If you asked this question 10 years ago, people would say, absolutely not. We're not putting allogeneic transplant patients on ECMO. But that bar has moved substantially. And it's not in every center. And centers are still variable in their practice. But it is moving more towards it becoming more of a regular thing. Regular is a tough thing to use. Allogeneic transplant is rare but improving. But ECMO is expanding. And there are papers appearing reasonably frequently now talking about experience of children with allogeneic and autologous transplant ECMO. The numbers are still not good. But the numbers are not zero. And there is probably a space for this. So I'm, you know, I'm sorry? Yeah. Yeah, I think that this has changed. It would be very inappropriate, I think, to ask that type of question on a board exam now where the bar is changing. And you know, those of you that deal with transplanters and are in ECMO centers are hearing this constantly, where someone's coming up with pneumonia. And one of the first things that's being said by the transplanters is this patient's not, there's no contraindication to ECMO. ECMO can be done. And it has been proven not to be a total disaster. But I have to say that many times it is. OK. But to be fair, I kind of deal with those in mind. I will just, yeah. I'm just sure one last question. So with the new brain death criteria coming around, should we expect to follow those guidelines? Or is there something that is new? I think we have some questions going to what you're saying on the Q&A section. So we will go over those. But that's an important question. Usually for the board, they will not ask you something that just came up. They will not ask you for something that just came up. Because the questions were written like a year before, or even more. So let's say some new guidelines came up this year. They will not ask you that. It won't be on this exam. It will be in the next one. OK. So this session is about pictures. Let me set my timer. So I am on time. OK. So there you go. So this is about pictures. I won't go in detail about each picture. Because you have the larger lecture that is recorded. And all the pictures are there, except a couple of other pictures that I added. The reason for this talk is that you review these. And you know some of these are going to be on your exam. And they actually like to book pictures. So I would definitely review them. So I have nothing to disclose. OK, we'll start with a question. Which of the following statements is correct? Point D correspond to entitled CO2. Segment AB represents alveolar plateau. CD represents tracheal dead space. DE represents expiratory upstroke. So what's the correct? A, B, C, or D? A, perfect. OK. So if you have this question in the exam, and you read the first answer, you don't need to waste your time reading the other answers. So that's the entitled CO2. You know the right answer. Move on to the next question. OK. This picture is to show you. Oh, I'm not touching anything. OK. I don't know why I'm pointing there. But anyway, this is the cap. Oh, gosh. This is the, OK. I don't know. So this is the capnogram. And basically, you have on the y-axis the CO2. And on the x-axis, you have time. And so it's important that you know the different phases of the capnogram, not only the entitled CO2. Know when the inhalation starts. Know that you don't have CO2 at the beginning because you are exhaling from dead space. And then as you're exhaling, CO2 will increase. Any questions on this one? No? And they may, again, there won't be any labels. But they may give you different shapes. And we're going to review some now. And I may ask you to correlate that with the clinical setting. OK. So these ones, I represented several of these. And I think Robby presented some. And this is just for a review so you remember the patterns. So the first one is carotid cleft. So this patient is mechanically ventilated and is kind of paralyzed. And he's trying to take a breath. And this is called carotid cleft. Asthma, shark fin, clear. You lose the plateau, the alveolar plateau. And you have that shark fin. And in difficult exhalation, basically. OK. This cardiac arrest. So cardiac arrest, when you're doing CPR, where should your, well, we should always monitor entitled, number one. Number two, where should the entitled be? What's the cutoff number? 