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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