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 --> 00:00:33.130 fast. Welcome to the emergency room. Welcome 00:00:33.130 --> 00:00:50.170 back to Deep Dive. Today we're opening up a topic 00:00:50.170 --> 00:00:52.770 that I think a lot of us, especially those outside 00:00:52.770 --> 00:00:55.310 pediatrics, tend to minimize. We were talking 00:00:55.310 --> 00:00:57.369 about the pediatric gastrointestinal system. 00:00:57.829 --> 00:01:00.090 And I know the instinct is to just think, OK, 00:01:00.170 --> 00:01:02.090 tummy aches, spitting up, maybe some constipation. 00:01:02.390 --> 00:01:05.170 But looking at the massive stack of research, 00:01:05.390 --> 00:01:07.329 nursing protocols, and case studies we have for 00:01:07.329 --> 00:01:09.870 today, that feels like a really dangerous oversimplification. 00:01:10.189 --> 00:01:12.709 Oh, it is a massive oversimplification. Yeah, 00:01:12.750 --> 00:01:15.590 in adult medicine, GI issues are often chronic 00:01:15.590 --> 00:01:19.109 inconveniences, things like GRD or IBS, things 00:01:19.109 --> 00:01:22.629 people just live with for decades. But in pediatrics 00:01:22.629 --> 00:01:24.819 specifically, in infants and toddlers, the GI 00:01:24.819 --> 00:01:27.060 system is literally the engine of growth. If 00:01:27.060 --> 00:01:29.459 the plumbing fails, the child doesn't just get 00:01:29.459 --> 00:01:31.319 a stomach ache. They stop growing their brain 00:01:31.319 --> 00:01:32.959 development stalls, and in several of the conditions 00:01:32.959 --> 00:01:34.420 we're covering today, they can actually go into 00:01:34.420 --> 00:01:37.260 shock and die within hours. Wow, so the stakes 00:01:37.260 --> 00:01:40.159 are just incredibly high. We're looking at a 00:01:40.159 --> 00:01:43.060 system that is literally folding itself into 00:01:43.060 --> 00:01:46.560 existence while the baby is growing. So our mission 00:01:46.560 --> 00:01:49.709 today is to take... this mountain of material, 00:01:49.989 --> 00:01:52.189 all these textbook chapters, surgical protocols, 00:01:52.370 --> 00:01:54.769 pharmacology guides, and distill it into what 00:01:54.769 --> 00:01:57.930 we call the Pareto 8020. Exactly. We want to 00:01:57.930 --> 00:02:00.849 identify that 20 % of the pathophysiology and 00:02:00.849 --> 00:02:03.870 clinical science that will answer 80 % of your 00:02:03.870 --> 00:02:06.170 exam questions. And honestly, more importantly, 00:02:06.409 --> 00:02:08.389 catch 80 % of the life -threatening events at 00:02:08.389 --> 00:02:10.830 the bedside. Right. And we have a ton of ground 00:02:10.830 --> 00:02:12.919 to cover. So we're going to start with a master 00:02:12.919 --> 00:02:15.080 map to sort of categorize these threats so you 00:02:15.080 --> 00:02:17.240 aren't just memorizing blind lists. Then we're 00:02:17.240 --> 00:02:19.659 going to do a deep dive into the specific disease 00:02:19.659 --> 00:02:22.379 processes. But here's the key shift for this 00:02:22.379 --> 00:02:24.900 deep dive. We aren't just doing the biology. 00:02:25.120 --> 00:02:27.500 We are cross -referencing every single disease 00:02:27.500 --> 00:02:30.139 with the child's developmental stage. Which is 00:02:30.139 --> 00:02:32.280 completely non -negotiable. I mean, you cannot 00:02:32.280 --> 00:02:34.780 treat a three -week -old with pyloric stenosis 00:02:34.780 --> 00:02:36.560 the exact same way you treat a 14 -year -old 00:02:36.560 --> 00:02:39.639 with celiac disease. The actual science might 00:02:39.639 --> 00:02:41.500 be straightforward, but the patient changes the 00:02:41.500 --> 00:02:44.439 entire game. Totally. And finally, we will hit 00:02:44.439 --> 00:02:47.020 the pharmacology module, looking specifically 00:02:47.020 --> 00:02:49.340 at the mechanism of action and the safety traps 00:02:49.340 --> 00:02:51.879 for little bodies. Just a quick reminder before 00:02:51.879 --> 00:02:55.060 we really jump in, we are impartial synthesizers 00:02:55.060 --> 00:02:56.900 of the medical texts provided today. We're here 00:02:56.900 --> 00:02:59.000 to help you understand the logic behind the medicine, 00:02:59.360 --> 00:03:01.960 not to provide medical advice for your specific 00:03:01.960 --> 00:03:04.740 situation. Right. So let's get into the plumbing. 00:03:04.919 --> 00:03:07.780 Yes. Section A, the master map. When I first 00:03:07.780 --> 00:03:09.599 opened these files, I was just hit with a wall 00:03:09.599 --> 00:03:12.699 of Latin. Intuse deception, volvulus atresia. 00:03:12.819 --> 00:03:16.020 It feels incredibly chaotic. How do we organize 00:03:16.020 --> 00:03:17.860 this mentally so that when you see a symptom, 00:03:17.900 --> 00:03:19.800 you know exactly which bucket you're playing 00:03:19.800 --> 00:03:22.740 in? The best way to approach pediatric GI is 00:03:22.740 --> 00:03:24.879 to just stop thinking about individual organs 00:03:24.879 --> 00:03:27.039 and start thinking about patterns. There are 00:03:27.039 --> 00:03:29.580 really only four main ways the GI system breaks 00:03:29.580 --> 00:03:32.819 in a catastrophic way. If you recognize the pattern, 00:03:33.080 --> 00:03:35.219 the intervention usually reveals itself pretty 00:03:35.219 --> 00:03:37.159 fast. OK, walk me through that first bucket, 00:03:37.300 --> 00:03:39.199 because this seems to be the most critical one 00:03:39.199 --> 00:03:41.360 based on the notes. Yeah, the first bucket is 00:03:41.360 --> 00:03:44.639 the extractive emergencies. This is the something 00:03:44.639 --> 00:03:47.500 is blocked pattern. The plumbing is literally 00:03:47.500 --> 00:03:51.539 clogged. This includes hypertrophic pyloric stenosis, 00:03:51.819 --> 00:03:54.900 intestiception, malrotation, and volvulus. So 00:03:54.900 --> 00:03:57.139 basically, food goes in, but it just can't get 00:03:57.139 --> 00:03:58.759 through. Correct. And because it can't get through, 00:03:58.780 --> 00:04:01.599 it comes back up. But here is the single most 00:04:01.599 --> 00:04:03.800 important decision point in all of pediatric 00:04:03.800 --> 00:04:06.840 GI. If you take nothing else away from this whole 00:04:06.840 --> 00:04:08.659 deep dive, take this. You have to look at the 00:04:08.659 --> 00:04:11.319 vomit. We're getting gross immediately. I love 00:04:11.319 --> 00:04:14.560 it. What exactly are we looking for? Color. Specifically, 00:04:14.680 --> 00:04:16.959 is it bilious or non -bilious? Break that down 00:04:16.959 --> 00:04:20.500 for us. Non -bilious implies what? Non -bilius 00:04:20.500 --> 00:04:22.939 vomit looks like milk or formula or whatever 00:04:22.939 --> 00:04:25.740 the kid just ate. It might be curdled from stomach 00:04:25.740 --> 00:04:28.459 acid, but it is white, yellow, or clear. This 00:04:28.459 --> 00:04:31.139 tells you the blockage is high up. It's above 00:04:31.139 --> 00:04:33.939 the ampulla of Vader, which is the specific point 00:04:33.939 --> 00:04:37.040 where bile enters the intestine. If you see non 00:04:37.040 --> 00:04:39.759 -bilius projectile vomiting, you're almost certainly 00:04:39.759 --> 00:04:42.680 looking at pyloric stenosis. OK. And if it is 00:04:42.680 --> 00:04:45.779 bilious? Bilious means green. And not a subtle 00:04:45.779 --> 00:04:48.860 yellowish -green, but bright lime -gatorade green. 