10. Ideally, 20. But you're right. I mean, it should be at least 10. Ideally, 20. So this one, they were doing pretty good here. And then, whoop, there is a dip there. So what happened is you're changing the people who are doing CPR. So you just, oops. So there is a little dip there. And then they recover. And then they may give you, and you're doing a resuscitation. And this is the entitled that you're monitoring. And then you have an entitled that basically goes up. And they may ask you some, what was the mechanism? It depends on the case, right? If you were shoving the patient or so. But they will ask you why, right? And why the entitled you two went up. Because the patient, you have a cardiac arrest patient. You're doing CPR. You have entitled because you're doing good CPR, right? But your entitled is, yeah, 20. And then your entitled goes up to 40. What happened? Yeah. Yeah, correct. So return to spontaneous circulation, and you have good response. OK. Questions about this one? Some of these, for sure, will be there. OK. So esophageal intubation. You cannot miss the first one. It's not there. I don't know why I have that pointed. I'm sorry, because I'm not touching anything. It's like energy. So the other one is the one that you already saw in previous lectures. And it's also in my lecture, and the one that is recorded. So basically, you have CO2 millimeters of mercury, and you have here time. And what happens is that many times when you intubate a patient, and the tube is not in the esophagus, you still may be able to detect some CO2, but it's not sustained, and you don't have a very good waveform, right? So you can see here, I mean, it's kind of like a little hump there, and then it kind of fades in and goes away. So in patients who have had carbonated drinks, for example, you intubate a patient with a full stomach, and they have had a Coke or something before resting, and you will have CO2, and it will be initially detected in the entidal. If you have a little colored cap, that will change, because it will detect CO2. That's not the ideal way to monitor, right, CO2? But it will change, and perhaps it won't be as strong. I won't turn yellow, strong yellow, but you will have some detection, and you may think the patient was intubated. OK. What happened here? So you have, what is that? So clearly, the patient doesn't have a cardiac arrest, right, because we have the other. So we have a pretty good EKG. You have full socks. So what happened? What is it? Yeah, so it's something technical. Now, it could be disconnected, or the ventilator disconnected, but if you see a flat entidal CO2, and generally, if you don't detect CO2, you will say, oh, wow, I mean, this is bad. You know, go and do CPR. Look at the other things, because she has perfect heart rate and perfect pulse socks. Now, eventually, if nobody intervenes, and the push is an event, and you lose, you know, you have a loose connection, then eventually, we have certainly hypoxemia, et cetera. OK. OK, so based on that wave picture, this patient flow volume loop will look like which one of these, A, B, C, D, or E? D, perfect. OK, so this patient has severe subglottic stenosis. Subglottic stenosis, depending on the degree, may or may not give you this one, but this one you can see is tiny, tiny, right? So you have blunted exhalation in both phases, inhalation and exhalation, right? OK, very good. So fixed obstruction. I'm not going to go over these ones in detail, because it will take time, but review Robbie's lecture. He went in detail about this and very nicely explained. So important things to know. A, know what is normal to identify what's abnormal. That's number one. Asthma, for sure. It may be on your exam, right? And then you already know this one. And remember, the other thing to remember is that in the flow volume loops, this patient is not on a vent, right? So expiration is on top and inspiration is on the bottom. Remember that one and don't get confused. Same thing. OK, same thing. OK, recognize otopip. You need to know how to measure otopip and how to fix it. So you measure at end exhalation, right? You have an expiratory hold maneuver. And then what's your otopip? It's your total PIP minus the PIP that you already set on the patient. And I will review Ira's lecture on this. What are the things that you would do to decrease it? So which are? Just name a few. The patient is having air trapping. What did you say? OK, decreased the rate. That's one, right? OK, good. You guys are no pass. OK, another one important, static compliance and plateau pressure. Plateau pressure, I'm sure you have more than one question in many different ways. So they may give you a disease process and they may ask you, you may need to calculate it as well. So remember the formula for static compliance is tal volumes divided plateau minus PIP, right? These ones, at least when I took my exam, or not specifically this one, but all the formulas that we have been reviewing that you need to know and there is no other way like Raj was saying the other day. You just have to remember. What I did had little notes like that. And then I put them everywhere, inverted, in different places in my house. So if I was going to have it, so I was like, OK, ideal oxygen content, but I didn't have the formula on that side. So this one was blank. And then I was just doing it like when I was making coffee and I would write it. And then I checked if I was doing it right or wrong. So you can use your own technique. But before going to sleep, I had something. So I had them everywhere, like my house was decorated