PICU Doc On Call

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

Resources:

• American Board of Pediatrics. Pediatric Critical Care Medicine Content Outline. https://www.abp.org/sites/abp/files/outline-critical-care-updated.pdf
• Fuhrman & Zimmerman’s Pediatric Critical Care, 6th ed. (Elsevier) — chapters on cardiopulmonary interactions, respiratory physiology and mechanical ventilation, neurocritical care, and hematologic emergencies. (add chapter numbers)
• Emeriaud G, et al. Executive Summary of the Second International Guidelines for the Diagnosis and Management of Pediatric Acute Respiratory Distress Syndrome (PALICC-2). Pediatr Crit Care Med. 2023;24(2):143–168.
• Greer DM, et al. Pediatric and Adult Brain Death/Death by Neurologic Criteria Determination: Consensus Guideline. Neurology. 2023.
• Kochanek PM, et al. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition. Pediatr Crit Care Med. 2019;20(3S Suppl 1):S1–S82.
• American Heart Association & American Academy of Pediatrics. 2025 Pediatric Advanced Life Support Guidelines. https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/pediatric-advanced-life-support
• Kapur J, et al. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus (ESETT). N Engl J Med. 2019;381:2103–2113.
• Lacroix J, et al. Transfusion Strategies for Patients in Pediatric Intensive Care Units (TRIPICU). N Engl J Med. 2007;356:1609–1619.
• Valentine SL, et al. Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children (TAXI). Pediatr Crit Care Med. 2018;19(9):884–898.

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

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 126. Toxidromes and their treatment. Joshi P. Pages 1504-1505
• Reference 1: Rogers textbook of Pediatric Intensive Care: Chapter 36: Poisoning. Nares M, Jeyapalan A, Weisman R: pages 525-543
• Reference 2: Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR; American Heart Association. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2023 Oct 17;148(16):e149-e184. doi: 10.1161/CIR.0000000000001161. Epub 2023 Sep 18. PMID: 37721023.
• Suarez F, Koyfman A, Long B. Pearls and Pitfalls for the Emergency Clinician: Beta Blocker and Calcium Channel Blocker Toxicity. J Emerg Med. 2026 May;84:1-11. doi: 10.1016/j.jemermed.2026.01.021. Epub 2026 Jan 27. PMID: 41833262.

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

We welcome your feedback and reviews. Please visit our website at https://picudoconcall.org/, where you can find our episodes.

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

Resources:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter: Nothing found
• Reference 1: Noites I, Figueiredo M, Shchomak Z, Boto L, Camilo C. Fatal Pediatric Metformin-Associated Lactic Acidosis: When Severity Goes Unnoticed. Cureus. 2026 Feb 16;18(2):e103719.
• Reference 2: Bebarta VS, Pead J, Varney SM. Lacticemia After Acute Overdose of Metformin in an Adolescent Managed Without Intravenous Sodium Bicarbonate or Extracorporeal Therapy. Pediatr Emerg Care. 2015 Aug;31(8):589-90.

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

References:

1. Noninvasive respiratory monitoring and assessment of gas exchange. David F. Butler; Kenneth A. Schenkman. Fuhrman and Zimmerman's Pediatric Critical Care, 43, 483-491.e3
2. Humphreys S, Schibler A, von Ungern-Sternberg BS. Carbon dioxide monitoring in children—A narrative review of physiology, value, and pitfalls in clinical practice. Pediatr Anaesth. 2021;31:839–845. https://doi.org/10.1111/pan.14208
3. Lasa JJ, Dhillon GS, Duff JP, et al. Part 8: Pediatric Advanced Life Support: 2025 American Heart Association and American Academy of Pediatrics Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2026;157(1):e2025074351
4. O'Flaherty. Capnography: principles and practice. London: BMJ Publishing Group; 1994.
5. Aminiahidashti H, Shafiee S, Zamani Kiasari A, Sazgar M. Applications of End-Tidal Carbon Dioxide (ETCO2) Monitoring in Emergency Department; a Narrative Review. Emerg (Tehran). 2018;6(1):e5. Epub 2018 Jan 15. PMID: 29503830; PMCID: PMC5827051.

In this special episode of *PICU Doc on Call*, hosts Dr. Monica Gray and Dr. Rahul Damania welcome new pediatric critical care fellows across the U.S. with practical advice for day one of fellowship. Joined by third-year PICU fellow Dr. Alexandra Bryant, the episode covers three key areas: navigating PICU logistics, protecting mental health, and managing the overwhelming volume of critical care knowledge. Dr. Bryant shares candid insights from her own training journey, offering actionable strategies for success. The hosts remind listeners that fellowship is a learning process and that new fellows can make a meaningful impact.