00:04:49.480 --> 00:04:51.740 This means the blockage is below the bile duct. 00:04:52.220 --> 00:04:54.060 Bile is being dumped into the gut, hitting a 00:04:54.060 --> 00:04:56.660 physical wall, and reversing course. In a newborn 00:04:56.660 --> 00:04:59.240 or an infant, green vomiting is a surgical emergency 00:04:59.240 --> 00:05:02.519 until proven otherwise. It screams volvulus or 00:05:02.519 --> 00:05:04.500 intussusception. So if I'm understanding this 00:05:04.500 --> 00:05:06.579 right, nonbilious is a fix -it -soon kind of 00:05:06.579 --> 00:05:09.040 problem, but green means fix it right now. Green 00:05:09.040 --> 00:05:11.300 means run, do not walk. Because volvulus where 00:05:11.300 --> 00:05:13.180 the bowel physically twists on itself can kill 00:05:13.180 --> 00:05:15.839 the entire gut in a matter of hours due to strangulation 00:05:15.839 --> 00:05:18.439 of the blood supply, it's ischemic. Terrifying. 00:05:18.540 --> 00:05:20.779 Okay, what's bucket number two? Missing parts 00:05:20.779 --> 00:05:23.160 or missing nerves. These are your congenital 00:05:23.160 --> 00:05:25.639 defects. The blueprint was just wrong from the 00:05:25.639 --> 00:05:28.310 start. We're talking Hirschsprung disease, biliary 00:05:28.310 --> 00:05:31.069 atresia, imperforate anus esophageal atresia. 00:05:31.370 --> 00:05:33.050 This feels like it would be super obvious right 00:05:33.050 --> 00:05:35.709 at birth, right? Usually, yes. The assessment 00:05:35.709 --> 00:05:38.089 priority here is the newborn period. The clock 00:05:38.089 --> 00:05:40.750 starts ticking right at delivery. The big question 00:05:40.750 --> 00:05:43.310 is, did they pass meconium in the first 24 to 00:05:43.310 --> 00:05:46.410 48 hours? If they didn't, we start worrying about 00:05:46.410 --> 00:05:49.870 Hirschsprung's or maybe cystic fibrosis. Or is 00:05:49.870 --> 00:05:52.790 their jaundice persisting way past two weeks? 00:05:53.189 --> 00:05:56.079 Then we worry about biliary atresia. Got it. 00:05:56.139 --> 00:05:58.959 I'll get three. Absorption failures. The plumbing 00:05:58.959 --> 00:06:01.319 works. Technically, things move through just 00:06:01.319 --> 00:06:03.699 fine. But the absorption factory is shut down. 00:06:04.060 --> 00:06:06.899 Celiac disease, cystic fibrosis, short bowel 00:06:06.899 --> 00:06:09.420 syndrome. So the kid is eating, but basically 00:06:09.420 --> 00:06:11.560 starving. Exactly. The food passes right through 00:06:11.560 --> 00:06:14.100 them. The key indicators here are failure to 00:06:14.100 --> 00:06:16.339 thrive, where you see the growth chart just completely 00:06:16.339 --> 00:06:18.899 flatten out, and steteria. Steteria, that's the 00:06:18.899 --> 00:06:21.920 fatty stool, right? Yeah. Because the gut isn't 00:06:21.920 --> 00:06:24.199 absorbing fat. It just comes out in the poop. 00:06:24.430 --> 00:06:27.670 It's pale. It's bulky. It's incredibly fable 00:06:27.670 --> 00:06:30.970 smelling. And it floats. If you see floating 00:06:30.970 --> 00:06:33.149 poop in a really skinny kid, you need to think 00:06:33.149 --> 00:06:35.709 malabsorption. And the final bucket. Surgical 00:06:35.709 --> 00:06:39.029 inflammations, appendicitis and mechel diverticulum. 00:06:39.470 --> 00:06:42.029 This is less about pure mechanics and more about 00:06:42.029 --> 00:06:44.829 infection and inflammation. The key pattern you'll 00:06:44.829 --> 00:06:47.829 see here is pain migration. It starts vague and 00:06:47.829 --> 00:06:50.269 moves to a very specific spot. Okay, that framework 00:06:50.269 --> 00:06:53.290 helps immensely. Obstructive congenital malabsorption 00:06:53.290 --> 00:06:55.750 and inflammation. Now I want to go really deep. 00:06:56.069 --> 00:06:58.089 Let's start with the condition that seems to 00:06:58.089 --> 00:07:01.649 be the classic exam topic. Hypertrophic pyloric 00:07:01.649 --> 00:07:04.850 stenosis. Ah yes, the case of the hungry vomitor. 00:07:04.990 --> 00:07:07.149 Let's start with the physiology. We know it's 00:07:07.149 --> 00:07:09.189 a blockage, but what is actually happening to 00:07:09.189 --> 00:07:11.629 the stomach itself? So the pylorus is a circular 00:07:11.629 --> 00:07:13.850 muscle that acts as a valve between the stomach 00:07:13.850 --> 00:07:16.129 and the duodenum, which is that first part of 00:07:16.129 --> 00:07:18.410 the small intestine. In these infants, for reasons 00:07:18.410 --> 00:07:20.529 we don't fully understand, though there's definitely 00:07:20.529 --> 00:07:23.350 a genetic component that muscle starts to hypertrophy, 00:07:23.389 --> 00:07:25.850 it gets really thick. Like a bodybuilder muscle. 00:07:26.209 --> 00:07:29.189 Exactly like it bulks up. And as it bulks inward, 00:07:29.329 --> 00:07:32.029 the actual channel gets narrower and narrower. 00:07:32.550 --> 00:07:34.990 It typically starts causing symptoms around three 00:07:34.990 --> 00:07:38.019 to five weeks of life. And that is a key detail 00:07:38.019 --> 00:07:40.959 for exams. Babies aren't usually born vomiting 00:07:40.959 --> 00:07:43.120 with this. They're totally fine for a few weeks, 00:07:43.160 --> 00:07:45.079 and then this muscle grows enough to just shut 00:07:45.079 --> 00:07:48.240 the door. So the door slams shut, the baby eats, 00:07:48.399 --> 00:07:50.379 the stomach fills up, and then what? Physics 00:07:50.379 --> 00:07:53.029 takes over. The stomach is a muscle, too, and 00:07:53.029 --> 00:07:55.649 it tries to push against that closed door. It 00:07:55.649 --> 00:07:58.790 contracts harder and harder. We call that hyperparastalsis. 