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Pediatrics 5

Traumatic Neurological Conditions

    1. Head trauma
      1. Etiology: force to the scalp, skull, meninges, or brain
      2. Pathophysiology
        1. directly related to force of impact and secondary forces
        2. types: primary and secondary
        3. cerebral function depends on oxygen, glucose and blood flow to brain; cerebral edema and hypoxia can occur quickly
      3. Findings: neurological status depends on ICP
      4. Management
        1. acute
          1. control ICP: medications, ventilatory support, positioning, fluids
          2. surgical repair of fractures
        2. long-term rehabilitation
      5. Complications: hemorrhage, infection, cerebral edema and herniation through the tentorium
        1. epidural hemorrhage
        2. subdural hemorrhage
  1. Pediatric Endocrinology


  1. The endocrine system (illustration )
  1. Hypopituitarism
  1. Syndrome of inappropriate antidiuretic hormone (SIADH)
  1. Hypothyroid, hyperthyroid
  1. Diabetes mellitus


  1. The endocrine system
    1. Three types of tissues
      1. cells that send chemical message via hormones
      2. target cells in end organ that receive chemical message
      3. environment: medium through which chemical message travels from the site of synthesis to area of cellular action
    2. Endocrine function
      1. endocrine + autonomic systems = neuroendocrine system
      2. neuroendocrine system: synthesizes and releases chemical substances that then regulate bodily function: messages are carried by nerve impulses in the nervous component and by blood in the endocrine system. (illustration)
      3. the two systems function synergistically. Impulses transmitted via the nervous system stimulate the hypothalamus to secrete releasing or inhibiting factors
    3. Hypopituitarism
      1. Definition: diminished or deficient secretion of pituitary hormones
      2. Etiology: tumors, hypoplasia, auto-immune, congenital, acquired, irradiation, malnutrition, trauma
      3. Pathophysiology: leads to gonadotropin deficiency
      4. Findings
        1. usually dependent on hormone involved and age of onset
        2. absence or regression of secondary sex characteristics
        3. example: slow growth, short stature, normal intelligence; delayed puberty
      5. Management
        1. depends on cause
        2. hormone replacement therapy: growth hormone
    4. "Precocious puberty"
      1. Definition: manifestations of sexual development before age nine in boys or age eight in girls
      2. Etiology: brain lesions, inflammatory disorders, idiopathic
      3. Pathophysiology
        1. premature activation of hypothalamic-pituitary-gonadal axis
        2. early increased release of LH and FSH
        3. early acceleration of linear growth with early closure of growth plates
        4. ultimate height less than if puberty had been normal
      4. Findings
        1. development of breasts in prepubertal females
        2. early development of sexual hair
        3. isolated menses
        4. development of secondary sex characteristics
      5. Management
        1. directed toward specific cause
        2. hypothalamic - pituitary origin: luteinizing hormone - releasing hormone (LHRH) injections monthly
    5. SIADH: syndrome of inappropriate antidiuretic hormone
      1. Definition: hypersecretion of antidiuretic hormone or ADH (vasopressin)
      2. Etiology: infections, head trauma, or brain tumors
      3. Pathophysiology
        1. kidneys reabsorb too much free water
        2. decreased urine output, increased specific gravity (SG), and decreased serum sodium
      4. Findings
        1. urine SG > 1.030
        2. anorexia, nausea, weakness, stomach cramps
        3. increased weight (edema)
        4. decreased serum sodium
      5. Management
        1. restrict fluids to correct hyponatremia
        2. correct underlying etiology
        3. monitor I & O, electrolytes, neuro status
        4. observe for signs of fluid overload
    6. Hypothyroidism (illustration)
      1. Definition: deficiency of thyroid hormone (TH); common childhood endocrine disorder
      2. Etiology
        1. congenital or acquired deficiency in thyroid hormones
        2. thyroid irradiation
      3. Pathophysiology
        1. absent or underdeveloped gland
        2. decreased triiodothyronine (T3) or thyroxine (T4)
      4. Findings: depend on extent of dysfunction and age of child at onset
        1. lethargy, constipation, feeding problems
        2. hypotonia, large tongue
        3. dry skin, weight gain, puffy eyes, sparse hair
        4. intolerance to cold
        5. slowed growth, developmental delay and/or retardation if T4 low at birth and thyroid replacement not started
        6. if findings develop after two to three years, when brain has grown, no mental retardation
      5. Diagnostics:
        1. history and physical
        2. increased TSH
        3. decreased serum T3 and T4
        4. anemia
        5. decreased BMR (basal metabolic rate)
        6. increased cholesterol and triglycerides
        7. hypoglycemia
      6. Management:
        1. lifelong hormone replacement (levothyroxine)
        2. rest
        3. protect client from cold
    7. Hyperthyroid: "Graves' disease"
      1. Definition: hypersecretion of thyroid hormones, causing increased BMR or hyperactivity of thyroid gland
      2. Etiology: auto-immune response to TSH (thyroid-stimulating hormone) receptors; idiopathic; familial
      3. Findings
        1. increases in: BMR, appetite, nervousness, heart rate
        2. gradual weight loss despite voracious appetite
        3. lowered tolerance to heat
        4. exophthalmos (eyes bulge)
        5. myopathy
        6. personality changes, poor school performance, mood instability
        7. linear growth and bone age accelerated
        8. insomnia
        9. increased blood pressure
      4. Diagnostics
        1. history and physical
        2. palpable thyroid enlargement (goiter)
        3. elevated serum T3 and T4 levels
        4. elevated radioactive iodine uptake
        5. presence of thyroid antibodies
        6. decreased TSH levels
      5. Management
        1. antithyroid therapy
        2. surgery (subtotal thyroidectomy)
      6. Concern: thyrotoxicosis or "thyroid storm" from sudden release of hormone:
        1. can be life threatening
        2. findings
          1. acute onset of severe irritability
          2. vomiting
          3. diarrhea
          4. hyperthermia
          5. hypertension
          6. tachycardia
          7. prostration
        3. treat with: cooling blanket
        4. propranolol (inderol), potassium iodine (thyro-block)
        5. antithyroid drugs
    8. Diabetes mellitus - type 1
      1. Definition: deficiency of hormone insulin
      2. Etiology: genetic, auto-immune response; usually with viral trigger
      3. Pathophysiology:
        1. trigger directs islet cellantibodies against cell surfaces
        2. antibodies destroy the insulin-secreting Beta cells -
        3. less insulin means glucose is blocked from intracellular space
        4. when glucose level exceeds kidney's threshold (about 180 mg/dl), result is hyperglycemia
        5. kidney then "spills" glucose into urine, producing osmotic diuresis
        6. starved for glucose, body instead breaks down fats, producing ketones
      4. Findings
        1. hyperglycemia:
          1. the three "polys" of diabetes: polydipsia, polyuria, polyphagia
          2. additional findings: fatigue, hunger, weight loss, enuresis