CRITICAL CARE MEDICINE

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

7. PREP AND CONTENT SPECS

8. 2012

9. 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

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

11. 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

12. 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

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

15. 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

16. LARYNGOMALACIA

17. SYNDROMES ASSOCIATED WITH RESPIRATORY FAILURE PIERRE-ROBIN SEQUENCE

19. 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

20. CROUP

21. EPIGLOTTITIS

22. EPIGLOTTITIS

23. 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

24. RETROPHARYNGEAL ABSCESS

25. Rapid Drill 1 Diagnosis Bugs Drugs Management Complications

26. TONSILLAR HYPERTROPHY

27. TONSILLAR HYPERTROPHY

28. 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

29. 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

30. RSV

31. 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

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

33. Vascular Rings and Other Things

34. “It’s not always the lungs”

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

36. REVIEW BASIC LIFE SUPPORT AND PALS

37. Managing the Airway

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

39. Right Main stem Intubation

40. RMS Intubation and Left Lung Collapse

41. PNEUMOTHORAX

42. Tension Pneumothorax

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

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

45. CNS INJURY

46. LAYERS OVER THE BRAIN

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

48. 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

49. SDH WITH MIDLINE SHIFT

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