with little. But it was a way to remember the formulas because sometimes there's nothing else you can do, right? So anyway, so you can use your own technique. How do you measure plateau? Well, it's written there. So you measure it with an inspiratory hole. So autopip, expiratory hole maneuver, plateau, inspiratory hole maneuver. And a very important topic, review the respiratory lectures. OK, this is, it's just driving me crazy, this little pointer there. OK, this is, it's really my, it's AI, it's really my mind. What is going on? So OK, so it's a little cheat sheet, basically, that if the plateau is elevated, yes or no. And basically, this can overlap. Yeah, you want to, I don't know what's going on. It's distracting me. It's hypnotizing me. Oh, thank you. I'm glad that I have a bro here. Yeah, so this is just to walk you through the things that, you know, what we talk. So basically, if the plateau is elevated, the problem is mainly a problem of compliancy. If it's not elevated, the problem is resistance. They can overlap, right? You can have an asthmatic that can have ARDS, and then, you know, your pathology will change. OK, so more than one question on this one you'll find on the exam. OK, so I know, these ones are painful, right, for many people unless you do cardiac. But some things, review Ravi's lecture. Excellent lecture, a lot of information. OK, again, back there. Oh, no, I have it now. This is me. This is me. It's not the AI. So you have left ventricular pressure and left ventricular volume. So I'm not going to go through every curve, but I want to give you an idea how to review them. This one is normal. Know what's normal before going to abnormal, right? So remember normal. Normal looks like a French toast, right? It does, right? Yeah. So then, you need to understand what each phase is, right? I mean, this is your left ventricular pressure. You know, you have, for example, arterial stenosis. I mean, you know, the heart is trying to, so the ventricle is pumping against the clothes or partially, you know, like a small valve. So the pressure is going to increase, right? Because they will ask you mechanisms. So you need to understand that. But for a graph, OK, you have a French toast here. For me, this one is a French baguette. So, OK, we call it French. So, but you will remember what the shape is, but don't get just, you know, paralyzed or affixed with just that, understand what each phase, you know, of this curve is, right? So, and like I was saying, this one specifically, you have aortic stenosis, the pressure will increase. That's it. And they may put some questions related to that, to the, you know, pathophysiology. Okay. EKG. They may give you just an EKG and say, what's the problem, or they may give you more data of a clinical case that will guide you to this one. So I didn't put any information. And what do you think? Is it sinus rhythm? Yes, now. Yeah. Yeah. So, okay. Somebody says over there, don't be shy, this is hyperkalemia. You can see, you know, there are peak T waves. So when you get an EKG and you don't have any information, because they are not going to tell you the patient has renal failure, is, you know, not pain, and you got electrolytes and got this EKG, you know, they won't give you that much information to make it obvious. But just walk, you know, look at the basics of the EKG. You know, is this sinus rhythm or not? You know, they won't give you esoteric EKGs. So don't look at weird things, because first, we tend to do that. But in reality, they, number one, not everyone is cardiac intensivist, right? There are a few cardiac intensivists in the room, but not everyone. But any intensivist should know and should recognize hyperkalemia and should know how to treat hyperkalemia, right? So don't look at, you know, oh, yeah, this is, you know, second degree, or do I see this? Do I see that? No. Look at the basics. So sinus rhythm, high peak T waves, hyperkalemia, definitely know the treatment for hyperkalemia and watch the algorithm. What about this one? Well, just to balance, since we did hyperkalemia, we did hypokalemia. And so this is the EKG that you can see a little bit more detail. And here is kind of like this, you know, before amplified here, no? And basically, in hyperkalemia, you have high T waves. And in hypokalemia, you see depressed or, you know, decreased amplitude in the T waves. And sometimes, I mean, in severe hypokalemia, you will see U waves. And the pseudo-prolonged QT is because, you know, you have the U wave. And when you try to, when you measure QT, it looks like it's prolonged. But in reality, the T, it's the U is giving you that false reading. How do you fix it? Replace the potassium. Okay. What about this one? Okay. I don't want the cardiac intensivist. I want a regular intensivist. Okay. SVT. Very good. So regular. So and this one, they may just give you the EKG or may give you a case and say, you know, three-month-old baby, parents brought him because he's not feeling