So, we have questions now. So, are you guys, your GABA painting levels are too high or a lot of glutamate and we can do like 30 minutes or so of questions. We will not get offended if you are too tired and, you know, don't want to stay. The ones who want to stay, we just do half an hour and go over it. Yeah. So, let's see. Teresa, 30 minutes is okay? Yeah, perfect. Okay. So, I will try to bring the glutamate. Okay. You guys read the question. What is it? Okay. So, you guys see TBI and they're asking you in a patient with a TBI and a large subthrottle, which is the recommendation and you have the, that's what you want them to do? I don't know. You do whatever you want. Just remember, we're standing between them and dinner. Okay. So, are you guys okay? I go to the, okay. So, those, that. Okay. So, which of the following measures is recommended that's based on the TBI guidelines? Go back. Yeah. Okay. So, four month old. GCS is six. Temperature study is 8.1. Chlorate 140. Blood pressure 90 over 60. And SATS 100 percent. What is recommended based on the TBI? So, can I go back? Okay. So, you have steroids, anti-epileptics, maintain CPP at above 40, maintain PCO2 between 20 and 30, and Tylenol. Okay. So, can you put us the answer? Do you see how many have responded? Okay. So, I will get the correct answer. That is the one that most of you have chosen, basically. Oops. I can't do that. I think you have to treat the temperature first because they're fed around to 38.1, right? It's 38.1. Temperature is usually 38. What's the most important things? It would be the cerebral perfusion pressure to maintain that flow. So, that's. Which would make the biggest difference. We have to have money. Oh, okay. Yeah. What is the other one? I've always wanted to do stand-up. So, basically, when you look at the choices there, you're like, which one? So, dexamethasone, no. We don't use steroids in head injury, period. Anti-epileptics for two to four weeks, no. The recommendation is the first seven days. Controversial which one you want to use, but seven days for the early seizures. Maintain the PCO2 between 20 and 30, no. That's what we did when Jerry and I were fellows. We used to hyperventilate them down. And then we realized that the patients had bigger ischemic areas. So, we aimed for normal carbia. And then you want to treat the acetaminophen. We're going to do it, follow the temperature. I think the guideline is 38? 38. And this was 38.1? They are treating you at 38.1. Right. But the cerebral perfusion pressure is going to be the most important thing, keeping that blood flow up to the brain. Correct. Okay. They're telling me we have to read the questions. So, sorry. So, I let Ed read that he reads fast. Okay. You don't have to read the answer though. No, no, we won't read the answers. Okay. Do you want to read? It doesn't matter. So, previous healthy four-year-old boy, 24-hour history, bilateral lower extremity weakness and pain. History significant upper respiratory infection two weeks ago, or he went to a petting zoo, either one. He has no exposure to recent tick bites, so we don't have to look for the tick anyway, and no known ingestions. Vital signs are normal. He's got one plus patella reflexes. Lower extremity strength is weak. His cranial nerves are intact. He can't ambulate unassisted. Three out of five upper extremities, decreased tone. Which of the following is the most appropriate man? So, you have to say to yourself, what's he got and how do you manage it? So, observation, assessment of force, vital capacity, and negative inspiratory force, placement of a catheter for immediate plasma exchange, clonidine and propranolol to prevent dysautonomia, measurement of immunoglobulin levels. I'm just looking to see how you're doing there. So, I'm done showing it, you know, so. So, do you know when to stop? Do they get out of program? Yeah, I cannot take a look at, you know, when it's changing the air, and I cannot see. That's too small for me. Oh, the number? Yeah, I can't hear that. Oh, okay. So, this is pretty good. We can stop it now. Okay. Okay. All right. We're going to stop it a little earlier. Obviously, you've got to drift. So, what does he have? Guillain-Barre, okay. So, ascending. So, if you look at the choices, we're not just going to reserve. He's already weak. Bad is going to become worse. Anybody from New York, there's such a word as worser. It doesn't exist elsewhere. Are we going to get assessment of force, vital capacity, and NIF? He's a four-year-old. I mean, that's the correct answer. If I was writing the question, I would have made him a little older, knowing that he could do it. Give me a number. But again, clinically, he's got it. A catheter for plasma exchange. So, the