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7 th ANNUAL PEDIATRIC BOARD REVIEW. CRITICAL CARE MEDICINE. Edward E. Conway Jr., M.D., M.S. FAAP, FCCM, FCCP, FHM Professor and Chairman Milton and Bernice Stern Department of Pediatrics Chief Pediatric Critical Care Medicine Beth Israel Medical Center

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critical care medicine

7thANNUAL PEDIATRIC BOARD REVIEW

CRITICAL CARE MEDICINE

Edward E. Conway Jr., M.D., M.S.

FAAP, FCCM, FCCP, FHM

Professor and Chairman

Milton and Bernice Stern

Department of Pediatrics

Chief Pediatric Critical Care Medicine

Beth Israel Medical Center

Professor of Clinical Pediatrics @ AECOM

slide9

HOW MUCH TIME DO I HAVE UNTIL THE EXAM?

  • 178 DAYS
  • ~ 25 WEEKS
  • Assume 2 hr/day/4days/week
  • 195 hrsof study time
  • 128 DAYS
  • ~ 18 WEEKS
  • Assume 2 hr/day/4dasy/week 144 hrs study time
  • PREP 240 Quests/Year
  • I min/quest=240min= 4 hrs
  • Review ans 8 min x 240 = 1920 min = 32 hrs& therefore 36hrs/ Year/ PREP
slide10

READ THE QUESTIONS CAREFULLY!!

They are all worth the same amount!!!!!!!

slide11

A two month old infant is brought to the emergency room for poor feeding and “breathing funny”. Mother had a normal birth and was sent home on day 2. Which of the following is the earliest finding suggestive of impending respiratory failure??

  • Nasal flaring
  • Grunting
  • Use of accessory muscles
  • Presence of a pectusexcavatum
  • Respiratory rate of 70

5

slide12

A 2 month old male with Trisomy 21 is brought to you for noisy breathing. He has had no choking or difficulty feeding. The noise appears to occur on inspiration and is loudest when the infant is supine. Which of the following is the MOST likely explanation for the infants symptoms?

  • A) laryngomalacia
  • B subglottic tracheal web
  • C) tracheomalacia
  • D) vascular ring
  • E) vocal cord paralysis

6

respiratory failure
RESPIRATORY FAILURE

FAILURE TO VENTILATE (PaCO2)

- Increasing PaCO2 with a decreasing PH

FAILURE TO OXYGENATE(PaO2)

- PaO2 < 60 TORR while breathing

FIO2 > .60

pediatric versus adult airways
PEDIATRIC VERSUS ADULT AIRWAYS

Narrower Airways (Higher resistance)

Decreased cartilaginous support

Decreased number and size of alveoli

Decreased elastic recoil

Orientation of ribs

Insertion of diaphragm

Increased oxygen consumption

Higher minute ventilation

slide19

A 13 month old infant is brought to your office for a five day history of low-grade fever, rhinorrhea and a harsh non-productive barking cough and inspiratorystridor. Today the child is irritable, has a fever of 102oF and is not feeding well. You obtain a radiograph shown below. Which of the following is the MOST likely diagnosis at this time?

  • spasmodic croup
  • retropharyngeal abscess
  • epiglottis
  • bacterial tracheitis
  • laryngomalacia

5

slide23

A 13 mos old infant was previously healthy and fully immunized. On physical exam he has a temperature of 1010F, heart rate 150 bpm, respiratory rate 36 bpm while crying and pulse oximetry on room air is 97%. Once the infant settles down you note inspiratorystridor and mild suprasternal retractions. He prefers to sit up and looks slightly anxious. Which of the following is MOST likely to provide for clinical improvement?

  • ceftriaxone intramuscularly
  • dexamethasone orally or intramuscularly
  • humidified oxygen by face mask
  • nebulizedalbuterol
  • nebulizedbudesonide

6

rapid drill 1
Rapid Drill 1

Diagnosis

Bugs

Drugs

Management

Complications

obstructive sleep apnea
Obstructive Sleep Apnea

Complete or partial airway collapse leads to hypoxemia & hypercarbia

Occurs during REM sleep

Loud snoring, excessive respiratory effort during sleep, profuse nocturnal sweating, enuresis and daytime sleepiness

Long term effects include sleep disturbance, failure to thrive, systemic and pulmonary hypertension, polycythemia and behavioral abnormalities

slide29

You have admitted a 13 month old healthy infant with poor feeding and respiratory distress. The infant has rhinorrhea and fever to 101oF for 2 days. Which of the following best explains this scenario and x-ray?