00:07:59.129 --> 00:08:01.370 You can sometimes even see the waves on the baby's 00:08:01.370 --> 00:08:03.569 belly. Eventually, the pressure gets so high 00:08:03.569 --> 00:08:05.990 that the milk is violently ejected. And we use 00:08:05.990 --> 00:08:08.670 the word projectile very literally here. We are 00:08:08.670 --> 00:08:10.589 talking three to four feet across the room. That 00:08:10.589 --> 00:08:12.670 is just violent. It's incredibly violent. And 00:08:12.670 --> 00:08:15.110 remember our map. It is non bilious. The milk 00:08:15.110 --> 00:08:17.170 never made it past the pylorus to the bile duct. 00:08:17.449 --> 00:08:19.189 One of the most famous findings in textbooks 00:08:19.189 --> 00:08:22.569 is the olive. Can we talk about the reality of 00:08:22.569 --> 00:08:25.269 finding this olive -shaped mass? Yeah, the elusive 00:08:25.269 --> 00:08:29.250 olive. The textbook says you can palpate an olive 00:08:29.250 --> 00:08:31.850 -shaped mass in the right upper quadrant. This 00:08:31.850 --> 00:08:35.450 is the thickened muscle itself. But here is the 00:08:35.450 --> 00:08:39.049 absolute clinical reality. Have you ever tried 00:08:39.049 --> 00:08:41.450 to push on the belly of a screaming, vomiting, 00:08:41.730 --> 00:08:43.909 starving four -week -old? I imagine their abs 00:08:43.909 --> 00:08:46.889 are just rock hard from crying. Right. The rectus 00:08:46.889 --> 00:08:49.470 muscles are totally tense. If the baby is crying, 00:08:49.529 --> 00:08:51.610 you will never, ever feel the olive. You have 00:08:51.610 --> 00:08:53.929 to wait for them to relax. Maybe give them a 00:08:53.929 --> 00:08:56.009 pacifier or some sugar water. Flex their knees 00:08:56.009 --> 00:08:58.570 up. It requires a lot of patience. If you feel 00:08:58.570 --> 00:09:00.389 it, great. It's diagnostic. If you don't, you 00:09:00.389 --> 00:09:02.210 just send them for an ultrasound. Now, I want 00:09:02.210 --> 00:09:04.850 to unpack the chemistry here because the text 00:09:04.850 --> 00:09:09.059 emphasizes metabolic alcohol. This is a huge 00:09:09.059 --> 00:09:11.279 exam concept, but I feel like people just memorize 00:09:11.279 --> 00:09:13.639 the phrase without understanding it. Walk us 00:09:13.639 --> 00:09:15.139 through the why. Okay, let's do the chemistry. 00:09:15.600 --> 00:09:18.120 The stomach is full of hydrochloric acid, HCl, 00:09:18.360 --> 00:09:20.399 that's hydrogen, which is the H +, and chloride, 00:09:20.500 --> 00:09:23.940 the Cl -. When a baby has pyloric stenosis, they 00:09:23.940 --> 00:09:26.519 are vomiting out that acid constantly. So they 00:09:26.519 --> 00:09:29.279 are losing hydrogen. Right. Hydrogen is acidic. 00:09:29.580 --> 00:09:31.720 If you lose acid, your body naturally becomes 00:09:31.720 --> 00:09:34.539 basic or alkalotic. That's step one. But there's 00:09:34.539 --> 00:09:37.039 a second hit here. They are also losing chloride. 00:09:38.019 --> 00:09:40.620 When the body loses chloride, the kidneys get 00:09:40.620 --> 00:09:43.200 stressed trying to compensate to keep the electrical 00:09:43.200 --> 00:09:46.200 charge balanced. So to save fluids, the kidneys 00:09:46.200 --> 00:09:48.879 hold onto bicarbonate, which is HCO3, and that 00:09:48.879 --> 00:09:51.360 is a base. So you're losing acid through the 00:09:51.360 --> 00:09:52.919 mouth and holding onto base through the kidneys. 00:09:53.059 --> 00:09:56.940 Exactly. It's a double whammy. You get a hypokalemic 00:09:56.940 --> 00:10:00.710 metabolic alkalosis. And here is why this matters 00:10:00.710 --> 00:10:03.070 so much for the nurse. You cannot send this kid 00:10:03.070 --> 00:10:05.220 to surgery yet. Wait, really? But they have a 00:10:05.220 --> 00:10:06.860 mechanical blockage. Don't they need the muscle 00:10:06.860 --> 00:10:10.059 cut? They do eventually. But if you put a baby 00:10:10.059 --> 00:10:12.919 with severe metabolic alkalosis under general 00:10:12.919 --> 00:10:15.259 anesthesia, they will likely stop breathing. 00:10:15.379 --> 00:10:18.240 Why? Because of respiratory compensation. If 00:10:18.240 --> 00:10:20.039 your blood is too basic, your brain tells your 00:10:20.039 --> 00:10:21.879 lungs to slow down. It says, hey, hold your breath. 00:10:22.000 --> 00:10:23.799 Keep the CO2 in to balance the blood, because 00:10:23.799 --> 00:10:27.399 CO2 is an acid. So these babies are already hypoventilating 00:10:27.399 --> 00:10:30.240 to compensate for the vomiting. If you give them 00:10:30.240 --> 00:10:32.519 anesthesia, which also depresses respiration, 00:10:32.580 --> 00:10:34.490 you might never get them back. Wow. that is a 00:10:34.490 --> 00:10:37.409 massive safety flag. So the need to know priority 00:10:37.409 --> 00:10:40.149 isn't the surgery at all. No, the immediate priority 00:10:40.149 --> 00:10:43.429 is fluid and electrolyte resuscitation. You absolutely 00:10:43.429 --> 00:10:46.049 have to fix the pH and the dehydration first. 00:10:46.750 --> 00:10:49.610 The surgery, the pilaromyotomy is not an emergency. 00:10:49.889 --> 00:10:52.370 The dehydration is the emergency. Let's cross 00:10:52.370 --> 00:10:53.870 -reference this with development. We're talking 00:10:53.870 --> 00:10:56.289 about a four -week -old infant. Erickson's stage 00:10:56.289 --> 00:10:59.740 here is... Trust versus mistrust. And this is 00:10:59.740 --> 00:11:02.059 just heartbreaking to watch. The primary way 00:11:02.059 --> 00:11:04.139 an infant builds trust is through the feeding 00:11:04.139 --> 00:11:07.759 cycle. I feel hunger pain. I cry. My parent feeds 00:11:07.759 --> 00:11:10.600 me. The pain goes away. That is the entire foundation 00:11:10.600 --> 00:11:12.580 of human trust for them. And here that cycle 00:11:12.580 --> 00:11:15.080 is totally broken. Completely shattered. The 00:11:15.080 --> 00:11:17.419 baby feels hunger. They eat. They vomit violently, 00:11:17.539 --> 00:11:19.779 which is painful and scary. And then they are 00:11:19.779 --> 00:11:22.409 immediately starving again. They are often described 00:11:22.409 --> 00:11:24.809 in charts as fussy or irritable, but really they 00:11:24.809 --> 00:11:27.049 are just frantic. So what does the bedside nurse 00:11:27.049 --> 00:11:30.190 do? Well, you have to cluster your care to minimize 00:11:30.190 --> 00:11:33.169 stress so they can rest. But you also really 00:11:33.169 --> 00:11:35.370 have to manage the parents. The parents feel 00:11:35.370 --> 00:11:38.250 like massive failures. They are trying to feed 00:11:38.250 --> 00:11:40.070 their child and the child is basically rejecting 00:11:40.070 --> 00:11:42.549 it. You have to explicitly teach them this is 00:11:42.549 --> 00:11:45.210 mechanical. This is not your technique. You're 00:11:45.210 --> 00:11:47.549 doing a good job. It's just a blocked pipe. That's 00:11:47.549 --> 00:11:49.789 great