DED/72 Hr Return Learning highlights with Dr. Royalty

A patient is considered refractory after 3 or more defibrillators, 3 or more doses of epinephrine, AND 300 mg Amiodarone 

What therapies can you try?

-Hold additional epinephrine 

-Administer Esmolol for electrical storm: 500 mcg/kg bolus followed by infusion (50-100 mcg/kg/min)

-Dual-sequential Defibrillation: Place a second set of pads (R upper chest/left lateral and anterior/posterior), deliver 200J simultaneously from both defibrillators

Pediatric Cardiac Disease with Dr.Wadih

Cyanotic lesions: 5 T’s-Tetralogy of Fallot, Transposition, Tricuspid atresia, Truncus arteriosus, TAPVR

Truncus arteriosus: Associated with 22q11 deletion (DiGeorge), Primitive truncus does not divide into PA and aorta, Leads to significant pulmonary over circulation, Ductal independent 

Tetrology of Fallot: Large VSD, RVOT obstruction, RVH, overriding aorta. Tet spells= episodes of cyanosis usually triggered by crying. Treat tet spells by calming, knees to chest, supplemental O2, morphine, IN fentanyl or versed if no IV, IVF to increase preload. If these fail, move to beta blocker propranolol or esmolol, ECMO last resort. Degree of RVOT obstruction determines if lesion is ductal dependent. All require surgery

Total anomalous pulm venous return: Pulm vein do not return to L atrium, degree of illness depends on degree of obstruction of pulm venous return. Ductal independent. Must have ASD to survive 

Transposition of Great arteries: Must have large ASD , VSD, or PDA to survive. Usually presents within hours of birth. If not responding to prostin need a balloon atrial septostomy.

Tricuspid atresia: Absence of tricuspid valve w/ hypolastic RV. Relies on ASD 

L->R shunts: ASD, VSD, PDA, AV canal 

ASD: rarely symptomatic, usually close on their own. Typically close ASD around age 2-5 if becomes larger or persists. “fixed split S2” is a buzzword for ASD on exam 

AV canal (AV septal defect) commonly associated with trisomy 21. Spectrum of severity, all require repair 

VSD: Highly variable. Bigger VSD= more likely to cause heart failure, less likely to hear on exam. Smaller VSD= less likely to cause issues and may close on their own, louder murmur on exam. Over time will lead to increased PVR, increased RV pressure and RVH. May present at 4-8 weeks of life in heart failure, slightly later in trisomy 21

PDA: Machine like murmur at left upper sternal border. Persistence of ductus arteriosus. Ibuprofen used to encourage closure. More common in premature infants 

Ductal dependent lesions (depend on PDA): HLHS, critical aortic stenosis, critical coarctation of aorta, pulm atresia, +/- tet

These NEED PGEs. Prostaglandins cause apnea. Presents with murmur, cyanosis, heart failure on exam. Poor feeding with poor weight gain, sweating with feeds, irritability, tachypnea. W/u with pulse ox: R hand is pre ductal, >3% difference b/t pre and post ductal sats. Need CXR, EKG, Echo. Give prostaglandin .05-.1 mcg/kg/min, watch for apnea. Milrinone typically inotrope of choice due to vasodilation (doesn’t increase SVR). Consider epi for shock 

Coarctation of aorta: As PDA closes- hypoperfused lower extremities, hypertensive upper extremities, associated with turner’s. Present in shock as PDA closes. Coarct located pre-ductal is ductal dependent. Coarct other locations may not present until later in life 

HLHS:Hypoplasia of LV and ascending aorta, mitral valves with ASD and PDA. Cardiogenic shock when PDA closes. Mortality highest in 1^st year of life. Staged repair, first stage is Norwood(BT shunt connects PA and aorta) which is done during the 1^st few weeks of life. IF BT shunt clots they will die. 12% rate of clotting. Post op period is high risk. Listen for a shunt murmur

If you think shunt closed, bolus heparin and start drip. Consider ECMO, likely needs emergent surgery. Increase SVR with pressors (epi first choice), sedate and paralyze to reduce PVR( intubate). Once make it through staged repair survival rate is 90% at 30 years old. Atrial arrythmia is common comorbidity, also liver failure 

Ebstein’s anomaly- associated with maternal lithium use. R atrium enlargement, malformed tricuspid valve 

Eisenmenger syndrome: complications of uncorrected L->R shunt. Can occur in childhood or adulthood depending on the lesion. Cyanosis, syncope, dyspnea, fatigue, chest pain, sudden death. Increased pulm resistance, pulm HTN causes shunt to switch to R->L

Thoracic review with Dr. Baker 

Light’s criteria- if any one of the following is present the fluid is almost always an exudate: pleural fluid/serum protein ratio > 0.5, pleural fluid/serum LDH ratio > 0.6, pleural fluid LDH > 2/3 upper limit for serum LDH 

TB drug side effects: Ethambutol can cause optic neuritis.. starts with E and is eye pathology. Rifampin= orange body fluids. Isoniazid= peripheral neuropathy, seizures, B6

-Spontaneous PTX >20% needs chest tube. Smaller can be observed with oxygen administration 

-To prevent BPD in neonates: within one hour of birth give neonate surfactant, after an hour give caffeine. Risk factors are tobacco use, IUGR, preeclampsia

-Tracheoinonomate artery fistula. Overinflate cuff-> intubate-> remove trach-> digital compression of innominate artery 

-Pertussis buzz words: several weeks, eye sxs, post-tussive emesis 

-Coin position on xray: SAFE= sideways airway, frontal esophagus 

Most common symptom in PE: dyspnea

Most common sign in PE: tachypnea 

Tolerating secretions and toxic= tracheitis

Drooling and toxic= epiglottitis (Hib), thumbprint sign 

Spontaneous and stable Pneumomediastinum: dc with f/u. asthma most common trigger.. Hamman sign, pleuritic pain and neck pain. Usually self-resolving 

-Gram+ cocci in clusters= staph aureus 

-PNA+ bullous myringitis= Strep pneumo Phosgene smells like hay or cut grass 

CURB65: confusion, BUN>19, RR > 30, SBP <90 or DBP < 60, Age > 65

Berylliosis= Aerospace, fluorescent bulbs

Silicosis: glass, sand blasting, miners

Asbestosis: shipyard workers

Siderosis: arc welding (iron)

Most specific US finding for PTX: lung point sign 

Pneumocystis jirovecci: elevated LDH

Give prednisone if PaO2 less than 70 

Fat embolism: IVF and supplemental O2, may see petechial rash