pregnant while on it, the fetal outcomes 00:21:23.660 --> 00:21:26.859 are catastrophic. Craniofacial abnormalities, 00:21:27.079 --> 00:21:30.720 heart defects, brain malformations, it is incompatible 00:21:30.720 --> 00:21:33.460 with a healthy pregnancy. Which leads to the 00:21:33.460 --> 00:21:36.420 IPLGG's program. I remember this being a huge 00:21:36.420 --> 00:21:38.299 logistical hurdle in the clinic. Can you explain 00:21:38.299 --> 00:21:41.059 what that is? It is, but it's necessary. You 00:21:41.059 --> 00:21:43.920 cannot just write a script. The patient, the 00:21:43.920 --> 00:21:45.839 provider who prescribes it, and the pharmacist 00:21:45.839 --> 00:21:48.099 who dispenses it all have to be registered in 00:21:48.099 --> 00:21:49.940 a federal database. Everyone has to be in the 00:21:49.940 --> 00:21:52.720 system. Yes. And clinically, what does that look 00:21:52.720 --> 00:21:54.599 like for the nurse? You aren't just asking, are 00:21:54.599 --> 00:21:56.799 you pregnant? No, I imagine it's more involved. 00:21:56.980 --> 00:21:59.609 Much more. You need proof. two negative pregnancy 00:21:59.609 --> 00:22:02.230 tests before you even start the first dose, a 00:22:02.230 --> 00:22:04.390 negative test every single month before a refill 00:22:04.390 --> 00:22:07.069 can be dispensed, and usually a requirement for 00:22:07.069 --> 00:22:09.170 two simultaneous forms of birth control. Two 00:22:09.170 --> 00:22:13.150 forms. So the pill plus condoms or an IUD plus 00:22:13.150 --> 00:22:17.430 condoms. Exactly. Redundancy is key. And here 00:22:17.430 --> 00:22:20.190 is where the art of nursing comes in. You are 00:22:20.190 --> 00:22:22.349 having this conversation with a 16 year old girl, 00:22:22.450 --> 00:22:24.789 maybe with her mom in the room. It can be awkward. 00:22:25.779 --> 00:22:28.099 Extremely. How do you navigate that? You have 00:22:28.099 --> 00:22:30.319 to be fearless and non -judgmental. You have 00:22:30.319 --> 00:22:32.740 to advocate for that safety protocol because 00:22:32.740 --> 00:22:35.839 the alternative is tragic. You explain the risks 00:22:35.839 --> 00:22:38.039 clearly, you assess their understanding, and 00:22:38.039 --> 00:22:40.619 you document everything. Is there a mental health 00:22:40.619 --> 00:22:42.359 component, too? I feel like I've heard about 00:22:42.359 --> 00:22:45.579 mood changes. There is. It's controversial in 00:22:45.579 --> 00:22:47.859 the data. Some studies show a link, some don't. 00:22:47.940 --> 00:22:50.559 But the protocols are clear. Monitor for depression 00:22:50.559 --> 00:22:54.670 and suicidal ideation. But isn't the acne itself 00:22:54.670 --> 00:22:56.970 causing depression? It is. That's the confounding 00:22:56.970 --> 00:22:59.549 variable. Does the drug cause depression or does 00:22:59.549 --> 00:23:01.690 the drug fail to relieve the depression caused 00:23:01.690 --> 00:23:04.509 by the acne fast enough? Regardless, our job 00:23:04.509 --> 00:23:07.190 is to monitor. So you are monitoring the skin, 00:23:07.450 --> 00:23:10.130 the womb, and the brain. Wow. It's a heavy -duty 00:23:10.130 --> 00:23:12.930 medication. It absolutely is. All right. We have 00:23:12.930 --> 00:23:15.529 arrived at the final bucket, the most critical 00:23:15.529 --> 00:23:18.309 section of this entire deep dive. If you are 00:23:18.309 --> 00:23:20.750 listening to this on your commute, turn the volume 00:23:20.750 --> 00:23:25.430 up. Bucket four. Trauma, specifically burns. 