context. Let's move down the GI track to 00:11:49.789 --> 00:11:53.870 the next obstruction. into suception. The intermittent 00:11:53.870 --> 00:11:56.549 screamer. This one fascinates me because of the 00:11:56.549 --> 00:12:00.129 mechanics. The notes describe it as telescoping 00:12:00.129 --> 00:12:02.750 bow. Yeah, imagine you are closing a collapsible 00:12:02.750 --> 00:12:05.649 telescope or an old -school radio antenna. One 00:12:05.649 --> 00:12:07.870 segment slides right inside the other. That is 00:12:07.870 --> 00:12:09.710 exactly what the intestine does. Usually it's 00:12:09.710 --> 00:12:12.470 the small intestine sliding into the large intestine 00:12:12.470 --> 00:12:14.889 right at the cecum. What happens to the tissue 00:12:14.889 --> 00:12:16.789 when it slides inside itself like that? It's 00:12:16.789 --> 00:12:18.990 a complete disaster. The blood vessels get dragged 00:12:18.990 --> 00:12:22.289 in with it. The veins get compressed first because 00:12:22.289 --> 00:12:25.230 they are floppier. So blood can get in via the 00:12:25.230 --> 00:12:27.549 arteries, but it can't drain out. The bowel just 00:12:27.549 --> 00:12:30.210 swells up like a balloon. Eventually that swelling 00:12:30.210 --> 00:12:32.700 cuts off the arterial blood supply too. And that 00:12:32.700 --> 00:12:35.600 means necrosis. Ischemia, necrosis, perforation, 00:12:35.740 --> 00:12:37.980 and then sepsis. The symptom presentation here 00:12:37.980 --> 00:12:39.860 is really specific, and I can see how it's very 00:12:39.860 --> 00:12:44.019 confusing for parents. You mentioned paroxysmal 00:12:44.019 --> 00:12:47.259 pain. This is the absolute hallmark. The child, 00:12:47.580 --> 00:12:50.179 usually a toddler, maybe 18 months old, will 00:12:50.179 --> 00:12:53.019 be playing with blocks. Suddenly out of nowhere, 00:12:53.620 --> 00:12:56.179 they scream, they draw their knees up to their 00:12:56.179 --> 00:12:58.279 chest, and look like they're dying. It lasts 00:12:58.279 --> 00:13:01.379 for a minute or two. Then the bowel relaxes slightly, 00:13:01.500 --> 00:13:03.879 the pain stops, and the kid just gets up and 00:13:03.879 --> 00:13:06.220 goes back to playing with blocks. That is the 00:13:06.220 --> 00:13:08.419 gaslighting part. The parents probably think, 00:13:08.440 --> 00:13:10.519 oh, maybe it was just bad gas, because 10 minutes 00:13:10.519 --> 00:13:12.679 later, the kid looks totally fine. Exactly. So 00:13:12.679 --> 00:13:15.509 they wait and wait. Meanwhile, the bowel is dying 00:13:15.509 --> 00:13:18.350 inside. Eventually, those play periods get shorter 00:13:18.350 --> 00:13:20.970 and the scream periods get much longer. Let's 00:13:20.970 --> 00:13:22.789 talk about the current jelly stool. That sounds 00:13:22.789 --> 00:13:25.730 like a classic textbook term. What does it actually 00:13:25.730 --> 00:13:28.350 look like in practice? It looks like dark red 00:13:28.350 --> 00:13:31.230 mucus. It's not a normal formed poop at all. 00:13:31.269 --> 00:13:34.389 It is literally the sliffing off of the mucosal 00:13:34.389 --> 00:13:37.250 lining of the gut mixed with blood. If you see 00:13:37.250 --> 00:13:39.350 this, the damage is already quite significant. 00:13:39.929 --> 00:13:42.129 Diagnosis and treatment are often the exact same 00:13:42.129 --> 00:13:45.409 thing here, right? The air enema. Yes, this is 00:13:45.409 --> 00:13:48.429 high drama radiology. They insert a tube into 00:13:48.429 --> 00:13:51.289 the rectum and pump air, or sometimes a contrast 00:13:51.289 --> 00:13:54.250 fluid in. The actual pressure of the air pushes 00:13:54.250 --> 00:13:57.009 the telescope bowel back out. It unfolds it. 00:13:57.129 --> 00:13:59.730 Sounds kind of risky. Oh, it is. There is a real 00:13:59.730 --> 00:14:02.710 risk of perforating the weakened bowel. The pediatric 00:14:02.710 --> 00:14:05.009 surgeon is usually standing right nearby just 00:14:05.009 --> 00:14:07.309 in case they need to rush to the OR. But when 00:14:07.309 --> 00:14:09.679 it works... It is instant relief. Is there an 00:14:09.679 --> 00:14:13.539 exam trap here? A huge one. Imagine you are prepping 00:14:13.539 --> 00:14:15.639 the child for the enema or surgery. They've been 00:14:15.639 --> 00:14:18.340 NPO, they've got their IV. Suddenly the child 00:14:18.340 --> 00:14:21.019 passes a normal brown stool. That seems like 00:14:21.019 --> 00:14:23.679 really good news. It is the best news. It means 00:14:23.679 --> 00:14:27.320 the bowel spontaneously fixed itself. It untelescoped. 00:14:27.360 --> 00:14:29.600 You must notify the provider immediately because 00:14:29.600 --> 00:14:32.299 you can cancel the procedure. Do not send a kid 00:14:32.299 --> 00:14:34.720 to surgery who just fix themselves. Let's look 00:14:34.720 --> 00:14:36.960 at the developmental impact. We're dealing with 00:14:36.960 --> 00:14:40.080 toddlers one to three years old. Autonomy versus 00:14:40.080 --> 00:14:43.919 shame and doubt. Toddlers are absolute control 00:14:43.919 --> 00:14:46.340 freaks. They are just learning to control their 00:14:46.340 --> 00:14:49.639 own bodies, right? Walking, feeding themselves, 00:14:49.840 --> 00:14:52.820 potty training, hospitalization strips all of 00:14:52.820 --> 00:14:54.919 that control away. You strap them down for an 00:14:54.919 --> 00:14:57.080 IV, you take away their food, you poke them with 00:14:57.080 --> 00:14:59.340 needles. You'll see regression. Almost 100 % 00:14:59.340 --> 00:15:02.159 of the time. A potty trained toddler will start 00:15:02.159 --> 00:15:04.639 wetting the bed again. A kid who speaks in full 00:15:04.639 --> 00:15:07.440 sentences might revert to just pointing and grunting. 00:15:07.620 --> 00:15:09.480 How does a nurse handle that? Do we correct them? 00:15:09.600 --> 00:15:12.279 Never. You reassure the parents, you tell them 00:15:12.279 --> 00:15:14.179 this is a normal coping mechanism and it will 00:15:14.179 --> 00:15:16.899 pass once they go home. And critically, you try 00:15:16.899 --> 00:15:19.960 to give the toddler choices where no real choices 00:15:19.960 --> 00:15:21.759 exist. Like, do you want the red Band -Aid or 00:15:21.759 --> 00:15:23.220 the blue one? Do you want to take your medicine 00:15:23.220 --> 00:15:25.679 from a cup or a syringe? Give them back just 00:15:25.679 --> 00:15:28.100 a tiny sliver of autonomy. That makes so much 00:15:28.100 --> 00:15:30.340 sense. Okay, let's move to the congenital missing 00:15:30.340 --> 00:15:33.899 parts bucket. Hirschsprung disease. Congenital 00:15:33.899 --> 00:15:36.720 aganglionic megacolon. Let's break that down 00:15:36.720 --> 00:15:40.889 word by word. Aganglionic. So during embryology, 00:15:41.230 --> 00:15:43.169 neural crest cells, which are the cells that 00:15:43.169 --> 00:15:45.690 will eventually become nerves, migrate down the 00:15:45.690 --> 00:15:48.350 gut tube from the mouth all the way down to the 00:15:48.350 --> 00:15:51.490 anus. In hersprungs, they basically get tired 00:15:51.490 --> 00:15:54.350 and stop before they reach the very end. So that 00:15:54.350 --> 00:15:56.909 bottom segment of the colon has absolutely no 00:15:56.909 --> 00:16:00.129 nerves. And no nerves means no signal to squeeze. 