WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:46.789 fast. Welcome to the emergency room. Welcome 00:00:46.789 --> 00:00:50.929 to the Deep Dive. Today we are opening up the 00:00:50.929 --> 00:00:52.929 hood of the human body to look at the master 00:00:52.929 --> 00:00:55.659 control panel. You know, usually when we talk 00:00:55.659 --> 00:00:57.399 about pediatrics, we're worried about the loud 00:00:57.399 --> 00:00:59.240 stuff. Right, the wheezing lungs, the murmuring 00:00:59.240 --> 00:01:02.079 hearts. Exactly, the broken bones. But today 00:01:02.079 --> 00:01:05.099 we are talking about the silent puppet master, 00:01:05.379 --> 00:01:06.840 the system that decides if you're going to be 00:01:06.840 --> 00:01:09.340 six feet tall or four feet tall, if you're going 00:01:09.340 --> 00:01:11.980 to be the captain of the track team or just too 00:01:11.980 --> 00:01:14.040 tired to get out of bed. And honestly, if your 00:01:14.040 --> 00:01:16.840 brain is going to develop correctly or not, we 00:01:16.840 --> 00:01:19.299 are talking about the endocrine system. It really 00:01:19.299 --> 00:01:23.379 is the Goldilocks system of the body. And I don't 00:01:23.379 --> 00:01:25.219 use that term lightly. Coldy locks. You mean 00:01:25.219 --> 00:01:27.840 like porridge and bears? I mean, the principle 00:01:27.840 --> 00:01:31.219 of just right. In pediatric endocrine disorders, 00:01:31.599 --> 00:01:33.680 it is rarely about something being mechanically 00:01:33.680 --> 00:01:36.379 broken like a fracture. It is almost always about 00:01:36.379 --> 00:01:39.799 things being too much or too little, too hot, 00:01:40.019 --> 00:01:42.200 too cold, too fast or too slow. So it's a balance 00:01:42.200 --> 00:01:44.879 issue. Exactly. It's a delicate system of balance. 00:01:44.959 --> 00:01:47.560 And when that balance tips in a growing child, 00:01:48.329 --> 00:01:50.650 The consequences are massive, not just for their 00:01:50.650 --> 00:01:52.950 health today, but for their entire developmental 00:01:52.950 --> 00:01:56.069 trajectory. I mean, a hormonal imbalance in an 00:01:56.069 --> 00:01:58.170 adult might mean a rough month, but a hormonal 00:01:58.170 --> 00:02:01.010 imbalance in a toddler. It can permanently alter 00:02:01.010 --> 00:02:03.349 their IQ, right? Yes, their IQ or their adult 00:02:03.349 --> 00:02:06.090 height. It changes everything. That is a high 00:02:06.090 --> 00:02:08.490 stakes intro. And look, you guys, we have a massive 00:02:08.490 --> 00:02:10.710 stack of source material here today, specifically 00:02:10.710 --> 00:02:13.490 Chapter 26, which covers the nursing care of 00:02:13.490 --> 00:02:16.270 children with metabolic and endocrine alterations. 00:02:16.789 --> 00:02:18.830 Our mission today is pretty specific. We aren't 00:02:18.830 --> 00:02:20.729 just reading the textbook to you. No, definitely 00:02:20.729 --> 00:02:23.330 not. We are synthesizing this into a guide that 00:02:23.330 --> 00:02:25.129 helps you, if you're a nursing student, crush 00:02:25.129 --> 00:02:27.789 your exams, but also helps you as a bedside nurse 00:02:27.789 --> 00:02:30.389 catch a crisis before it happens. That's the 00:02:30.389 --> 00:02:32.870 goal. We're going to apply the Pareto principle 00:02:32.870 --> 00:02:35.610 here, the 80 -20 rule. We're going to focus on 00:02:35.610 --> 00:02:38.289 the 20 % of the endocrine concepts that generate 00:02:38.289 --> 00:02:41.370 80 % of the exam questions and more importantly 00:02:41.370 --> 00:02:43.550 80 % of the safety issues you will actually see 00:02:43.550 --> 00:02:46.569 in practice. You need to move beyond memorizing 00:02:46.569 --> 00:02:48.909 lists and start recognizing patterns. I love 00:02:48.909 --> 00:02:51.310 that. So we're skipping the fluff and going straight 00:02:51.310 --> 00:02:54.430 for the jugular or I guess the thyroid. We have 00:02:54.430 --> 00:02:56.530 to. The entrance system is incredibly dense. 00:02:56.710 --> 00:02:59.930 If you try to memorize every single hormone pathway, 00:02:59.990 --> 00:03:02.500 you're just going to drown. But if you recognize 00:03:02.500 --> 00:03:05.060 the red flags of growth and metabolism, you will 00:03:05.060 --> 00:03:07.699 be safe. Alright, let's map this out. We're going 00:03:07.699 --> 00:03:10.259 to start with what you call the master map, the 00:03:10.259 --> 00:03:12.740 high yield patterns. Then we'll do a deep dive 00:03:12.740 --> 00:03:16.039 into the specific disease processes, pituitary 00:03:16.039 --> 00:03:18.479 thyroid adrenal. And here's a change in our usual 00:03:18.479 --> 00:03:21.139 plan. Instead of saving the meds for the end, 00:03:21.159 --> 00:03:23.340 we're going to weave the pharmacology right into 00:03:23.340 --> 00:03:25.800 the disease discussions. Because you can't really 00:03:25.800 --> 00:03:27.599 treat the disease without understanding the drugs 00:03:27.599 --> 00:03:31.000 right. Absolutely. The pharmacology is the intervention. 00:03:31.180 --> 00:03:33.879 You can't separate them. And finally, we will 00:03:33.879 --> 00:03:36.060 constantly cross -link everything to development. 00:03:36.319 --> 00:03:38.580 Because as we always say, a sick kid isn't just 00:03:38.580 --> 00:03:41.819 a small, sick adult. They are a developing organism. 00:03:42.060 --> 00:03:44.300 OK, let's unpack this master map. Before we even 00:03:44.300 --> 00:03:47.340 get to the specific diseases, what are the patterns 00:03:47.340 --> 00:03:49.919 that should make a nurse's spidey sense tingle? 00:03:50.259 --> 00:03:51.960 I like to think of them in three big buckets. 00:03:52.800 --> 00:03:54.979 If you see a disruption in any of these three 00:03:54.979 --> 00:03:57.960 areas, it is endocrine until proven otherwise. 00:03:58.159 --> 00:04:01.150 Bucket number one. Growth velocity. This is the 00:04:01.150 --> 00:04:03.469 single most sensitive indicator of pediatric 00:04:03.469 --> 00:04:05.729 health. We aren't just talking about a kid being 00:04:05.729 --> 00:04:08.930 short. We are talking about the curve. The growth 00:04:08.930 --> 00:04:10.949 chart. I feel like parents obsess over this constantly, 00:04:10.990 --> 00:04:13.009 but why is it so critical for us as clinicians? 00:04:13.349 --> 00:04:16.250 The growth chart is your detective tool. Pattern 00:04:16.250 --> 00:04:18.589 one is what I call the drop. Picture this. A 00:04:18.589 --> 00:04:21.149 child is born, normal size, maybe tracks along 00:04:21.149 --> 00:04:24.029 the 50th percentile for a year or two, and then 00:04:24.029 --> 00:04:26.170 suddenly flatline. They just stop. They start 00:04:26.170 --> 00:04:28.620 falling across the percentile lines. They were 00:04:28.620 --> 00:04:31.100 at the 50th, now they're at the 10th. That is 00:04:31.100 --> 00:04:33.879 the classic signature of hypopituitarism, which 00:04:33.879 --> 00:04:37.100 is growth hormone deficiency or it could be hypothyroidism. 