00:23:25.869 --> 00:23:28.109 This is the section where skin issues stop being 00:23:28.109 --> 00:23:30.890 dermatology and start being critical care. A 00:23:30.890 --> 00:23:33.690 severe burn is a full body insult. You called 00:23:33.690 --> 00:23:36.609 it systemic trauma earlier. But a burn is on 00:23:36.609 --> 00:23:39.390 the skin, why is it systemic? What's the mechanism? 00:23:39.690 --> 00:23:42.369 Because the skin does so much for us. It keeps 00:23:42.369 --> 00:23:44.490 fluids in, it keeps heat in, it keeps bacteria 00:23:44.490 --> 00:23:47.309 out. When you burn a large percentage of a child's 00:23:47.309 --> 00:23:50.109 body, all those systems fail at once. You lose 00:23:50.109 --> 00:23:52.150 fluid, you lose heat, you invite infection. But 00:23:52.150 --> 00:23:54.150 there's more to it than that, right? Much more. 00:23:54.589 --> 00:23:57.450 The burn releases a storm of inflammatory mediators, 00:23:57.670 --> 00:23:59.609 cytokines, that cause blood vessels all over 00:23:59.609 --> 00:24:01.809 the body to dilate and leak. So even if the burn 00:24:01.809 --> 00:24:04.460 is just on the legs? the blood vessels in the 00:24:04.460 --> 00:24:06.640 lungs or the arms might start leaking. Exactly. 00:24:06.839 --> 00:24:09.119 It's a systemic inflammatory response syndrome, 00:24:09.400 --> 00:24:12.480 or SIRS. The whole body is on fire, metaphorically. 00:24:12.759 --> 00:24:15.240 The outline gives us a very specific need -to 00:24:15.240 --> 00:24:17.519 -know list for emergency assessment priorities. 00:24:17.859 --> 00:24:20.920 It's the ABCs, but tailored for burns. Let's 00:24:20.920 --> 00:24:22.240 walk through them in order, because the order 00:24:22.240 --> 00:24:24.839 matters for the exam. Airway is always king. 00:24:25.299 --> 00:24:28.700 Always. But in burns, the threat is insidious. 00:24:29.000 --> 00:24:31.099 What do you mean by insidious? It's not obvious. 00:24:31.240 --> 00:24:34.049 Well, if a kid breaks their leg, The leg is broken, 00:24:34.130 --> 00:24:36.809 you can see it. In a burn, specifically with 00:24:36.809 --> 00:24:39.809 smoke inhalation, the damage is internal. You 00:24:39.809 --> 00:24:42.109 might look at the child and they seem fine, they 00:24:42.109 --> 00:24:44.450 were talking to you. But five minutes later, 00:24:44.650 --> 00:24:47.490 their airway has swollen shut due to edema from 00:24:47.490 --> 00:24:50.970 the heat and soot. That is terrifying. So what 00:24:50.970 --> 00:24:52.509 are the clues? If I can't see the swelling yet, 00:24:52.569 --> 00:24:54.170 what am I looking for? What are the red flags 00:24:54.170 --> 00:24:56.109 for airway involvement? You are looking for the 00:24:56.109 --> 00:24:58.890 evidence of the fire on the face, singed nasal 00:24:58.890 --> 00:25:01.150 hairs, soot around the mouth or in the sputum, 00:25:01.690 --> 00:25:04.390 burns on the neck or face, and listen to their 00:25:04.390 --> 00:25:07.750 voice. Any hoarseness is a major red flag. And 00:25:07.750 --> 00:25:11.430 if I see those, what's the move? You assume the 00:25:11.430 --> 00:25:13.470 airway is compromised until proven otherwise. 