well in the EKG. And this is, you know, what you saw. So regular, really fast. And okay. So how do you treat it? It depends. Stable patient or stable or slightly unstable, let's say, but not unstable and stable. First thing you do, the kid shows up because you don't have the meds. You don't have anything. No, you're in the AV. It's like the case on SVT. Vagal maneuvers. Okay. So you do vagal maneuvers. You know, I put the eyes, blah, blah, the carotid remains the same. So what's the next thing? Adenosine. So you give the adenosine. Okay. And we know that's what happened, right? It's kind of scary when you see you gave the adenosine. How much you give? 0.1. Yeah. 100 mics per kilo, right? Okay. And if you have that and rebounds, okay, okay, oh, so, okay, I can still take five more minutes. Well, in theory, it should be until 10, but is it until 10? I'm good, right? Yeah. Okay. Because Madeline was there. Anyway. Okay. So you increase the dose, right? So you give 0.2 per kilo. And the other thing they may ask, because they ask thing about technique, you know, it's important how you give the adenosine. So they may put some things, you know, you have a new grad nurse who is giving the adenosine and we know that if you don't use, you know, the stopgog and you don't push it immediately, push the drug and push the flush, I mean, you may not see the effect, right? So sometimes they ask those things. Okay. Oh, okay. It says what it is now. Okay. So then you gave the adenosine, I mean, so SVT, you give the adenosine, nothing happened. You give another adenosine, nothing happened. You give another adenosine, nothing happened. But usually the kids with World Parkinson's White, you know, they don't respond, right? Because it's a different type of tachycardia. So clear, of course, I mean, you see the delta waves, they are easy in the EKG, but they won't make it that obvious. They may give you certainly an EKG that will show, but it may give you a case that you have a baby who is presenting with a tachyarrhythmia that doesn't respond to your initial maneuvers. And you know, again, I mean, you were called cardiology, right? By the time you gave how many adenosines you gave and you try the maneuvers and all that. But look carefully at the EKG. Okay. These ones are pretty straightforward. I will skip this one. Okay. Five months old with debt. Jet. Okay. If you don't know what it is, post-op day number one or post-op day number two is jet. They won't, you know, you won't fail on that one. So okay, perfect. Oops. How do you treat it? What do you do? So five months old, day one, post-op, debt, and jet. What do you do? Decrease catecholamines. Sedate. The patient is already on the bed, right? First day and now. Okay. So you sedate the patient. Avoid fever. You don't have to call the patient, but avoid fever. Anything that, you know, will help you to decrease the catecholamines. What else? He has pacing wires. Your surgeon was very nice and said put some pacing wires because I was manipulating a lot. They always put pacing wires. Okay. So you can override pacing, right? So you do all those things, and if the patient remains in jet, what else you can do if you need? What did you guys say? Yeah, well, that could be one, but, you know, in general, you give Amio, but yeah, it won't be wrong. And what's the dose of Amiodarone? Yeah. So, okay. Okay. So this is a real case. So I brought it here. It's not in my main talk, but I thought it was a cool case. So 16-year-old with syncope who, if I give you the rest of the history, you will figure out, but anyway, a person with syncope and DCKG. Any thoughts? What is it? I'm just seeing my hearing, I think. So is this sinus? No. Okay. Okay. It's all over the place, right? Maybe a block. Yeah. What did you say? I'm thinking it gets longer and longer, like the PR gets longer and longer. Yeah. And then is there a good correlation between the QRS and the... No. Right. Yeah. So he has heart block. Yeah. So he has heart block. So healthy kid who presents in our unit with syncope and heart block. To give you a little more story, he did have, which had resolved by the time he came to us, but had Bell's palsy. Okay. Yeah. Somebody said that there. Yeah. No, that was good. Somebody said. Yeah. Good job. This was what the mother took. By the time he came to us, we didn't see. She's like, oh, he had this rash that, you know. Anyway, for me that I have seen Lyme disease, but I had not seen Lyme carditis before, and I've been doing this for many years. So I don't know if some of the senior intensivists have or have not, but I haven't. Anyway, so how do you treat it? So he was stable. So he was stable. He had the syncope episode, but he was stable. So you have to treat the Lyme disease, and with that, they get better. But really, it was, for me, it was great, because it was like, oh, at this stage, I've been doing so many years of ICU, but I had never seen a kid like this. So he got Ceftraxone, because you could give