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In this episode, Stephanie Mitchell, a certified personal trainer (CPT) and the inspiring wellness coach behind Stephanie Mitchell Fitness, joins us for a discussion around how women can prioritize wellness through the complex journey of perimenopause and menopause. In our conversation, Stephanie shares insights on staying connected to our "why" in our wellness routines, staying resilient as our bodies change, and building community as a powerful support network during this phase of life.Stephanie is a dedicated wellness, meditation and fitness professional who helps women to become stronger and more mindful so they may live their most fearless life, especially during their perimenopausal and menopausal years. Through a balanced and holistic approach to wellness, she helps women discover what's right for them when it comes to changing up their routine when they reach midlife. Topics covered in this episode:Build the life you want moving forward: One of Stephanie's key insights is that motivation to stay active and healthy shouldn't come from a desire to “get back” to our past selves but to build the life we want moving forward. Too often, we focus on goals like losing weight or looking younger, but Stephanie encourages women to go deeper and ask, "Why do I want this?" Whether it's the energy to keep up with family or the strength to pursue new adventures, finding a motivating factor for the future helps us prioritize what truly matters.Small sustainable changes to build systems: Stephanie is a firm believer in small, sustainable changes over extreme, quick-fix solutions. Drawing inspiration from James Clear's book, "Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad One", she encourages clients to build systems, like starting their day with just the act of putting on workout clothes before progressing to a workout routine. This approach keeps us from feeling overwhelmed and leads to long-lasting, positive changes in how we care for ourselves.Community's role in keeping healthy habits: Whether we need to get healthy or maintain our health, community can play such an essential role in sticking with healthy habits. Studies show that people who exercise with friends or in groups are more likely to maintain a consistent routine. Whether working one-on-one with a trainer or joining a group class, community can provide accountability, encouragement, and a much-needed sense of camaraderie. Connect with StephanieWebsite: https://www.stephaniemitchellfitness.com LinkedIn: https://www.linkedin.com/in/stephanie-mitchell-074497335/ Instagram: @stephaniemitchellfitness Your Empowered Evolution, A Podcast Dedicated to Women in Mid-Life Podcast

The new Fearless Aging Podcast is dedicated to helping Elders( 60+) become much healthier, energetic and live longer so they can give back theirknowledge and wisdom to help solve the monumental challenges we as humanity or now facing. Also so they can be role models and mentors for young people. You will learn how big the problem is, why it is happening, and what are proven solutions for preventing and reversing pre mature aging.This podcast is a must for people 60+ and for people with parents who aren't doing well health wise and/or financial wise as well.Subscribe to our podcast @ agelesslivinglifestyle.com/podcast. You will receive a valuable ebook - How to Be Bold and Never Be Old. And be notified when our next podcast is live.To try out the world's healthiest coffee go to: live pure.com/agelesscoffeeand click on the cafe pure link.To learn more about Jon's wealth building system contact him @ jon@truthfulkernel.com Become a supporter of this podcast: https://www.spreaker.com/podcast/fearless-aging--2801795/support.

Todd and Jasper are basking in the glow of a top four team, all thanks to midfield maestros Sam Durham and Jye Caldwell. They chat the much-needed positional moves from Brad Scott, Nate Caddy's sparkling goals and being favourites vs Geelong for the first time in 12 years. Todd's Twitter: https://x.com/ToddJDavey Jasper's Twitter: https://x.com/Jasperc53

In this episode we ask the question, why did we get married? When Mark & Marc proposed it was a sign of commitment, that they wanted to be with us forever. We knew we needed to be with people who weren't going to judge us. Who let us be us. We are lucky, we have husbands who know exactly who we are. Want our podcasts sent straight to your phone? Text us the word "Podcast" to +1 (917) 540-8715 and we'll text you the new episodes when they're released!Tune in for new Cat & Nat Unfiltered episodes every Monday, Tuesday, Thursday and Friday!Follow @catandnatunfiltered on Instagram: https://instagram.com/catandnatunfilteredOur new book "Mom Secrets" is now available! Head to www.catandnat.ca/book to grab your autographed copy! Come see us LIVE on tour!! To see a full list of cities and dates, go to https://catandnattour.com.Follow our parenting platform - The Common Parent - over on Instagram: https://instagram.com/thecommonparentBecome a Member of The Common Parent, our ultimate parenting toolkit for parents of teens and tweens for just $74.99/year: https://thecommonparent.comGet a FREE “Thoughts Between Us” Journal with The Common Parent Annual Membership: Click Here!Make sure you subscribe to our YouTube channel for our new cooking show and our #momtruth videos: https://bitly.com/catnatyoutubeCheck out our Amazon Lives here: https://bitly.com/catnatamazonliveOrder TAYLIVI here: https://taylivi.comGet personalized videos from us on Cameo: https://cameo.com/catandnatCome hang with us over on https://instagram.com/catandnat all day long.And follow us on https://tiktok.com/@catandnatofficial! Hosted on Acast. See acast.com/privacy for more information.

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.Hosts:Dr. Pradip Kamat: Children's Healthcare of Atlanta/Emory University School of MedicineDr. Rahul Damania: Cleveland Clinic Children's HospitalIntroduction:Pediatric Intensive Care Unit (PICU) physicians passionate about medical education in the acute care pediatric settingEpisode focus: A case of a 23-month-old ex-28 week premie presenting with sudden high fever and rapidly rising ETCO2 during surgeryCase Presentation:Presented by Dr. Rahul Damania23-month-old ex-28 week premie intubated during hernia repair surgeryNoticed rapidly rising ETCO2, unprovoked tachycardia, and elevated temperatureTransferred to PICU, exhibiting rigidity, clenched jaw, metabolic acidosis, and elevated lactate.Consideration of Malignant Hyperthermia (MH) crisisKey Points:Elevated temperature, hypercapnia, metabolic acidosis, and unprovoked tachycardia raise concern for MHOrganized discussion on pathophysiology, clinical signs, symptoms, and managementMultiple Choice Question:Diagnosis of MH crisis during scoliosis repairCorrect Answer: D) Sarcoplasmic reticulumDantrolene acts on the sarcoplasmic reticulum to inhibit calcium release, crucial in MH managementClinical Presentation of MH Crisis:Tachycardia, acidosis, muscle stiffness, and hyperthermia are hallmark featuresPotential life-threatening complications underscore the urgency of recognition and treatmentTriggers and Pathophysiology of MH Crisis:Triggered by inhalational agents and depolarizing neuromuscular blocking agentsPathophysiology involves defective Ryanodine receptor leading to uncontrolled calcium releaseDifferential Diagnosis:Includes sepsis, thyroid storm, pheochromocytoma, and neuroleptic malignant syndromeDifferentiation from similar conditions crucial for accurate managementDiagnostic Approach:High clinical suspicionGenetic testing (ryanodine...

Welcome to this week’s Talking the Blues Podcast, dedicated to the life and memory of Mark,  better known as Roydo from Grandoldteam, sadly now departed, far too soon – a wonderful man, […]

Boomer Bevo Podcast - Episode 104- This is the one-hundred fourth episode of the only podcast dedicated to the greatest rivalry in college football, The University of Texas and The University of Oklahoma. Kevin breaks down the projected SEC win totals.  The guys also talk Big 12 basketball and NBA.

Sign up on Patreon for only $1! There's additional episodes there! https://www.patreon.com/MattMillerComedy I talk about: - Hot Dogs - My Dad passing away - Being in hospital - Death - Getting High - Life Support - Donuts - Jewish Poem - Excommunication - Therapy - Emotions - Gaslighting - Family Units - Dumps - Mom - Paperwork - Broken Finger - Love - Domestic Abuse - Estranged - Jewish stuff - Laughing - OCD Instagram/Twitter/Facebook: @MattMillerReal www.mattmillercomedy.com #funny #MattMiller #comedy

Welcome to 'She's Having an Episode,' a podcast dedicated to celebrating TV's very best female characters. Hosted by journalist Aisling O'Leary (the irish one) and screenwriter Lela London (the American one).Our first three episodes will be released next Monday, so follow on your preferred podcast platform now, and do feel free to send any character recommendations to hello@sheshavinganepisode.com now!'Til then!xo Hosted on Acast. See acast.com/privacy for more information.

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine and I'm Rahul Damania from Cleveland Clinic Children's Hospital. We are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode.In today's episode, we're bringing together some of the best content from our previous podcasts to present a comprehensive clinical case. We're also excited to share with you some of the most highly cited articles from the past year, presented in a practical, case-based format. This episode will offer you valuable insights into the latest research findings while also highlighting the real-world application of this knowledge in a clinical setting.We'll start by presenting an interesting case of a toddler who was transferred to the PICU due to increasing respiratory distress:A 2-year-old male was brought to the emergency department with a chief complaint of increased work of breathing and URI symptoms, including a cough and runny nose. The child had no significant past medical history, was not taking any medications, and had no known allergies. The child was up-to-date on immunizations, and there were no significant sick contacts.The family brought the child to the emergency department after noticing a significant increase in work of breathing, including the use of accessory muscles, nasal flaring, and chest retractions. The initial physical exam revealed tachypnea and decreased breath sounds on the right side. The child's vital signs were concerning for respiratory distress, with a heart rate of 170 beats per minute, respiratory rate of 50 breaths per minute, and oxygen saturation of 85% on room air. Chest X-ray revealed right lower lobe pneumonia.The child was started on supplemental oxygen, and broad-spectrum antibiotics, and trialed with albuterol. Despite initial treatment, the child's respiratory distress worsened, and the decision was made to transfer the child to the PICU and place the patient on HFNC 1.5 L/kg. Upon admission to the PICU, the child's vital signs were still concerning, he was afebrile, with a heart rate of 180 beats per minute, respiratory rate of 60 breaths per minute, and oxygen saturation of 85% on 1.5L/kg HFNC at 75% FiO2. Given the persistent respiratory distress, the decision was made to intubate the child in the PICU for acute hypoxemic respiratory failure. Shortly after intubation, a central line is placed in the R internal jugular vein.To summarize key elements from this case:2-year-old with a prodrome of URI symptomsIs otherwise previously healthy with no significant medical history or allergiesDeveloped respiratory distress and diagnosed with pneumoniaTransferred to PICU, intubated for respiratory failureLet's fast forward in the case and talk about a scenario that frequently arises in the PICU. It's hospital day 2, and the patient's RSV swab is positive, and we're seeing some improvement on the X-ray....

