Pediatric Critical Care Board Review Part 2

A hemoglobin increase from 8 to 12 can boost oxygen delivery far more than raising oxygen saturation from 88% to 98%—but that doesn’t mean transfusing every child to 12 is the right call. In part one of this pediatric Critical Care Board Review, Dr. Pradip Kamat, Dr. Rahul Damania, and Dr.Monica Gray connect high-yield equations to urgent bedside decisions: when intubation may improve a failing heart, why a normal blood gas can hide impending respiratory failure, and how hyperventilation can lower intracranial pressure while dangerously reducing cerebral blood flow. They also tackle ventilator waveforms, ECMO anticoagulation, transfusion complications, and the test-taking strategies that make physiology easier to apply under pressure. Show Highlights: Board-preparation strategies and physiology-based clinical reasoning Oxygen delivery, oxygen content, and hemoglobin’s role Cardiac shunts, Qp:Qs, and duct-dependent congenital heart disease Cardiopulmonary interactions, ventilation, and hemodynamics Rhythm disturbances, CPR, and ECMO perfusion concepts Gas exchange, alveolar gas equation, and oxygenation indices Ventilator pressures, waveforms, time constants, and dead space Cerebral perfusion, traumatic brain injury, and neurologic emergencies Neuromuscular respiratory failure, seizures, and brain death assessment Anticoagulation, transfusion complications, sickle cell disease, and other hematologic emergencies

In this episode of *PICU Doc on Call*, Drs. Pradip Kamat and Rahul Damania dive into the topic of beta-blocker toxicity. They walk through a case of a 15-year-old who comes in with bradycardia, hypotension, hypoglycemia, and altered mental status after an intentional ingestion. Using a board-style question, they break down how to tell the difference between beta-blocker and calcium channel blocker poisoning and review key points about cardiac physiology and receptor signaling. Drs. Kamat and Damania discuss management strategies, including glucagon, high-dose insulin therapy, vasopressors, calcium, and ECMO as a last resort. They also spend some time focusing on specific agents like propranolol and sotalol, highlighting what makes their toxicologic profiles unique. This is a high-yield episode packed with pearls for pediatric intensivists! Show Highlights: Clinical case of a 15-year-old patient with bradycardia and hypotension due to intentional drug ingestion Beta-blocker toxicity and its clinical features Differentiation between beta-blocker and calcium channel blocker toxicity Key physiological concepts related to cardiac action potentials and beta receptor function Clinical presentation and diagnostic workup for beta-blocker toxicity Management strategies for beta blocker overdose, including airway control and fluid resuscitation Specific toxicologic profiles of common beta-blockers (e.g., propranolol, sotalol, metoprolol) Importance of recognizing hypoglycemia and CNS effects in beta-blocker toxicity Summary of critical management steps and take-home points for pediatric intensivists Encouragement for further learning and engagement on related topics

In this episode of PICU Doc on Call, third-year PICU fellow Dr. Alexandria Edwards joins Drs. Pradip Kamat, Monica Gray, and Rahul Damania for a quick and practical dive into pediatric transport medicine. Dr. Edwards walks us through her go-to framework for handling transport calls, highlighting the importance of systematically checking vitals, respiratory support, the physical exam, labs, and any interventions. The team uses a real-life case of a 12-year-old with severe status asthmaticus to talk through how to pick the right transport mode, why it’s best to avoid intubation if you can, and how to make sure you’re on the same page with the ICU team before the patient arrives. The main message? Build a solid, structured approach to transport calls and practice it every time. Show Highlights: Overview of pediatric intensive care unit (PICU) fellowship and training Importance of transport medicine in the PICU setting Framework for handling transport calls effectively Key considerations for assessing patient stability during transport Importance of vital signs and current patient status in decision-making Strategies for communicating with referring providers Discussion of a specific case involving a pediatric patient with asthma exacerbation Decision-making process for mode of transport (ground vs. air) Role of critical care transport teams in patient transfer Tips for preparing the receiving ICU team for incoming patients

In this episode, Drs. Pradip Kamat, Monica Gray, and Rahul Damania talk through a heartbreaking case involving a 14-year-old girl with a history of psychiatric illness who intentionally took 45 tablets of metformin and empagliflozin. Things went downhill quickly—she developed severe lactic acidosis, hypoglycemia, acute kidney injury, and eventually suffered a cardiac arrest that required ECMO and continuous dialysis. Sadly, even with the most aggressive care, she didn’t make it. The doctors walk listeners through the pharmacology and toxicity of metformin and empagliflozin, discuss how these drugs can cause harm, and share key management strategies. They really stress the importance of early recognition, using extracorporeal therapies, and working as a multidisciplinary team when dealing with severe pediatric overdoses of antidiabetic medications. Show Highlights: Case study of a 14-year-old girl with intentional ingestion of an oral antidiabetic agent Presentation of severe lactic acidosis, hypoglycemia, acute kidney injury, and cardiac arrest Discussion of the pharmacology and toxicology of metformin and empagliflozin Mechanisms of metformin toxicity and its effects on metabolic processes Differentiation between types of lactic acidosis related to metformin Importance of early recognition and management of metformin toxicity Supportive care strategies for managing severe metformin overdose Role of extracorporeal therapies, including ECMO and dialysis, in treatment Multidisciplinary approach involving intensivists, nephrologists, and toxicologists Clinical implications and outcomes of severe metformin toxicity in pediatric patients

In this episode of *Pediatric Critical Care Insights*, Dr. Monica Gray and Dr. Pradip Kamat chat about how capnography, specifically end-tidal CO2 monitoring, is used in the pediatric ICU. They walk through a real-life case of a 9-year-old with respiratory failure from influenza A, showing how ETCO2 monitoring helps confirm endotracheal tube placement, guides ventilation, spots cardiac arrest, and even helps assess the quality of CPR. Along the way, they break down how to interpret capnography waveforms, discuss different types of devices, and explain the key physiological concepts. The episode is packed with practical, bedside tips for intensivists caring for critically ill kids. Show Highlights: Importance of capnography (end-tidal CO2 monitoring) in the pediatric intensive care unit (PICU) Clinical case study of a 9-year-old boy with respiratory failure due to influenza A Use of capnography for confirming endotracheal tube placement and assessing ventilation status Detection of cardiac arrest and guidance for CPR quality through ETCO2 monitoring Overview of capnography physics and physiology, including terminology distinctions Types of capnography: mainstream vs. sidestream, and their applications in pediatric patients Assumptions for accurate ETCO2 approximation of arterial CO2 and conditions affecting this relationship Analysis of capnography waveform phases and their clinical significance Prognostic value of ETCO2 during cardiac arrest and its correlation with patient outcomes Practical applications of ETCO2 monitoring in critical care, focusing on airway, breathing, and circulation management