00:04:37.220 --> 00:04:39.120 So it's not just that they are small, it's that 00:04:39.120 --> 00:04:41.839 they actually stopped tracking. Exactly. A kid 00:04:41.839 --> 00:04:45.480 who is genetically short, say his parents are 00:04:45.480 --> 00:04:47.839 both five foot nothing. He will be on the fifth 00:04:47.839 --> 00:04:49.800 percentile, but he will stay on the fifth percentile. 00:04:49.920 --> 00:04:52.139 He's consistent. The endocrine kid falls off 00:04:52.139 --> 00:04:55.339 the cliff. OK, so the drop is a huge red flag. 00:04:55.420 --> 00:04:57.620 What about the opposite, the spike? That's the 00:04:57.620 --> 00:04:59.199 too fast pattern. You might think, hey, great, 00:04:59.319 --> 00:05:01.079 my kid is growing like a weed. He's the tallest 00:05:01.079 --> 00:05:05.060 in his class. But in pediatrics, rapid vertical 00:05:05.060 --> 00:05:08.079 growth accompanied by early puberty signs, like 00:05:08.079 --> 00:05:10.279 before age nine and boys or eight and girls, 00:05:10.660 --> 00:05:13.079 is a disaster waiting to happen. That's precocious 00:05:13.079 --> 00:05:15.870 puberty, right? Yes. They shoot up fast, but 00:05:15.870 --> 00:05:18.029 their bones fuse early and they end up as very 00:05:18.029 --> 00:05:21.129 short adults. So extreme shifts in the growth 00:05:21.129 --> 00:05:23.649 curve, up or down, are your first major pattern. 00:05:23.930 --> 00:05:26.189 Got it. Pattern one is watch the curve. What 00:05:26.189 --> 00:05:29.430 is pattern two? Pattern two is the salt and water 00:05:29.430 --> 00:05:32.949 disaster. This is where things get acute and 00:05:32.949 --> 00:05:35.790 really dangerous. You have two main players here 00:05:35.790 --> 00:05:39.170 that exam writers absolutely love to test, because 00:05:39.170 --> 00:05:41.410 they look similar on the surface, but they're 00:05:41.410 --> 00:05:43.550 physiological opposites. Give us the breakdown. 00:05:43.709 --> 00:05:46.089 On one side you have the dry pattern, the child 00:05:46.089 --> 00:05:48.970 is peeing constantly, polyuria, they're drinking 00:05:48.970 --> 00:05:52.470 water like a fish, polydipsia. But here is the 00:05:52.470 --> 00:05:56.050 key, their sodium is high, they are drying out, 00:05:56.189 --> 00:05:58.529 that's diabetes insipidus. And the other side. 00:05:58.629 --> 00:06:01.079 The shock pattern. This is the scary one. The 00:06:01.079 --> 00:06:03.819 child is dehydrated, but their sodium is low 00:06:03.819 --> 00:06:06.620 and their potassium is dangerously high. They 00:06:06.620 --> 00:06:08.680 look like they are in shock. That is congenital 00:06:08.680 --> 00:06:12.259 adrenal hyperplasia or CAH. So if you see a mess 00:06:12.259 --> 00:06:14.480 of fluids and electrolytes, you need to stop 00:06:14.480 --> 00:06:17.379 and ask, is this a water problem like DI or a 00:06:17.379 --> 00:06:19.759 salt and adrenal problem like CAH? Perfectly 00:06:19.759 --> 00:06:21.800 said. You have to make that distinction. High 00:06:21.800 --> 00:06:23.899 sodium versus low sodium. We'll dig into the 00:06:23.899 --> 00:06:25.319 why in a minute, but I want to get to the third 00:06:25.319 --> 00:06:27.500 bucket. Let's hear it. The third bucket is the 00:06:27.500 --> 00:06:30.240 metabolic throttle. Think of the thyroid as the 00:06:30.240 --> 00:06:32.360 gas pedal of the body. OK, I like that analogy. 00:06:32.680 --> 00:06:34.899 Gas pedal. Right. So in hyperthyroidism, the 00:06:34.899 --> 00:06:37.600 pedal is stuck to the floor. Everything is fast. 00:06:38.079 --> 00:06:40.240 Heart rate is up. They're pooping constantly. 00:06:40.360 --> 00:06:42.459 They're hyperactive. They're sweating. It's like 00:06:42.459 --> 00:06:44.459 the engine is redlining. And the reverse would 00:06:44.459 --> 00:06:47.160 be hypothyroidism. Exactly. The foot is completely 00:06:47.160 --> 00:06:50.379 off the gas. Heart rate slows down. Bowels slow 00:06:50.379 --> 00:06:53.980 down. Hello, constipation energy drops. They 00:06:53.980 --> 00:06:56.459 are lethargic. Even the skin gets cool and dry. 00:06:57.060 --> 00:06:59.360 If you can categorize the symptoms into fast 00:06:59.360 --> 00:07:02.540 versus slow, you are halfway to the diagnosis. 00:07:03.139 --> 00:07:05.300 Growth velocity, salt and water, and the metabolic 00:07:05.300 --> 00:07:07.699 throttle. That is a solid framework for you guys 00:07:07.699 --> 00:07:09.959 to keep in mind. Let's dive into the specifics 00:07:09.959 --> 00:07:12.819 now. Let's go back to that first pattern. The 00:07:12.819 --> 00:07:15.910 child who stops growing. growth hormone deficiency. 00:07:16.209 --> 00:07:18.769 Right, also called hypopituitarism. The need 00:07:18.769 --> 00:07:20.970 to know one -liner here is that the pituitary 00:07:20.970 --> 00:07:23.470 gland simply isn't pushing the grow button. And 00:07:23.470 --> 00:07:25.470 biologically, what is happening there? Or rather, 00:07:25.490 --> 00:07:27.569 what is not happening? The pituitary gland, which 00:07:27.569 --> 00:07:29.970 is usually triggered by the hypothalamus, fails 00:07:29.970 --> 00:07:33.350 to secrete growth hormone, or GH. Now, GH isn't 00:07:33.350 --> 00:07:36.269 just about making bones longer. It is a fundamental 00:07:36.269 --> 00:07:38.829 metabolic hormone. It helps metabolize protein, 00:07:38.970 --> 00:07:41.910 fat, and carbs to actually build tissue. So without 00:07:41.910 --> 00:07:44.149 it, you get this very specific presentation. 00:07:44.379 --> 00:07:46.060 What does that look like? You mentioned they 00:07:46.060 --> 00:07:49.439 are born normal size. That's the trick. At birth, 00:07:49.560 --> 00:07:51.980 they look perfectly normal because maternal hormones 00:07:51.980 --> 00:07:54.819 have been doing the heavy lifting in utero. But 00:07:54.819 --> 00:07:57.899 as they get into childhood, the percentiles decrease. 00:07:58.120 --> 00:08:01.180 They fall off the curve. By adolescence, you 00:08:01.180 --> 00:08:05.160 see delayed puberty, delayed skeletal maturation, 00:08:05.879 --> 00:08:08.959 which we check with a bone age X -ray, and decreased 00:08:08.959 --> 00:08:11.319 muscle mass. Let's create a scenario here for 00:08:11.319 --> 00:08:14.019 you listening. You're a school nurse. You have 00:08:14.019 --> 00:08:17.439 a 10 -year -old boy. Let's call him Leo. Leo 00:08:17.439 --> 00:08:19.259 is the smallest kid in the fifth grade. He looks 00:08:19.259 --> 00:08:21.379 like a second grader. He's got a slightly chubby 00:08:21.379 --> 00:08:23.379 face, maybe a little extra fat around the middle 00:08:23.379 --> 00:08:25.959 because he's not metabolizing well. What are 00:08:25.959 --> 00:08:28.240 the developmental implications for Leo? Oh, they 00:08:28.240 --> 00:08:30.759 are huge. This is the need to know for psychosocial 00:08:30.759 --> 00:08:33.100 care. Leo's going to be treated like a baby. 00:08:33.519 --> 00:08:36.000 Teachers will baby him. Other kids might exclude 00:08:36.000 --> 00:08:38.320 him from sports because he's physically fragile. 