Introduction

Welcome to PICU Doc On Call, a podcast dedicated to current and aspiring pediatric intensivists. I'm Dr. Pradip Kamat from Children’s Healthcare of Atlanta/Emory University School of Medicine, and I’m Dr. Rahul Damania from Cleveland Clinic Children’s Hospital. We are two Pediatric ICU physicians passionate about medical education in the PICU. This podcast focuses on interesting PICU cases and their management in the acute care pediatric setting.

Episode Overview

In today’s episode, we are excited to welcome Dr. Karen Zimowski, Assistant Professor of Pediatrics at Emory University School of Medicine and a practicing pediatric hematologist at Children’s Healthcare of Atlanta at the Aflac Blood & Cancer Center. Dr. Zimowski specializes in pediatric bleeding and clotting disorders.

Case Presentation

A 16-year-old female with a complex medical history, including autoimmune thyroiditis and prior cerebral infarcts, was admitted to the PICU with acute chest pain and difficulty breathing. Despite being on low-dose aspirin, her oxygen saturation was 86% on room air. A CT angiography revealed a pulmonary embolism (PE) in the left lower lobe and signs of right heart strain. The patient was hemodynamically stable, and thrombolytic therapy was deferred in favor of anticoagulation. She was placed on BiPAP to improve her respiratory status. Her social history was negative for smoking, illicit drug use, or oral contraceptive use.

Key Case Points

Diagnosis: Pulmonary embolism (PE)
Hemodynamics: Stable with no right ventricular (RV) strain on echocardiogram
Management Focus: Anticoagulation and consultation with the hematology/thrombosis team

Expert Discussion with Dr. Karen Zimowski

Risk Factors and Epidemiology of VTE in Pediatrics

Pathophysiology: Venous thromboembolism (VTE) in children involves components of Virchow’s triad: stasis of blood flow, endothelial injury, and hypercoagulability.
Incidence: VTE is rare in the general pediatric population but increases significantly in hospitalized children.
Age Distribution: Bimodal peaks in infants and adolescents aged 15-17 years.
Risk Factors: Central venous lines, infections, congenital heart disease, cancer, and autoimmune disorders.

Clinical Manifestations of DVT

Symptoms: Swelling, pain, warmth, and skin discoloration in the affected extremity.
Specific Presentations:
SVC syndrome from superior vena cava thrombosis
Abdominal pain from portal vein thrombosis
Hematuria from renal vein thrombosis
Neurological symptoms...

Hemostatis and Coagulation in the PICU

PICU Doc On Call