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CRITICAL CARE MEDICINE

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

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  1. 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

  2. What are my chances?????

  3. How do I know what to study??

  4. American Board of Pediatrics website

  5. HOW DO YOU PREPARE FOR THE ABP EXAM??????? READ & USE PREP

  6. PREP AND CONTENT SPECS

  7. 2012

  8. 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

  9. READ THE QUESTIONS CAREFULLY!! They are all worth the same amount!!!!!!!

  10. 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

  11. 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

  12. RESPIRATORY FAILURE FAILURE TO VENTILATE (PaCO2) - Increasing PaCO2 with a decreasing PH FAILURE TO OXYGENATE(PaO2) - PaO2 < 60 TORR while breathing FIO2 > .60

  13. 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

  14. LARYNGOMALACIA

  15. SYNDROMES ASSOCIATED WITH RESPIRATORY FAILURE PIERRE-ROBIN SEQUENCE

  16. 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

  17. CROUP

  18. EPIGLOTTITIS

  19. EPIGLOTTITIS

  20. 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

  21. RETROPHARYNGEAL ABSCESS

  22. Rapid Drill 1 Diagnosis Bugs Drugs Management Complications

  23. TONSILLAR HYPERTROPHY

  24. TONSILLAR HYPERTROPHY

  25. 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

  26. 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

  27. RSV

  28. 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

  29. REMEMBER NOT ALL THAT WHEEZES IS ASTHMA!!!!!!

  30. Vascular Rings and Other Things

  31. “It’s not always the lungs”

  32. Resuscitation & Stabilization • Airway • Breathing • Circulation • Depressed level of consciousness • Disability • Dextrose

  33. REVIEW BASIC LIFE SUPPORT AND PALS

  34. Managing the Airway

  35. DON’T BE A “DOPE” DISLODGEMENT OBSTRUCTION PNEUMOTHORAX EQUIPMENT

  36. Right Main stem Intubation

  37. RMS Intubation and Left Lung Collapse

  38. PNEUMOTHORAX

  39. Tension Pneumothorax

  40. DIFFERENTIAL DIAGNOSIS of Altered Mental Status • Alcohol • Encephalitis/Endocrinopathy Electrolytes • Ingestion/Insulin • Opiates • Uremia AEIOU

  41. DIFFERENTIAL DIAGONSIS ofAltered Mental Status • Trauma • Hypo/Hypertension Hyper/Hypothermia Hypoglycemia/Hyperglycemia • Infection/Intussception • Psychogenic • Structural/Syncope/Seizures THIPS

  42. CNS INJURY

  43. LAYERS OVER THE BRAIN

  44. EPIDURAL HEMORRHAGE • What is the mechanism of injury? • What vessel is injured? • What bony area is involved?

  45. 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

  46. SDH WITH MIDLINE SHIFT

  47. CNS BLEEDS A A Subarachnoid Hemorrhage B Subdural Hemorrhage C Intracerebral Hemorrhage D Epidural Hemorrhage C B D

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