00:08:38.620 --> 00:08:40.919 He might be bullied. So the nurse has to intervene 00:08:40.919 --> 00:08:43.500 there. The nurse has to educate the parents and 00:08:43.500 --> 00:08:46.840 the teachers to treat Leo according to his chronological 00:08:46.840 --> 00:08:49.320 age, not his size. You don't talk to a 10 -year 00:08:49.320 --> 00:08:51.840 -old like he's six, even if he looks six. It 00:08:51.840 --> 00:08:54.620 damages his self -esteem and his autonomy. That's 00:08:54.620 --> 00:08:57.120 a great clinical point. Treat the age, not the 00:08:57.120 --> 00:08:59.179 size. Now, medically, how do we confirm this? 00:08:59.220 --> 00:09:01.440 Can we just draw a quick blood level? I wish. 00:09:01.820 --> 00:09:04.059 But GH is released in pulses mostly at night 00:09:04.059 --> 00:09:07.919 while you sleep. If you draw blood at 2 PM, The 00:09:07.919 --> 00:09:10.039 level might be zero, even in a perfectly normal 00:09:10.039 --> 00:09:13.360 kid. So a random draw is totally useless. So 00:09:13.360 --> 00:09:15.919 what's the test? We have to do stimulation testing 00:09:15.919 --> 00:09:18.799 or provocative testing. We give meds to stimulate 00:09:18.799 --> 00:09:21.399 the pituitary and see if it responds. If the 00:09:21.399 --> 00:09:24.059 levels stay low despite stimulation, then you 00:09:24.059 --> 00:09:26.559 have your diagnosis. Okay, so Leo is diagnosed. 00:09:26.620 --> 00:09:29.039 Now we have to treat him. This brings us to our 00:09:29.039 --> 00:09:31.879 first major pharmacology integration. We are 00:09:31.879 --> 00:09:34.740 talking about semitropin. Yes, recombinant growth 00:09:34.740 --> 00:09:37.299 hormone. This is a synthetic replacement. And 00:09:37.299 --> 00:09:39.179 how is it given? Because I'm guessing Leo isn't 00:09:39.179 --> 00:09:41.480 going to like this. He is not. It's a subcutaneous 00:09:41.480 --> 00:09:44.779 injection, and it is given daily, usually at 00:09:44.779 --> 00:09:47.139 bedtime, to mimic the body's natural release 00:09:47.139 --> 00:09:49.559 cycle. Every single night, that is a massive 00:09:49.559 --> 00:09:51.759 burden on a family. It is. It's expensive, it's 00:09:51.759 --> 00:09:54.139 painful, and it requires incredibly strict compliance. 00:09:54.759 --> 00:09:57.139 But here is the massive need -to -know safety 00:09:57.139 --> 00:09:59.740 flag. There's a specific complication you have 00:09:59.740 --> 00:10:02.960 to watch for with semitropin. What is it? Slipped 00:10:02.960 --> 00:10:07.990 capital femoral epithesis, or SCFE. SCFE. Let's 00:10:07.990 --> 00:10:09.990 break that down for everyone. Imagine you were 00:10:09.990 --> 00:10:12.690 forcing the bones to grow rapidly with this medication. 00:10:13.210 --> 00:10:16.070 The growth plate. The epithesis is the weak point. 00:10:16.610 --> 00:10:19.129 Sometimes the top of the thigh bone, the femoral 00:10:19.129 --> 00:10:21.509 head, can actually slip off the neck of the bone 00:10:21.509 --> 00:10:24.690 at the growth plate. It is exactly like a scoop 00:10:24.690 --> 00:10:26.909 of ice cream sliding off a cone. That sounds 00:10:26.909 --> 00:10:29.909 incredibly painful. It is. But here is the exam 00:10:29.909 --> 00:10:32.679 trap. Kids are terrible at localizing pain. A 00:10:32.679 --> 00:10:34.519 child with a hip problem will very often complain 00:10:34.519 --> 00:10:36.840 of knee pain. It's referred pain. OK, so the 00:10:36.840 --> 00:10:39.419 scenario is Leo's mom calls the clinic. She says 00:10:39.419 --> 00:10:41.679 Leo has been on GH for six months, and now he's 00:10:41.679 --> 00:10:44.779 limping and says his knee hurts. And if the nurse 00:10:44.779 --> 00:10:47.440 says, oh, put some ice on it, it's probably growing 00:10:47.440 --> 00:10:50.500 pains that nurses failed. That is a can't miss 00:10:50.500 --> 00:10:53.860 error. Any child on GH complaining of hip or 00:10:53.860 --> 00:10:56.299 knee pain needs to stop the med and get an x 00:10:56.299 --> 00:10:58.019 -ray immediately. You have to rule out SCFE. 00:10:58.200 --> 00:11:01.179 Brilliant. Knee pain in a GH kid is an emergency 00:11:01.179 --> 00:11:03.320 until proven otherwise. Also, parents need to 00:11:03.320 --> 00:11:06.480 report headaches, right? Yes. Rarely the medication 00:11:06.480 --> 00:11:09.360 can cause increased intracranial pressure. So 00:11:09.360 --> 00:11:11.779 severe headaches are another huge red flag you 00:11:11.779 --> 00:11:14.059 teach the parents to look out for. OK, let's 00:11:14.059 --> 00:11:16.820 flip the coin. Pattern one, part two. the kid 00:11:16.820 --> 00:11:19.379 growing too fast, precocious puberty. This is 00:11:19.379 --> 00:11:21.279 where the biological alarm clock goes off way 00:11:21.279 --> 00:11:23.659 too early. We're talking secondary sexual characteristics 00:11:23.659 --> 00:11:26.379 like breast buds, pupic hair, axillary hair appearing 00:11:26.379 --> 00:11:28.740 before age eight in girls or nine in boys. And 00:11:28.740 --> 00:11:31.159 the cause. Often it's idiopathic, meaning we 00:11:31.159 --> 00:11:33.620 don't know. But it can be a CNS abnormality like 00:11:33.620 --> 00:11:35.720 a tumor triggering the release of hormones. Oh. 00:11:35.980 --> 00:11:37.759 The hypothalamus basically wakes up and tells 00:11:37.759 --> 00:11:40.440 the pituitary to release gonadotropins, which 00:11:40.440 --> 00:11:43.919 are LH and FSH. And those tell the ovaries or 00:11:43.919 --> 00:11:46.259 testes to get to work. No, I have to play devil's 00:11:46.259 --> 00:11:49.360 advocate here. If a kid hits puberty at seven, 00:11:50.000 --> 00:11:51.820 they're going to be the tallest kid in the second 00:11:51.820 --> 00:11:53.519 grade. They're the star of the basketball team. 00:11:54.039 --> 00:11:56.460 Why is that bad? Being tall is usually seen as 00:11:56.460 --> 00:11:58.940 a good thing. Why do we treat this? That is the 00:11:58.940 --> 00:12:01.840 most common question parents ask. Why stop it? 00:12:02.019 --> 00:12:05.139 Here is the clinical answer. They are tall now, 00:12:05.519 --> 00:12:08.759 but puberty triggers the closure of the epiphyseal 00:12:08.759 --> 00:12:11.519 plates, the growth plates in the bones. Once 00:12:11.519 --> 00:12:14.990 those close growth stops forever. Oh, wow. Yeah, 00:12:15.049 --> 00:12:17.350 so a child with untreated precocious puberty 00:12:17.350 --> 00:12:20.070 will have a rapid growth spurt at seven or eight, 00:12:20.330 --> 00:12:22.409 and then stop growing completely at, say, 10. 