PICU Doc On Call

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.

Dr. Matthew Kirschen, a leader in pediatric neurocritical care and one of the authors of new brain death guidelines, discusses the prerequisites for determining brain death, updates in the guidelines for pediatric neurocritical care, brain death examinations, diagnostic tests, and the importance of communication with families in brain death cases.

The podcast discusses the case of a 2-year-old girl with acute respiratory distress and the use of High-Flow Nasal Cannula (HFNC) therapy. They explore the mechanisms and advantages of HFNC, including improved oxygen efficiency and reduced upper airway resistance. The podcast also debunks the myth of PEEP theory in HFNC and emphasizes the importance of monitoring parameters for assessing its efficacy. Finally, they summarize the physiologic effects of HFNC and encourage listener feedback.

An 8-year-old boy with chest pain, fatigue, and decreased oral intake is admitted to the PICU. They discuss the pathophysiology and epidemiology of acute rheumatic fever, its manifestations and diagnostic measures. Management goals include eliminating strep infection, controlling inflammation, and preventing recurrence. They also explore the use of biomarkers for early detection and treatment of acute rheumatic fever.

The podcast delves into pediatric drowning cases in the PICU, covering topics like severe respiratory failure, electrolyte imbalances, and neurological complications. It clarifies drowning terminology, discusses pathophysiology including laryngospasm and gas exchange compromise. The episode emphasizes treatment approaches, prognostic factors, and the importance of immediate resuscitation and inpatient therapeutic strategies.

Pediatric ICU physicians discuss lactic acidosis in a 4-year-old boy with hypotension, fatigue, and respiratory distress. They explore the causes, types, and management of lactic acidosis in the PICU. The use of blood lactate levels as markers, the phenomenon of lactic acid washout, and the controversy surrounding bicarbonate therapy are also discussed.

In this episode of PICU Doc On Call, Dr. Pradip Kamat and Dr. Rahul Damania discuss a case of a 4-year-old girl with bite marks and swelling of her foot, presenting with concerning vital signs and abnormal labs. They explore snake envenomation and its management in the pediatric critical care setting.Classifying Snake EnvenomationSnakes with venom-delivering fangs, primarily Elapidae and Viperidae, are responsible for most human envenomations and fatalities. We're focusing on Pit Vipers today, including rattlesnakes, cottonmouths, and the copperhead. Elapids, such as the coral snake, differ by having round pupils, short fangs, and no facial pit.Risk Factors for Pediatric SnakebitesSnakebite incidents can happen when toddlers unintentionally disturb snakes, particularly in low-light conditions or grassy areas. Teenagers trying to capture snakes are another frequent group presenting with upper extremity bites. Pathophysiology of Snake EnvenomationSnake venoms contain toxic proteins that affect various physiological systems, leading to neurotoxic, hemotoxic, myotoxic, or cytotoxic effects. Envenomation can happen immediately or be delayed, presenting with various clinical and laboratory anomalies.Syndromes Observed After Snake EnvenomationThe impact of a snakebite depends on the snake type, fang size, and venom injection site. Effects may include cytotoxicity, lymphatic system damage, platelet dysfunction, neurotoxicity, cardiotoxicity, hypotension, and nephrotoxicity.General Management FrameworkIn snakebite cases, prehospital care involves immediate EMS call and ensuring airway, breathing, and hemodynamic stability. In the hospital, general supportive care is crucial, and antivenin administration depends on clinical presentation and snake type.Antivenin ConsiderationsAntivenin dosage is challenging due to unknown venom load, and its choice depends on safety, kinetics, cost, and the specific snake involved. Smaller fragments of antivenin have larger distribution volumes and shorter half-lives. Recurrence, anaphylaxis, and serum sickness are potential side effects of antivenin.Clinical PearlsA high index of suspicion is required to diagnose snake envenomation.Antivenin is the mainstay of therapy, and rapid transport to a facility with antivenin is crucial.Patients should be educated about recurrence, serum sickness, and lifestyle adjustments after a pit viper bite.Thank you for listening to this episode on snake envenomation in the PICU. For more episodes, visit our website picudoconcall.org. Stay tuned for our next episode! Don't forget to share your feedback and subscribe to our podcast.