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine. I'm Rahul Damania from Cleveland Clinic Children's Hospital and we are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode.Today, we are going to discuss the management of the postoperative patient admitted to the PICU. Our discussion will focus on the non-cardiac and non-transplant admission. Our objective in this episode is to create a framework on what areas of care to focus on when you have a patient admitted to the PICU post-operatively. Each surgery and patient is unique; however, we hope that you will garner a few pearls in this discussion so you can be proactive.in your management. Without any further delay, let's get started with today's case:We begin with a 13-year-old child, Alexa, with h/o of a genetic syndrome, who presents today with a history of thoracolumbar kyphoscoliosis. Over the years, Alexa's curvature has progressively worsened, resulting in difficulty breathing and chronic back pain. The decision was made to proceed with a complex spinal surgery, including posterior spinal fusion and instrumentation.In the weeks leading up to the surgery, Alexa underwent a thorough preoperative evaluation, including consultations with specialists and relevant imaging studies. Pulmonary function tests revealed a restrictive lung pattern, while the echocardiogram showed no significant cardiac abnormalities. Preoperative labs, including CBC, electrolytes, and coagulation profile, were within normal limits.During the surgery, Alexa was closely monitored by the anesthesia team, who administered general anesthesia with endotracheal intubation. The surgery was performed by the pediatric neurosurgery and orthopedics, with intra-operative neuromonitoring to assess spinal cord function. The surgical team encountered an unexpected dural tear, which was repaired using sutures and a dural graft. Due to the prolonged surgical time, a temporary intra-operative loss of somatosensory evoked potentials was noted. However, signals were restored after adjusting the patient's position and optimizing blood pressure. The posterior spinal fusion and instrumentation were completed successfully, but the surgery lasted 8 hours. Total intra-operative blood loss was 800 mL, and Alex received 2 units of packed red blood cells and was on NE for a little over half the case before weaning off.Alexa was admitted to the PICU intubated and sedated for postoperative care. The initial assessment showed stable vital signs, with a systolic blood pressure of 100 mmHg, heart rate of 90 bpm, and oxygen saturation of 99% on mechanical ventilation. Postoperative pain was managed with a continuous morphine infusion. The surgical team placed a closed suction drain near the surgical site and a Foley catheter for urinary output monitoring. You are now at the bedside for OR to PICU handoff…To summarize key components from this case:This is a patient with thoracolumbar kyphoscoliosis, underwent complex spinal surgery (posterior spinal fusion and instrumentation) due to progressive curvature, breathing difficulties, and chronic pain.

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine and I'm Rahul Damania from Cleveland Clinic Children's Hospital. We are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode.Here's the case of a 12-week-old girl old who is limp and seizing presented by Rahul.Chief Complaint: A 12-week-old previously healthy female infant was found limp in her crib and developed generalized tonic-clonic seizures on the way to the hospital.History of Present Illness: The mother returned from work on a Saturday to find her daughter unresponsive in her crib. The infant had been left in the care of her mother's boyfriend, who stated that the daughter had been sleeping all day and had a small spit up. As the patient continued to have low appetite throughout the day and continued to be unresponsive in her crib, mother called EMS to bring her to the emergency department. En route, the patient had tonic movement that did not resolve with intranasal benzodiazepines.ED Course: The infant presents to the ED being masked. Upon arrival at the ED, the infant was in respiratory distress, with a heart rate of 190 beats per minute, respiratory rate of 50 breaths per minute, and oxygen saturation of 85% with bagging. She was intubated for seizure control upon arrival at the ED. Physical examination in the ED revealed bruising on the right neck region but was otherwise unremarkable. A non-contrast head CT showed no acute intracranial abnormalities. The initial diagnostic workup revealed normal CBC, mildly elevated hepatic enzymes, and pancreatic enzymes which were within normal limits. The blood gas showed metabolic acidemia with PCO2 in the 60s.Admission to PICU: Upon admission to the PICU, neurosurgery and trauma teams were consulted. A skeletal survey and ophthalmology consult for a fundoscopic examination were ordered, as there were concerns of non-accidental trauma. Further investigation is underway to determine the cause of the infant's condition.To summarize key elements from this case, this patient has:Patient left with mother's boyfriendInfant found limp and had seizures requiring intubationNeck bruiseAll of these bring up a concern for Non-Accidental Trauma (NAT) the topic of our discussion.Let's start with a short multiple-choice question:Which imaging modality is the most appropriate for establishing a diagnosis of abusive head trauma (AHT) in a 12-week-old infant with an open fontanelle on the exam?A. CT scan of the brain without contrast B. MRI of the brain without contrast C. Skull X-ray D. Doppler ultrasound of the headRahul, the correct answer is A. Though

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine and I'm Rahul Damania, from Cleveland Clinic Children's Hospital. We are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode:Welcome to our Episode about a 14-year-old male who collapsed on the baseball field.Here's the case presented by Rahul:A 14-year-old male athlete was playing in a high school baseball tournament when he was hit in the chest with a pitched ball. The impact caused him to collapse on the field. Bystander CPR was begun given his unresponsiveness and emergency medical services were immediately called. The patient was transported to the hospital. Upon arrival, he was unresponsive and had no pulse. An electrocardiogram (ECG) showed ventricular fibrillation, and advanced cardiac life support was initiated. After several shocks and cardiac compressions, the patient regained a pulse and was transferred to the pediatric intensive care unit for further evaluation and management.To summarize key elements from this case, this patient has:Been struck by a high-velocity object in the chestSuffered a cardiac arrest, likely due to an arrhythmia from the blunt chest traumaThe presentation brings up a concern for Commotio Cordis, our topic of discussion today!We wanted to create this educational episode in light of the recent medical event experienced by the Buffalo Bill's safety Damar Hamlin. His blunt chest trauma, which led to cardiac arrest, has been postulated to be due to commotio cordis. At the date of this record, we are glad that Damar Hamlin is on the road to recovery.Absolutely, let's dive in more into this topic, Let's start with a short multiple-choice question:The 14-year-old described in our case suffered cardiac arrest after blunt chest trauma. Based on the working diagnosis of comottio cordis, what is the most likely EKG finding which may be seen in this patient?A. Ventricular fibrillationB. Ventricular tachycardiaC. Complete heart blockD. AsystoleThe correct answer is A. In a study published in JAMA (2002; 287(9):1142-1146) which used data from the US Commotio Cordis registry maintained by the Minneapolis Heart Institute Foundation, reported that the most common arrhythmia out of the 128 confirmed cases, 82 of which had EKGs which could be analyzed was ventricular fibrillation. Three patients had Vtach, 3 had Bradyarrhythmia and 1 had complete heart block. Although 40 patients had asystole, this was unlikely to be the initial rhythm after impact. Interestingly, the majority of these rhythms were recorded at the scene.Rahul, What is the definition of Commotio...

Approach to Pediatric Trauma Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine and I'm Rahul Damania, from Cleveland Clinic Children's Hospital. We are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode.Welcome to our Episode today of a 7 yo M who presents to the PICU after a severe Motor Vehicle Accident.Here is the case presented by RahulA 7-year-old male child is admitted to the PICU after sustaining severe trauma. The patient was brought to the emergency department after a motor vehicle accident that involved an 18-wheeler truck & the family's car; in this severe accident the 7 yo was noted to be restrained however upon impact was ejected from the vehicle. He was unconscious and had multiple injuries, including a laceration on the head and bruising on the chest. The EMS was activated and the patient presented to the ED for acute stabilization. Upon examination, the patient was found to have a Glasgow Coma Scale score of 8, indicating a serious head injury. He had multiple bruises and abrasions on the chest and arms, and his pulse was rapid and weak. The patient was resuscitated with colloid and blood products, intubated, and transferred to the pediatric intensive care unit for further management.Notably, a CT scan of the head showed a skull fracture and a subdural hematoma. A chest X-ray showed multiple rib fractures and bilateral pulmonary opacities with no evidence of pneumothorax. The patient was also found to have a grade 2 liver laceration and a splenic injury. Pelvic x-ray and cardiac FAST exam were unrevealing.To summarize key elements from this case, this patient has:A traumatic brain injuryPulmonary contusions and is at risk for PARDSLiver and spleen injuryAnemiaPertinent negative includes: No pelvic injuries or injuries to great vessels in the chestRahul, let's approach the PICU medical management of this case based on a culmination of various guidelines published in the Pediatric Critical Care literature. Namely, let's use this case to dive deep into guidelines for:Traumatic brain injury (TBI)****Transfusion and Anemia Expertise Initiative (****TAXI)pediatric blunt liver and spleen injury management, are also known as the ATOMAC protocol, as well as general PICU management of acute trauma.As we take the management of this pediatric trauma patient in a systems-based fashion let's first go into the Management of Pediatric Traumatic Brain Injuries, can you start us off with some key management considerations?Based on the March 2019 TBI guidelines published in Pediatric Critical Care Medicine in 2019 (PCCM20(3S):p S1-S82, March 2019)This patient should have an ICP monitor or even an EVD placed for CSF diversion in consultation with the NS and trauma team. A CPP of at least >50 in our 7 yo patient and ICP < 20 mm Hg has been shown to improve outcomes and reduce mortality.Just as a quick review, CPP stands for cerebral perfusion pressure, which is the pressure that maintains blood flow to the brain. The formula for CPP is:CPP = MAP (mean arterial pressure) - ICP (intracranial pressure)Monitoring does not affect outcomes directly; rather the information from monitoring can be used to direct treatment decisions. Treatment informed by data from monitoring may result in better outcomes than treatment informed solely by data from clinical assessment. In short, it is important to have qualitative and quantitative data to optimize your decision-making.As we talked about ICP control is so crucial for

Dear Listeners & Peds ICU community, WE are back on air!Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.I'm Pradip Kamat coming BACK to you from Children's Healthcare of Atlanta/Emory University School of Medicineand I'm Rahul Damania from Cleveland Clinic Children's Hospital and we are two Pediatric ICU physicians passionate about all things MED-ED in the PICU.PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting.As we turn into a new year, we would like to introduce Season 2 of PICU Doc on Call. Yes Pradip, I am super excited for this year & I want to take this moment to thank YOU all, our listener community for making PICU Doc on Call such a success as we share our passion for medical education thru this forum!This episode will give you a quick layout of how we will be organizing each episode of PICU doc on call this year. We will also highlight some tips and tricks on how to best learn from a medical podcast. Our goal in this episode is to provide you a framework on some best practices in medical podcasting and how to retain information from a podcast. Especially for our past & future episodes, we hope you can use this audio learning platform to assist you in applying the knowledge at the bedside when you are working in the acute care setting.Let's get into our first learning objective,Rahul, did you know that learning via podcasts can actually benefit your brain & change the neural chemistry.In fact, a 2016 med ed study published out of UC Berkeley concluded that listening to narrative stories from podcasts can stimulate multiple parts of your brain such as the limbic system and can enhance mood as it modulates dopamine and serotonin driven neural pathways. Think about listening to your favorite true-crime podcast — the suspense actually allows for you to stimulate centers in your medulla that increase the amount of endorphines, dopamine and serotonin that keep you on the edge of your seat.That is so unique, so based on this, I do want to highlight some of the key elements which will make our podcast or any medical podcast you listen to beneficial. These pearls will also help you if you are developing a medical podcast of your own!The first concept here is that many podcasts provide narratives.When it comes to medical podcasts, narratives are in the form of medical cases which allow for you to retain content knowledge as a patient case invokes emotion and this can help you remember information more robustly.When listening to a podcast, you have to use your imagination to picture what's going on. For example, if I painted a 2 yo M with a history of rhinorrhea at home for about a week who now presents to the ED with subcostal & intercostal retractions that then progresses to intubation in the PICU, you not only are envisioning a patient in front of you, but also are shifting your mind across settings. Our brain has to work at the pace of the audio, so hopefully your mind doesn't wander off like it does when reading a textbook page. And because you have to...