00:12:22.909 --> 00:12:25.029 They will end up as a significantly short adult. 00:12:25.830 --> 00:12:28.409 We are talking about losing four, five, maybe 00:12:28.409 --> 00:12:31.110 six inches of potential adult height. So it's 00:12:31.110 --> 00:12:33.230 literally a race against time to keep the bones 00:12:33.230 --> 00:12:35.370 open. Exactly. That's why we treat it. And here 00:12:35.370 --> 00:12:37.929 is our next pharmacology pearl. The need -to 00:12:37.929 --> 00:12:40.330 -know intervention is a medication called luprolide. 00:12:40.769 --> 00:12:43.970 It's a GnRH agonist. Agonist usually means it 00:12:43.970 --> 00:12:46.330 stimulates something. How does stimulating the 00:12:46.330 --> 00:12:48.700 hormones stop puberty? It's a brilliant mechanism, 00:12:48.700 --> 00:12:51.480 actually. The body relies on the pulsatile release 00:12:51.480 --> 00:12:53.240 of hormones, a little bit here, a little bit 00:12:53.240 --> 00:12:57.080 there. Luprolide floods the system with a constant 00:12:57.080 --> 00:13:00.220 steady stream. It overstimulates the receptors 00:13:00.220 --> 00:13:02.460 until they basically say, I'm overwhelmed, I'm 00:13:02.460 --> 00:13:05.220 shutting down. It desensitizes the pituitary. 00:13:05.559 --> 00:13:08.259 It hits the pause button on puberty. So we just 00:13:08.259 --> 00:13:09.899 keep them on this medication until they reach 00:13:09.899 --> 00:13:12.200 a normal age for puberty? Yes, usually around 00:13:12.200 --> 00:13:15.039 11 or 12. Then we stop the meds, the receptors 00:13:15.039 --> 00:13:17.720 wake back up and... Nature takes its normal course. 00:13:18.299 --> 00:13:20.820 Let's talk about the child experience here. Imagine 00:13:20.820 --> 00:13:23.179 being a seven -year -old girl. You're in second 00:13:23.179 --> 00:13:26.120 grade. You still play with dolls. But you've 00:13:26.120 --> 00:13:28.460 rest development. You look like you're 12. It 00:13:28.460 --> 00:13:31.250 is devastating. This is the developmental cross 00:13:31.250 --> 00:13:33.549 -link you need for your exams. These children 00:13:33.549 --> 00:13:36.529 face immense social isolation. They are teased, 00:13:36.710 --> 00:13:39.710 they are confused, and critically, they are vulnerable. 00:13:39.950 --> 00:13:42.710 They look older. So adults and older children 00:13:42.710 --> 00:13:45.070 might treat them as sexual objects or expect 00:13:45.070 --> 00:13:47.090 them to act more maturely than they are capable 00:13:47.090 --> 00:13:50.000 of. Act your age, but their age is seven. Exactly. 00:13:50.179 --> 00:13:52.100 Their brain is still seven. The nurse has to 00:13:52.100 --> 00:13:54.799 coach the parents, protect her childhood, dress 00:13:54.799 --> 00:13:57.200 her age appropriately to minimize teasing. But 00:13:57.200 --> 00:13:59.820 remember, she is still a little girl inside. 00:14:00.200 --> 00:14:02.559 And a safety note that honestly shocked me when 00:14:02.559 --> 00:14:04.919 reading the source notes. These children are 00:14:04.919 --> 00:14:08.419 fertile. Biologically, yes. If the system is 00:14:08.419 --> 00:14:11.799 turned on ovulation or spermatogenesis is absolutely 00:14:11.799 --> 00:14:14.720 possible. It's a jarring thought. But as nurses, 00:14:14.720 --> 00:14:16.659 we have to be aware of the safety and social 00:14:16.659 --> 00:14:18.830 implications there. Okay, let's move to pattern 00:14:18.830 --> 00:14:22.090 two, the salt and water disasters. This is where 00:14:22.090 --> 00:14:23.830 the physiology gets a little intense, so let's 00:14:23.830 --> 00:14:25.929 walk through it slowly. Let's start with a dry 00:14:25.929 --> 00:14:29.309 pattern, diabetes insipidus. Diabetes insipidus. 00:14:29.590 --> 00:14:31.429 First, let's clear up the biggest exam trap. 00:14:31.649 --> 00:14:33.509 This has absolutely nothing to do with blood 00:14:33.509 --> 00:14:36.370 sugar. Nothing at all. Zero. The word diabetes 00:14:36.370 --> 00:14:38.690 comes from a Greek word meaning siphon or to 00:14:38.690 --> 00:14:41.929 pass through. Insipidus means tasteless. As opposed 00:14:41.929 --> 00:14:44.769 to mellitus, which means sweet or honey. Right. 00:14:45.029 --> 00:14:47.090 In diabetes mellitus, the urine is sweet with 00:14:47.090 --> 00:14:50.309 sugar. In diabetes insipidus, the urine is tasteless 00:14:50.309 --> 00:14:53.549 because it's just pure water. The problem here 00:14:53.549 --> 00:14:56.769 is a deficiency in ADH, antidiuretic hormone, 00:14:56.889 --> 00:14:59.350 also known as vasopressin. I always call ADH 00:14:59.350 --> 00:15:02.090 the anti -potty hormone. That's honestly the 00:15:02.090 --> 00:15:04.490 best way to remember it. ADH's job is to tell 00:15:04.490 --> 00:15:06.529 the kidneys, hey, stop, hold on to that water. 00:15:06.610 --> 00:15:09.230 We need it in the blood. Without ADH, the kidneys 00:15:09.230 --> 00:15:12.350 act like a colander. They just dump water. We 00:15:12.350 --> 00:15:15.559 are talking massive polyuria. So the kid is peeing 00:15:15.559 --> 00:15:17.740 a lot. Like, how much are we talking? Volumes. 00:15:18.639 --> 00:15:21.240 A small child might put out liters a day. And 00:15:21.240 --> 00:15:23.139 because they're losing so much water, they are 00:15:23.139 --> 00:15:26.100 incredibly thirsty. Polydipsia. You might have 00:15:26.100 --> 00:15:28.379 a child who is fully potty trained, suddenly 00:15:28.379 --> 00:15:31.240 wetting the bed every single night. And uresus. 00:15:31.419 --> 00:15:33.220 And the parents notice the drinking too. The 00:15:33.220 --> 00:15:34.899 parents will say he drinks water from the toilet 00:15:34.899 --> 00:15:36.980 bowl if we don't give him a bottle. It's that 00:15:36.980 --> 00:15:39.259 intense. They are desperate for fluid. Let's 00:15:39.259 --> 00:15:41.919 look at the labs, because this is an exam favorite 00:15:41.919 --> 00:15:44.549 for sure. It is. Think about it like making soup. 00:15:45.090 --> 00:15:47.210 If you boil off all the water, the soup gets 00:15:47.210 --> 00:15:49.950 incredibly salty. That's the blood. The child 00:15:49.950 --> 00:15:51.909 is peeing out pure water so the serum sodium 00:15:51.909 --> 00:15:54.289 goes extremely high. High sodium in the blood. 00:15:54.529 --> 00:15:56.990 And the urine. The urine is very dilute. It basically 00:15:56.990 --> 00:15:59.730 looks like tap water. The specific gravity will 00:15:59.730 --> 00:16:03.710 be incredibly low. Less than 1 .005. So to recap 00:16:03.710 --> 00:16:06.669 that, high sodium, low specific gravity, dry 00:16:06.669 --> 00:16:10.350 child. Correct. The danger here is rapid dehydration. 