00:16:00.450 --> 00:16:02.669 Correct. No peristalsis. The sphincter just stays 00:16:02.669 --> 00:16:05.590 clamped shut. Stool comes down, hits this dead 00:16:05.590 --> 00:16:08.210 zone, and piles up. It's a massive traffic jam. 00:16:08.519 --> 00:16:11.240 The colon above the jam stretches out immensely, 00:16:11.360 --> 00:16:13.580 and that's your mega colon. In a newborn, this 00:16:13.580 --> 00:16:16.600 presents as a failure to pass meconium. But what 00:16:16.600 --> 00:16:18.940 if it's a short segment defect and they aren't 00:16:18.940 --> 00:16:20.600 diagnosed until they are, say, six years old? 00:16:20.820 --> 00:16:22.279 What does that look like? These are the kids 00:16:22.279 --> 00:16:25.200 with chronic, severe, lifelong constipation. 00:16:25.600 --> 00:16:27.399 And their stools are often described as ribbon 00:16:27.399 --> 00:16:30.259 -like. Why ribbons? Because the only way poop 00:16:30.259 --> 00:16:32.519 can get through that tight clamped down nerve 00:16:32.519 --> 00:16:35.200 dead segment is to be squeezed completely flat. 00:16:35.259 --> 00:16:37.940 It looks like a linguine. And it smells incredibly 00:16:37.940 --> 00:16:39.720 foul because it has been sitting in the colon 00:16:39.720 --> 00:16:42.480 fermenting for weeks. There is a really specific 00:16:42.480 --> 00:16:44.580 physical exam finding mentioned in the notes. 00:16:45.039 --> 00:16:46.919 The squirt sign. It's exactly what it sounds 00:16:46.919 --> 00:16:49.639 like. When the doctor does a digital rectal exam, 00:16:50.120 --> 00:16:53.159 the finger momentarily dilates that tight sphincter. 00:16:53.559 --> 00:16:56.610 When they pull the finger out, the pressure releases 00:16:56.610 --> 00:16:59.690 and you get an explosive release of trapped gas 00:16:59.690 --> 00:17:02.169 and liquid stool. The dangerous complication 00:17:02.169 --> 00:17:05.619 here is enterocolitis. Why is this the killer 00:17:05.619 --> 00:17:08.180 for Hirschsprungs? When stool sits in the colon 00:17:08.180 --> 00:17:10.740 for too long, bacteria overgrow aggressively. 00:17:11.240 --> 00:17:13.519 The bowel wall gets inflamed and starts to break 00:17:13.519 --> 00:17:16.000 down. Those bacteria can then cross the wall 00:17:16.000 --> 00:17:18.720 into the bloodstream. If a Hirschsprung kid suddenly 00:17:18.720 --> 00:17:20.960 spikes a high fever and has explosive bowel diarrhea, 00:17:21.079 --> 00:17:24.319 that is not a stomach bug. That is sepsis. It 00:17:24.319 --> 00:17:27.039 is a code level emergency. Developmental impact 00:17:27.039 --> 00:17:30.420 for a school -aged child. Industry versus inferiority. 00:17:30.569 --> 00:17:32.869 This is absolutely brutal for a seven or eight 00:17:32.869 --> 00:17:35.329 -year -old. At this age, being normal and fitting 00:17:35.329 --> 00:17:37.910 in with peers is literally everything. Imagine 00:17:37.910 --> 00:17:40.309 the deep shame of having chronic constipation, 00:17:40.349 --> 00:17:42.630 malodorous gas, or soiling your pants at school. 00:17:42.869 --> 00:17:45.089 It's called incompressus. It's socially devastating. 00:17:45.269 --> 00:17:47.690 And the treatment for hersprungs is often a colostomy, 00:17:48.009 --> 00:17:50.589 at least temporarily, right? Right. So now you 00:17:50.589 --> 00:17:52.490 have a child with a bag of poop on their stomach. 00:17:53.049 --> 00:17:55.470 The nurse's job is to help the child master this 00:17:55.470 --> 00:17:59.220 new reality. Industry means I can do it. You 00:17:59.220 --> 00:18:01.480 have to involve them in the care. Okay, can you 00:18:01.480 --> 00:18:04.460 hold the new bag while I clean the stoma? Moving 00:18:04.460 --> 00:18:06.680 them from being a passive victim to an active 00:18:06.680 --> 00:18:08.960 participant is crucial for their psychological 00:18:08.960 --> 00:18:11.279 survival. Let's shift gears to the appendix. 00:18:11.799 --> 00:18:14.099 It seems simple, but it's the most common emergency 00:18:14.099 --> 00:18:17.839 surgery in kids. Appendicitis usually hits school 00:18:17.839 --> 00:18:21.480 -age kids and teens. The pathophysiology is almost 00:18:21.480 --> 00:18:23.779 always an obstruction of the appendix lumen, 00:18:24.180 --> 00:18:26.549 often by something called a fecal lift. Fecolith 00:18:26.549 --> 00:18:28.869 is, wait, is that a storm made of poop? Essentially, 00:18:29.009 --> 00:18:31.869 yes, a calcified poop stone. It blocks the opening. 00:18:32.329 --> 00:18:34.890 The appendix keeps secreting mucus because that's 00:18:34.890 --> 00:18:37.170 what it does. Bacteria multiply, the pressure 00:18:37.170 --> 00:18:39.569 builds up, and the wall starts to literally rot. 00:18:39.849 --> 00:18:41.829 We talked about pain migration earlier. Right. 00:18:41.930 --> 00:18:44.390 It starts periambilical, just vague pain around 00:18:44.390 --> 00:18:47.170 the belly button. Over 12 to 24 hours, it migrates 00:18:47.170 --> 00:18:49.930 to the right lower quadrant, specifically McBurney's 00:18:49.930 --> 00:18:52.599 point. And the physical exam. Rebound tenderness 00:18:52.599 --> 00:18:55.380 is key. You press down slowly on the abdomen 00:18:55.380 --> 00:18:58.079 and the kid grimaces, but when you let go quickly, 00:18:58.259 --> 00:19:01.539 they scream. That is the inflamed peritoneum 00:19:01.539 --> 00:19:04.019 snapping back against the swollen organ. Also 00:19:04.019 --> 00:19:06.240 look at how they move. They will be walking hunched 00:19:06.240 --> 00:19:08.519 over. They won't want to jump or climb up onto 00:19:08.519 --> 00:19:10.900 the exam table. The sudden relief sign. The notes 00:19:10.900 --> 00:19:14.460 say, this is the biggest exam trap. It is so 00:19:14.460 --> 00:19:17.519 counterintuitive. If a child has been in 10 out 00:19:17.519 --> 00:19:21.089 of 10 pain for hours, crying, inconsolable, and 00:19:21.089 --> 00:19:22.849 suddenly says, hey, the pain is gone. I'm actually 00:19:22.849 --> 00:19:26.109 hungry. You do not celebrate. Why? Because the 00:19:26.109 --> 00:19:28.509 appendix just ruptured. The intense pressure 00:19:28.509 --> 00:19:30.789 is released, just like popping a balloon. But 00:19:30.789 --> 00:19:33.210 now all that infected pus and stool is freely 00:19:33.210 --> 00:19:36.029 spilling into the sterile abdominal cavity. The 00:19:36.029 --> 00:19:38.109 pain relief is very temporary. In a few hours, 00:19:38.170 --> 00:19:40.650 they will have a rigid, board -like abdomen and 00:19:40.650 --> 00:19:42.829 massive peritonitis. So sudden relief equals 00:19:42.829 --> 00:19:46.240 a rapid response. Yes. Keep them. NTO, start 00:19:46.240 --> 00:19:48.960 4V antibiotics immediately and prep for emergency 00:19:48.960 --> 00:19:51.759 surgery and absolutely no heat pads. Right, because 00:19:51.759 --> 00:19:54.140 heat brings blood flow. And can hasten the rupture. 