We are joined by Marc Alden Taylor from the Free Form Rock Podcast to jump into The Cars and their sophomore album Candy-O! We discuss how revolutionary The Cars were to the 80s, why Candy-O in some ways may be better than the debut, the amazing album artwork, Candy Moore, Phoebe Cates, and Benjamin Orr's dreamy looks and voice! We also do a special news segment in which we hash out some Facebook drama with Marc, talk about David Crosby, heavy metal elitism, Metallica's new song, and we pay tribute to friend and brother Donny Allen.

Well, as promised, here is my long-awaited episode on Architecture and how you can apply a lot of themes and forms from these gorgeous and historical monuments to your automotive/transportation designs. Lets explore the world together, one epic building at a time! --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app --- Send in a voice message: https://anchor.fm/sketchbookaudio/message

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Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine and I'm Rahul Damania from Cleveland Clinic Children's Hospital. We are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode: Welcome to our Episode a three-year-old girl with altered mental status and acute respiratory failure Here's the case presented by Rahul— A three-year-old presents to the PICU with altered mental status and difficulty breathing. Per the mother, the patient was in the usual state of health on the day prior to admission when the mother left her in the care of her maternal grandmother. When mom arrived home later in the afternoon, mom was unable to wake her and reported that she seemed "stiff". She did not have any abnormal movements or shaking episodes. Mom called 911 and the patient was brought to our ED. No known head trauma, though the patient is in the care of MGM throughout the day. No emesis. Nhttp://emesis.no/ (o) recent sick symptoms. No witnessed ingestion, however, the patient's mother reports that MGM is on multiple medications (Xarelto, zolpidem, Buspar, gabapentin, and acetaminophen) and uses THC-containing products specifically THC gummies. In the ED: The patient had waxing and waning mentation with decreased respiratory effort. GCS was recorded at 7. Arterial blood gas was performed showing an initial pH of 7.26/61/31/0. The patient was intubated for airway protection in the setting of likely ingestion. The patient has no allergies, immunizations are UTD. BP 112/52 (67) | Pulse 106 | Temp 36.2 °C (Tympanic) | Resp (!) 14 | Ht 68.5 cm | Wt 14.2 kg | SpO2 100% | BMI 30.26 kg/m² Physical exam was unremarkable-pupils were 4-5mm and sluggish. There was no rash, no e/o of trauma Initial CMP was normal with AG of 12, CBC was unremarkable, and Respiratory viral panel was negative. Serum toxicology was negative for acetaminophen, salicylates, and alcohol. Basic Urine drug screen was positive for THC To summarize key elements from this case, this patient has: Altered mental status: - waxing and waning with GCS less than 8 suggestive of decreased ventilatory effort pre-intubation impending acute respiratory failure Dilated but reactive pupils All of which brings up a concern for possible ingestion such as THC (but cannot rule out other ingestion) This episode will be organized… Pharmacology of Cannabis Clinical presentation of Cannabis toxicity Workup & management of Cannabis toxicity The Cannabis sativa plant contains over 500 chemical components called cannabinoids, which exert their psychoactive effect on specific receptors in the central nervous system and immune system. The 2 best-described cannabinoids are THC and cannabidiol (CBD)—and are the most commonly used for medical purposes. Patients with intractable epilepsy or chronic cancer pain may be using these drugs. THC is the active ingredient of the cannabis plant that is responsible for most symptoms of central nervous system intoxication. The term cannabis and the common name, marijuana, are often used interchangeably). Rahul, can you shed some light on the pharmacokinetics/pharmacodynamics of cannabis? Cannabis exists in various forms: marijuana (dried, crushed flower heads, and leaves), hashish (resin), and hash oil (concentrated resin extract), which can be smoked, inhaled, or ingested. THC is the active ingredient of the cannabis plant that is responsible for most symptoms of central nervous system intoxication, in contrast to CBD, the main non-psychoactive component of cannabis. The potency of cannabis is usually based on the THC content of the preparation. The THC is lipid soluble and highly protein bound and has a volume of distribution of 2.5 to 3.5...

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine and I'm Rahul Damania from Cleveland Clinic Children's Hospital. We are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode: Welcome to our Episode: A Somnolent Toddler. Here's the case: A 2 yo M presents to the PICU after being found increasingly sleepy throughout the day. The toddler is otherwise previously healthy and was noted to be in his normal state of health prior to today. The mother dropped the toddler off at his Grandmother's home early this morning. Grandmother states that he was playing throughout the day, and she noticed around lunchtime the toddler stumbles around and acts more sleepy. She states that this was around his nap time so she did not feel it was too out of the ordinary. The toddler 1 hr later was still very sleepy, and the grandmother noticed that the toddler had some shallow breathing. She called mother very concerned as she also found her purse open where she typically keeps her pills. The grandmother has a history of MI and afib as well as hypertension. She is prescribed a multitude of medications. Given the child's increased lethargy, the grandmother presents the patient to the ED. In the ED, the child is noted to be afebrile with HR 55 & RR of 18. His blood pressure is 78/40. On exam he has minimal reactivity to his pupils, he has shallow breathing and laying still on the bed. A POC glucose is 68 mg/dL. Acute resuscitation is begun and the patient presents to the PICU. To summarize key elements from this case, this patient has: Drowsiness Bradycardia Normotension This is in the setting of being at grandma's home and having access to many medications Given the hemodynamic findings and CNS obtundation, this patient's presentation brings up concern for a clonidine or beta-blocker ingestion. This episode will be organized: Beta-Blocker poisoning We will also examine other medications that potentially can be toxic to a toddler (one pill can kill) present in Grandma's purse which include: TCA, CCB, Opioids, oral anti-diabetic agents, digoxin, etc. The presence of a grandparent is a risk factor for unintentional pediatric exposure to pharmaceuticals commonly referred to as the Granny Syndrome. Grandparents' medications account for 10% to 20% of unintentional pediatric intoxications in the United States. To kids, all pills look like candy. Let's start with a multiple choice. An overdose of which of the following medications may mimic the presentation of Metoprolol overdose? A. Verapamil toxicity B. Ketamine toxicity C. Valium toxicity D. Lithium toxicity The correct answer is A, verapamil toxicity. Verapamil is a non DHP CCB. It acts at the level of the SA and AV node similar to Metoprolol, a beta-1-specific antagonist. Both cause bradycardia and AV node block. Valium though a CNS depressant, can cause CV depression as well, however, would have fewer changes on the conduction system compared to a non-DHP CCB.  What is the mechanism of toxicity with beta-blockers? Beta-blockers are competitive inhibitors at beta-adrenergic binding sites, which results in decreased production of intracellular cyclic adenosine monophosphate (cAMP) with a resultant blunting of multiple metabolic and cardiovascular effects of circulating catecholamines. They attenuate the effect of adrenergic catecholamines on the heart Decrease inotropic and chronotropic response. Some drugs like Propranolol can act as Na channel blockers (myocyte membrane stabilizing activity) at high doses resulting in arrhythmias and seizures. Toxic doses of drugs like Sotalol can result in K channel blockade giving rise to prolonged QT and risk for...

#nfl #ufc #rip Elias Theodoru was an MMA fighter, actor, stuntman, TV pitchman, cannabis advocate and more. He will be very missed after passing away yesterday from liver cancer at the young age of 34. We discussed Elias and dedicated this podcast episode to him and his lasting memory. We went into a lot of detail in covering week 1 of the NFL. It ended tonight with a Seattle Seahawks huge upset win over Russell Wilson and the Denver Broncos on Monday Night Football. Russell spent his first 10 years of his career in the Emerald City and this was his much anticipated return. He was loudly booed and it made the Hawks faithful very happy to defeat their former QB. There were so many great games and moments and we are so happy the NFL is finally back! UFC 279 was this weekend and was a crazy mixed up card that had more twists and turns than a snake with an itch. Many fighters missed weight and so the fights had to be shuffled and new matchups formed. The best part was that Nate Diaz went out with a victory and could be celebrated for a long and great career. He won via submission over another OG and long time great UFC fighter Tony Ferguson. It was a fun card to watch and even better to break down. Check out our websites for tons of content. www.completesportsmedia.com www.completemedianetwork.com Enjoy, Take care, Love yah, Bye for now!

#nfl #ufc #rip Elias Theodoru was an MMA fighter, actor, stuntman, TV pitchman, cannabis advocate and more. He will be very missed after passing away yesterday from liver cancer at the young age of 34. We discussed Elias and dedicated this podcast episode to him and his lasting memory. We went into a lot of detail in covering week 1 of the NFL. It ended tonight with a Seattle Seahawks huge upset win over Russell Wilson and the Denver Broncos on Monday Night Football. Russell spent his first 10 years of his career in the Emerald City and this was his much anticipated return. He was loudly booed and it made the Hawks faithful very happy to defeat their former QB. There were so many great games and moments and we are so happy the NFL is finally back! UFC 279 was this weekend and was a crazy mixed up card that had more twists and turns than a snake with an itch. Many fighters missed weight and so the fights had to be shuffled and new matchups formed. The best part was that Nate Diaz went out with a victory and could be celebrated for a long and great career. He won via submission over another OG and long time great UFC fighter Tony Ferguson. It was a fun card to watch and even better to break down. Check out our websites for tons of content. www.completesportsmedia.com www.completemedianetwork.com Enjoy, Take care, Love yah, Bye for now!

