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Good Morning and Welcome Applicants! November 11, 2010.

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Presentation on theme: "Good Morning and Welcome Applicants! November 11, 2010."— Presentation transcript:

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 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 - Pathophysiology

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 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



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 VCDAsthma 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

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