Good Morning and Welcome Applicants!

1. Good Morning and Welcome Applicants! November 11, 2010

3. Acute Pulmonary Embolism • Origin • Deep venous system of lower extremities, right heart, pelvic, renal or upper extremity veins • Travel to lungs • Large thrombi • Lodge at bifurcations and can cause hemodynamic compromise • Small thrombi • Travel distally cause pleuritic chest pain

4. Acute Pulmonary Embolism - Pathophysiology • Impaired gas exchange • Mechanical obstruction – V/Q mismatch • Inflammatory mediators • Surfactant dysfunction, atelectasis and functional intrapulmonary shunting • Hypotension • Diminished CO • Increased PVR leading to decreased RV outflow and decreased LV preload

5. Acute Pulmonary Embolism • More than half of all PE are underdiagnosed • Mortality rate 30% without treatment • Reduced to 2-8% with anticoagulation • RV dysfunction associated with two-fold increase • RV thrombus • BNP • Serum troponins

6. VTE in Children • Central Venous Access • Associated with 2/3 of VTEs in children • Inherited Hypercoagulable State • Other Conditions • Infection, Congenital Heart Disease, Trauma, Nephrotic Syndrome, Lupus Erythematosus or complication from chemotherapy (L-asparaginase and steroids) for ALL

7. Acute Pulmonary Embolism • Clinical Signs • Pleuritic chest pain • Tachypnea • Cough • Tachycardia • Acute dyspnea • Signs of DVT • Sudden collapse • Most common – nonspecific • PE should be considered in the differential diagnosis of cardiorespiratory deterioration in all critically ill children

8. Diagnosis of Acute Pulmonary Embolism • Modified Wells Criteria for PE • Clinical symptoms of DVT (3 points) • Other diagnosis less likely than PE (3 points) • Heart rate >100 (1.5 points) • Immobilization or surgery in previous four weeks (1.5 points) • Previous DVT/PE (1.5 points) • Hemoptysis (1 point) • Malignancy (1 point) • Traditional clinical probability assessment: • High >6 • Moderate 2 to 6 • Low <2 • Simplified clinical probability assessment: • PE likely (score >4) • PE unlikely (score <=4)

9. Diagnosis of Acute Pulmonary Embolism

11. Vocal Cord Dysfunction • AKA – Paradoxical vocal cord motion (PVCM) • Paradoxical vocal cord adduction during inspiration

12. Vocal Cord Dysfunction • Signs • Wheezing • Stridor • Dyspnea • Cough • Chest tightness • Exercise intolerance • F>M • 20-40y

13. Vocal Cord Dysfunction • Medical Risk Factors • Asthma (50%) • GER • CF • Postnasal drip • Cold air • Cigarette smoke • Brainstem abnormalities • Stroke • Myasthenia gravis

14. Vocal Cord Dysfunction • Psychological Risk Factors • Anxiety over school performance • Parent-child conflict • Divorce • Emotional upset • Abuse • Psychiatric disturbances • Somatization disorder

15. VCD vs Asthma VCD Asthma • Inspiratorydyspnea • Abnormalities heard on inspiration • No response to bronchodilators • Normal ABG if hypoxemic • Normal A-A gradient • Normal CXR • PFTs • Flattening of inspiratory limb • Expiratory dyspnea • Abnormalities heard on expiration • Respond to bronchodilators • Abnormal ABG if hypoxemic • VQ mismatch • CXR with hyperinflation • PFTs • Scooped out expiratory limb

17. VCD Diagnosis • Direct visualization

18. VCD Management • Mulitdisciplinary • Primary cause if present • Acute • Panting • Short acting benzos • Long-term • Speech therapy • Relaxation techniques • Psychological intervention • Education