PICU Doc On Call

A riveting case of a 15-year-old girl grappling with progressive headaches and severe hydrocephalus takes center stage. The discussion delves into the urgency of evaluation and the critical symptoms to watch for. Insightful insights on managing acute hydrocephalus, including both temporary and permanent CSF diversion techniques, are unveiled. The complexities of differential diagnoses between obstructive and non-obstructive hydrocephalus are thoroughly explored, alongside the implications of various causes and the significance of timely intervention.

IntroductionHosts: Dr. Pradip Kamat (Children’s Healthcare of Atlanta/Emory University) and Dr. Rahul Damania (Cleveland Clinic Children’s Hospital)Mission: A podcast dedicated to current and aspiring pediatric intensivists, exploring intriguing PICU cases and acute care pediatric managementFocus of the Episode: Managing toxic alcohol ingestion in the PICU with emphasis on ethanol, methanol, ethylene glycol, propylene glycol, and isopropyl alcoholCase PresentationPatient Details: A 7-month-old male presented with accidental ethanol ingestion after his formula was mixed with vodkaKey Symptoms: Lethargy, uncoordinated movements, decreased activity, and ethanol odorInitial Labs & Findings:EtOH level: 420 mg/dL.Glucose: 50 mg/dL.Normal CXR and EKG.PICU Presentation: Tachycardic, normotensive, lethargic, with signs of CNS depressionInitial Management: Dextrose infusion, glucose monitoring, neurological observation, and ruling out complicationsKey Learning Points from the CaseToxic alcohol ingestion in pediatrics requires rapid stabilization and targeted interventionsHypoglycemia and CNS depression are common features of ethanol toxicity in infantsManagement prioritizes glucose correction, airway support, and close neurological monitoringDeep Dive: Toxic Alcohols in the PICU1. EthanolTypical Presentation in Infants/Toddlers: Hypotonia, ataxia, coma, hypoglycemia, hypotension, and hypothermiaDiagnostic Workup:Focus on CNS and metabolic effectsLabs: Glucose, electrolytes, bicarbonate, anion gap, ketones, toxicology screenImaging (head CT) if indicatedManagement: Stabilization, IV dextrose for hypoglycemia, NPO status until alert, and consultation with poison control and social work2. MethanolSources: Windshield fluids, cleaning agents, moonshineClinical Stages:Early: Dizziness, nausea, vomiting (0–6 hours)Latent: Asymptomatic (6–30 hours)Late: Vision disturbances, seizures, respiratory failure (6–72 hours)Key Symptoms: “Snowstorm blindness” from retinal toxicityManagement: Fomepizole, correction of metabolic acidosis, and hemodialysis in severe cases3. Ethylene GlycolSources: Antifreeze, brake fluids, household cleanersPathophysiology: Metabolism to glycolic acid (acidosis) and oxalic acid (renal failure due to calcium oxalate crystals)Red Flags: Hypocalcemia, renal failure, QT prolongationManagement: Fomepizole, supportive care, and hemodialysis for severe toxicity4. Propylene GlycolSources: Medications like lorazepam and pentobarbitalPresentation: High anion gap metabolic acidosis at high doses, with renal and liver dysfunctionManagement: Discontinue offending agent, supportive care, and hemodialysis if severe5. Isopropyl AlcoholSources: Disinfectants, hand sanitizersPresentation: CNS depression, GI irritation, fruity acetone breath, but no metabolic acidosisManagement: Supportive care; fomepizole and ethanol are ineffectiveKey Laboratory InsightsOsmolar Gap Formula:Measured Osmolality - Calculated OsmolalityA high osmolar gap indicates unmeasured osmoles like toxic alcohols.Lactate Gap in Ethylene Glycol: Discrepancy between bedside and lab lactate levels due to glycolate interferenceManagement PearlsEthanol and Ethylene Glycol: Fomepizole as first-line treatment; hemodialysis for severe casesMethanol: Similar approach with additional focus on preventing blindnessPropylene Glycol: Monitor lactate and renal function, discontinue offending medicationsIsopropyl Alcohol: Supportive care, no acidosis presentMnemonics for Toxic AlcoholsMEGA GAP:Methanol and Ethylene Glycol: Anion Gap Acidosis with elevated Osmolar GapIsopropyl Alcohol: Isolated Osmolar Gap (no acidosis)Propylene Glycol: Mimics ethylene glycol with HAGMA at high dosesTakeaway MessagesEarly recognition of toxic alcohol ingestion is critical for successful managementDifferentiate between toxic alcohols using anion gap, osmolar gap, and clinical presentationEngage poison control and social work early in the processConclusionPediatric toxic alcohol ingestions are rare but potentially life-threateningFomepizole is a cornerstone therapy for methanol and ethylene glycol toxicitySupportive care remains essential across all toxic alcohol ingestionsConnect with US!Twitter: @PICUDocOnCallEmail: contact@picudoconcall.com