00:16:10.490 --> 00:16:13.710 If this child gets a normal stomach bug and stops 00:16:13.710 --> 00:16:16.190 drinking for even a few hours, they can crash 00:16:16.190 --> 00:16:18.730 into hypovolemic shock very quickly because they 00:16:18.730 --> 00:16:21.070 physically cannot stop peeing. So medical alert 00:16:21.070 --> 00:16:23.350 bracelets are mandatory here. Now how do we treat 00:16:23.350 --> 00:16:25.370 it? Pharmacology time. We replace the hormone. 00:16:25.610 --> 00:16:28.269 We use a synthetic version of ADH called desmopressin 00:16:28.269 --> 00:16:31.370 or DDAVP. And how is that given? Usually intranasally 00:16:31.370 --> 00:16:34.350 as a nose spray or as oral tablets, sometimes 00:16:34.350 --> 00:16:36.470 sub -Q in the hospital setting. What's the catch? 00:16:36.669 --> 00:16:38.350 With endocrine meds, there's always a catch. 00:16:38.600 --> 00:16:41.460 The catch is the water balance. Imagine you give 00:16:41.460 --> 00:16:44.440 the kid the DDAVP. The med works. It shuts down 00:16:44.440 --> 00:16:46.720 the kid to his water dumping. But the kid is 00:16:46.720 --> 00:16:49.360 still thirsty out of pure habit. So he keeps 00:16:49.360 --> 00:16:52.019 drinking gallons of water. But he's not peeing 00:16:52.019 --> 00:16:54.919 it out anymore. Exactly. Now you have the exact 00:16:54.919 --> 00:16:58.659 opposite problem. Water intoxication. The body 00:16:58.659 --> 00:17:01.659 holds too much water. The sodium drops dangerously 00:17:01.659 --> 00:17:04.539 low hyponatremia. And you can get cerebral edema 00:17:04.539 --> 00:17:08.390 and seizures. Whoa. So when we start DDAVP, we 00:17:08.390 --> 00:17:10.609 have to heavily restrict their water intake. 00:17:10.750 --> 00:17:13.049 You have to monitor it incredibly closely. You 00:17:13.049 --> 00:17:15.269 want to match the intake to the new lower output. 00:17:15.410 --> 00:17:18.190 It requires strict INO monitoring. Also, practically 00:17:18.190 --> 00:17:20.210 speaking, if you have a kid with a cold and a 00:17:20.210 --> 00:17:22.609 stuffy nose, the nasal spray might not absorb 00:17:22.609 --> 00:17:24.289 well. Oh, that makes sense. Yeah. You need to 00:17:24.289 --> 00:17:26.569 switch to oral or call the doc. That's a huge 00:17:26.569 --> 00:17:29.369 bedside nursing pearl. That is huge. A runny 00:17:29.369 --> 00:17:31.890 nose could literally send a DI kid into crisis. 00:17:33.039 --> 00:17:34.839 Okay, compare that to the other side of the coin, 00:17:35.180 --> 00:17:38.500 the shock pattern. Congenital adrenal hyperplasia. 00:17:38.859 --> 00:17:41.819 CAH. This is probably the most complex mechanism 00:17:41.819 --> 00:17:43.799 we will discuss today, so let's use an analogy. 00:17:44.480 --> 00:17:47.180 Imagine a factory assembly line. The adrenal 00:17:47.180 --> 00:17:49.960 gland is the factory. Its job is to take raw 00:17:49.960 --> 00:17:52.539 materials, which is cholesterol, and turn them 00:17:52.539 --> 00:17:55.460 into three distinct products. Cortisol for stress 00:17:55.460 --> 00:17:58.900 and sugar, aldosterone for salt, and androgens 00:17:58.900 --> 00:18:00.880 for sex characteristics. Okay, I'm tracking. 00:18:01.400 --> 00:18:03.480 Cortisol, aldosterone, androgens. The acetylene 00:18:03.480 --> 00:18:06.119 relies on workers, which are enzymes to modify 00:18:06.119 --> 00:18:09.460 the raw material. In CAH, one specific worker 00:18:09.460 --> 00:18:12.920 is missing, the enzyme 21 -hydroxylase. This 00:18:12.920 --> 00:18:14.759 worker is responsible for making cortisol and 00:18:14.759 --> 00:18:17.359 aldosterone. So the worker is on strike, no cortisol, 00:18:17.660 --> 00:18:19.700 no aldosterone. Right, but the brain doesn't 00:18:19.700 --> 00:18:21.900 know the worker is missing. The brain sees low 00:18:21.900 --> 00:18:24.019 cortisol and screams at the factory, make more. 00:18:24.299 --> 00:18:26.900 It sends tons of ACTH, which is the manager. 00:18:27.380 --> 00:18:29.500 The factory goes into overdrive trying to comply. 00:18:29.579 --> 00:18:31.680 It gets huge. That's the hyperplasia part. It 00:18:31.680 --> 00:18:33.819 pumps tons of raw material into the line. But 00:18:33.819 --> 00:18:35.519 the worker's still missing, so it hits a wall. 00:18:36.019 --> 00:18:38.440 Exactly. So all that raw material hits the roadblock. 00:18:38.559 --> 00:18:40.779 It can't become cortisol. It can't become aldosterone. 00:18:40.799 --> 00:18:43.079 So where does it go? It spills over into the 00:18:43.079 --> 00:18:45.400 only line that is actually working, the androgen 00:18:45.400 --> 00:18:48.039 line. So you have no cortisol, no aldosterone, 00:18:48.039 --> 00:18:50.819 but a massive flood of testosterone. Precisely. 00:18:51.019 --> 00:18:53.579 And that explains every single symptom. Let's 00:18:53.579 --> 00:18:56.299 look at the need -to -know assessment. In a female 00:18:56.299 --> 00:18:59.279 infant, all that extra testosterone and utero 00:18:59.279 --> 00:19:03.359 causes ambiguous genitalia. And in large clitoris, 00:19:03.380 --> 00:19:05.400 that might actually look like a penis labia that 00:19:05.400 --> 00:19:08.480 are fused. So a baby is born, and the delivery 00:19:08.480 --> 00:19:10.660 team says, we aren't sure if it's a boy or a 00:19:10.660 --> 00:19:13.440 girl. Right. That triggers an immediate endocrine 00:19:13.440 --> 00:19:16.980 workup. But here is the massive danger. In males, 00:19:17.319 --> 00:19:20.509 the genitalia look normal. Maybe slightly enlarged, 00:19:20.609 --> 00:19:23.210 but often completely missed. That's why boys 00:19:23.210 --> 00:19:25.849 with CAH are often diagnosed later, unfortunately, 00:19:26.029 --> 00:19:28.269 often in an active crisis. And the crisis is 00:19:28.269 --> 00:19:30.730 the salt -wasting part. Yes. This is where the 00:19:30.730 --> 00:19:32.829 missing aldosterone kills you. Aldosterone's 00:19:32.829 --> 00:19:34.869 job is to hold on to salt, sodium, and pee out 00:19:34.869 --> 00:19:37.170 potassium. Without it, you lose sodium and you 00:19:37.170 --> 00:19:38.869 keep potassium. Just low sodium, high potassium. 00:19:39.029 --> 00:19:42.230 Correct. And remember, water follows salt. So 00:19:42.230 --> 00:19:44.390 if you are peeing out salt, you are peeing out 00:19:44.390 --> 00:19:46.650 your blood volume. These babies present with 00:19:46.650 --> 00:19:49.210 failure to thrive, severe vomiting, and then 00:19:49.210 --> 00:19:52.569 sudden shock. Hypotremia, hyperkalemia, hypotension. 00:19:53.569 --> 00:19:56.269 That is an adrenal crisis. That sounds terrifying 00:19:56.269 --> 00:19:59.769 for a parent. Low sodium, high potassium shock. 