1
A 7 yo boy presents to the PICU with severe TBI. After initial resuscitation, his ICP remains more than 25 mmHg despite adequate sedation, analgesia and neuromuscular blockade. His CPP is currently 50. Which interventions represent the most appropriate second tire therapy to aggressively lower ICP while maintaining CPP?
2
A 2yo child on VV ECMO develops acute and severe hypoxemia (Sat o2 drops from 90% to 75%) without changes in ventilator settings or ECMO blood flow. The pre oxygenator saturation is 88% and the post oxygenator sat is 100%. What is the most likely cause of the patients, acute systemic hypoxemia?
3
What is the effect of positive pressure ventilation on LV transmural pressure?
4
1. Your patient is POD#0 s/p repair of Tetralogy of Fallot and now has developed a narrow complex tachycardia to 200 bpm with no clear p waves preceding the QRS on ECG monitoring. What might you see on the CVP waveform to support your suspected diagnosis?
5
Which of the following is not a way to treat a pulmonary hypertensive crisis?
6
Which of the following patients would benefit most from irradiated PRBC's?
7
A 5 yo boy is 4 days status post-Fontan procedure for hypoplastic left heart syndrom. He develops new onset desaturation ( Sats 78% down from 88% ) abd decreased cardiac output and UOP. Hemodynamics show a significantly elevated CVP of 22 and low MAP. Which of the following is the most immediate therapeutic goal to address his acute deterioration?
8
A 10 yo girl in the PICU 4 hrs after being diagnosed with a severe TBI, develops a serum sodium of 128 ( down from 136) and her free water intake restricted. Her UOP has increased to 6 ml/kg/h with a urine sodium of 95, and serum BUN/Cr ration that is high. She appears volume depleted. This presentation is most consistent with which condition and what is the most appropriate initial fluid management?
9
A 3 yo child in septic shock has an indewlling radial line. The monitor suddenly displays a flat-line tracing with an unreadable pressure. You flush the line vigorously, and the pressure wave briefly returns but immediately flattens again, showing an overestimated diastolic pressure and a smooth, rounded systolic peak. The cuff MAP is 55 but A line MAP is 48. Which is the most likely cause of this waveform abnormality?
10
A 9 yo boy in cardiac arrest is receiving high quality CPR via an endotracheal tube. The Etco2 monitor shows a consistent reading of 8 mmHg. Despite excellent chest compression depth, the reading does not improve after 3 minutes of resuscitation. Which clinical issue is the Etco2 primarily indicating?
11
A 15 yo girl with status asthmaticus is intubated and mechanically ventilated. Initial ABG shows PaCo2 59 with end tidal Co2 48. Later the patient develops profound hypotension and is started on Epi drip. A repeat ABG shows PaCo2 55 but the end tidal is now 35 .
What is the primary physiological explanation for widening of the Paco2 to EtCo2 gradient?
12
A previously healthy 1 month old is admitted with diffuse meningococcemia and severe sepsis. Labs reveal platelet count of 25,000, INR 2.5, PTT 70, D dimer>10,000. The patient develops significant pulmonary hemorrhage and is actively bleeding from the central lines.
Which components of blood product therapy is the most crucial initial step to address the life-threatening hemorrhage caused by DIC?
13
A 4 yo child on CRRT is receiving regional citrate anticoagulation. The nurse calls because the post-filter ionized calcium is 0.2 (target 0.25-.035), and the patient's systemic ionized calcium is 0.9. which is the most appropriate initial action to correct this imbalance and ensure circuit function?
14
A 16 yo is placed on femoral VA ECMO for myocarditis causing cardiogenic shock. On day 3, the native heart shows some pulse pressure on the A line. Pulse oximetry on the right hand shows o2 saturation 70%, with post oxygenator Sato2 100% and O2Sat from the lower extremity of 95%. What is the term for this phenomenon and what is the underlying cause?
15
A 1 yo with MRSA pneumonia is being treated with Vancomycin. The patient is receiving CRRT for AKI. The vancomycin trough level is 18. Which is the most appropriate next step in managing the Vancomycin dosing?
Feedback
- Transmural pressure: LV pressure ( inside) - Outside LV pressure ( intrathoracic)
Positive pressure ventilation raises pressure around the heart (in the chest). That reduces the pressure gradient the LV must overcome to eject blood — which effectively lowers LV afterload.
* RV dysfunction → often worsens with PPV
❤️ LV dysfunction → often benefits from PPV
In JET after congenital heart surgery, look for regular narrow complex tachycardia (~180–220 bpm) without visible P waves and cannon a waves on CVP — this supports AV dissociation and helps confirm the diagnosis.
While sildenafil, a PDE5 inhibitor, is used to treat pulmonary hypertension in children, it is not used to treat acute episodes of pulmonary hypertension. All of the other choices can be helpful in managing a pulmonary hypertensive crisis.
Irradiated PRBC's are used for patients at risk for transfusion associated graft vs. host disease (TA-GVHD). In particular, these patients include those with severe T cell deficiencies or suspected of having a severe immunodeficiency. In addition, those who are undergoing bone marrow transplant, those with Hodgkin lymphoma, and those treated with certain chemotherapuetics (fludaribine, cladribine, deoxycoformicin) should receive irradiated blood products. Prematurity, cardiac surgery (unless suspected of having T cell deficiency- i.e. DiGeorge syndrome as well), and risk for severe allergic reactions are not indications for irradiated PRBC's.
The success of the Fontan circulation is dependent on very low PVR and low CVP to passively drive blood flow to the lung. An acute rise in CVP and desaturation indicates Fontan failure, which is often related to increased PVR (due to hypoxemia, acidosis, etc) or compression of Fontan baffle. The most critical intervention is to decrease PVR.
During CPR, an EtCO2 of more than 20 is often associated with a gigher likelihood of ROSC.
ETT dislodgement: sudden decrease in Etco2 to zero or near zero
Hyperventilation: Would decrease Co2 15-15, 8 is too low
Hypermatbolic state: increase the Etco2
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