In this enlightening discussion, Dr. Jordan Dent, a second-year fellow from Children’s Healthcare of Atlanta, dives into a critical case of a 15-year-old male suffering from exertional heat stroke during football practice. They explore the pathophysiology of heat stroke, emphasizing the failure of thermoregulation and the severe complications that can arise, such as multiorgan dysfunction. Dent and the hosts discuss vital management strategies, including rapid cooling techniques and the importance of early recognition to minimize risks in young athletes.

Dive into the urgent case of a 16-year-old girl with a pulmonary embolism, showcasing the critical role of diagnostic imaging. Discover the complexities of managing venous thromboembolism in pediatric care, highlighting risk factors and the necessity for interdisciplinary collaboration. Learn about the intricacies of heparin therapy, including potential side effects and monitoring protocols. Explore the benefits of low-molecular weight heparin and the evolving landscape of direct oral anticoagulants tailored for young patients.

Dive into the Alveolar Gas Equation with Dr. Pradip Kamat and Dr. Rahul Damania as they unravel the complexities of oxygenation, hypoxemia causes, and A-a gradient interpretation in pediatric critical care. Learn how atmospheric pressure, FiO2, PaCO2, and R influence PAO2 calculation, and explore clinical scenarios highlighting VQ mismatch, shunting, and diffusion defects.

Explore a case of Malignant Hyperthermia in a 23-month-old premature boy during surgery, discussing pathophysiology, clinical signs, symptoms, and management. Learn about Dantraline's role in inhibiting calcium release, clinical features of MH crisis, triggers, and potential complications. Understand differential diagnoses like Neuroleptic Malignant Syndrome and Serotonin Syndrome. Gain insights into managing MH crisis in pediatric patients, emphasizing the need for a coordinated team and pharmacist collaboration.

Exploring the challenging case of a 14-year-old patient with depression who ingested a large amount of medications. Discussing the crucial history and physical exam in ingestion work-up. Differentiating between Calcium Channel Blocker and Beta-Blocker overdose based on ECG findings. Detailing the approach to managing Calcium Channel Blocker overdose with resuscitation, IV calcium salts, and vasopressors. Highlighting the importance of early intervention and specific medical therapies in such overdose cases.

An 8-month-old infant with severe bronchospasm and RSV is discussed. Topics include epidemiology, pathophysiology, diagnosis, and evidence-based management of acute bronchiolitis. The podcast covers etiology, diagnosis, and management frameworks for patients requiring PICU admission. Other topics include inappropriate antibiotic use, mechanical ventilation, ECMO, nitric oxide therapy, and prevention strategies for RSV bronchiolitis in high-risk infants.

Discussion on the management of a six-year-old patient with severe pneumonia and pediatric ARDS, understanding and assessing dead space in arterial blood gas measurements, significance of dead space ratio in evaluating gas exchange, implications and management of dead space in obstructive lung disease, and the concept of dead space fraction in pediatric ARDS.

Explore a unique case of retropharyngeal abscess in a 9-month-old, including clinical manifestations, diagnostic workup, and management strategies. Learn about the dangers and potential complications of RPA in pediatric patients. Gain valuable clinical takeaways for diagnosing and treating this condition.