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine and I'm Rahul Damania from Cleveland Clinic Children's Hospital and we are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode: Welcome to our Episode of a 4-day-old with jaundice and vomiting. Here's the case presented by Rahul: A full-term 4-day-old boy presents to the ED after recently being discharged from the newborn nursery. Per mom, the patient "look yellow" and was having difficulty with feeding. The mother states that the patient would be increasingly sleepy, and will only latch to the breast for five minutes. The patient has been having decreased wet diapers, and the stool is loose and non-bloody. Mother was concerned today as the child continue to look yellow, especially in the eyes, had four episodes of vomiting, and overall was acting lethargic. The patient presented to the emergency room afebrile, tachypneic, and tachycardic. The patient was noted to have initial serum glucose of 70. As the patient was increasingly dehydrated, laboratory testing was difficult to obtain. The infant was fussy for the caregivers. The patient was resuscitated with 2 x 10 per kilo boluses and responded well. Point of care ultrasound noted normal four-chamber cardiac anatomy and squeeze. Given the instability of the patient, a RAM cannula was initiated, and the patient presented to the PICU. To summarize key elements from this case, this 4-day-old infant has: an acute presentation of jaundice and poor feeding Prominent GI symptoms and dehydration A sepsis-like presentation with hemodynamic instability responsive to fluids All of which brings up a concern for inborn error of metabolism, likely galactosemia. This episode will be organized… Clinical Presentation Laboratory Findings & Biochemistry Management of Galactosemia Rahul, let's start with a short multiple choice question: Of the following biochemical enzymes, which of the following is deficient in classic galactosemia? A. UDP Glucoronyl Transferase B. Aldolase B C. Galactose 1 Uridyl Transferase D. Galactokinase The correct answer is C. Galactose 1 Uridyl Transferase aka GALT. Classic galactosemia is caused by a complete deficiency of galactose-1-phosphate uridyl transferase (GALT). We should contrast this with galactokinase deficiency. These two present quite differently — GALT deficiency presents like our patient with jaundice, vomiting, hepatomegaly, renal dysfunction, and sepsis. Galactokinase deficiency has less of systemic symptoms and these patients similar to GALT deficiency have cataracts that are usually bilateral and resolved with dietary therapy. To go through our other answer choices, remember that Aldolase B is the rate-limiting enzyme in fructose metabolism, thus a deficiency in this enzyme would cause hereditary fructose intolerance. With this lead in question, let's pivot into the biochemistry of galactose and review key lab findings in our patient with galactosemia. Rahul, can you give us a quick summary of how galactose is metabolized in our body? Galactose is a sugar found primarily in human milk and milk products as part of the disaccharide lactose. Lactose is hydrolyzed to glucose and galactose by the intestinal enzyme lactase. The galactose then is converted to glucose for use as an energy source, however it needs a series of reactions: Galactokinase → which catalyzes the rxn galactose to galactose 1 PO4 Our rate limiting enzyme Galactose-1-phosphate uridyl transferase (GALT). GALT helps place a sugar moiety on galactose 1 PO4 to turn it into glucose 1 Phos which can then be utilized in glycolysis or glycogenesis. A complete deficiency in GALT is known as classic...

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine. I'm Rahul Damania from Cleveland Clinic Children's Hospital and we are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode: Here's the case presented by Rahul: A 21-month-old girl was brought to an OSH ED for somnolence and difficulty breathing, which developed after she accidentally ingested an unknown amount of liquid medicine that was used by her grandfather. Per the mother, the patient's grandfather was given the liquid medication for the treatment of his opioid addiction. The patient took some unknown amount from the open bottle that was left on the counter by the grandfather. Immediately after ingestion of the medicine, the patient initially became irritable and had some generalized pruritus. The patient subsequently became sleepy followed by difficulty breathing and her lips turned grey. The patient was rushed to an outside hospital ED for evaluation. OSH ED: The patient arrived unresponsive and blue, she was noted to be sleepy and difficult to arouse on arrival, with pinpoint pupils and hypoxic to 88%. , but After receiving Naloxone, however, she became awake and interactive. Her glucose on presentation was 58 mg/dL and Her initial VBG resulted 7.3/49.6/+2. She continued to have intermittent episodes of somnolence without apnea. Poison control called and recommend starting a naloxone infusion; she was also given dextrose bolus. The patient was admitted to the PICU. To summarize key elements from this case, this patient has: Accidental ingestion of an unknown medication Altered mental status Difficulty breathing—with grey lips suggestive of hypoventilation/hypoxia All of which brings up a concern for a toxidrome which is our topic of discussion for today The typical symptoms seen in our patient of pinpoint pupils, respiratory depression, and a decreased level of consciousness is known as the “opioid overdose triad” Given the history of opioid addiction in the grandfather, the liquid medicine given to him is most likely methadone.In fact, in this case, the mother brought the bottle of medicine, which was subsequently confirmed to be prescription methadone given to prevent opioid withdrawal in the grandfather.   To dive deeper into this episode, let's start with a multiple choice question: Which of the following opioids carries the greatest risk of QTc prolongation? A. Methadone B. Morphine C. Fentanyl D. Dilaudid The correct answer is methadone. Methadone prolongs QT interval due to its interactions with the cardiac potassium channel (KCNH2) and increases the risk for Torsades in a dose-dependent manner. Besides the effect on cardiac repolarization, methadone is also associated with the development of bradycardia mediated via its anticholinesterase properties and through its action as a calcium channel antagonist. Hypokalemia, hypocalcemia, hypomagnesemia, and concomitant use of other drugs belonging to the family of CYP3A4 system inhibitors such as erythromycin can prolong Qtc. Even in absence of these risk factors, methadone alone can prolong QTc.   Thanks for that, I think it is very important to involve your Pediatric Pharmacy team to also help with management as children may be concurrent qt prolonging meds. Rahul, what are some of the pharmacological and clinical features of methadone poisoning? Methadone is a synthetic opioid analgesic made of a racemic mixture of two enantiomers d-methadone and l-methadone. besides its action on mu and kappa receptors, it is also an NMDA receptor antagonist. Due to its long action, methadone is useful as an analgesic and to suppress opioid withdrawal symptoms (hence used for opioid...

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine. Today we are joined by two wonderful clinical pharmacists — Whitney Moore & Stephanie Yasechko. Whitney is a Clinical Pharmacy Specialist at Children's Healthcare of Atlanta. She is on Twitter at @MoorephinRx. Stephanie is a Pediatric Lung Transplant Clinical Pharmacy Specialist at Cincinnati Children's Hospital Medical Center. We are so excited to have you both on today. My name is Rahul Damania and I am a Pediatric Intensivist at Cleveland Clinic Children's Hospital; Welcome to PICU Doc On Call where we focus on all things MED-ED in the PICU. Our podcast focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode: Welcome to our Episode an 18 yo immunocompromised patient with headache & sore throat Here's the case presented by Rahul: An 18-year-old female (40 kg) with PMH significant for fibrolamellar carcinoma of the liver, presents to the ED with headache and sore throat. She is febrile to 38.3, tachycardic, tachypneic, and has a WBC of 27K on her CBC. She is markedly hypotensive with BP on the arrival of 99/65. Cultures were drawn, the patient was given x1 doses of vancomycin and meropenem, and she was transported to the PICU for further workup and management. Due to her progressive hemodynamic instability, increased inflammatory markers, and marked immunocompromised state, the team is considering broadening her anti-microbial coverage. To summarize key elements from this case, this patient has: Fibrolamellar carcinoma of the liver A presentation of headache, sore throat, and hemodynamic instability with concern for sepsis A current regimen of just antibacterials, which brings up the consideration of adding anti-fungal coverage in her clinically ill state. Our episode today will be covering anti-fungal agents in the PICU. We will review general mycology, understand different classes of antifungals, and highlight practical clinical pearls in the acute care setting. As mentioned, this patient has risk factors for an immunocompromised state due to her underlying liver condition. As we dive deeper into antifungals, Whitney, can you please give us an overview of common fungal pathogens in the PICU? Before we discuss the major drugs, it's important that we take some time to briefly review the most common fungi we encounter clinically since it's hard to choose the right agent when you don't know exactly what you are treating. Clinically, Candida is probably the most common fungal pathogen encountered, especially in warm, moist environments. It is important to determine what type of species is growing. The three major species known to cause infection are C. albicans, C. glabrata, and C. krusei, but it is important to differentiate these species when identified since they have different resistance patterns. Cryptococcus is another type of fungus that is known to cause meningitis or fungemia, especially in immunocompromised or cirrhotic patients. Both Candida and Cryptococcus are classified as yeast on Gram stain. Treating cryptococcus will require the use of an agent that has good penetration to the CNS. Endemic fungi known as Coccidia, Histoplasma, and Blastomyces are known to cause disseminated infections in immunocompromised hosts; however, each fungus is associated with a different geographic region in the United States. With any type of infection, it is always very important to consider your patients' exposures and recent travel history. And finally, there are two major molds that have the potential to be pathogenic. The first is Aspergillus which is identified via hyphae (tall filaments) on Gram stain well known to cause invasive pulmonary infections in the immunocompromised, specifically those who are neutropenic and/or received a lung transplant.

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine and I'm Rahul Damania from Cleveland Clinic Children's Hospital. We are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode: Welcome to our Episode about a 4-year-old girl with a chief complaint of headache and vomiting Here's the case: A 4-year-old presents to the PICU with headaches + vomiting and abnormal CT scan findings. The patient presented to the ED with h/o abdominal pain X 5 days with nonbilious, non-bloody emesis. Initial CBC, UA was normal. The patient was given some pain meds and IV fluids. Further history revealed that the patient has been having severe headaches for the last 5 days and had emesis secondary to the headaches resulting in generalized, non-specific abdominal pain. No h/o of trauma or seizures, no h/o of fever or diarrhea, no h/o toxic ingestions h/o recent travel, exposure to sick contacts, COVID test negative. No family h/o migraines, her immunizations are UTD. Besides the normal UA and CBC, her CMP was also normal. A CT scan of the head revealed right frontoparietal mass with moderate surrounding edema, 6 mm leftward midline shift, diffuse sulcal narrowing, and right cisternal narrowing. Imaging of the abdomen (US and CT w/ contrast) was unremarkable. An MRI done revealed: Right parietal diffusion restricting lesion, most compatible with abscess. Moderate surrounding vasogenic edema. Given her abdominal pain- Abdominal KUB as well as contrast CT scan of abdomen and pelvis were performed and revealed no abdominopelvic pathology. In the ED her vitals were normal and the patient was afebrile. On her PE: the patient appeared sleepy but woke up and answered questions appropriately. No focal deficits, PERRL, normal tone and strength. The rest of her physical exam was completely normal. She now is transferred to the PICU for serial neurological exams. To summarize key elements from this case, this patient has: Headache with altered mental status No focal deficits Vomiting surprisingly no fever Imaging showing right frontoparietal mass. All of which brings up a concern for brain abscess This episode will be organized… Epidemiology and pathogenesis Diagnosis Management Rahul, can you inform our listeners about the epidemiology of brain abscesses? Only about 25% of brain abscesses occur in children. Incidence in developed countries is about 1-2% while in developing countries it's about 8%. Peak incidence in children is seen between the ages of 4-7 years and is more common in males. Brain abscess in the neonatal age group is rare but are associated with a higher risk of complications and mortality. Risk factors for brain abscess include Otologic infections (ear, sinus, and dental infections), Congenital heart disease (30% of patients with BA have an underlying heart defect) with intra-cardiac or intrapulmonary shunting (pulmonary AV malformations in hemorrhagic telangiectasis), immunodeficiencies (solid organ transplantation, HIV, etc), prolonged steroid use, diabetes, alcoholism neurosurgical procedures, trauma. Other rare causes can be airway foreign bodies, congenital dermal sinuses, and esophageal procedures (such as dilatations). Brain abscess typically begins with a localized area of cerebritis which evolves through various stages (typically 10-14 days) to develop into an encapsulated collection of purulent material with peripheral gliosis or fibrosis. 40-50% of the spread of infection is via a contiguous site of infection such as otitis, sinusitis or mastoiditis or from head trauma or neurosurgical procedure. 30-40% is spread through the hematogenous route from endocarditis, pulmonary infections, or dental abscess. 90% of brain...