00:19:54.380 --> 00:19:56.700 Ice is fine for comfort. Heat is strictly forbidden. 00:19:57.099 --> 00:19:59.859 Let's move to the absorption bucket. Celiac disease. 00:20:00.440 --> 00:20:02.799 This isn't just a trendy lifestyle diet. It's 00:20:02.799 --> 00:20:06.220 an actual autoimmune disaster. Correct. In celiac, 00:20:06.359 --> 00:20:08.680 the body views gluten, which is a protein found 00:20:08.680 --> 00:20:11.259 in wheat, barley, and rye, as a dangerous foreign 00:20:11.259 --> 00:20:14.400 invader. The immune system attacks the gut lining, 00:20:14.779 --> 00:20:17.400 specifically the villi. I really love the analogy 00:20:17.400 --> 00:20:19.900 you used in the pre -show notes. The shag carpet 00:20:19.900 --> 00:20:22.670 versus the tile floor. It's the best way to visualize 00:20:22.670 --> 00:20:24.769 what's happening. The small intestine is lined 00:20:24.769 --> 00:20:27.450 with villi. Millions of tiny little fingers that 00:20:27.450 --> 00:20:29.289 stick up. They increase the surface area so you 00:20:29.289 --> 00:20:32.069 can absorb nutrients. A healthy gut is a thick 00:20:32.069 --> 00:20:35.369 shag carpet. Plush deep tons of surface area. 00:20:35.970 --> 00:20:38.250 In celiac, the immune system essentially hacks 00:20:38.250 --> 00:20:40.910 all those villi down. The gut becomes a flat 00:20:40.910 --> 00:20:43.950 tile floor. Smooth, flat, and completely unable 00:20:43.950 --> 00:20:46.349 to absorb nutrients. The kid eats the food digests, 00:20:46.569 --> 00:20:48.650 but the nutrients just slide right across the 00:20:48.650 --> 00:20:50.779 tile floor and out the back door. Resulting in 00:20:50.779 --> 00:20:53.619 steteria, that fatty foul stool and severe malnutrition, 00:20:53.740 --> 00:20:56.559 you see a really classic look. A child with thin 00:20:56.559 --> 00:20:59.059 -waisted buttocks and limbs but a huge distended 00:20:59.059 --> 00:21:01.440 belly due to the fermentation of all that unabsorbed 00:21:01.440 --> 00:21:04.619 food. The crisis. What exactly is a celiac crisis? 00:21:04.940 --> 00:21:08.099 This happens mostly in very young children. It's 00:21:08.099 --> 00:21:10.680 profuse watery diarrhea and vomiting, leading 00:21:10.680 --> 00:21:13.660 to severe dehydration and metabolic acidosis. 00:21:14.180 --> 00:21:16.380 It looks exactly like sepsis, but it's triggered 00:21:16.380 --> 00:21:19.380 by a massive gluten exposure or sometimes a secondary 00:21:19.380 --> 00:21:22.180 infection on top of the untreated disease. And 00:21:22.180 --> 00:21:24.059 the management is strictly diet. The acronym 00:21:24.059 --> 00:21:29.680 is B -Ear -O. P -O. barley, rye oats, and wheat. 00:21:30.059 --> 00:21:31.980 Let's talk about oats for a second. Oats are 00:21:31.980 --> 00:21:34.200 the really tricky one. Technically, pure oats 00:21:34.200 --> 00:21:37.259 do not contain gluten, but they are almost always 00:21:37.259 --> 00:21:39.359 processed in the exact same mills and factories 00:21:39.359 --> 00:21:41.859 as wheat. So cross -contamination is rampant. 00:21:42.279 --> 00:21:44.599 Unless the box specifically says certified gluten 00:21:44.599 --> 00:21:46.819 -free oats, they are strictly on the no list. 00:21:47.299 --> 00:21:49.299 Developmental nightmare here is adolescence rate. 00:21:49.420 --> 00:21:51.319 Teenagers are just trying to establish their 00:21:51.319 --> 00:21:53.259 identity. They want to be exactly like their 00:21:53.259 --> 00:21:55.660 friends. Celiac makes them inherently different. 00:21:55.960 --> 00:21:58.160 They can't eat the pizza at the party, the birthday 00:21:58.160 --> 00:22:00.400 cake, the late night fast food. So they cheat? 00:22:00.660 --> 00:22:02.559 They cheat all the time. They think just one 00:22:02.559 --> 00:22:05.279 slice won't hurt. And in celiac, the symptoms 00:22:05.279 --> 00:22:07.700 might not be immediate, like a peanut allergy 00:22:07.700 --> 00:22:10.480 anaphylaxis. They might not feel violently sick 00:22:10.480 --> 00:22:12.420 until the next day, or they might just get silent 00:22:12.420 --> 00:22:15.299 damage to their villi. This makes compliance 00:22:15.299 --> 00:22:18.769 incredibly hard. The nurse really has to negotiate 00:22:18.769 --> 00:22:21.910 here, not dictate. Connect them with peer support 00:22:21.910 --> 00:22:24.650 groups or smartphone apps that find safe restaurants. 00:22:25.150 --> 00:22:27.609 You have to give them tools that fit their actual 00:22:27.609 --> 00:22:30.329 adolescent life. Let's dive into the core add 00:22:30.329 --> 00:22:33.049 -ins from the standards, cleft lip and palate. 00:22:33.490 --> 00:22:35.829 Right, these are facial fissures affecting feeding 00:22:35.829 --> 00:22:39.349 and speech. Pathophysiology is a failure of fusion 00:22:39.349 --> 00:22:42.009 during embryonic development. What's the priority 00:22:42.009 --> 00:22:44.369 assessment here? You must palpate the palate 00:22:44.369 --> 00:22:47.230 with a gloved finger. Visual inspection just 00:22:47.230 --> 00:22:49.609 isn't enough to rule out an occult cleft palate. 00:22:49.789 --> 00:22:52.170 And for feeding, because they obviously can't 00:22:52.170 --> 00:22:54.049 create suction. We use special nipples like the 00:22:54.049 --> 00:22:55.970 Haberman feeder. You feed them upright, and you 00:22:55.970 --> 00:22:57.890 have to do frequent burping because they swallow 00:22:57.890 --> 00:23:00.809 massive amounts of air. But the real exam focus 00:23:00.809 --> 00:23:03.470 is post -op care. You must protect the suture 00:23:03.470 --> 00:23:05.950 line. How do we do that with a baby who constantly 00:23:05.950 --> 00:23:07.890 puts their hands in their mouth? Elbow restraints. 