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Good Morning and Welcome Applicants!

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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 Inherited Hypercoagulable State
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
CT experienced institutions Angiography is the gold standard though


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 20-40 although it is becoming more common in the pediatric population

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 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


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 Panting with the tongue out increases the glottic aperture resulting in acute relief Psychological intervention if speech therapy and relaxatin techniques do not work

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