  • Pneumocyctisjiroveci
  • Mycoplasma
  • Streptoccocus
  • Respiratory Syncytial Virus
  • Chlamydia
slide31

VIRAL INFECTION/ LOWER RESPIRATORY TRACT

Edema

Sloughed Epithelium

Bronchospasm

Secretions

Small Airway Obstruction

Atelectasis & Hyperinflation

Decreased

Compliance

V/Q Mismatch

Hypoxemia

Increased WOB

Resp Muscle Fatigue

Shock and Respiratory Arrest

Hypercarbia

Apnea

Acidosis

resuscitation stabilization
Resuscitation & Stabilization
  • Airway
  • Breathing
  • Circulation
  • Depressed level of consciousness
  • Disability
  • Dextrose
don t be a dope
DON’T BE A “DOPE”

DISLODGEMENT

OBSTRUCTION

PNEUMOTHORAX

EQUIPMENT

differential diagnosis of altered mental status
DIFFERENTIAL DIAGNOSIS of Altered Mental Status
  • Alcohol
  • Encephalitis/Endocrinopathy

Electrolytes

  • Ingestion/Insulin
  • Opiates
  • Uremia

AEIOU

differential diagonsis of altered mental status
DIFFERENTIAL DIAGONSIS ofAltered Mental Status
  • Trauma
  • Hypo/Hypertension

Hyper/Hypothermia

Hypoglycemia/Hyperglycemia

  • Infection/Intussception
  • Psychogenic
  • Structural/Syncope/Seizures

THIPS

epidural hemorrhage
EPIDURAL HEMORRHAGE
  • What is the mechanism of injury?
  • What vessel is injured?
  • What bony area is involved?
slide48

A 2 month old is brought to the office because of fussiness, increased sleeping and poor feeding. He was well until 3 days ago when he was taking less formula and had to be awakened for his feedings. On physical exam she is difficult to console, temperature is 36.8 0C, HR 160 bpm and RR 30 bpm. Anterior fontanelle is full and pupils are 4mm and reactive.. Of the following which is the MOST likely cause of the CT findings?

  • Arteriovenous malformation
  • Galactosemia
  • Meningoencephalitis
  • Nonaccidental trauma
  • Von Willebrand disease

6

cns bleeds
CNS BLEEDS

A

A Subarachnoid Hemorrhage

B Subdural Hemorrhage

C Intracerebral Hemorrhage

D Epidural Hemorrhage

C

B

D

classification of shock
CLASSIFICATION OF SHOCK
  • HYPOVOLEMICEnteritis/Hemorrhage
  • SEPTIC Bacterial/Viral/Fungal
  • CARDIOGENIC CHD,Cardiomyopathy
  • DISTRIBUTIVE Anaphylaxis, toxins
  • OBSTRUCTIVE Tension PTX & Cardiac Tamponade
shock pathophysiology common themes
Shock Pathophysiology“Common Themes”
  • Extracorporeal fluid loss
  • Lowering of plasma oncotic forces
  • Vasodilatation
  • Increased vascular permeability
  • Cardiac dysfunction
epidemiology of pediatric sepsis
Epidemiology of Pediatric Sepsis
  • Blood Borne
  • Pneumonia
  • Urinary Tract
  • Surgical site/wounds

Advances in Sepsis 2003;3(2):45–55.

slide58

A 4 year old child is brought to the Emergency Department with a 12 hour history of fever and rash. Physical exam reveals: temperature of 104oF, heart rate 164 bpm, respiratory rate 42 bpm and a blood pressure of 75/45 mmHg. You decide to administer an immediate dose of antibiotics. Which of the following is the MOST appropriate therapy?

  • ceftriaxone
  • penicillin
  • vancomycin
  • vancomycin and ceftriaxone
  • vancomycin and gentamicin

6

slide59

The child described in the question above has required multiple fluid boluses and inotropic support to maintain her blood pressure. She has been intubated for respiratory distress. Her white blood cell count is 1.2 X 103/mc/L and a platelet count of 32 X 103 mc/L . Which of the following is the MOST important additional laboratory test?

  • erythrocyte sedimentation rate
  • creatinekinase
  • fibrinogen
  • lactic acid
  • peripheral blood smear

6

slide63

WHAT’S YOUR DIAGNOSIS??

Mottling

ACRYCYANOSIS

slide64

The mother of one of your patients calls frantically because she found her 2 year old daughter with an open bottle of prenatal vitamins and several tablets in her mouth. The label states there is 30mg elemental iron per tablet and 5 tablets are missing as she just bought the bottle this morning. The child weighs 25 lbs. Which of the following is the MOST appropriate advice to give the mother?