B•Inspired Podcast would like to introduce our special guests, Bonnie Schneider & Artie Kelsey. Bonnie is the founder and Executive Director of IGA Nephropathy Foundation of America. In this episode, NJ Hall of Fame Broadcast Association Inductee/Producer/Host Bert Baron and Producer /Host Lisa Anderson learn how a mother's life was turned upside down when her son Edward Schneider was diagnosed with IGA Nephropathy in 2004. After finding a lack of information available and hearing that there was no ongoing research to find a cure, Bonnie quit her job in marketing and started the IgA Nephropathy Foundation with her husband, Ed. Years later, Bonnie was introduced to a local legend and bartender Artie Kelsey, whose kidneys were failing due to IGA Nephropathy and formed a bond that would last forever. To date; Bonnie and team have awarded almost $1,000,000 to research fellowship grants for research into the causes and a cure for IGA Nephropathy.Most recently, the foundation donated $80,000 to UAB research, the donation was matched by the University making the total donation towards UAB research $160,000. In addition, been recognized around the world and in May 14, 2022 received official recognition as IgA Nephropathy Awareness Day in the U.S. Congress and in these states: Washington, D.C, Wisconsin & New Jersey.B•INSPIRED YouTube ChannelB•INSPIRED is a audio/video Podcast where we bring you real stories from folks just like you and I who share stories of love and loss, struggles and perserverance, laughter and tears and overcoming adversity!B•INSPIRED YouTube: https://www.youtube.com/channel/UCx6p...B•INSPIRED Facebook: https://www.facebook.com/BInspiredpod...B•INSPIRED Instagram: https://www.instagram.com/binspiredpo...B•INSPIRED Twitter: https://twitter.com/binspiredpodca1

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine and I'm Rahul Damania from Cleveland Clinic Children's Hospital and we are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode: Welcome to our Episode an 18 -year old with sore throat, and unilateral L-sided neck pain for ~2 weeks. Here's the case presented by Rahul: An 18-year-old female presents to the ED with cough, fever, fatigue, sore throat, and unilateral L-sided neck pain for ~2 weeks. The patient also has been having non-specific chest pain, weight loss, and decreased appetite for ~ 1 month. Patient has no recent travel h/o, no h/o of vaping or illicit drug use, and there were no sick contacts at home. Vitals revealed an HR 105, BP 116/66, Temp 38.3, and respiratory rate 35, She was 65 Kg and SPO2 on 2L NC was 100%. Physical exam was negative except (L) neck tender to palpation. There was no goiter, lymphadenopathy or hepatosplenomegaly. An initial chest x-ray was significant for possible multi-lobar pneumonia versus metastases. A Chest CT revealed multifocal septic emboli in the lungs. Echo did not show any gross vegetation. She has no rash or any trauma to the neck or difficulty swallowing, no oral ulcers, joint pain, or diarrhea. She had no recent dental work or drinking of unpasteurized milk or eating raw fish or meat. She was admitted to the PICU as she had hypotension requiring fluid boluses, and lab works significant for hyponatremia, rhabdomyolysis, worsening AKI, elevated ferritin, and elevated D-dimer. Her serum uric acid was 9.9, LDH = 230 (normal) ,ESR 78 (normal = 20 or less). Her serum lactate and serum troponin and BNP were all normal. Pertinently, US neck revealed an occlusive thrombus in the (L) IJ vein (done so as to avoid contrast in face of AKI), and blood cultures sent. To summarize key elements from this case, this 18-year-old female presents with fever +cough+sore throat Fatigue + Weight loss (L) neck pain Hypotension with abnormal labs including a concerning WBC with (L) shift, anemia, AKI, elevated uric acid, and ESR Chest CT with possible pulmonary emboli US showing occlusion. All of which brings up a concern for possible malignancy or pulmonary emboli from a septic focus in the neck and a possible diagnosis of Lemierre syndrome This episode will be organized… Definition Diagnosis (physical, laboratory) Management Rahul: What is the definition of Lemierre's syndrome? Lemierre's syndrome, also known as post-anginal septicemia or necrobacillosis, is characterized by bacteremia, internal jugular vein thrombophlebitis, and metastatic septic emboli secondary to acute pharyngeal infections. All of which are seen in our above case presentation. Previously called as the forgotten disease as its incidence was decreasing due to the increasing use of antibiotics especially penicillin for URI. However, recently there is an increase in Lemierre's disease cases with decreased use of antibiotics due to antibiotic stewardship. The recent increase in Lemierre disease due to decreased antibiotic use has not been proven and remain controversial. Rahul what are some of the causative organisms of Lemierre syndrome? The most common causative agent of Lemierre's syndrome is Fusobacterium necrophorum, followed by Fusobacterium nucleatum and anaerobic bacteria such as streptococci, staphylococci, and Klebsiella pneumoniae. Rahul: Can you tell our listeners about the pathophysiology of Lemierre's syndrome? Lemierre syndrome can occur in health adults (more common in males in the age group of 14-24 years). Risk factors include immunocompromised patients, organisms, and environmental conditions. Lipopolysaccharides in F. necrophorum have endotoxic...

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. Welcome to our Episode a 16-year-old who is coughing up blood. Here's the case: A 16-year-old female with h/o SLE was transferred to the PICU due to hypoxia requiring increasing FIO2. A few hours prior to admission to the PICU patient also started coughing up blood and had difficulty breathing. The patient was admitted to the general pediatric floor 2 days earlier for pneumonia requiring an IV antibiotic and O2 via NC. Once transferred to the PICU, she had a rapid deterioration with progressive hematemesis, worsening respiratory distress, and saturations in the low 70s requiring escalating FIO2. The patient was emergently intubated using ketamine + fentanyl and rocuronium. Chest radiograph showed: Worsening bibasilar alveolar and interstitial airspace disease concerning pulmonary hemorrhage. The patient was initially placed on HFOV Paw 26, FIO2 70%, Hz 8, Dp 70, and later transitioned to airway pressure release ventilation or APRV. The patient was also started on inhaled tranexamic acid or TXA and high-dose pulse steroids. The patient initially continued to have some blood coming out from the ETT with suctioning but secretions became clear in ~24 hours. The mother reported that the patient has never had hematemesis/hemoptysis before, or bleeding from any site in the past. Denied history of frequent respiratory infections or recent URI symptoms. The patient has been vaccinated/boosted x3 vs covid. Her COVID PCR is negative. The mother states that she does not engage in tobacco products or alcohol. A physical exam revealed a well-developed teenage girl laying supine in bed deeply sedated and mechanically ventilated. There was decreased AE at lung bases and coarse breath sounds throughout. There was no hepatosplenomegaly and exams of the heart, abdomen and other systems were normal. There was no skin rash and extremities were well perfused with no clubbing in the fingers. The pulmonary team was consulted and a workup was started for pulmonary hemorrhage. To summarize key elements from this case, this patient has: Autoimmune disease: Systemic lupus erythematosus Respiratory Failure warranting MV 2/2 Pulmonary hemorrhage Her presentation and deterioration bring up a concern for diffuse alveolar hemorrhage our topic of discussion for today. This episode will be organized… Definition Etiology Pathophysiology Diagnosis Management Rahul: How do we define pulmonary hemorrhage (PH): PH is defined as the extravasation of blood into airways and/or lung parenchyma. Blood in the airways produces a diffusion barrier resulting in hypoxemia. Due to the reduction of airway diameter from accumulated blood, there is increased airway resistance and even airway obstruction. Subsequently, ventilation can be impaired leading to increased WOB as well as myocardial work required for O2 delivery. Repeated episodes of PH can result in interstitial fibrosis thus changing lung compliance. Hemoptysis by definition is any bleeding from below the vocal cords. PH can be classified as focal or diffuse. Diffuse is further classified as diffuse immune or diffuse nonimmune. Loss of 10% of a patient's circulating blood volume into the lungs, regardless of age, causes a significant alteration in cardiorespiratory function and should be considered massive. In adults, massive pulmonary hemorrhage is defined as blood loss of 600mL or more in 24 hours. In infants, the involvement of at least two pulmonary lobes by confluent foci of extravasated RBCs constitutes as massive PH. “Enough bleeding to make one nervous is probably massive.” Let's pivot and talk about etiologies. Pradip, What are some of the causes of pulmonary hemorrhage in the PICU? Non-immune diffuse PH is usually seen in patients with congenital heart disease (TAPVR, pulmonary atresia, mitral stenosis, hypoplastic left heart syndrome to name a few) neonates (secondary to sepsis, HIE, BW < 1500...

Are you ready for some love and thunder!?? Our hosts Joe Dea and Brandon Knight give their takes on the Thor series in the MCU and discuss the upcoming film, "Thor: Love and Thunder". When does the new movie come out? Who is Christian Bale / Gorr? Who is Thor's love interest in this film? Is Natalie Portman a good actor? Are you going to get the Thor popcorn bucket at AMC? Let us know on our website: systematicgeekology.org In all seriousness, we know of a killer podcast completely dedicated to Thor, called "https://open.spotify.com/show/1aYccuyLpFhna3KktI6XqB?si=9805deb49c664ce4 (Across the Bifrost)" and we seriously suggest you all check it out! This was an on-going joke this episode, because everyone should already be subscribed to https://open.spotify.com/show/1aYccuyLpFhna3KktI6XqB?si=9805deb49c664ce4 (this show) with our good friend Ryan Does!