00:20:00.009 --> 00:20:02.390 That is the exact opposite of the DI kid we just 00:20:02.390 --> 00:20:04.630 talked about. It is. And the high potassium can 00:20:04.630 --> 00:20:07.190 cause lethal cardiac arrhythmias. This is a top 00:20:07.190 --> 00:20:09.450 -tier medical emergency. How do we fix it? We 00:20:09.450 --> 00:20:11.049 need to replace the missing hormones, right? 00:20:11.130 --> 00:20:13.930 Yes. We basically need to do the job of the missing 00:20:13.930 --> 00:20:16.970 enzyme worker. We give glucocorticoids, like 00:20:16.970 --> 00:20:18.990 hydrocortisone, to replace the cortisol. And 00:20:18.990 --> 00:20:21.490 we give mitralocorticoids, like flujocortisone, 00:20:21.730 --> 00:20:23.920 to replace the aldosterone. Hydro for the sugar 00:20:23.920 --> 00:20:26.319 and stress, fludro for the fluid and salt. I 00:20:26.319 --> 00:20:28.140 really like that memory trick. It works perfectly. 00:20:28.680 --> 00:20:31.059 But here is the single most important parent 00:20:31.059 --> 00:20:34.220 education point for CAH. You'll see this on every 00:20:34.220 --> 00:20:37.240 exam. It's called stress dosing. Explain that, 00:20:37.339 --> 00:20:39.660 because this is life or death, right? It absolutely 00:20:39.660 --> 00:20:43.019 is. Cortisol is our stress hormone. If you or 00:20:43.019 --> 00:20:45.140 I get the flu or get into a car accident or have 00:20:45.140 --> 00:20:48.180 surgery, our bodies naturally pump out five or 00:20:48.180 --> 00:20:50.279 ten times the normal amount of cortisol to keep 00:20:50.279 --> 00:20:52.720 our blood pressure up and handle the physiological 00:20:52.720 --> 00:20:55.839 stress. These kids simply cannot do that. Their 00:20:55.839 --> 00:20:58.539 factory is broken. So if they get sick, what 00:20:58.539 --> 00:21:01.720 happens? If they get a fever over 101, break 00:21:01.720 --> 00:21:04.940 a bone or need surgery, the parents must manually 00:21:04.940 --> 00:21:07.390 increase the dose of hydrocortisone. usually 00:21:07.390 --> 00:21:09.109 double or triple it depending on the protocol. 00:21:09.650 --> 00:21:11.490 If they don't, the child will run out of cortisol, 00:21:11.910 --> 00:21:13.890 their blood pressure will completely tank, and 00:21:13.890 --> 00:21:16.190 they will go into shock and die. That is definitely 00:21:16.190 --> 00:21:18.890 a can't miss for nurses. Stress dosing saves 00:21:18.890 --> 00:21:21.859 lives. Absolutely. We teach parents, when in 00:21:21.859 --> 00:21:24.240 doubt, give the dose. It's better to have a little 00:21:24.240 --> 00:21:26.180 too much steroid for a day than to go into shock. 00:21:26.279 --> 00:21:28.539 And what if the child is vomiting from a stomach 00:21:28.539 --> 00:21:30.799 bug and can't keep the oral pills down? They 00:21:30.799 --> 00:21:33.579 need to go to the ER immediately for IV steroids. 00:21:34.180 --> 00:21:36.380 Parents need an emergency kit at home, usually 00:21:36.380 --> 00:21:38.180 Solacortef, just like you would have an EpiPen. 00:21:38.700 --> 00:21:41.700 And they need to know how to inject it intramuscularly 00:21:41.700 --> 00:21:44.420 while waiting for the ambulance. Okay, deep breath. 00:21:45.039 --> 00:21:47.900 We've done growth. We've done salt and water. 00:21:48.099 --> 00:21:50.599 Let's hit the metabolic throttle, the thyroid. 00:21:50.900 --> 00:21:53.440 This is the Goldilock engine. Let's start with 00:21:53.440 --> 00:21:57.079 the slow side, congenital hypothyroidism. This 00:21:57.079 --> 00:21:59.259 one is very personal to the public health community 00:21:59.259 --> 00:22:01.799 because it's one of the greatest victories of 00:22:01.799 --> 00:22:05.259 modern newborn screening. We are talking about 00:22:05.259 --> 00:22:09.380 a baby born with a broken or entirely missing 00:22:09.380 --> 00:22:11.700 thyroid gland. And why is this an emergency? 00:22:11.980 --> 00:22:13.779 I mean, if an adult has hypothyroidism, they 00:22:13.779 --> 00:22:16.160 just gain some weight and feel tired. In an adult, 00:22:16.380 --> 00:22:20.440 yes. But in an infant, thyroid hormone is absolutely 00:22:20.440 --> 00:22:22.980 essential for brain development, specifically 00:22:22.980 --> 00:22:25.000 the myelination of the nerves in the first two 00:22:25.000 --> 00:22:26.859 to three years of life. So if you miss it early 00:22:26.859 --> 00:22:29.099 on? Permanent intellectual disability. It used 00:22:29.099 --> 00:22:31.200 to be a leading cause of preventable cognitive 00:22:31.200 --> 00:22:33.259 impairment. We called it cretinism historically, 00:22:33.319 --> 00:22:34.859 though we obviously don't use that term anymore 00:22:34.859 --> 00:22:37.539 in practice. Wow. So how do we spot it? What 00:22:37.539 --> 00:22:39.829 does the baby actually look like? That's the 00:22:39.829 --> 00:22:42.910 clinical trap. The symptoms are all slow. The 00:22:42.910 --> 00:22:45.470 baby is lethargic. They sleep all the time. They 00:22:45.470 --> 00:22:48.109 are hypotonic, meaning floppy. They have a really 00:22:48.109 --> 00:22:50.750 poor suck. Parents might say, oh, he's such a 00:22:50.750 --> 00:22:52.369 good baby. He never cries. He sleeps through 00:22:52.369 --> 00:22:54.829 the night. The good baby trap? That gives me 00:22:54.829 --> 00:22:57.130 chills. A baby that is too good might actually 00:22:57.130 --> 00:23:00.289 be in neurological trouble. Exactly. Other physical 00:23:00.289 --> 00:23:03.150 signs to look for are an enlarged tongue macroglossia 00:23:03.150 --> 00:23:05.930 that sticks out of the mouth, cool, dry skin, 00:23:06.170 --> 00:23:09.890 severe constipation, and a persistent open posterior 00:23:09.890 --> 00:23:12.730 fontanel. But we don't wait for symptoms to show 00:23:12.730 --> 00:23:14.809 up, do we? Because by the time the tongue is 00:23:14.809 --> 00:23:16.910 visibly sticking out, the brain damage might 00:23:16.910 --> 00:23:19.569 already be done. Correct. That's why the absolute 00:23:19.569 --> 00:23:22.230 need -to -know diagnostic is the newborn screening, 00:23:22.650 --> 00:23:25.230 the heel stick. Every single baby in the U .S. 00:23:25.369 --> 00:23:28.349 gets tested. We look for low T4 and a high TSH. 00:23:28.589 --> 00:23:31.230 High TSH because the brain is screaming at the 00:23:31.230 --> 00:23:33.960 thyroid to work. Exactly. The pituitary is yelling 00:23:33.960 --> 00:23:36.400 work harder, but the thyroid just can't answer. 00:23:36.460 --> 00:23:38.660 And the treatment for this. Lifelong thyroid 00:23:38.660 --> 00:23:41.579 replacement. Sodium levothyroxine. Let's talk 00:23:41.579 --> 00:23:43.819 about administering this to a newborn. Because 00:23:43.819 --> 00:23:45.740 you can't just toss a pill in a baby's mouth. 