00:25:13.740 --> 00:25:16.299 You don't wait for them to start gasping or for 00:25:16.299 --> 00:25:19.319 their oxygen saturation to drop. We often intubate 00:25:19.319 --> 00:25:22.319 these kids prophylactically early. Better to 00:25:22.319 --> 00:25:24.720 intubate early than try to shove a tube through 00:25:24.720 --> 00:25:27.299 a swollen throat later. 100%. Once that airway 00:25:27.299 --> 00:25:29.759 swells, it can be impossible to get a tube in. 00:25:30.420 --> 00:25:32.440 So secure the airway. That's priority number 00:25:32.440 --> 00:25:35.160 one. Now once the airway is secure, we move to 00:25:35.160 --> 00:25:38.779 the other silent killer. Priority two, fluid 00:25:38.779 --> 00:25:41.619 volume. Hypovolemic shock. Right. And this is 00:25:41.619 --> 00:25:43.839 pure physics. The skin holds our water in. You 00:25:43.839 --> 00:25:45.900 burn the skin, the water evaporates. But it's 00:25:45.900 --> 00:25:47.740 worse than that. We talked about those leaky 00:25:47.740 --> 00:25:50.220 capillaries. Fluid rushes out of the blood vessels 00:25:50.220 --> 00:25:52.839 and into the tissue. We call this third spacing. 00:25:53.160 --> 00:25:56.400 So the patient looks puffy and swollen, but their 00:25:56.400 --> 00:25:59.099 blood vessels are empty. Exactly. It's a paradox. 00:25:59.200 --> 00:26:01.380 Yeah. They are demidus, but their blood pressure 00:26:01.380 --> 00:26:03.680 is tanking because the tank is empty. The heart 00:26:03.680 --> 00:26:06.000 has nothing to pump. This is burn shock. And 00:26:06.000 --> 00:26:07.940 kids are at higher risk for this than adults, 00:26:08.079 --> 00:26:11.400 right? Why is that? Yes. Kids have a larger body 00:26:11.400 --> 00:26:14.359 surface area relative to their weight. Think 00:26:14.359 --> 00:26:17.480 of a baby's head. It's huge compared to its body. 00:26:18.000 --> 00:26:20.660 They have more skin per pound, so they lose fluid 00:26:20.660 --> 00:26:23.640 much, much faster. This brings us to the Parkland 00:26:23.640 --> 00:26:25.980 formula. I know we aren't doing math on a podcast, 00:26:26.140 --> 00:26:28.779 but conceptually, what is the goal here? The 00:26:28.779 --> 00:26:31.980 goal is aggressive replacement. using lactated 00:26:31.980 --> 00:26:34.720 ringers. We are pouring fluids in to keep up 00:26:34.720 --> 00:26:37.200 with the leak. The formula gives you a target 00:26:37.200 --> 00:26:40.680 volume to infuse over 24 hours, with half of 00:26:40.680 --> 00:26:43.180 it going in during the first eight hours. But, 00:26:43.319 --> 00:26:45.880 and here's the pediatric nuance, you can't just 00:26:45.880 --> 00:26:48.339 open the fire hose. You absolutely cannot. Kids 00:26:48.339 --> 00:26:50.720 have tiny hearts and a fixed stroke volume. If 00:26:50.720 --> 00:26:52.640 you flood them with fluid too fast, you send 00:26:52.640 --> 00:26:54.680 them into pulmonary edema, you drown their lungs, 00:26:55.000 --> 00:26:56.839 it is a tightrope walk. So how do you know if 00:26:56.839 --> 00:26:58.759 you're giving the right amount? You titrate the 00:26:58.759 --> 00:27:00.859 fluids based on urine output. Urine output is 00:27:00.859 --> 00:27:03.880 the speedometer. Exactly. If they're making adequate 00:27:03.880 --> 00:27:06.059 urine, which for a child is about one milliliter 00:27:06.059 --> 00:27:08.539 per kilogram per hour, then the kidneys are happy. 