We discuss an approach to the critically ill infant.

Hosts:
Ellen Duncan, MD, PhD
Brian Gilberti, MD

• ‘T’ in the mnemonic stands for trauma, which includes both accidental and intentional causes.
• Considerations for Non-accidental Trauma:
  • Stresses the importance of considering non-accidental trauma, especially given that it may not always present with obvious external signs.
• Anatomical Vulnerabilities:
  • Highlights specific anatomical considerations for infants who suffer from trauma:
    • Infants have proportionally larger heads, increasing their susceptibility to high cervical spine (c-spine) injuries.
    • Their liver and spleen are less protected, making abdominal injuries potentially more severe.

• 5 T’s of Cyanotic Congenital Heart Disease: Introduces a mnemonic to help remember key right-sided ductal-dependent lesions:
  • Truncus Arteriosus: Single vessel serving as both pulmonary and systemic outflow tract.
  • Transposition of the Great Arteries: The pulmonary artery and aorta are switched, leading to improper circulation.
  • Tricuspid Atresia: Absence of the tricuspid valve, leading to inadequate development of the right ventricle and pulmonary circulation issues.

We review Acute Respiratory Distress Syndrome

Hosts:
Sadakat Chowdhury, MD
Brian Gilberti, MD

• Definition of ARDS:
  • Non-cardiogenic pulmonary edema characterized by acute respiratory failure.
  • Berlin criteria for diagnosis include acute onset within 7 days, bilateral pulmonary infiltrates on imaging, not fully explained by cardiac failure or fluid overload, and impaired oxygenation with PaO2/FiO2 ratio <300 mmHg, even with positive end-expiratory pressure (PEEP) >5 cm H2O.
• Severity based on oxygenation (Berlin criteria):
  • Mild: PaO2/FiO2 200-300 mmHg
  • Moderate: PaO2/FiO2 100-200 mmHg
  • Severe: PaO2/FiO2 <100 mmHg
• Epidemiology:
  • Occurs in up to 23% of mechanically ventilated patients.
  • Mortality rate of 30-40%, primarily due to multiorgan failure.
• Differentiation from Cardiogenic Pulmonary Edema:
  • Chest CT shows diffuse edema and pleural effusion in cardiogenic edema; patchy edema, dense consolidation in ARDS.
  • Ultrasound may show diffuse B lines in cardiogenic edema; patchy B lines and normal A lines in ARDS.
• Pathophysiology:
  • Exudative phase: Immune-mediated alveolar damage, pulmonary edema, cytokine release.
  • Proliferative phase: Reabsorption of edema fluid.
  • Fibrotic phase: Potential for prolonged ventilation.
• Etiology:
  • Direct lung injury (pneumonia, toxins, aspiration, trauma, drowning) and indirect causes (sepsis, pancreatitis, transfusion reactions, certain drugs).
• Diagnostics:
  • Comprehensive workup including imaging (chest X-ray, CT),

We review Nitrous Oxide Toxicity: Symptoms, diagnosis, and treatment overview

Hosts:
Stefanie Biondi, MD
Brian Gilberti, MD

Patient Case Illustration

• Hypothetical case: 21-year-old male with no previous medical history, experiencing a month of progressively worsening numbness, tingling, and weakness. Initially starting in his toes and spreading to his hips, and later involving his hands, the symptoms eventually escalated to the point of immobilization. Despite initially denying drug use, the patient admitted to using 40-60 canisters of nitrous oxide (whippets) every weekend for the last three months.

Background and Recreational Use of Nitrous Oxide

• Nitrous oxide, a colorless, odorless gas with anesthetic properties.
• Synthesized in the 18th century.
• Its initial medical purpose expanded into recreational use due to its euphoric effects.
• Resurgence as a recreational drug during the COVID-19 lockdowns.
• Accessibility and legal status.

Public Misconceptions and Health Consequences

• There are widespread misconceptions about nitrous oxide
  • Particularly the belief in its safety and lack of long-term health risks.
  • Contrary to popular belief, frequent use of nitrous oxide can lead to significant, sometimes irreversible, health issues.

Neurological Examination and Diagnosis