  • Bring the child to the office in the morning for a serum iron concentration
  • Give the child activated charcoal
  • Give the child syrup of ipecac
  • Observe the child at home for symptoms
  • Take the child to the nearest emergency department

6

iron toxicity clinical stages
Iron ToxicityClinical Stages

1 – Vomiting, diarrhea, pain

2 – Latency

3 – Hypovolemia, shock, acidosis

4 – Hepatic failure

5 – Gastric outlet obstruction

one pill can kill
ONE PILL CAN KILL

Peds Annals :34(12) ;December 2005

decontamination
DECONTAMINATION
  • Ocular  saline lavage
  • Skin  water, then soap and water
  • Gastrointestinal
      • Ipecac/gastric lavage/cathartics: not recommended
      • Whole Bowel Irrigation (500 mL/hr in toddlers, otherwise 2 L/hour)
        • Helpful for: iron, lead, theophylline, crack vials/packets overdoses
decontamination1
DECONTAMINATION
  • Activated charcoal (1 gm/kg, adolescents 50-100 grams PO)
    • Not helpful for: lithium, iron, alcohols, cyanide, acid/alkali, hydrocarbons
  • Multidose activated charcoal

(1 gram/kg q4-6 hours)

    • Helpful for: theophylline, phenobarbital, digoxin, salicylate, tricyclic antidepressants, carbamazepine, phenytoin
antidotes i
ANTIDOTES I
  • Acetaminophen n-Acetylcysteine (NAC)
  • Anticholinergic Physostigmine
  • Anticholinesterase Atropine
  • Organophosphates Atropine/pralidoxime
  • Carbamate Atropine/pralidoxime
  • Benzodiazepine Flumazenil
  • Beta adrenergic blocker Glucagon
  • Calcium channel blocker Calcium chloride/calcium gluconate
  • Botulism Botulin antitoxin trivalent (A,B,E)
  • Carbon monoxide Oxygen
  • Cyanide Amyl nitrate
  • Digitalis Fab antibodies
  • Ethylene glycol Fomepizole (4-Methylpyrazole)
  • Fluoride Calcium gluconate
  • Heavy Metals BAL
  • Arsenic BAL
  • Mercury BAL, DMSA
antidotes ii
ANTIDOTES II
  • Iron Deferoxamine
  • Isoniazid Pyridoxine
  • Lead BAL, EDTA, penicillamine. DMSA
  • Methanol Fomepizole (4-Methylpyrazole)
  • Methemoglobin Methylene blue
  • Neuroleptic syndrome Dantrolene
  • Opioids Naloxone
  • Phenothiazine (dystonic) Diphenhydramine
  • Sulfonylurea Octreotide
  • Tricyclic antidepressants Sodium bicarbonate
  • Warfarin Vitamin K
  • Snakes, spiders:
  • Black widow Antivenin
  • Coral Antivenin
  • Crotaline Antivenin
  • Elapid Antivenin
neurologic findings pupillary exam
Amphetamine/cocaine

Anticholinergics

Antihistamines

Sympathomimetics

Cholinergics

Narcotics

Organophosphates

Neurologic FindingsPupillary Exam
co poisoning
Binds to Hb with high affinity

Non specific early symptoms (Flu-like)

Administration of 100% FiO2

Hyperbaric therapy

Pregnancy & Fetal effects

CO POISONING
near drowning
NEAR DROWNING
  • ASPHYXIA

1) Pulmonary System

2) Central Nervous System

3) Cardiac

4) Renal

  • WATER OVERLOAD

1) Pulmonary

2) Central Nervous System

3) Gastrointestinal

4) Dilution Effects

  • HYPOTHERMIA
which of the following statements regarding pediatric trauma is not correct
Which of the following statements regarding pediatric trauma is NOT correct??
  • The most common type of shock is hypovolemic secondary to hemorrhage
  • Head injury accounts for the majority of deaths from pediatric trauma
  • Pulmonary contusions occur more frequently in young children
  • Pancreatic and small bowel contusions & hematomas are the most common abdominal lesions
  • On arrival to the ED many children are hypothermic

6

pediatric burns indications for admission
Pediatric BurnsIndications for Admission
  • Burns great than 15% BSA
  • High tension electrical burns
  • Inhalation injury
  • Inadequate home situation
  • Suspected abuse
  • Burns to the genitals, hands, feet
exam tips
Exam Tips
  • Study and Review
  • Don’t Panic
  • Calculate Time allowed per question
  • Skip the tough ones
  • Visit the ABP On-line Site
  • Review the Content Specifications
  • Read the Question Carefully

-Distracters

-Should be able to answer the question before reading the choices

slide80

THE END

GOOD LUCK