00:27:08.809 --> 00:27:10.930 If the kidneys are happy, it means they're getting 00:27:10.930 --> 00:27:13.109 enough blood flow, which means the heart is pumping 00:27:13.109 --> 00:27:16.029 effectively. It's our best real -time indicator 00:27:16.029 --> 00:27:19.089 of organ perfusion. Okay. Airway, then fluids. 00:27:19.730 --> 00:27:23.069 Priority three. Hypothermia. Again, skin keeps 00:27:23.069 --> 00:27:25.930 us warm. A burned child has no insulation. They 00:27:25.930 --> 00:27:28.210 lose heat rapidly to the environment. And getting 00:27:28.210 --> 00:27:30.609 cold is bad for more than just comfort. It's 00:27:30.609 --> 00:27:33.150 deadly. If they get cold, their clotting factors 00:27:33.150 --> 00:27:35.200 stop working and they can start bleeding. Their 00:27:35.200 --> 00:27:37.200 metabolism crashes. You have to keep them warm. 00:27:37.480 --> 00:27:40.299 Crank the room heat. Use warm IV fluids. Use 00:27:40.299 --> 00:27:43.380 warming blankets. Priority four. Infection. The 00:27:43.380 --> 00:27:46.599 barrier is gone. Sepsis is a huge risk, but it's 00:27:46.599 --> 00:27:48.519 usually a later complication, not an immediate 00:27:48.519 --> 00:27:50.480 one. Right. This is why we use sterile technique 00:27:50.480 --> 00:27:53.079 for dressing changes and monitor for signs of 00:27:53.079 --> 00:27:55.720 infection down the line. And finally, the last 00:27:55.720 --> 00:27:58.680 two pieces. Pain management and nutrition. Pain 00:27:58.680 --> 00:28:01.599 is obvious. Burns are excruciating. We use IV 00:28:01.599 --> 00:28:04.759 opioids. Never IM injections in a burn patient. 00:28:04.859 --> 00:28:08.240 Why no IM shots? Because absorption is totally 00:28:08.240 --> 00:28:10.599 unpredictable in that edematous third spaced 00:28:10.599 --> 00:28:12.839 tissue. You might give a shot and it just sits 00:28:12.839 --> 00:28:14.779 there. Then suddenly it all gets absorbed at 00:28:14.779 --> 00:28:17.799 once. FOIVI is the only safe way. And nutrition. 00:28:18.220 --> 00:28:21.519 A major burn puts the body into a hyper metabolic 00:28:21.519 --> 00:28:24.660 state. The body is burning calories like crazy 00:28:24.660 --> 00:28:27.660 trying to heal and stay warm. They need massive 00:28:27.660 --> 00:28:30.690 nutritional support. high protein, high calorie, 00:28:31.049 --> 00:28:33.430 to rebuild that tissue. If you don't feed them, 00:28:33.650 --> 00:28:36.250 they won't heal. So for the exam, airway first, 00:28:36.589 --> 00:28:39.509 always, check for certs, singed hair, then fluids 00:28:39.509 --> 00:28:41.609 using the Parkland formula and watching urine 00:28:41.609 --> 00:28:44.769 output, then temperature, then later, infection, 00:28:44.970 --> 00:28:46.890 pain, and nutrition. That is your roadmap. Yeah. 00:28:47.029 --> 00:28:49.430 If a question asks what is the nurse's priority 00:28:49.430 --> 00:28:51.509 action for a child with facial burns, the answer 00:28:51.509 --> 00:28:55.279 is assess airway, not start an IV. Airway first. 00:28:55.599 --> 00:28:57.759 Got it. Okay, let's move into section C, the 00:28:57.759 --> 00:28:59.420 medication module. We've touched on some of these, 00:28:59.460 --> 00:29:01.740 but let's do a rapid fire review of the specific 00:29:01.740 --> 00:29:03.480 drugs mentioned in the source material. I want 00:29:03.480 --> 00:29:05.579 the Pearls, the specific nursing considerations. 