00:23:07.950 --> 00:23:10.210 We call them no -nos. They keep the arms straight 00:23:10.210 --> 00:23:12.970 so the hands can't reach the face. And absolutely 00:23:12.970 --> 00:23:16.940 no spoon, straws, or pacifiers post up. And developmentally, 00:23:17.119 --> 00:23:18.920 this impacts speech and bonding, right? Yeah, 00:23:19.000 --> 00:23:20.900 high risk for speech impediment, so early referral 00:23:20.900 --> 00:23:24.339 to therapy is key. And nurses must assess parental 00:23:24.339 --> 00:23:27.160 bonding. There can be real shock or grief over 00:23:27.160 --> 00:23:28.799 the facial appearance, and we have to support 00:23:28.799 --> 00:23:31.000 the parents through that. Another core add -in 00:23:31.000 --> 00:23:35.599 is esophageal atresia and TE, tracheoesophageal 00:23:35.599 --> 00:23:37.740 fistula. The plumbing is totally crossed here. 00:23:37.920 --> 00:23:40.779 The esophagus ends in a blind pouch and the trachea 00:23:40.779 --> 00:23:42.759 connects directly to the stomach. That sounds 00:23:42.759 --> 00:23:45.519 immediately lethal if they feed. It is. The exam 00:23:45.519 --> 00:23:48.160 classic is the three C's. Choking, coughing, 00:23:48.319 --> 00:23:51.059 and cyanosis with the very first feed. You also 00:23:51.059 --> 00:23:53.460 see excessive drooling in a newborn because they 00:23:53.460 --> 00:23:56.400 literally cannot swallow their own saliva. Intervention. 00:23:56.579 --> 00:23:59.779 NPO immediately. Constant suction of the pouch. 00:24:00.359 --> 00:24:02.579 And elevate the head of the bed to prevent gastric 00:24:02.579 --> 00:24:04.720 juices from refluxing up the fistula into the 00:24:04.720 --> 00:24:07.099 lungs, which causes severe aspiration pneumonia. 00:24:07.519 --> 00:24:10.880 Moving on to mecal diverticulum. A leftover pouch 00:24:10.880 --> 00:24:14.079 near the ilium from embryology. The key symptom 00:24:14.079 --> 00:24:17.480 is completely painless rectal bleeding, often 00:24:17.480 --> 00:24:20.339 brick red or current jelly. We diagnose it with 00:24:20.339 --> 00:24:22.900 a Meckle scan. It's a bleeding risk and can also 00:24:22.900 --> 00:24:25.359 lead to intersusception. And the last disease, 00:24:25.859 --> 00:24:30.099 GER versus GUR. GER is gastroesophageal reflux. 00:24:30.279 --> 00:24:32.440 This is your normal happy spitter. They spit 00:24:32.440 --> 00:24:35.059 up, but they are growing fine. It usually resolves 00:24:35.059 --> 00:24:38.970 by 12 to 18 months. GER with a D for disease 00:24:38.970 --> 00:24:41.789 is pathology. The infant fails to gain weight, 00:24:41.970 --> 00:24:44.930 has respiratory issues or apnea, and classically 00:24:44.930 --> 00:24:46.869 they arch their back during feeds because of 00:24:46.869 --> 00:24:49.390 the acid burning the esophagus. Intervention 00:24:49.390 --> 00:24:52.009 for GER. Thickened feeds with rice cereal keep 00:24:52.009 --> 00:24:54.549 them upright 30 minutes after feeds and use meds 00:24:54.549 --> 00:24:57.130 like PPIs. Speaking of meds, let's transition 00:24:57.130 --> 00:24:59.549 to Section C, the medication module. We have 00:24:59.549 --> 00:25:01.849 a few key drugs here, and I really want to focus 00:25:01.849 --> 00:25:04.289 on the safety protocols. Let's start with pancreatic 00:25:04.289 --> 00:25:06.910 enzymes, pancrelipase, used primarily for cystic 00:25:06.910 --> 00:25:09.009 fibrosis. Right, the pancreas is blocked with 00:25:09.009 --> 00:25:10.670 thick mucus, so we have to replace the enzymes 00:25:10.670 --> 00:25:13.289 manually. How exactly do we give it? The golden 00:25:13.289 --> 00:25:16.319 rule is if they eat, they treat. These enzymes 00:25:16.319 --> 00:25:18.519 must be in the stomach at the exact same time 00:25:18.519 --> 00:25:21.640 as the food. So snacks do. Every single meal, 00:25:22.000 --> 00:25:25.000 every single snack. If a kid eats a handful of 00:25:25.000 --> 00:25:27.140 pretzels, they take enzymes. What if the kid 00:25:27.140 --> 00:25:29.440 is a toddler and can't swallow pills? You open 00:25:29.440 --> 00:25:31.900 the capsule and sprinkle the little beads on 00:25:31.900 --> 00:25:35.279 something acidic like applesauce. But here is 00:25:35.279 --> 00:25:38.640 the exam warning. Do not ever sprinkle it on 00:25:38.640 --> 00:25:41.180 alkaline food like milk or yogurt. If you do, 00:25:41.319 --> 00:25:42.980 the enzymes will activate right there in the 00:25:42.980 --> 00:25:45.599 mouth and literally digest and burn the oral 00:25:45.599 --> 00:25:48.420 mucosa. And you must tell the child not to chew 00:25:48.420 --> 00:25:51.140 the beads. Just swish and swallow. How do we 00:25:51.140 --> 00:25:53.220 know if the dose is actually right? The poop 00:25:53.220 --> 00:25:55.619 check. If the dosing is correct, the stool should 00:25:55.619 --> 00:25:58.180 look normal. If the child still has stearia, 00:25:58.359 --> 00:26:00.059 you need to call the provider to increase the 00:26:00.059 --> 00:26:02.529 enzyme dose. The poop tells the truth. Let's 00:26:02.529 --> 00:26:04.809 talk about vitamins for these kids. With cystic 00:26:04.809 --> 00:26:07.630 fibrosis or biliary atresia, you have massive 00:26:07.630 --> 00:26:10.789 fat malabsorption. So they need the fat soluble 00:26:10.789 --> 00:26:13.609 vitamins A, D, N, and K. But the petty pearl 00:26:13.609 --> 00:26:16.210 is they must be in a water -missable form. Because 00:26:16.210 --> 00:26:19.309 they can't digest the regular fat version. Exactly. 00:26:19.509 --> 00:26:21.809 If you give standard vitamin D drops suspended 00:26:21.809 --> 00:26:23.269 in oil, they will just poop it straight out. 00:26:23.430 --> 00:26:26.130 It has to be the special water -soluble formulation. 00:26:26.910 --> 00:26:29.190 And watch for deficiencies like bleeding for 00:26:29.190 --> 00:26:32.450 vitamin K or rickets for vitamin D. Next, drug 00:26:32.450 --> 00:26:35.450 gentamisin, often used for ruptured appendix 00:26:35.450 --> 00:26:38.470 or peritonitis. A very heavy -hitter antibiotic. 00:26:38.720 --> 00:26:41.819 It's an aminoglycoside. It clears gram -negative 00:26:41.819 --> 00:26:44.680 bacteria beautifully, but it has an incredibly 00:26:44.680 --> 00:26:47.299 narrow therapeutic index. Meaning the difference 00:26:47.299 --> 00:26:49.640 between cure and poison is super small. Very 00:26:49.640 --> 00:26:52.059 small. It is highly nephrotoxic, damaging the 00:26:52.059 --> 00:26:54.720 kidneys and autotoxic, damaging the ears. How 00:26:54.720 --> 00:26:57.460 do we monitor that safely? We draw peak and trough 00:26:57.460 --> 00:26:59.920 blood levels. The trough is the most crucial 00:26:59.920 --> 00:27:01.759 one. That's the lowest level right before the 00:27:01.759 --> 00:27:04.099 next dose is due. If the trough is too high, 00:27:04.180 --> 00:27:06.740 it means the drug isn't clearing, and the kidneys 00:27:06.740 --> 00:27:09.079 are basically soaking in toxin. Not in the ears. 00:27:09.220 --> 00:27:11.579 It permanently kills the hair cells in the cochlea. 