treatment is either gamma globulin or to do a plasmapheresis. So, again, which is more benign and quicker? And the data is pretty equivalent. So, I would probably give him gamma globulin at this point. The clonidine and propranolol for the dysautonomia, he's not really having it when you see the Fischer-Miller variant with the upper cranial nerves and dysautonomia. But no sooner you go to treat it than it goes away. So, I wouldn't do that. And then immune globulin levels, we're always asked to get an IGA level. It's the most common immunodeficiency. There are IGA-deficient gamma globulins. You may be able to get them where you are. The risk is anaphylaxis. If we wait to get our IGA level back where I am, it's three days. So, we've got to make a decision. Can you repeat the question? Yeah, she's being literal and saying a management question. So, just so you know, when you get board questions, they've been given, they've been verified, they do statistical analysis when the questions come back, 80% should get it right, and depending on the number of choices, they should be equally divided. If we find a heavy-weighted question one way or the other, then the reason it takes so long to get your scores back, then they get assessed about the highest 25% people scored, how did they answer it, the lowest 25%, and then they decide, is the question salvageable? So I agree we could change the verbiage on that, but again, looking at the choices that you had there, I think that, again, I would like it to be an older patient. How cooperative is a four-year-old going to be to do this? Would you also agree that within critical care, monitoring is a part of management strategy perhaps, even for the literal folks? That's a big portion of the board, of the content specs is monitoring of organ function. So we have an ingestion, an 18-month-old boy comes to the ED, brought in by his parents, who is found in grandpa's kitchen with a half-empty bottle of a beta blocker, immediate-release tablets. He's transferred to the PICU, where on arrival, he's bradycardic with a heart rate of 60, hypotensive with a blood pressure of 55 over 30. Which of the following is the most appropriate treatment sequence for the toxicity? So think about his clinical vignette, and then looking at the choices and saying which would prevent harm. Fluid bolus, atropine, calcium, glucagon, low-dose insulin therapy, epi, calcium chloride, fluid bolus, glucagon, low-dose insulin therapy, fluid bolus, glucagon, epinephrine, dextrose, high-dose insulin therapy, fluid bolus, calcium chloride, epinephrine, and lipid emulsion therapy. OK, so the correct answer is fluid bolus, glucagon, epinephrine, dextrose, high-dose insulin therapy. So let's just go through. He's hypotensive, so fluid therapy is probably where we're all going to start. Now, did they give a blood pressure? It was low, right? So we're going to start with that. Now, when we see bradycardia in most ingestions, atropine usually doesn't work, doesn't do anything. So just put that out there. So now we've got to think about beta blocker, beta 1, beta 2 receptors, where they go, what they control, what they do. And now they're blocked. So we give him the fluid bolus. What are we going to do next? Well, we decided that atropine isn't a choice. It's not going to work well in him. The next choice, epinephrine, we're going to start right with a beta agonist, calcium chloride, fluid bolus, glucagon, and low dose, versus starting with the most benign and working our way up with a fluid bolus. Then glucagon increases cyclic AMP, gives you more chronotropy, inotropy, more bang for the buck. Then if that doesn't work, epinephrine to support. Again, you've got alpha, beta receptors. I would refer you back to the cardiology slide with all of those where they are. And then if that doesn't work, it's dextrose high dose insulin therapy. We mix them together. We put them in there. And then just to get to the next question, lipid emulsion therapy is sort of a last ditch effort after you've tried everything else. And in that choice, they didn't do the high dose insulin therapy at all. So again, you would sort of start with fluids, glucagon. You can consider calcium in beta blockers as well because you're looking to do the heart. We give the glucagon first. And that wasn't a choice in the answer. So in your mind, when I read a question, the first thing I'm like, I ask myself, what would I do? Because sometimes when you read the choices, it can bias you or confuse you. Because then you're like, eh, you don't want to get. So if I figured out what algorithm I would use, see if it's there. Then if it's not, they're like, OK, second best. Let's work it out. OK, next. Jen, do you want to do it? Oh, was