00:23:46.039 --> 00:23:48.900 No, you have to crush it. You mix it with a tiny 00:23:48.900 --> 00:23:52.599 amount of water or breast milk. And here is the 00:23:52.599 --> 00:23:54.859 massive petty pearl. You never mix it with soy 00:23:54.859 --> 00:23:58.279 formula. Why not soy? Soy protein heavily binds 00:23:58.279 --> 00:24:00.779 to the medication and prevents it from absorbing 00:24:00.779 --> 00:24:03.740 in the gut. If the baby is on a soy formula, 00:24:04.059 --> 00:24:06.859 you have to time the meds very carefully or ideally 00:24:06.859 --> 00:24:09.680 switch formulas. Also, avoid giving it with iron 00:24:09.680 --> 00:24:12.319 or calcium supplements. Ideally, it's given on 00:24:12.319 --> 00:24:14.519 an empty stomach, but with a newborn eating every 00:24:14.519 --> 00:24:17.339 two hours, that's hard. So consistency is the 00:24:17.339 --> 00:24:19.359 key. And if we treat it early and consistently? 00:24:19.460 --> 00:24:22.339 They grow up completely normal. Normal IQ, normal 00:24:22.339 --> 00:24:24.640 height. It's truly a miracle of modern medicine. 00:24:24.859 --> 00:24:26.519 But if parents stop the meds because they think 00:24:26.519 --> 00:24:28.779 the baby looks fine, the brain damage resumes. 00:24:29.279 --> 00:24:31.579 Compliance is non -negotiable. Let's quickly 00:24:31.579 --> 00:24:34.000 touch on acquired hypothyroidism before we move 00:24:34.000 --> 00:24:36.380 on. That's the older kid. Right, usually Hashimoto's, 00:24:36.400 --> 00:24:38.660 which is autoimmune. The presentation is what 00:24:38.660 --> 00:24:41.819 you'd expect. Fatigue, weight gain, cold intolerance, 00:24:42.099 --> 00:24:44.619 maybe a goiter, which is an enlarged thyroid 00:24:44.619 --> 00:24:46.660 gland. Treatment is the same, levothyroxine. 00:24:47.079 --> 00:24:49.140 Okay, let's shift gears. The engine goes from 00:24:49.140 --> 00:24:52.339 slow to fast, hyperthyroidism, Graves' disease. 00:24:52.680 --> 00:24:55.680 This usually hits in adolescents. It's also autoimmune. 00:24:56.430 --> 00:24:59.109 The body makes antibodies that attack the thyroid, 00:24:59.250 --> 00:25:01.569 but instead of breaking it, they stimulate it. 00:25:01.670 --> 00:25:03.549 They basically turn the gas pedal to the floor. 00:25:03.829 --> 00:25:05.529 So everything speeds up. What does that look 00:25:05.529 --> 00:25:08.410 like in a teenager? Imagine a kid who drinks 00:25:08.410 --> 00:25:12.289 10 espressos. They're hyperactive. They're irritable. 00:25:12.430 --> 00:25:15.349 They have severe emotional atribility. Their 00:25:15.349 --> 00:25:17.589 school performance suddenly drops because they 00:25:17.589 --> 00:25:20.009 just can't focus. And physically. Rapid weight 00:25:20.009 --> 00:25:22.990 loss. They're eating like a horse polyphagia, 00:25:23.029 --> 00:25:25.029 but losing weight because their metabolism is 00:25:25.029 --> 00:25:27.660 burning it off instantly. They are hot all the 00:25:27.660 --> 00:25:30.859 time, heat intolerance. Their heart is racing 00:25:30.859 --> 00:25:33.900 tachycardia. And they very often have exothelmos, 00:25:33.980 --> 00:25:36.539 which are those bulging, staring eyes. And the 00:25:36.539 --> 00:25:39.720 skin. Smooth, velvety, and warm. The exact opposite 00:25:39.720 --> 00:25:42.559 of the dry, cool skin in hypothyroidism. What's 00:25:42.559 --> 00:25:45.039 the can't -miss danger here? Thyroid storm. This 00:25:45.039 --> 00:25:47.200 is a life -threatening crisis where the thyroid 00:25:47.200 --> 00:25:50.079 hormones surge uncontrollably. It's often triggered 00:25:50.079 --> 00:25:52.400 by an infection, severe stress, or even physically 00:25:52.400 --> 00:25:54.220 squishing the gland during surgery. What does 00:25:54.220 --> 00:25:56.799 a storm look like at the bedside? Sudden onset 00:25:56.799 --> 00:26:01.059 of severe restlessness, a very high fever diaphoresis, 00:26:01.259 --> 00:26:03.319 meaning there are sweating buckets, and extreme 00:26:03.319 --> 00:26:06.039 tachycardia. They can go into heart failure or 00:26:06.039 --> 00:26:08.740 shock very quickly. So if you have a Graves patient 00:26:08.740 --> 00:26:11.640 who suddenly gets agitated and feverish, you 00:26:11.640 --> 00:26:13.680 run. You run. You need to block that hormone 00:26:13.680 --> 00:26:16.400 synthesis immediately. We use propylthuracil 00:26:16.400 --> 00:26:19.559 PTU or methamazole. And we use beta blockers 00:26:19.559 --> 00:26:22.019 like propranolol to control the heart rate while 00:26:22.019 --> 00:26:24.079 we wait for the anti -syroid meds to kick in. 00:26:24.279 --> 00:26:26.380 And if the meds don't work long term, we do surgery. 00:26:26.460 --> 00:26:28.220 Yes, a thyroidectomy. We take the gland out. 00:26:28.619 --> 00:26:31.119 But that brings us to a perfect clinical segue. 00:26:31.720 --> 00:26:33.720 If you take out the thyroid, what is the huge 00:26:33.720 --> 00:26:35.740 surgical risk? We're talking about our next disease 00:26:35.740 --> 00:26:39.289 process, hypoparathyroidism. Right. The parathyroid 00:26:39.289 --> 00:26:41.710 glands are these four tiny little buttons that 00:26:41.710 --> 00:26:44.470 sit right on top of the thyroid. During a thyroidectomy, 00:26:44.490 --> 00:26:46.769 they can be accidentally removed or damaged because 00:26:46.769 --> 00:26:48.730 they are just so incredibly small. And what do 00:26:48.730 --> 00:26:51.329 they do? They control calcium. Parathyroid hormone, 00:26:51.329 --> 00:26:54.390 or PTH, raises blood calcium. If you lose the 00:26:54.390 --> 00:26:57.289 glands, PTH drops and calcium crashes. Hypocalcium. 00:26:57.369 --> 00:27:00.670 Yes. And the need -to -know signs of hypocalcemia 00:27:00.670 --> 00:27:04.589 are neuromuscular excitability. The muscles basically 00:27:04.589 --> 00:27:06.549 go crazy. Excitability? I would have thought 00:27:06.549 --> 00:27:09.480 low meant slow. That's a common misconception. 00:27:10.339 --> 00:27:12.259 Calcium actually acts like a sedative on the 00:27:12.259 --> 00:27:14.700 nerve endings. Remove the sedative and the nerves 00:27:14.700 --> 00:27:17.740 fire uncontrollably. You get tetany muscle cramps, 00:27:18.160 --> 00:27:21.319 severe twitching. Give us the famous exam signs 00:27:21.319 --> 00:27:24.319 for this. Trostex sign. You tap the facial nerve 00:27:24.319 --> 00:27:26.680 on the cheek and the facial muscles twitch. And 00:27:26.680 --> 00:27:28.970 the other one. Drusso. Drusso sign. You pump 00:27:28.970 --> 00:27:31.049 up a blood pressure cuff on the arm, keep it 00:27:31.049 --> 00:27:33.329 inflated above systolic for three minutes, and 00:27:33.329 --> 00:27:35.589 the hand spasms into a stiff claw shape. His 00:27:35.589 --> 00:27:37.690 claw. Okay, yeah. But the real danger isn't the 00:27:37.690 --> 00:27:41.160 hand, it's the throat. Laryngospasm. The airway 00:27:41.160 --> 00:27:43.779 muscles can spasm and close off completely. That 00:27:43.779 --> 00:27:47.380 is a massive airway emergency. So post -thyroidectomy 00:27:47.380 --> 00:27:50.500 nursing care 101, have a track tray at the bedside 00:27:50.500 --> 00:27:52.900 at all times, and what medication do we need 00:27:52.900 --> 00:27:55.880 ready? IV calcium gluconate. You absolutely must 00:27:55.880 --> 00:27:57.779 have it available for emergency administration. 