In this episode PICUDoc On Call, we discuss the case of a six-month-old ex-preemie with bacterial meningitis who presents with symptoms of cerebral sinus venous thrombosis. We explore the anatomy of the venous distribution in the brain and the clinical syndromes associated with sinus venous thrombosis. Our focus is on the imaging techniques, laboratory tests, and management strategies involved in diagnosing and treating this challenging condition.You will learn:A six-month-old ex-preemie presents with persistent fever, recurrent emesis, and increased somnolence.The patient experiences eye rolling and decreased oxygen saturation, prompting a visit to the emergency department.Physical examination reveals rigidity in all four limbs, and a head CT shows dilated ventricles and encephalomalacia.Lumbar puncture confirms an infection, and the patient is admitted to the hospital.After a 14-day course of antibiotics, the patient's clinical status worsens, leading to intubation and neurosurgery consultation.An MRI confirms cerebral venous sinus thrombosis.Anatomy of Venous Distribution in the Brain:Dural venous sinuses serve as conduits for venous blood return from the brain to the internal jugular veins.The superior sagittal sinus, cortical veins, transverse sinus, sigmoid sinus, and internal jugular vein are key components of the venous drainage system.Clinical Syndromes of Sinus Venous Thrombosis:Symptoms can be related to elevated intracranial pressure or focal brain damage from venous ischemia, infarction, or hemorrhage.Headache, seizures, focal neurologic deficits, and cranial nerve paralysis are common presentations.Cavernous sinus thrombosis can cause periorbital pain, ocular chemos, and paralysis of cranial nerves passing through the sinus.Risk Factors for Cerebral Sinus Venous Thrombosis:Dehydration, CNS or sinus infections, intracranial surgery, autoimmune disorders, genetic syndromes, metabolic syndromes, medications, and genetic thrombophilic states can predispose children to thrombosis.Thorough evaluation for risk factors, including thrombophilia, is recommended in children with cerebral venous thrombosis.Imaging and Laboratory Tests:CT and MRI with contrast-enhanced venography are preferred imaging tools to detect cerebral sinus venous thrombosis.Non-enhanced CT scans and T1/T2-weighted MRI scans show characteristic signs of thrombosis.Lab tests include CBC with differential, DIC panel, comprehensive metabolic panel, ESR, and specific thrombophilia tests.Management Strategies:Supportive care, including airway management, hemodynamics, and neurologic monitoring, is crucial.Consultation with a multidisciplinary team (neurosurgeons, neuro-interventional radiologists, hematologists, etc.) is necessary.Anticoagulation therapy with heparin is initiated and closely monitored.Surgical interventions (e.g., EVD placement, ventricular peritoneal shunt, decompressive hemicraniectomy) may be required in severe cases.Long-term rehabilitation may be necessary for neurological deficits.In summary:Cerebral sinus venous thrombosis in pediatric patients requires a multidisciplinary approach for prompt diagnosis and management. Recognizing the clinical signs, conducting appropriate imaging and laboratory tests, and initiating timely interventions are crucial for improved outcomes.

Pediatric ICU physicians discuss a case of a 5-year-old with unexplained fatigue and fever, exploring genetic blood disorders, physiological adaptations in severe acute anemia, different types of hemolytic anemias, and management of hereditary spherocytosis in the PICU.

Welcome to "PICU Doc On Call," a podcast dedicated to current and aspiring intensivists. In this episode, Dr. Pradip Kamat and Dr. Rahul Damania discuss an interesting case of a 16-year-old male with high-grade fever and abdominal pain. The patient also presents with a rash and other concerning symptoms, leading to urgent medical attention. They provide a summary of the key elements from the case, including vital signs, physical examination findings, and laboratory and imaging results.Dr. Kamat then shares his thought process regarding the working diagnosis for this patient, considering several possibilities such as severe bacterial infection, atypical appendicitis or cholecystitis, toxic shock syndrome, and systemic inflammatory processes like Multisystem Inflammatory Syndrome in Children (MIS-C) and atypical Kawasaki disease.Moving on to the topic of vasopressors, Dr. Damania explains the importance of understanding how these medications work and their specific pharmacological properties. They discuss the classification of shock as cold or warm and the limitations of relying solely on clinical signs to categorize septic shock in children.They highlight the challenges in selecting the appropriate vasopressor, such as a lack of standardization in clinical examination and individual variability in response to medications. They emphasize the need for a comprehensive approach when evaluating and managing pediatric shock patients, considering multiple factors beyond traditional bedside signs.The hosts then engage in a rapid review of pressors, starting with a multiple-choice question regarding the choice of vasoactive infusion for a patient with toxic shock syndrome. They discuss the pros and cons of using norepinephrine (NE) in distributive shock and highlight its vasoconstrictive effects, inotropic activity, and potential side effects.They proceed to compare NE with epinephrine, explaining the differences in their actions on adrenergic receptors and their effects on various circulations. They mention that epinephrine acts on all adrenergic receptors and has hemodynamic and metabolic effects, redirecting cardiac output and increasing myocardial oxygen demand.Lastly, the hosts touch on phenylephrine, a vasopressor that acts on the alpha-1 receptor and elevates systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR). They stress the importance of securing central line access when administering vasopressors to avoid harm to peripheral and systemic tissues.In conclusion, this episode provides valuable insights into the diagnosis and management of a complex pediatric case involving high-grade fever, abdominal pain, and shock. The hosts also offer a rapid review of common vasopressors, highlighting their mechanisms of action, pros, and cons.