In this episode of PICU DOC on Call, Dr. Rahul Damania and Dr. Pradip Kamat discuss the resurgence of measles in the United States. They explore the virus's pathophysiology, clinical features, diagnostic methods, treatment options, and complications. They emphasize the critical role of vaccination in preventing measles outbreaks and address the historical context and public health challenges related to vaccine hesitancy. The speakers highlight the severe complications of measles, especially in immunocompromised patients, and advocate for robust vaccination efforts to protect vulnerable populations and prevent the spread of this preventable disease. Tune in to hear more!

Show Highlights:

• Resurgence of measles in the United States
• Historical context of measles outbreaks and vaccination impact
• Current statistics and recent cases of measles
• Pathophysiology of the measles virus
• Clinical features and progression of measles infection
• Diagnostic approaches for confirming measles
• Differential diagnosis considerations for fever and rash
• Treatment options and the role of vaccination
• Complications associated with measles, including severe outcomes
• Public health challenges related to vaccine hesitancy and advocacy for immunization

Resources:

CDC Measles Info Page

WHO Measles Global Surveillance

References:

Fuhrman & Zimmerman. Textbook of Pediatric Critical Care, Ch. 52

Long S et al. Principles and Practice of Pediatric Infectious Diseases, Ch. 227

Moss WJ. Measles. Lancet. 2017;390(10111):2490-2502

Paules CI, Marston HD, Fauci AS. NEJM. 2019;380(23):2185-2187

In this episode of PICU DOC on Call, Dr. Rahul Damania and Dr. Pradip Kamat chat about a challenging case involving a 15-year-old girl dealing with acute myocarditis and worsening respiratory failure. They explore the intricate dance between the heart and lungs, especially how positive pressure ventilation can affect heart function. They cover important topics like cardiac output, preload, and afterload, and discuss the delicate balance needed to manage myocarditis effectively. The episode offers practical tips for optimizing care for critically ill children, underscoring the importance of personalized treatment plans and teamwork in pediatric critical care. Tune in!

Show Highlights:

• Clinical case of a 15-year-old girl with acute myocarditis and respiratory failure
• Importance of understanding cardiopulmonary interactions in pediatric critical care
• Effects of positive pressure ventilation on cardiac function
• Key concepts of cardiac output, preload, and afterload in the context of myocarditis
• Challenges of managing hemodynamic instability in critically ill pediatric patients
• Differences between spontaneous breathing and positive pressure ventilation
• Strategies for optimizing preload and fluid management in myocarditis patients
• Tailoring ventilatory support and transitioning to invasive mechanical ventilation
• Monitoring for arrhythmias and managing myocardial function with inotropic support
• Importance of frequent assessments and collaboration with cardiac ICU teams for patient care

Optimizing Preload:

• Volume depletion is common in patients with hypotension and tachycardia. A careful fluid challenge is important to restore circulatory volume, but fluid overload should be avoided, especially with impaired left ventricular function.

Tailoring Ventilatory Support:

• Adjust BiPAP settings to improve oxygenation without overloading the heart with excessive positive pressures.
• Use the optimal level of PEEP to recruit alveoli while maintaining adequate venous return to the heart.

Supporting Myocardial Function:

• Inotropic support (e.g., milrinone) may be necessary to improve myocardial contractility. Milrinone also provides vasodilation, which can reduce afterload but must be used cautiously due to its potential to lower blood pressure.

Frequent Reassessments:

• Bedside echocardiography and regular monitoring of biomarkers (lactate, BNP) and clinical status are essential for ongoing evaluation.
• In severe cases, advanced therapies like ECMO may be required if the patient’s hemodynamic status continues to deteriorate.

Today, pediatric intensivists Dr. Pradip Kamat and Dr. Rahul Damania discuss a complex case of a 12-year-old girl who suffered a seizure and unresponsiveness due to a subarachnoid hemorrhage from a ruptured aneurysm. They explore the multi-system effects of traumatic brain injury (TBI) and intracranial hemorrhage, focusing on non-neurologic organ dysfunction.

They’ll also highlight the impact on cardiovascular, respiratory, renal, and hepatic systems, emphasizing the importance of understanding these interactions for better patient management.

Tune in to hear relevant studies and management strategies to improve outcomes in pediatric TBI cases.

In This Episode:

• Clinical case of a 12-year-old girl with seizure and unresponsiveness due to subarachnoid hemorrhage from a ruptured aneurysm
• Management of non-neurologic organ dysfunction in traumatic brain injury (TBI) and intracranial hemorrhage
• Multi-system effects of brain injuries, including cardiovascular, respiratory, renal, and hepatic complications
• Importance of recognizing non-neurologic organ dysfunction in pediatric patients
• Epidemiology and prevalence of non-neurologic organ dysfunction in patients with aneurysms or subarachnoid hemorrhage
• Mechanisms of organ dysfunction following brain injury, including inflammatory responses and cytokine release
• Management strategies for cardiovascular complications in TBI patients.
• Discussion of respiratory complications, such as acute lung injury and ARDS, in the context of TBI
• Renal and hepatic dysfunction associated with traumatic brain injury and their management
• Emphasis on the need for a comprehensive understanding of organ interactions to improve patient outcomes in pediatric critical care

Conclusion

In summary, the episode underscores the complex interplay between brain injury and multi-system organ dysfunction. The hosts emphasize the need for a comprehensive understanding of these interactions to improve patient outcomes in pediatric TBI cases. They advocate for a team-based approach to management, focusing on individual patient physiology and the delicate balance required to address the challenges posed by non-neurologic organ dysfunction.

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