Dr. Cycline, I mean, you get IV involved, but that's not going to be your decision, right? But not mine, and not mine either. But basically, because he had a 30-degree heart block, he got Ceftraxone. You could, if it's first or second degree, you can give Dr. Cycline. But anyway, they won't ask you that, but what I just wanted to show you was the EKG more than anything else, but they won't ask you how to treat Lyme carditis, I think. And if they do, you know. Okay, what about this? Ooh, that's bad. Okay. Okay, good. Yes, somebody said TORSAD. What do you do? MAG. Good. Know the doses. I can't miss this one. No, nobody can miss this one, right? What is it? Okay. Huh? Fib. Okay, so what do we do? Shock, shock? Epishock. Epishock. Okay, you remember that from Rabi, right? Yeah. Okay, great. So, know the pulse algorithm for the different, you know, like tachycardia, bradycardia, cardiac arrest. Okay. So, cardiac intensivies, of course, you are very comfortable doing ECOP, POCUS, and everything else. But for non-cardiac intensivies, you need to know the basics. And remember, this exam is for all the intensivies, not just for the ones that have more expertise in cardiology. So, if they ask you anything in terms of cardiac echo or cardiac ultrasound, it's going to be bradycardia diffusion. They are not going to ask, or perhaps, you know, they can give you a cohort, but I don't think they're going to be, you know, to show you anything that is more complex than that, I think. So, know just how to recognize the bradycardia diffusion. Know the, you know, the anatomy, basically, what is what you're looking. You know, here you can see the RV compressed. But again, I don't think they will ask you too much detail. Okay. I have a few more minutes, and I should finish. Right? I see Teresa. Okay. Invasive blood pressure monitor. Know how to set up the monitor, right, to atmospheric pressure. And know what happens if the transducer is up or down, right, the right atrium. And that how you get false higher blood pressure readings or lower blood pressure readings. Same thing, same principles of, you know, to any other type of pressure monitoring, CVP, or what we were talking about, the EVDs yesterday. So, I will skip that, but you can review it. That's pretty straightforward. They like to put these ones, and I don't, I won't explain either because I'm running out of time, but they like to ask you, you know, how do you check the fidelity of the system. And I don't know if you guys have ever done it, you know, just, you know, do the little rapid flash test. And then just understand this is in real life, you know, understand what happened with the system is overdamped or when these are underdamped and what are the causes. That one you can review it. CVP waveform, know how to recognize kind of waves, and when do you see them. You know, we saw jet, I didn't put a, you know, CVP waveform, but that's where you see them. And know what, you know, in the CVP waveform, what, when you correlate that with the EKG, which part of the EKG corresponds to each wave, basically. That's pretty straightforward. This one, so action potentials and the cardiac muscles. Things to know are which electrolytes are involved, right? You have them here, you have them here. This one, important. Amiodarone, potassium channel blocker. Keep that picture in your kitchen cabinet. The ones that, of course, I mean, there are all these drugs. I highlighted the ones that I think they may ask you, the mechanism. Definitely amiodarone, beta blockers, and DH. There may be a few more, but okay. ID, what is this? I'm running out of time, so I have to stop. I'm done? Yeah? Okay. So I go one minute and I stop. So I tell you what it is, malaria. Okay, what is this? Aspergillosis. Know how to treat it and know what happens when you get boriconazole. QT. This, toxic shock. Gram-positive cocci in clusters. Okay. Remember this one. Steven Johnson and toxic epidermal necrolysis. Scallop syndrome, you know, sparse mucous membranes. Okay. And trauma. So they won't give you all this because it's super obvious, right? But they may ask you, recognize, et cetera. Seat belt injury, they like that, and they ask that, and it was in my primary exam, and I heard some people who are taking the recertification, they have that as well, so recognize that. Snakebites, they won't ask about this one. They may ask about pit vipers, and the main thing to remember is get rid of any. Yeah, I'm done. Okay. Okay. We can talk during the break. I have to stop, and I'm sorry. So, okay, that's the last slide. So for the exam, read the questions carefully and do not agonize in things that you don't know, and Ira, when we close, will give you, you know, test-taking skills to just, you know, know how to answer quickly. Anyway, I'm around, so if you guys have any questions, thank you. All right. Thank you.

ECMO

allogeneic transplants

autologous transplants

board exam preparation

medical imaging

arrhythmias

patient monitoring