Transcript Good Morning and Welcome Applicants!

Good Morning and
Welcome Applicants!
November 11, 2010
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
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
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
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
Acute Pulmonary Embolism
• Clinical Signs
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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
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)
Diagnosis of Acute Pulmonary Embolism
Vocal Cord Dysfunction
• AKA – Paradoxical
vocal cord motion
(PVCM)
• Paradoxical vocal
cord adduction
during inspiration
Vocal Cord Dysfunction
• Signs
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Wheezing
Stridor
Dyspnea
Cough
Chest tightness
Exercise intolerance
• F>M
• 20-40y
Vocal Cord Dysfunction
• Medical Risk Factors
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Asthma (50%)
GER
CF
Postnasal drip
Cold air
Cigarette smoke
Brainstem abnormalities
Stroke
Myasthenia gravis
Vocal Cord Dysfunction
• Psychological Risk Factors
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Anxiety over school performance
Parent-child conflict
Divorce
Emotional upset
Abuse
Psychiatric disturbances
 Somatization disorder
VCD vs Asthma
VCD
Asthma
• Inspiratory dyspnea
• 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
VCD Diagnosis
• Direct visualization
VCD Management
• Mulitdisciplinary
• Primary cause if present
• Acute
▫ Panting
▫ Short acting benzos
• Long-term
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Speech therapy
Relaxation techniques
Psychological intervention
Education