00:29:05.599 --> 00:29:08.339 Let's do it. Category one, acne management. We 00:29:08.339 --> 00:29:10.440 talked about retinoids like tretinoin. What's 00:29:10.440 --> 00:29:13.500 the Pearl? The Pearl is photosensitivity and 00:29:13.500 --> 00:29:16.799 time. These take four to six weeks to work and 00:29:16.799 --> 00:29:19.740 they make the skin burn easily. Parent teaching. 00:29:20.599 --> 00:29:23.119 Wear sunscreen and don't give up after week one. 00:29:23.309 --> 00:29:26.910 It might get worse before it gets better. It 00:29:26.910 --> 00:29:29.970 bleaches everything. It bleaches towels, pillowcases, 00:29:30.109 --> 00:29:33.690 shirts. Tell the teen, use an old white towel, 00:29:34.029 --> 00:29:35.809 or your mom's gonna kill you for ruining the 00:29:35.809 --> 00:29:38.769 fancy linens. It's a real world tip that improves 00:29:38.769 --> 00:29:46.430 compliance. Used for resistant acne. The pearl 00:29:46.430 --> 00:29:48.609 here for pediatrics, and this is a general rule, 00:29:48.849 --> 00:29:51.720 is to be careful with age. Petrocyclins can stain 00:29:51.720 --> 00:29:54.259 developing teeth gray or yellow. Permanently. 00:29:54.519 --> 00:29:56.539 Permanently. So we usually reserve them for children 00:29:56.539 --> 00:29:58.819 over eight or nine years old, once the permanent 00:29:58.819 --> 00:30:01.180 teeth are fully calcified. OK, category two. 00:30:01.400 --> 00:30:04.359 Eczema management. Topical immunomodulators like 00:30:04.359 --> 00:30:07.279 Tacolimus. The plural is that it is a non -steroidal 00:30:07.279 --> 00:30:10.819 option. Great for faces. But it can burn or sting 00:30:10.819 --> 00:30:13.380 when first applied. You have to warn the parents 00:30:13.380 --> 00:30:15.240 so they don't think the child is having an allergic 00:30:15.240 --> 00:30:18.160 reaction to the medicine and stop using it. Topical 00:30:18.160 --> 00:30:21.519 steroids. Potency matters. Avoid the face and 00:30:21.519 --> 00:30:25.059 diaper area if possible, or use very low potency. 00:30:25.619 --> 00:30:28.480 Thin skin absorbs too much. The side effect to 00:30:28.480 --> 00:30:30.960 watch for long term is skin atrophy, which is 00:30:30.960 --> 00:30:34.599 thinning, and striae, or stretch marks. Antihistamines, 00:30:34.819 --> 00:30:37.759 like diphenhydramine or hydroxazine. Crucial 00:30:37.759 --> 00:30:40.240 distinction. Antihistamines treat the symptom, 00:30:40.440 --> 00:30:43.019 which is the itch, not the rash itself. They 00:30:43.019 --> 00:30:45.200 help the child sleep and break that itch scratch 00:30:45.200 --> 00:30:48.660 cycle. Side effect in kids. Sedation is common, 00:30:48.880 --> 00:30:51.160 but watch out for the paradoxical effect. Where 00:30:51.160 --> 00:30:52.920 they get hyper instead of sleeping. Exactly. 00:30:53.019 --> 00:30:54.579 Instead of calming down, they're bouncing off 00:30:54.579 --> 00:30:56.720 the walls. You need to warn parents that this 00:30:56.720 --> 00:30:59.279 can happen. Category three. Anti -infectives. 00:30:59.819 --> 00:31:02.220 Grizzofilvin. Oral antifungal for tinea capitis. 00:31:02.960 --> 00:31:06.259 The pearl is absorption. It is insoluble in water. 00:31:06.400 --> 00:31:08.599 It needs fat to be absorbed. So take it with 00:31:08.599 --> 00:31:12.259 what? A fatty meal. Whole milk. ice cream, peanut 00:31:12.259 --> 00:31:14.299 butter. If you give it with water or juice on 00:31:14.299 --> 00:31:15.960 an empty stomach, it won't work. The patient 00:31:15.960 --> 00:31:18.299 won't get better. That's a great tip. Take your 00:31:18.299 --> 00:31:20.180 medicine with ice cream. I bet compliance goes 00:31:20.180 --> 00:31:22.359 way up with that instruction. It definitely helps. 