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat coming to you from Children's Healthcare of Atlanta/Emory University School of Medicine and I'm Rahul Damania from Cleveland Clinic Children's Hospital. We are two Pediatric ICU physicians passionate about all things MED-ED in the PICU. PICU Doc on Call focuses on interesting PICU cases & management in the acute care pediatric setting so let's get into our episode: In today's episode, we discuss about a 12-year-old male with lethargy after ingestion. Here's the case presented by Rahul: A 12-year-old male is found unresponsive at home. He was previously well and has no relevant past medical history. The mother states that he was recently in an argument with his sister and thought he was going into his room to “have some space.” The mother noticed the patient was in his room for about 1 hour. After coming into the room she noticed him drooling, minimally responsive, and cold to the touch. The patient was noted to be moaning in pain pointing to his abdomen and breathing fast. Dark red vomitus was surrounding the patient. The mother called 911 as she was concerned about his neurological state. With 911 on the way, the mother noticed a set of empty vitamins next to the patient. She noted that these were the iron pills the patient's sister was on for anemia. EMS arrives for acute stabilization, and the patient is brought to the ED. En route, serum glucose was normal. The patient presents to the ED with hypothermia, tachycardia, tachypnea, and hypertension. His GCS is 8, he has poor peripheral perfusion and a diffusely tender abdomen. He continues to have hematemesis and is intubated for airway protection along with declining neurological status. After resuscitation, he presents to the Pediatric ICU. Upon intubation, an arterial blood gas is drawn. His pH is 7.22/34/110/-6 — serum HCO3 is 16, and his AG is elevated. To summarize key elements from this case, this patient has: Lethargy and unresponsiveness after acute ingestion. His hematemesis is most likely related to his acute ingestion. And finally, he has an anion gap metabolic acidosis, as evidenced by his low pH and low HCO3. All of these salient factors bring up the concern for acute iron ingestion! In today's episode, we will not only go through acute management pearls for iron poisoning, but also go back to the fundamentals, and cover ACID BASE disorders. We will break this episode down into giving a broad overview of acid base, build a stepwise approach, and apply our knowledge with integrated cases. We will use a physiologic approach to cover this topic! Pradip, can you give us a quick overview of some general principles when it comes to tackling this high-yield critical care topic? Absolutely, internal acid base homeostasis is paramount for maintaining life. Moreover, we know that accurate and timely interpretation of an acid–base disorder can be lifesaving. When we conceptualize acid base today, we will focus on pH, HCO3, and CO2. As we go into each disorder keep in mind to always correlate your interpretation of blood gasses to the clinical status of the patient. Going back to basic chemistry, can you comment on the relationship between CO2 and HCO3? Yes, now this is a throwback. However, we have to review the Henderson–Hasselbalch equation. The equation has constants & logs involved, however in general this equation shows that the pH is determined by the ratio of the serum bicarbonate (HCO3) concentration and the PCO2, not by the value of either one alone. In general, an acid–base disorder is called “respiratory” when it is caused by a primary abnormality in respiratory function (i.e., a change in the PaCO2) and “metabolic” when the primary change is attributed to a variation in the bicarbonate concentration. Now that we have some fundamentals down, let's move into definitions. Can you define acidemia and alkalemia and comment on how...

Listen to episode one of the Boomer Bevo podcast from our friend at Brown O'Haver. This podcast is dedicated to the greatest rivalry in college football OU/TX.  

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Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat I'm Rahul Damania, a third-year PICU fellow. I'm Kate Phelps, a second-year PICU fellow and we are all coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine, joining Pradip and Rahul today. Welcome to our episode, where will be discussing gastrointestinal bleeding. Kate: Let's start with a case: A 4-year-old, previously healthy male presents to the emergency room after a large, bloody stool at home. He notably had an episode of dark emesis and an episode of blood-tinged emesis on the day prior. In triage, he is altered and unable to answer questions coherently. Initial vital signs are temperature 36.1 C, RR 24, HR 146, BP 110/54. Point-of-care labs show hemoglobin to be 5.1 with hematocrit 15. His venous blood gas is reassuring against respiratory disease, and he is in no respiratory distress. Further labs are sent and a massive transfusion protocol is initiated before transfer to the PICU. Before arrival in the PICU, he receives two aliquots of RBCs, 1 aliquot of FFP, and 1 aliquot of platelets. Additional labs are sent from the PICU, post-transfusion. His post-transfusion hemoglobin is 8.8. Other labs are notable for normal MCV, elevated total bilirubin to 4.1 (with direct component 3.4), and elevated AST and ALT to 309 and 495 respectively. Rahul: To summarize key elements from this case, this patient has: An undifferentiated gastrointestinal bleed with both hematemesis and hematochezia. He has symptomatic anemia, as evidenced by tachycardia Altered mental status. He is initially stabilized via transfusion of several blood products and liver function labs are shown to be very abnormal — which we will get more into later! PK: Let's get into important parts of the history and physical. Kate, can you tell me what some key history items in this patient are — and what are some areas to make sure to touch on when a patient has a GI bleed? Kate: Yeah! I'd love to. First - in our patient, some important elements are his rather acute onset. His parents mention he has had one day of bleeding symptoms - first with emesis yesterday, with components of old, partially digested blood, as well as some fresh blood. Second, he has a frankly bloody stool at home. Given his clinical instability, history taking was probably limited at first, so it's important to ask follow-up questions and really dig into the case after stabilization! I like to put my questions about gastrointestinal bleeding into buckets based on the questions I need to answer. I need to answer: is this active bleeding or old blood? Is this slow, insidious bleeding or fast, life-threatening bleeding? Is this an upper GI bleed or a lower GI bleed? Bright red blood in emesis tells us that bleeding is active, whereas coffee-ground or dark emesis tells us that, while recent, the blood has been partially digested in the stomach and may not be ongoing. Similarly, melena (dark, tarry stool), tells us blood has come through the colon. While coffee-ground emesis and melena don't rule out an active bleed, they do tell us the bleeding may be slower, as large volume, active bleedy is irritating to the stomach and gastrointestinal tracks and moves through the system quickly. The next question I want to answer is: what is the cause of this bleed? Easy bruising, petechiae and mucosal bleeding may point to a coagulation disorder. Abdominal cramping, frequent stooling, and weight loss may point to inflammatory bowel disease. Past medical history, family history, and a thorough review of systems are key here. Rahul: Yeah, that's great! Let's talk about your question of upper GI vs lower GI bleed. First, a definition: an upper GI bleed is bleeding that occurs above the ligament of Treitz — which is ligamentous tissue that supports the end of the duodenum and beginning of the jejunum at their junction. While not 100% specific, some...

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kama and I'm Rahul Damania, a third-year PICU fellow. I'm Kate Phelps, a second-year PICU fellow and we are all coming to you from Children's Healthcare of Atlanta, Emory University School of Medicine, joining Pradip and Rahul today. Welcome to our episode, where will be discussing rhabdomyolysis and associated acute kidney injury in the ICU. Rahul: Here's the case, a 7-year-old female presents to the ED with three days of fever, poor PO, and diffuse myalgia. In the ED, her vital signs are T 39.1C, HR 139, BP 82/44, RR 32. She is pale and diaphoretic, complaining weakly about how much her legs hurt. Her parents note that she has not been peeing very well since yesterday, and when she does pee it is “very concentrated, almost brown.” She's also been spending all her time on the couch and has asked to be carried to the bathroom when she does need to go. An IV is placed by the emergency room team, and she is given a fluid bolus, acetaminophen, and initial labs are drawn (CMP, CBC, RSV/Flu swab) before she is admitted to the PICU. In the PICU, her fever is better and her vitals have improved to T 37.7, HR 119, BP 115/70, and RR 25. Her respiratory swab has just resulted positive for Influenza A. Further labs are sent, including creatine kinase (CK), coagulation studies, and a urinalysis. Labs are notable for K 3.9, Bicarb 22, BUN 15, Cr 0.8, and CK 5768 IU/L. Her urinalysis is notable for 1 WBC, 2 RBC, +3 blood, negative nitrites, and leukocyte esterase. Kate: To summarize key elements from this case, this patient has: Influenza A, as evidenced by her respiratory swab, as well as her clinical prodrome. She has diffuse myalgias, as well as fevers, diaphoresis, and hypotension. Labs are most notable for elevated creatinine and elevated creatine kinase, as well as an abnormal urinalysis. All of which brings up a concern for rhabdomyolysis and myoglobin-induced acute kidney injury. Before we get into this episode — let's create a mental framework for this episode — we will dissect our case by highlighting key H&P components, visit a differential diagnosis, pivot to speaking about pathophysiology, and finally, speak about management! Rahul: Let's transition into some history and physical exam components of this case. The classic presentation of rhabdomyolysis is myalgias, muscle weakness, and tea-colored urine, all of which our patient has. Decreased urinary output can also accompany, a variety of reasons, but most notably if the patient has myoglobin-induced acute kidney injury. In our patient, poor PO is also probably contributing to her decrease in urine output. Red flag signs or symptoms will include anuria, hypotension, and altered mental status (which is rare but may indicate severe acidemia and deterioration) Pradip: As we think about our case, what other disease processes might be in our differential? As we dive in a bit more, we'll come up with ways to distinguish between rhabdo and other things! Viral myositis - inflammation in the muscles in the setting of a viral illness, which can definitely happen with influenza and other common viruses Some other things which may cause reddish-brown urine, including hematuria, hemoglobinuria, porphyria, some specific foods or drugs (like rifampin, beets, food coloring — even ibuprofen) We also have to investigate a bit more to convince ourselves that our patient's AKI is due to rhabdomyolysis, as it could be from dehydration, sepsis, NSAIDS, etc. Kate: Let's dive further into rhabdomyolysis! Rhabdomyolysis affects over 25,000 adults and children every year. While toxins (including prescription drugs, alcohol, and illicit drugs) and trauma are two common causes of rhabdo in adults (and teens), infections, especially viruses, are the most common cause in young children. Influenza, EBV, and CMV are three most commonly reported. What's the pathophysiology of...

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat and I'm Rahul Damania. We are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine. Welcome to our Episode about a 14- year- old female who presented with hypotension after a suicide attempt. Here's the case: A 14 yo F with PMH of depression and oppositional defiant disorder presents with dizziness. Her mother states she was in her normal state of health when on the day of admission she noticed the patient to be dizzy, slurring speech, and pale. The mother became very concerned about the dizziness as the patient was stumbling and a few hours prior to presentation, became increasingly sleepy. The patient does have a history of depression and is controlled on sertraline. Other medications in the home include Metformin, Amlodipine, and Clonidine. The patient denies ingesting any substance. She does have a prior attempt two years prior, after an argument with her mother; however, her mother was able to “stop” her prior to the attempt. She presents to the ER via EMS. Her vital signs are notable for HR 50 bpm with occasional PACs and non-conducted QRS complexes on telemetry; BP of 75/40. A physical exam is notable for AMS and GCS of 10. She is noted to have clear breath sounds, with a cardiac exam notable for slowed and delayed pulses. Initial laboratory work is notable for serum glucose 180 mg/dL and B HCG negative. Initial resuscitation is begun with IV fluids and atropine. Serum acetaminophen and ASA levels are sent and upon stabilization, the patient presents to the PICU for admission. To summarize key elements from this case, this patient has: A history of depression with prior attempt An acute bout of altered mental status Bradycardia, hypotension, and hyperglycemia. All of which brings up a concern for an acute ingestion Let's take a step back and talk about the approach to ingestions in the PICU. What are key aspects to consider in the work-up of these patients? History and physical are key: Stratifying acute or chronic ingestions Baseline prescription medications a patient may be taking or have access to in the household Whether the ingestion involves a single drug or co-ingestants are all first steps in evaluating your patient. In an undifferentiated patient, management is paramount. Initial management is focused on pattern recognition and acute stabilization. A brief initial screening examination should be performed on all patients to identify immediate measures required to stabilize and prevent deterioration of the patient. Assess the airway, vital signs, mental status, pupil size, and skin temperature and moisture. These components of your physical exam should help allude to a toxidrome, and these syndromes are frequently tested on board examinations. Any time a patient has hypotension and bradycardia other drugs that should be considered include beta blockers, digoxin, clonidine, as well as ingestion of barbiturates, opioids, and even benzodiazepines. What are some diagnostic studies you will want to send immediately in a patient with suspected ingestion? Immediate diagnostic studies to be performed include pulse oximetry, continuous cardiac monitoring, an electrocardiogram (ECG), and a capillary glucose measurement (in altered patients). Intravenous (IV) access should be obtained in all cases of serious ingestion. You also want to send beta-hcg and acetaminophen and salicylate levels. an extended toxicology screen may be required on a case-by-case basis. One study found detectable serum acetaminophen concentrations in 9.6 percent of all overdose patients; almost one-third of this subset denied ingestion of acetaminophen. Now that you've focused on ABCs are there more detailed laboratory studies to send in patients with toxidromes? Symptomatic patients and those with an unreliable or unknown history should, at a minimum, undergo...

