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

•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

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

▫ 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

• 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

Diagnosis of Acute Pulmonary Embolism

Vocal Cord Dysfunction•AKA – Paradoxical

vocal cord motion (PVCM)

•Paradoxical vocal cord adduction during inspiration

Vocal Cord Dysfunction•Signs

▫Wheezing▫Stridor▫Dyspnea▫Cough▫Chest tightness▫Exercise intolerance

•F>M•20-40y

Vocal Cord Dysfunction•Medical Risk Factors

▫Asthma (50%)▫GER▫CF▫Postnasal drip▫Cold air▫Cigarette smoke▫Brainstem abnormalities▫Stroke▫Myasthenia gravis

Vocal Cord Dysfunction•Psychological Risk Factors

▫Anxiety over school performance▫Parent-child conflict▫Divorce▫Emotional upset▫Abuse▫Psychiatric disturbances

Somatization disorder

VCD vs AsthmaVCD 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▫Speech therapy▫Relaxation techniques▫Psychological intervention▫Education