00:31:22.740 --> 00:31:26.640 And one other thing, you need to monitor liver 00:31:26.640 --> 00:31:29.539 enzymes, the LFTs, if they are on it for a long 00:31:29.539 --> 00:31:32.480 time, as it can be hepatotoxic. Good to know. 00:31:32.920 --> 00:31:35.819 OK, we are in the home stretch, section D, cross 00:31:35.819 --> 00:31:38.160 -linking and synthesis. Let's connect some dots 00:31:38.160 --> 00:31:40.420 here, bring it all together. The biggest connection 00:31:40.420 --> 00:31:43.420 I want listeners to make is the scratch infection 00:31:43.420 --> 00:31:45.839 cycle. Walk me through it. Connect the dots for 00:31:45.839 --> 00:31:47.640 me between the different buckets. OK, so we talked 00:31:47.640 --> 00:31:49.720 about eczema. That's an inflammatory condition. 00:31:49.920 --> 00:31:51.940 It itches, the child scratches. Now you have 00:31:51.940 --> 00:31:54.440 an open wound, a breach in the barrier, what 00:31:54.440 --> 00:31:57.460 lives on the skin? Staff bacteria. Staff bacteria. 00:31:57.839 --> 00:32:00.079 The staff gets in the open wound, and now you 00:32:00.079 --> 00:32:02.500 have impetigo, an infectious condition, on top 00:32:02.500 --> 00:32:04.640 of eczema. This is called a secondary infection. 00:32:04.799 --> 00:32:07.099 So treating the itch isn't just about comfort, 00:32:07.380 --> 00:32:10.079 it's about infection prevention. Exactly. Giving 00:32:10.079 --> 00:32:12.880 that antihistamine for the eczema prevents the 00:32:12.880 --> 00:32:16.039 scratch, which prevents the impetigo. It's all 00:32:16.039 --> 00:32:18.359 connected. You're treating the inflammation to 00:32:18.359 --> 00:32:20.420 prevent the infection. Another theme I'm seeing 00:32:20.420 --> 00:32:23.160 is the barrier theme. It keeps coming up. It's 00:32:23.160 --> 00:32:26.500 the central theme of pediatric dermatology. Whether 00:32:26.500 --> 00:32:28.980 it's dipodermatitis, where we use zinc oxide, 00:32:29.099 --> 00:32:31.579 or eczema, where we use aquaphor, or burns, where 00:32:31.579 --> 00:32:34.079 we use dressings, the nursing goal is always 00:32:34.079 --> 00:32:36.880 restoring the skin barrier. The skin is the castle 00:32:36.880 --> 00:32:39.660 wall. If the wall is breached, the enemy gets 00:32:39.660 --> 00:32:42.960 in. Our job is to patch the wall. And finally, 00:32:43.000 --> 00:32:45.200 let's talk about the adolescent compliance piece. 00:32:45.339 --> 00:32:47.759 This seems to cross over from acne to other things 00:32:47.759 --> 00:32:51.119 too. It's huge for acne. The treatments retinoids, 00:32:51.319 --> 00:32:54.519 antibiotics, require long -term daily compliance. 00:32:54.960 --> 00:32:57.319 But adolescents are developmentally notorious 00:32:57.319 --> 00:33:00.160 for poor compliance. They want instant results. 00:33:00.460 --> 00:33:02.339 And these things don't work instantly. Not at 00:33:02.339 --> 00:33:04.180 all. When the cream doesn't fix their face in 00:33:04.180 --> 00:33:06.799 two days, they stop using it. Or they get frustrated 00:33:06.799 --> 00:33:09.119 and use way too much and burn their face, and 00:33:09.119 --> 00:33:11.099 then they stop using it. So nursing care involves 00:33:11.099 --> 00:33:13.680 a lot of expectation management. It's more coaching 00:33:13.680 --> 00:33:16.240 than just giving instructions. Exactly. You have 00:33:16.240 --> 00:33:18.539 to say, this will take six weeks to see a difference. 