it yours? I mean, I don't know. No, I mean, it's also us, but I can read it. Yeah, whatever. All right, I know. I thought it was yours. I don't know. So a 16-year-old attended a party, returned home late. She was difficult to arouse, mumbling incoherently and unable to stand the next morning, went to the ED, en route, had a 45-second shaking episode, followed by unconsciousness and snoring. Blood gas is acidotic, as you see there, with the rest of the chemistries and the ALT, AST, as you see, LDH. And they actually give you the osmolar gap. You didn't need to calculate it. Methanol levels, our results are pending. Salicylate is less than 2. Glucose is 110. Beta-hydroxybutyrate is low. She's given sodium bicarb, started on bicarb containing fluids, given a single dose of fomepazole, and comes to your ICU. So now, what do you do? So choice A is discontinue the fomepazole until a serum methanol level is available. Choice B is start IV ethanol. Choice C, repeat the lab tests. And if the osmolar gap is decreasing, then discontinue therapy and monitor. D is naloxone. C is consult nephrology and begin preparation for hemodialysis. Yeah, I'm sorry. I thought it was yours. Well, you guys tell me, I don't know. You can stop it. Yeah. Okay. All right, so I'll review the answer. This is not my question. This question was like an hour and a half to just read it. Basically, it was testing a couple of concepts. You saw the word osmolar gap in there. So already we talked about osmolar gap. You know, you do a calculated whatever, and there's only a handful of things that can raise it. They also gave you a hint that they had already treated her for potential methanol ingestion. And they were asking you what to do. What level do we worry about? When can we start, stop? What should we do next? So if you look at the correct choice was considered for hemodialysis. So if you look at the slide in the review on methanol, it lists everything to do, how to treat them, what to go down, what the levels are. And just for the sake of time, because we have to end in two seconds, I'm told. So we don't stop the formepazole. You don't wait for the level. You treat the patient, and you treat the symptoms. IV ethanol is tough. We've got an antidote that we can use. Just leave the patient on the antidote until we get a level and see what's gonna be going on a little bit later. We're not gonna repeat the laboratory test because it's gonna take a while. It can be falsely elevated, and we have all these equilibrium and different things happening in this particular patient. Naloxone is not gonna work in a toxic alcohol ingestion. So for better or worse, when you look at the choices, you would consult nephrology and go for hemodialysis. So if you go back in my first talk, one of the slides is which drugs you would hemodialyze for, and it's there. It's one of the five or six drugs. So not a great question, I would agree. Very long. Stems won't be that long. But you look for buzzwords. And as soon as you see has molar gap, there's only a handful of things that can cause it. So I think that's it, right? And then- 4.45. Oh, you told me 4.30. You're like my wife. That's why I'm here. She's home. You're telling me. All right. Okay. This is yours. Yeah, that's fine. 15-year-old boy admitted to the pediatric ICU following a birth fracture of the 10th thoracic vertebra and bilateral femur fractures. And so he has not intracranial injury. Initial imaging studies of his chest, abdomen, and pelvis show pulmonary contusions, but no visceral injury. Temperature is 38, heart rate 80, blood pressure 110 over 70, SATs 97% on two liters nesacandula. He's anxious but alert. Cardiopulmonary examination show bivascular crackles. His abdomen is not distended. The spine is immobilized. His lower extremities are splinted. He's unable to move his toes on command, and there is absent sensation and absent deep tendon reflexes in the lower extremities bilaterally. Which of the followings is true regarding his medical management? A, hypercalcemia is evident within 48 hours of injury. B, pressure ulcers may occur within two hours of injury. C, venous thromboembolism prophylaxis is not indicated. D, urinary retention is uncommon in the acute phase of injury. So spinal cord injury, just to summarize the long question. And so which of the followings are appropriate or is appropriate? Okay? We talked about this, so, okay. Okay. So, the correct answer is pressure ulcer may occur within two hours. If you remember what I mentioned during the spinal injury talk, you have to start, you know, moving the patient with precautions, of course, as soon as possible. So, that's the correct answer. Hypercalcemia is evident within 48 hours is incorrect. Usually, hypercalcemia