00:27:57.960 --> 00:27:59.839 Let's talk about giving IV calcium, though. It's 00:27:59.839 --> 00:28:02.539 not a benign drug you just push. No, it is a 00:28:02.539 --> 00:28:06.289 vesicant. If the IV infiltrates and the calcium 00:28:06.289 --> 00:28:08.690 leaks into the surrounding tissue, it causes 00:28:08.690 --> 00:28:11.470 severe necrosis. It will literally rot the skin 00:28:11.470 --> 00:28:14.049 and tissue. You need a patent -reliable IV line 00:28:14.049 --> 00:28:17.000 and you administer it very slowly. You also need 00:28:17.000 --> 00:28:19.259 the patient on a cardiac monitor because rapid 00:28:19.259 --> 00:28:22.759 calcium changes can cause arrhythmias like bradycardia 00:28:22.759 --> 00:28:24.980 or even cardiac arrest. Okay, so that tightly 00:28:24.980 --> 00:28:27.339 connects the thyroid surgery to the parathyroid 00:28:27.339 --> 00:28:29.519 complication. It's a physiological domino effect. 00:28:29.700 --> 00:28:31.960 Exactly. It's all connected. We have to mention 00:28:31.960 --> 00:28:34.420 diabetes mellitus briefly as it is in the source 00:28:34.420 --> 00:28:36.779 material. We do. We can't cover all of diabetes 00:28:36.779 --> 00:28:39.980 today, obviously. But for the 80 -20 of endocrine, 00:28:40.119 --> 00:28:42.680 focus on type 1 being the autoimmune destruction 00:28:42.680 --> 00:28:45.359 of the pancreas. These kids make zero in... They 00:28:45.359 --> 00:28:47.880 are insulin dependent for life. And the main 00:28:47.880 --> 00:28:50.759 safety item for exams in the bedside? Distinguishing 00:28:50.759 --> 00:28:54.420 hypoglycemia versus hyperglycemia quickly. Hypoglycemia, 00:28:54.519 --> 00:28:56.839 they are cold, clammy, shaky, and confused. The 00:28:56.839 --> 00:28:59.259 rhyme is cold and clammy needs some candy. This 00:28:59.259 --> 00:29:01.660 kills you fast. Hyperglycemia, they are hot, 00:29:01.779 --> 00:29:03.920 dry, thirsty with fruity breath. Hot and dry, 00:29:04.119 --> 00:29:07.220 sugar high. This leads to DKA over days. So what's 00:29:07.220 --> 00:29:09.440 the clinical takeaway for a pediatric nurse? 00:29:09.900 --> 00:29:11.839 The nurse needs to know that a temper tantrum 00:29:11.839 --> 00:29:15.259 in a diabetic toddler might actually be a hypoglycemic 00:29:15.259 --> 00:29:19.019 crash. Check the sugar first, punish later. Check 00:29:19.019 --> 00:29:21.480 the sugar first. I really like that rule. And 00:29:21.480 --> 00:29:24.099 developmentally, imagine being a teenager who 00:29:24.099 --> 00:29:26.099 just wants to fit in, but you have to check your 00:29:26.099 --> 00:29:29.140 blood sugar and inject insulin right at the lunch 00:29:29.140 --> 00:29:33.039 table. Adolescence is the peak time for noncompliance 00:29:33.039 --> 00:29:35.240 because they just want to be normal. nursing 00:29:35.240 --> 00:29:37.720 support and psychological care is huge there. 00:29:37.839 --> 00:29:39.880 Okay, we have covered a ton of ground today. 00:29:40.279 --> 00:29:41.779 We've integrated the meds, we've looked at the 00:29:41.779 --> 00:29:43.619 labs. I want to wrap up by bringing it all back 00:29:43.619 --> 00:29:46.039 to the so what. We've talked about growth, salt, 00:29:46.099 --> 00:29:49.539 and speed. Yes, the master map to review. If 00:29:49.539 --> 00:29:52.240 the growth is off, check the pituitary for GH 00:29:52.240 --> 00:29:54.759 or the thyroid. If the salt is off, check the 00:29:54.759 --> 00:29:57.839 adrenal for CAH or the pituitary for DI. If the 00:29:57.839 --> 00:30:00.099 speed is off, check the thyroid. And the core 00:30:00.099 --> 00:30:03.069 developmental takeaways. First, hypothyroidism 00:30:03.069 --> 00:30:05.869 directly links to cognitive delay. Catch it early 00:30:05.869 --> 00:30:09.269 with screening to save the IQ. Second, GH deficiency 00:30:09.269 --> 00:30:11.630 and precocious puberty directly link to self 00:30:11.630 --> 00:30:13.710 -esteem and social standing. Always treat the 00:30:13.710 --> 00:30:16.890 child's age and author size. And third, CAH and 00:30:16.890 --> 00:30:20.089 DI. These are the fast killers. Fluid and electrolyte 00:30:20.089 --> 00:30:22.890 management is the priority. Stress dosing for 00:30:22.890 --> 00:30:25.569 CAH prevents shock. And let's do a quick medication 00:30:25.569 --> 00:30:28.250 safety cross -check. For semitropin, watch for 00:30:28.250 --> 00:30:50.259 hip or knee pain indicating SCFE. This has been 00:30:50.259 --> 00:30:53.740 an incredibly dense overview. As we wrap up, 00:30:53.740 --> 00:30:55.599 what is your final provocative thought for our 00:30:55.599 --> 00:30:57.359 listeners to take away? I want you to think about 00:30:57.359 --> 00:31:01.000 the invisible puppet master again. Endocrine 00:31:01.000 --> 00:31:03.279 disorders don't bleed, they don't usually cough, 00:31:03.539 --> 00:31:05.660 and they don't show up on a cast. They show up 00:31:05.660 --> 00:31:08.700 in the behavior and on the growth chart. My provocative 00:31:08.700 --> 00:31:11.660 thought is this. How many difficult toddlers 00:31:11.660 --> 00:31:14.920 or lazy teenagers or clumsy kids are actually 00:31:14.920 --> 00:31:17.940 suffering from completely undiagnosed endocrine 00:31:17.940 --> 00:31:20.960 imbalances? That is powerful. Is the teen sleeping 00:31:20.960 --> 00:31:23.519 until noon just being a typical teen or is it 00:31:23.519 --> 00:31:26.480 severe hypothyroidism? Is the toddler's temper 00:31:26.480 --> 00:31:30.119 tantrum just behavioral or is it a hypoglycemic 00:31:30.119 --> 00:31:33.779 event or an electrolyte imbalance from CAH? Exactly. 00:31:34.160 --> 00:31:36.079 The takeaway for every nurse listening is this. 00:31:36.490 --> 00:31:39.069 If a child is falling off the growth curve, acting 00:31:39.069 --> 00:31:41.250 oddly lethargic, or drinking water like a fish, 00:31:41.630 --> 00:31:43.849 don't just document it. Investigate it. You might 00:31:43.849 --> 00:31:46.789 save a brain, a bone, or a life. Investigating 00:31:46.789 --> 00:31:48.630 the invisible. I love it. Thank you for joining 00:31:48.630 --> 00:31:50.769 us on this deep dive into the pediatric endocrine 00:31:50.769 --> 00:31:52.809 system. We really hope this helps you crush that 00:31:52.809 --> 00:31:54.869 exam. And more importantly, be the nurse who 00:31:54.869 --> 00:31:56.970 catches the subtle signs right at the bedside. 00:31:57.049 --> 00:31:59.450 Keep plotting those growth charts. See you next 00:31:59.450 --> 00:32:00.650 time on the Deep Dive.