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