with immobilization happens several weeks after being immobilized, basically. And DVT prophylaxis is not indicated. Yeah, it is indicated in patients like this because the patients are not moving and have higher risk, and you can decide what type of prophylaxis. But, and then urinary retention is uncommon. It is common during a spinal cord injury. Questions? No? Okay. Tom. Tom. Is it Kim? Okay. Tom, you want to do one? No, no, that's fine. He doesn't know who has who here. We didn't write this. Which one is? A 17-year-old girl attempted suicide for the fourth time by ingesting a combination of pills that included unknown quantities of ibuprofen, diphenhydramine, and acetaminophen plus diphenhydramine. She's evaluated in the emergency department 15 minutes later, where she was given a one-liter bowl of subnormal saline. After initial resuscitation, vital signs are blood pressure 100 over 56, temperature 37.8, and respiratory rate 26. She remains unresponsive with a Glasgow coma score of 8. After consulting poison control, an initial ECG is obtained as shown below. An arrival in the PEDS ICU or PDCG is obtained as shown below. I don't see them below. Electrolyte panel reveals sodium 127, potassium 6.2, 9, chloride 98, BUN 13, and creatinine 1.2, which of the following is the most essential treatment? Fossil stigmine, dopamine, normal saline, sodium bicarb, or hypertonic saline? Okay, so that's the EKG, and here are the --. There seems to be a consensus. Nineteen percent of the people. Okay. In the first talk, it was one of the first things I showed the EKGs because I wanted to get it out there. You have to be careful because they can develop hypokalemia, so just keep your therapeutic options in the back of your mind for what can make things get a little bit worse. But that's the Benadryl ingestion, not uncommon, one of the big five I would really work on and it's anti-cholinergic, so just go back and think your way through the nervous system again. Okay. Okay, we are going to do one more and since we were told we have to finish no later than 4.45, we will cut after the next question and tomorrow we will try to make time for the questions that are not being done today. Okay. So, eight-year-old, history of pulmonary hypertension, who's been taking Sildenafil, 10 milligrams every eight hours, and Bosentin, of the dose you see there. You as physician want to optimize the home medications in order to avoid the use of IV prostacyclin. The oral Sildenafil, which has a half-life of four hours, is increased to 20 milligrams every eight hours. The oral Bosentin, which has a half-life of five hours, is increased to 62.5 milligrams twice daily. Based on the pharmacokinetics of these two medications, when is the earliest they will be at steady state and therefore should exhibit their full effects? Six hours? Twelve hours? Twenty-four hours? Or 36 hours? Yeah. Yeah, so the one thing that this and the next question had in common is it gave you the information that you needed to answer the question and it gave you a whole lot of information you didn't need. So this is an example of a time-saving strategy when you're going through the exam of read the actual question and then identify what data you actually need to answer that question. It told you the half-life and if you know or remember how many half-lives it takes to get to steady state you've got the answer that question. You don't have to know anything about those drugs or that condition and so that's the sort of take-home point for it for that. It follows like if you have the basic information of how many half-lives to get steady state so you're looking at those that four half-lives two to three to get to like mostly steady state then you look at your the numbers will give you so then you look at the one that's the longest and like that gives you put that 24-hour range the people chose 36 like yeah be more accurate probably in terms of long term and that might be a little bit confusing but 24 hours is is a number where you think you can feel comfortable with because you're very close to being at that steady state and the hint there is when is the earliest that you may be at steady state and so you can go with that you know five hours times four is I think five times four still 20 it's late in the day well that four to five so five five hours times four half-lives is gonna be a range to get to 20 hours and that's gonna be your earliest that you might expect to be at steady state yeah okay so we will stop here because otherwise we are rushing this in a way that you know I think we need to review carefully

traumatic brain injury

toxic ingestions

spinal cord injuries

cerebral perfusion pressure

pharmacokinetics

medical treatments