00:33:18.700 --> 00:33:20.900 It might look worse before it looks better. You 00:33:20.900 --> 00:33:23.119 have to keep doing it every single day, even 00:33:23.119 --> 00:33:26.400 when you don't see results yet. Coaching the 00:33:26.400 --> 00:33:29.220 teen is just as important as writing the prescription. 00:33:29.880 --> 00:33:31.460 You have to treat them like a partner in their 00:33:31.460 --> 00:33:34.420 own care, not a child you're ordering around. 00:33:34.680 --> 00:33:36.740 This has been a fantastic run -through. Let's 00:33:36.740 --> 00:33:38.900 do the final tally. If you could only remember 00:33:38.900 --> 00:33:41.579 a few things from today for an exam, what are 00:33:41.579 --> 00:33:43.759 the big takeaways? Okay, the rapid -fire summary. 00:33:45.259 --> 00:33:48.640 Visuals. If you see Honeycrest, think in pedigo. 00:33:48.960 --> 00:33:51.660 If you see satellite lesions, think yeast. If 00:33:51.660 --> 00:33:54.200 you see a ring with a clear center, think Tina. 00:33:54.410 --> 00:33:57.029 Got it. Emergencies. If you see burns, think 00:33:57.029 --> 00:34:00.089 airway. Looking for singed hair or soot. And 00:34:00.089 --> 00:34:02.650 fluids. Thinking Quarklin formula and urine output. 00:34:02.849 --> 00:34:05.150 Those come first, before anything else. And meds. 00:34:05.230 --> 00:34:07.809 The big one. If you see Accutane or Isotretinoin, 00:34:07.930 --> 00:34:10.630 think safety. Think pregnancy prevention. And 00:34:10.630 --> 00:34:12.969 think mental health monitoring. Short, sweet, 00:34:13.110 --> 00:34:15.170 and saves lives. I want to leave the listeners 00:34:15.170 --> 00:34:17.349 with a final provocative thought. Something to 00:34:17.349 --> 00:34:20.230 chew on. Okay. We spend a lot of time looking 00:34:20.230 --> 00:34:24.059 at the surface. rashes, burns, pimples. But in 00:34:24.059 --> 00:34:26.980 pediatrics, the skin is just the messenger. My 00:34:26.980 --> 00:34:29.260 thought for you is specifically on burns. We 00:34:29.260 --> 00:34:31.860 treat the skin but the killer is often what we 00:34:31.860 --> 00:34:34.260 can't see. The insidious part you mentioned earlier? 00:34:34.480 --> 00:34:37.400 Exactly. It's the airway swelling shut inside 00:34:37.400 --> 00:34:39.860 the throat. It's the fluid leaking out of the 00:34:39.860 --> 00:34:42.900 vessels inside the body, causing shock. In pediatric 00:34:42.900 --> 00:34:45.619 burns, you must look past the surface immediately. 00:34:46.159 --> 00:34:48.139 Don't get distracted by the gore of the bulk 00:34:48.139 --> 00:34:51.179 itself. Focus on the invisible physiology that 00:34:51.179 --> 00:34:53.519 keeps them alive. That's where you'll save a 00:34:53.519 --> 00:34:56.159 life. That is a powerful place to end. Whether 00:34:56.159 --> 00:34:58.619 you are walking into an exam tomorrow or walking 00:34:58.619 --> 00:35:01.219 onto the unit, keep your eyes open, check that 00:35:01.219 --> 00:35:03.199 check engine light, and trust your assessment. 00:35:03.880 --> 00:35:05.639 Thanks for diving in with us. Good luck out there. 00:35:05.659 --> 00:35:06.940 It was a pleasure. See you next time.