00:27:12.000 --> 00:27:14.339 If a child on gentamicin says, my ears are ringing, 00:27:14.500 --> 00:27:17.420 you stop the infusion immediately. Tenitis is 00:27:17.420 --> 00:27:20.480 the final warning shot before irreversible deafness. 00:27:20.720 --> 00:27:23.839 Next is nystatin for thrush. We talked about 00:27:23.839 --> 00:27:26.859 this antifungal. The key pearl is contact time. 00:27:27.299 --> 00:27:29.859 Nostatin is not absorbed systemically. It only 00:27:29.859 --> 00:27:32.759 works by physically touching the fungus. So swish 00:27:32.759 --> 00:27:35.240 and swallow? Yes. And for little babies, you 00:27:35.240 --> 00:27:37.200 physically paint it on the white patches with 00:27:37.200 --> 00:27:40.619 a Q -tip. But critically, give it after the feeding. 00:27:40.859 --> 00:27:42.359 If you give it before the meal, it just washes 00:27:42.359 --> 00:27:44.200 it right down. You want it to sit on the tongue 00:27:44.200 --> 00:27:47.039 and cheeks for as long as humanly possible. And 00:27:47.039 --> 00:27:49.559 educate parents to boil pacifiers to prevent 00:27:49.559 --> 00:27:53.400 reinfection. Finally, PPIs like omeprazole or... 00:27:53.309 --> 00:27:56.410 H2 blockers like ranitidine. Used for severe 00:27:56.410 --> 00:27:58.950 G -iridy. The timing here is the exact opposite 00:27:58.950 --> 00:28:01.089 of enzymes. You want to give these 30 minutes 00:28:01.089 --> 00:28:04.109 before feeding usually in the morning. The drug 00:28:04.109 --> 00:28:07.029 needs time to get into the system, find the acid 00:28:07.029 --> 00:28:09.470 pumps, and physically shut them down before the 00:28:09.470 --> 00:28:11.529 food hits the stomach and triggers acid production. 00:28:11.910 --> 00:28:14.049 Okay, we have the maps, the diseases, and the 00:28:14.049 --> 00:28:16.589 meds. Now I want to do a final synthesis. We 00:28:16.589 --> 00:28:18.690 call this the matrix. I'm going to throw a symptom 00:28:18.690 --> 00:28:20.490 scenario at you and you give me the decision 00:28:20.490 --> 00:28:23.150 path. I'm ready. Let's do it. Scenario one. A 00:28:23.150 --> 00:28:26.630 four -week -old. Projectile vomiting. Hungry 00:28:26.630 --> 00:28:29.710 immediately after. Pyloric stenosis. Check for 00:28:29.710 --> 00:28:32.089 the olive mass in the right upper quadrant. Check 00:28:32.089 --> 00:28:34.910 the blood gas for metabolic alkalosis. Correct 00:28:34.910 --> 00:28:37.950 fluids first, then send for surgery. Scenario 00:28:37.950 --> 00:28:41.930 2. An 18 -month -old. Screaming intermittently, 00:28:42.089 --> 00:28:44.089 pulling their legs up to their chest, then acting 00:28:44.089 --> 00:28:47.029 totally fine. Into suception. Look for current 00:28:47.029 --> 00:28:49.769 jelly stool. Prepare for an air enema. Watch 00:28:49.769 --> 00:28:52.210 closely for a normal brown stool, which indicates 00:28:52.210 --> 00:28:55.589 spontaneous resolution. Scenario 3. A newborn. 00:28:55.930 --> 00:28:59.150 No meconium at 48 hours. Abdomen is distended. 00:28:59.309 --> 00:29:01.690 Hirschsprung disease. Crucial safety point. Do 00:29:01.690 --> 00:29:04.029 not do erectile temp because of the risk of perforation. 00:29:04.450 --> 00:29:07.390 Prepare for erectile biopsy to confirm a ganglionic 00:29:07.390 --> 00:29:10.609 cells and then surgery. Scenario 4. A 10 -year 00:29:10.609 --> 00:29:12.809 -old. Pain started at the belly button. Moved 00:29:12.809 --> 00:29:14.910 to the right lower quadrant. Walking hunched 00:29:14.910 --> 00:29:17.680 over. Appendicitis. Keep them NPO immediately. 00:29:17.900 --> 00:29:20.480 Absolutely no heat packs. If the pain suddenly 00:29:20.480 --> 00:29:22.779 stops, assume rupture peritonitis and call the 00:29:22.779 --> 00:29:31.589 surgeon immediately. Biliary atresia. This is 00:29:31.589 --> 00:29:34.130 a liver emergency. They need the Kasai procedure 00:29:34.130 --> 00:29:37.150 ASAP to prevent permanent cirrhosis while they 00:29:37.150 --> 00:29:39.809 wait for a transplant. We might use ursodial 00:29:39.809 --> 00:29:42.549 to improve bile flow in the meantime. That recap 00:29:42.549 --> 00:29:44.730 is just pure gold. It's the 80 -20 right there. 00:29:44.809 --> 00:29:47.089 If you know those, you are safe. Before we sign 00:29:47.089 --> 00:29:48.690 off, I want to circle back to a thought you had 00:29:48.690 --> 00:29:51.569 in the notes. Your folded tube concept. Oh, the 00:29:51.569 --> 00:29:54.289 embryology. Yeah. Yeah. We talked about cleft 00:29:54.289 --> 00:29:57.490 lips, esophageal atresia, imperfect anus. They 00:29:57.490 --> 00:29:59.900 are all midline defects. It really gives you 00:29:59.900 --> 00:30:02.000 a profound sense of humility about the human 00:30:02.000 --> 00:30:05.500 body. We all start as just a flat, tiny disk 00:30:05.500 --> 00:30:08.559 of cells. In the first few weeks of gestation, 00:30:08.680 --> 00:30:11.009 we fold longitudinally to make a tube, which 00:30:11.009 --> 00:30:13.650 is the gut, and we fold laterally to close the 00:30:13.650 --> 00:30:16.470 chest and the belly. It's like incredibly complex 00:30:16.470 --> 00:30:19.269 microscopic origami. And if the paper slips even 00:30:19.269 --> 00:30:21.630 a millimeter? You get a fistula. You get a natresia. 00:30:21.670 --> 00:30:24.309 You get a cleft. It highlights that pediatric 00:30:24.309 --> 00:30:26.609 nursing isn't just fixing leaks. It's helping 00:30:26.609 --> 00:30:29.269 a child and a family navigate a structural error 00:30:29.269 --> 00:30:32.230 in their very blueprint. It's about ensuring 00:30:32.230 --> 00:30:34.849 that despite the plumbing issue, the child can 00:30:34.849 --> 00:30:37.650 still achieve their full developmental destiny. 00:30:37.869 --> 00:30:40.670 That is a beautiful place to leave it. You have 00:30:40.670 --> 00:30:42.990 the science, you have the safety checks, and 00:30:42.990 --> 00:30:44.710 you have the developmental soul of the care. 00:30:44.829 --> 00:30:47.549 Now go ace the exam. And go save some little 00:30:47.549 --> 00:30:49.750 lives. Thanks for diving in with us. Until next 00:30:49.750 --> 00:30:49.970 time.