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat and I'm Rahul Damania. We are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine. Here's the case: A 6-year-old child with a known h/o craniopharyngioma who has been endocrinologically intact with exception of needing thyroid replacement was admitted to the PICU prior to craniotomy to proceed with further tumor resection as well as the removal of a secondary cyst impacting his brainstem. The patient is receiving Keppra for seizures and per mother, he has recently been significantly more sleepy at school. On POD Op day 5: the PICU the bedside nurse notices increased urine output (6cc/kg/hr to as high as 10cc/kg/hr). Initially, there was an increase in Na to 157mEq/L within 48-72 hours the serum Na dropped to 128mEq/L To summarize key elements from this case, this patient has: Increase UOP Rapidly increasing Na initially followed by a drop All of which brings up a concern for Na abnormality post craniotomy In today's episode, we will be breaking down all things Sodium & the Brain. We will discuss diagnostic & management frameworks related to three pathologies: Central Diabetes Insipidus Syndrome of inappropriate Anti-Diuretic Hormone or SIADH Cerebral Salt Wasting These diagnoses can certainly be seen individually inpatients or as a spectrum of diseases — as we go through each of these diagnoses, pay particular attention to patient characteristics and lab abnormalities. Namely, serum sodium, serum osm, and urine osm. To build the fundamentals, lets first start with classic nephrology saying: Serum Na represents Hydration This takes us into a brief review of normal physiology — talking about three important hormones: ADH Aldosterone Atrial Natriuretic Peptide (ANP) Let's go through a quick multiple-choice question. A patient is recently started on DDAVP for pan-hypopituitarism. The medication acts similarly to a hormone that is physiologically synthesized in which of the following from which are in the body? A. Paraventricular Nucleus of the Hypothalamus B. Supraoptic Nucleus of the Hypothalamus C. Anterior Pituitary D. Vascular Endothelium The correct answer here is B the Supraoptic Nucleus of the Hypothalamus. Remember that ADH is synthesized in the hypothalamus and released from the posterior pituitary. What are the physiologic actions of ADH? ADH Increases H2O permeability by directing the insertion of aquaporin 2 (AQP2) H2O channels in the luminal membrane of the principal cells. Thus, as we will see with Central Diabetes insipidus, in the absence of ADH, the principal cells are virtually impermeable to water. Let's talk about our next hormone, aldosterone. What are the important physiologic considerations? Aldosterone is secreted from the adrenal cortex as a byproduct of the RAAS. Aldosterone increases Na+ reabsorption by the renal distal tubule, thereby increasing extracellular fluid (ECF) volume, blood volume, and arterial pressure. It also helps in secreting K and H. This physiology is applied directly at the bedside when we have patients in the ICU who have a contraction alkalosis secondary to diuretics. The increase in aldosterone as these patients lose free water from their Lasix administration results in hypokalemia and metabolic alkalosis. Alright, what about the third hormone, ANP? Atrial natriuretic peptide (ANP) is released from the atria in response to an increase in blood volume and atrial pressure. ANP causes relaxation of vascular smooth muscle, dilation of arterioles, and decreased TPR. causes increased excretion of Na+ and water by the kidney, which reduces blood volume and attempts to bring arterial pressure down to normal. As ANP causes natriuresis, diuresis, and inhibition of renin, you can consider this hormone as having a complementary & opposite effect to ADH and aldosterone. Alright, now that we...

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat. I'm Dr. Ali Towne, a rising 3rd-year pediatrics resident interested in a neonatology fellowship, and I'm Rahul Damania and we are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine. Welcome to our Episode a 5-month-old, ex-28 week female with abdominal distention. Here's the case: A 5-month-old, ex 28 week, female with a past medical history of severe BPD, pulmonary hypertension, home oxygen requirement, and G-tube dependence presents with hypoxemia and increased work of breathing. The patient has a history of prolonged NICU stay with 8 weeks of intubation. The patient developed worsening respiratory distress requiring increased support and eventual intubation for hypoxemic respiratory failure. Echo showed worsened pulmonary hypertension with severe systolic flattening of the ventricular septum and a markedly elevated TR jet. The patient had poor peripheral perfusion, and upon intubation was started on milrinone and epinephrine. The patient improved, but the patient then developed abdominal distention and increasing FiO2 requirements prompting an abdominal x-ray. X-ray showed diffuse pneumatosis with portal venous gas. The patient was made NPO and antibiotic therapy was initiated. To summarize key elements from this case, this patient has NEC. NEC is not a homogenous disease, but rather a collection of diseases with similar phenotypes. Some people split NEC into two categories: Cardiac NEC and Inflammatory NEC. Babies who develop cardiac NEC tend to be significantly older than babies who develop inflammatory NEC (about 1 month vs 2 weeks). There are three main contributory factors to the development of NEC: gut prematurity, abnormal bacterial colonization, and ischemia-reperfusion injury. Many cases result from an ischemic insult to the bowel, resulting in translocation of intra-luminal bacteria into the wall of the bowel, but the etiology and course of NEC can be very variable. This translocation can cause sepsis and death; the ischemia of the bowel can result in intestinal perforation and/or necrosis. Necrotizing enterocolitis (NEC) is one of the most common gastrointestinal emergencies in the newborn infant. It is estimated to occur in 1 to 3 per 1000 live births. More than 90 percent of cases occur in very low birth weight (VLBW) infants (BW

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat and I'm Kate Phelps, a second-year pediatric critical care fellow joining Pradip and Rahul today! I'm Rahul Damania and we are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine. Today we are honored to have Dr. John Berkenbosch- senior author of the Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients with consideration of the ICU Environment and Early Mobility (PANDEM) guidelines recently published in February 2022 issue of the Pediatric Critical Care journal. Dr. Berkenbosch is a Professor of Pediatrics and Pediatric Critical Care at the University of Louisville School of Medicine, and continues to be nationally recognized as an expert in pediatric procedural sedation with multiple publications relating to sedation practices, particularly novel uses of procedural sedation medications and regimens. He currently also serves as co-chair for the American College of Critical Care Medicine's Task Force guidelines for sedation and analgesia in critically ill children which we will be discussing in today's episode. Dr. Berkenbosch's research interests have primarily focused on pediatric procedural sedation and implementation of technology advances in Pediatric Critical Care and have resulted in 57 publications as well as several book chapters Rahul: Dr. Berkenbosch welcome to the PICU Doc ON call podcast. I would also like to point out that the free full access to the PANDEM guidelines is available online athttp://pccmjournal.org ( pccmjournal.org) Dr. Berkenbosch: Thanks Rahul and Pradip. I am excited to be on the PICU Doc on Call Podcast to discuss the PANDEM guidelines. I want to first start by giving a huge shout-out to all the team members who contributed to these guidelines' development. This is a topic about which I am quite passionate but also one that provides much-needed guidance regarding pain/agitation/delirium to our entire pediatric critical care community! KATE: Dr. Berkenbosch, the rationale for the development of the PANDEM guidelines was the high variability in pediatric sedation and analgesia. Can you speak to this variability and why it was important to address that variability? That is a great question, the variability has been one of the key motivators in the creation of these guidelines. We also wanted to develop a guideline that was broader in scope than what was currently available. The ICU Liberation bundle provided a paradigm for liberating critically ill patients from mechanical ventilation and the ICU environment and as we delved into developing these guidelines, we realized that many elements of the ICU liberation bundle aligned very closely with PICU sedation and analgesia so it made imminent sense to incorporate all of these topics into the guidelines, an acknowledgment if you will, that PICU liberation & sedation go hand in hand! Absolutely, as we have stated in our prior episodes, the paradigm is: intubate → ventilate → liberate, and sedation/analgesia is intertwined in each of these processes. Dr. Berkenbosch, as we get into the guidelines, can you please highlight how the search strategy for these guidelines were derived? Of course, this was a remarkable group effort solicited by the Society of Critical Care Medicine. We were initially modeled after the adult PAD (pain, agitation, and delirium) guidelines task force but, as described already, extended beyond that to include Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in addition to the PICU Environment and Early Mobility. It was comprised of 29 national experts who collaborated over a ten-year period. The full task force gathered annually in person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in...

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat and I'm Rahul Damania. We are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine. I will turn it over to Rahul to start with our patient case... A 2 yo Asian M presents with difficulty feeding. He has a history of epilepsy and recently was switched to Valproic Acid for seizure control as well as OTC deficiency diagnosed at birth. He has had a 3-day history of URI, cough, which now progressed to this difficulty feeding. His parents state he was initially very fussy however in the past few hours he has been more sleepy. He has not had any fevers. They have noticed that while he is sleeping he has been breathing "fast." Prior to arrival at the emergency room, he was noted to have a large non-bloody, non-bilious emesis. Upon transfer to the trauma bay, the patient suddenly has a seizure. A quick POC glucose is normal. His care is escalated & diagnostic workup is initiated. Pradip, our case had two key elements in his history, namely the h/o OTC deficiency & VPA use, which place him, particularly at high risk to have hyperammonemia. As this is our topic of discussion today, would you mind starting with a general background & definition of hyperammonemia? Sure, this is a classic case of not only hyperammonemia but also a metabolic crisis in this case related to a urea cycle defect. As background, the urea cycle is the metabolic pathway that transforms nitrogen to urea for excretion from the body. We get nitrogen sources from a few areas in the body: from peripheral (muscle) enteral sources (protein ingestion) The urea cycle occurs in the liver and once the ammonia is converted to urea in the hepatocyte, it is excreted into the kidney as urea. We will dive into this deeper soon, however, pathologies that impair adequate hepatocyte function, can impair the urea cycle and thus lead to hyperammonemia. This is a great basic science summary, would you mind commenting about this patient's enzyme defect — the OTC deficiency? Yes, Ornithine transcarbamylase, or OTC for short, is one of the first few enzymes in the urea cycle. As a background, the inheritance pattern of majority, all of the urea-cycle-defects (UCD) is autosomal recessive, however, OTC deficiency is different — it is X linked. In a 21-year, multi-center retrospective study, it was noted that only 34 % of patients with UCD presented during the neonatal period (

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat and I'm Rahul Damania. We are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine. Welcome to our Episode a 2-year-old with severe pallor and O2 desaturation. Here's the case presented by Rahul: A two-year-old presents to the PICU with severe pallor + O2 requirement. The patient went for a routine check with her primary care who noted the patient appeared severely pale. He sent the patient to the ED. An initial Hgb check revealed a Hgb of 1.5gm/dL. Per mother, she is otherwise healthy but a very picky eater. She also reports the patient drinks milk as a soothing adjunct at night, consuming between 12 - 36oz a day. No family h/o of anemia or any other blood disorders. No h/o recent illness. Mother had a normal spontaneous full-term delivery. The patient is up to date on her immunizations. Per mother, developmental milestones are normal. The mother also denies any history of decreased activity in the child. Given the low Hgb, the patient was admitted to the PICU. Let's transition into some history and physical exam components of this case? What are key history features in this child? Severe pallor in a 2-year-old H/o being a picky eater H/o excessive milk consumption Pertinent negatives include: No obvious blood loss, No petechia, bruising, or jaundice What did the physical exam show? The patient was hypertensive, tachycardic to the 140s, and 10th% weight for growth percentiles On physical exam, the patient was in no acute distress. Her lips, gums, and conjunctiva were pale. She had a systolic ejection murmur. As a pertinent negative, she had no hepatosplenomegaly. She also has no rash, bruising, or petechiae. The lack of hepatosplenomegaly may indicate that the patient has no signs of extramedullary hematopoiesis. Patients with hemolytic processes resulting in anemia may present with signs of scleral icterus, jaundice, and hepatosplenomegaly resulting from increased red cell destruction. In fact, in an emergency department setting, the clinical detection of jaundice was found to have sensitivity and specificity of only approximately 70 percent. To continue with our case, then what were the patient's labs consistent with: Initial CBC showed: WBC 8.5K, RBC 1.14 (L), Hgb 1.5gm/dL; Hct 6.1, MCV 53.5, and an elevated RDW 37.7. Initial platelet count was 50K, reticulocyte count 1.1% Peripheral smear revealed no blasts, thrombocytopenia - with occasional medium-sized platelets - ghost cells and anisocytosis/poikilocytosis- which appears most consistent with iron deficiency. It was interesting that the patient had thrombocytopenia Absolutely, typically with Iron deficiency, there is thrombocytosis (erythropoietin is increased which closely mimics thrombopoietin stimulates platelets). In fact, both act via the non-TK, JAK-STAT pathway. OK, to summarize, we have: Two year old with severe anemia most likely secondary to iron deficiency. As you think about our case, what would be your differential? For any patient with acute severe anemia presenting to the PICU- One has to think in terms of blood loss, decreased or impaired production (i.e bone marrow failure), or peripheral blood destruction (i.e hemolysis). Here would be the organizations: Blood loss Decreased or impaired production Increased destruction Let's go into detail for each: Blood loss can be internal or external (due to trauma, excessive blood draws, due to surgery)-typically gives rise to normochromic normocytic anemia. Decreased or impaired production: Deficiency of substances needed for Hgb & RBC production such as iron Vit B12 etc. Depression of BM due to infection (parvo B), chemicals, pharmacologic agents or immune mechanisms. Bone marrow aplasia can be idiopathic with or without congenital anomalies. Infiltration of BM due to malignancies such as leukemia, Hodgkin disease,...

Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists. I'm Pradip Kamat and I'm Rahul Damania. We are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine. Welcome to our episode, which is Part 2 of our acute severe asthma management. Today we discuss invasive mechanical ventilation of the acute asthmatic. A patient with a history of asthma presents to the PICU with decreased air entry. Somnolence. Hypercarbia and drooling. The patient is hypoxemic and has see-saw breathing. Rahul: Let's dive right into this. What are the indications for intubating a child with acute severe asthma? Absolute indications include: Altered mental status which may be preceded by obtundation, agitation Cardiac and respiratory arrest Relative indications decided on a case by case basis: Progressive exhaustion-despite, despite maximal therapy. Profound hypoxemia refractory to supplemental oxygen administration, and respiratory failure. The decision to intubate should not be solely determined based on blood gas results. Pradip, can you shed light on how we prepare for the intubation of the patient with acute severe asthma? Rahul, first and foremost- we take the intubation of an asthmatic very seriously. In fact we try the whole “kitchen sink” to avoid intubation. But there will be times when we have to intubate especially for the indications you mentioned above. The intubation will worsen the patient's bronchospasm, put the patient at risk for barotrauma as well as cardiovascular collapse. Preparation is the key- A team huddle and mapping prior to proceeding to intubate is the key. Every person in the room should have clear roles and responsibilities. Scenarios of what to do if “X” happens should be clearly laid out to the team by the team leader (preferably the attending or a senior fellow). The senior-most experienced person should manage the airway. At least two dedicated RTs to provide bag-mask ventilation as well as manage the ventilator are required. Nursing roles to push meds, chart the vitals and other activities as well a role for the resource nurses to help in case of cardiac arrest should be clearly laid out. Additionally, facilities that have access to isoflurane should have that ready to go. We typically give a heads up to our ECMO team to be on stand-by. Prior to Intubation: Have central access or multiple large-bore PIVs if possible. Keep crystalloids boluses ready for hypotension. We also have peri-arrest epinephrine as well as an epinephrine infusion ready for any hypotension, bradycardia, or cardiac arrest. For intubation, we typically use Ketamine, fentanyl, and rocuronium (some centers may use succinylcholine). We use cuffed endotracheal tube. We don't bag-mask at fast rates but rather wait for a full expiration prior to the next breath being delivered. These patients require slow respiratory rates with very prolonged expiratory times to allow for adequate gas exchange and lung volumes. A helpful technique is to use a stethoscope to auscultate at the lower neck for the disappearance of expiratory wheezes prior to starting the next inspiration. We sometimes place a nasogastric tube to prevent gastric distension. If there is hypoxemia, hypotension, not improving with fluids, ventilator manipulation, - A consideration for tension pneumothorax should be given especially if there is asymmetric chest rise. Bedside POCUS can be used to make a diagnosis. Intubation of an asthmatic is a high-risk procedure and requires a team approach, proactiveness, and anticipation. Intubation should be approached cautiously in patients with severe acute asthma exacerbations because manipulation of the airway can cause laryngospasm and worsening bronchoconstriction. Rahul, what are some of the principles we should all follow prior to initiation of mechanical ventilation in an asthmatic after intubation? It is important to note that most complications of intubating...

Louisa Nicola is a Sydney University Trained Clinical Neuroscientist and Neurophysiologist. Training as a Triathlete and Racing For Australia at the 2011 Beijing and 2012 Auckland Triathlon World Championship Series Enabled Her to Grow and Peak as an Elite Athlete Herself and Understand the Neural Mechanisms Underlying Peak Athletic Performance. Louisa Now Resides in NYC With a Top 100 Podcast Dedicated to Neuroscience, Neurology, and Longevity Connect With Louisa  https://www.neuroathletics.com.au/founder-bio https://www.instagram.com/thediamondboss_/?hl=en https://www.linkedin.com/in/louisanicola/ https://twitter.com/thediamondbosss

Welcome to Your Empowered Evolution, A Podcast Dedicated to Women in Mid-Life. Here is the trailer for this podcast. I am beyond excited to connect with you. Thanks for being here. --- Send in a voice message: https://anchor.fm/stephanie-mitchell27/message

Dr. Jay T. Wiles is an international speaker, scientist, clinician, influencer, and subject-matter expert and authority on the interconnection between the human stress response and health performance/optimization. Dr. Wiles is a clinical health and performance psychologist with board certification in heart rate variability biofeedback and peripheral biofeedback and works as a leading consultant in psychophysiology to health influencers, professional athletes and teams, executives, and high performers. He has pioneered new and innovative means of using heart rate variability (HRV) and respiratory training as both diagnostic indicators of the dynamic nature of the human stress response, alongside therapeutic tools for regulating and conditioning this response for peak human performance. In this episode, you'll discover: -Why we should be concerned with heart rate variability (HRV)...05:20 -An overview of HRV and how it differs from your heart rate...10:46 -Where we often miss the point of tracking HRV...20:36 -Question: What is HRV training?...25:30 -Question: Should I be concerned with a comparatively low HRV score?...36:12 -Question: What ways outside of breathwork to build HRV?...46:03 Resources mentioned in this episode: https://bengreenfieldfitness.com/podcast/self-quantification-podcasts/what-is-heart-rate-variability/ (Dr. Wiles' overview of HRV on the Ben Greenfield Fitness podcast) Dr. Wiles' personal website https://hanuhealth.com/waitlist (Hanu Health Waitlist) https://amzn.to/3qOBmGN (Atomic Focus by Patrick McKeown) https://amzn.to/3nyRCty (Heart, Breath and Mind by Leah Lagos) Hanu Podcast w/ Dr. Leah Lagos https://player.captivate.fm/episode/ada48ded-9dac-4ef8-aa29-2ead2a8ff29c (Hanu podcast w/ Dr. Nathan Bryan) https://www.instagram.com/hanuhealth/?hl=en (@hanuhealth Instagram) https://www.instagram.com/drjaywiles/?hl=en (@drjaywiles Instagram)

A Podcast Dedicated to Unburying History and explaining the stories and reasoning behind some of Wrestling's most Legendary Stars. This Trailer will explain the inspiration and set the tone for what I hope is an amazing educational Series! Follow Us on Twitter: @LearnLegendPod Follow Us On Instagram: LearningLegendsPod

Podcast talks to podcast! And the topic is the COVID-19 vaccine.

Based upon my work in long term care over the last 40 years I have been fortunate to meet and work with many dedicated and talented individuals that are sharing their knowledge, passion and experience.Produced by:Ed Bejarana Zenith Exhibits Studios www.zenithexhibits.studio

This isn't a podcast for total beginners. We're going to assume that you know what plot structure is, what a protagonist is, where ideas come from, and how to use a semicolon. This is a podcast for people who can already write okay, but want to do better. The post Welcome to Rite Gud, a Podcast Dedicated to Helping You Write Better by Matt Keeley appeared first on Kittysneezes.