Show Highlights

• Introduction to pediatric critical care fellowship for new fellows and learners
• Key insights and advice for first-year fellows in pediatric intensive care
• Importance of understanding logistics in the PICU environment
• Strategies for effective communication and collaboration within the PICU team
• Managing mental health and self-care during fellowship
• Techniques for absorbing and retaining vast knowledge in pediatric critical care
• Recommendations for organizing study materials and resources
• Emphasis on lifelong learning and accessing information effectively
• Practical tips for time management and responsibility organization
• Suggested resources for mindfulness and emotional support in medical training

Resource:

PICU Doc on Call Episode 31

In this episode of *PICU Doc on Call Shorts*, pediatric ICU physicians Dr. Pradip Kamat and Dr. Rahul Damania discuss respiratory time constants and their clinical relevance in pediatric critical care. Using a case of a six-year-old with near-fatal status asthmaticus on mechanical ventilation, they explain how prolonged time constants from high airway resistance cause air trapping, dynamic hyperinflation, and intrinsic PEEP. They emphasize recognizing these issues through ventilator waveforms and highlight that increasing respiratory rate can worsen hypercapnia in obstructive disease. Key management strategies include reducing respiratory rate, extending expiratory time, and accepting permissive hypercapnia to ensure hemodynamic stability.

Show Highlights

• Respiratory time constants and their clinical significance in pediatric patients
• Case study of a six-year-old boy with near-fatal status asthmaticus
• Management of severe obstructive respiratory failure in pediatric patients
• Understanding airway resistance and lung compliance in relation to time constants
• Impact of ventilator settings on patient outcomes, including air trapping and intrinsic PEEP
• Importance of adequate expiratory time to prevent dynamic hyperinflation
• Recognizing signs of inadequate expiratory time in mechanically ventilated patients
• Strategies for managing hypercapnia and optimizing ventilator settings
• Differences in time constants related to various pediatric respiratory conditions
• Key takeaways for pediatric critical care practice and ventilator management

1. Depta F, Kallet RH, Gentile MA, Kassis EN. Expiratory time constants in mechanically ventilated patients: rethinking the old concept — a narrative review. Intensive Care Medicine Experimental. 2025;13:40. The review summarizes the definition of expiratory time constant, the relationship to resistance and compliance, the 63/86/95/98/99% rule, and clinical applications in obstructive and acute lung injury states.
2. Depta F, et al. Six methods to determine expiratory time constants in mechanically ventilated patients: a prospective observational physiology study. Intensive Care Medicine Experimental. 2024. This study describes expiratory time constant as a parameter that can guide respiratory rate and I:E adjustment to support complete exhalation.
3. Alibrahim O, Rehder KJ, Miller AG, Rotta AT. Mechanical Ventilation and Respiratory Support in the Pediatric Intensive Care Unit. Pediatric Clinics of North America. 2022;69(3):587–605. This pediatric review specifically discusses passive exhalation, the expiratory time constant, and why asthma and bronchiolitis require longer expiratory times to avoid gas trapping.
4. Arnal JM. Monitoring respiratory mechanics in mechanically ventilated patients. Hamilton Medical Knowledge Base. This source provides a practical bedside description of time constants, waveform-based respiratory mechanics, and typical RCexp ranges, while emphasizing dependence on resistance and compliance.
5. Emeriaud G, López-Fernández YM, Iyer NP, et al.; PALICC-2 Group; PALISI Network. Executive summary of the second international guidelines for the diagnosis and management of pediatric ARDS. Pediatric Critical Care Medicine. 2023;24(2):143–168. The PALICC-2 guideline framework supports lung-protective ventilation in PARDS, including attention to tidal volume, PEEP, plateau pressure, and driving pressure.

In this episode of PICU Doc on Call, hosts Dr. Monica Gray and Dr. Pradip Kamat explore procedural sedation in the pediatric ICU. They cover sedation levels, pre-screening, risk stratification using ASA classifications, and medication selection tailored to each patient's hemodynamic and respiratory status. Through real-world case discussions involving respiratory failure, septic shock, and acute neurological decline, they highlight the importance of end-tidal CO2 monitoring and early adverse event recognition. Key takeaways include avoiding the term "conscious sedation," preparing rescue plans, and prioritizing patient safety through careful assessment and monitoring.

Show Highlights:

• Definitions and levels of sedation (minimal, moderate, deep sedation, and general anesthesia)
• Importance of terminology in procedural sedation
• Monitoring sedation levels using scales like the Richmond Agitation-Sedation Scale (RASS)
• Pre-screening and risk stratification considerations for pediatric patients
• ASA physical status classification system for assessing patient risk
• Unique challenges of procedural sedation in critically ill children
• Adverse events associated with pediatric procedural sedation, particularly respiratory complications
• Management strategies for specific cases requiring sedation (e.g., respiratory failure, septic shock)
• Importance of end-tidal CO2 monitoring during sedation
• Key takeaways for safe sedation practices in the pediatric ICU setting

References:

1. Nir Atlas; Rahul C. Damania; Pradip P. Kamat In Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 135, 1624-1628
2. Statement on Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia by Committee on Quality Management and Departmental Administration. Last Amended: October 23, 2024.
3. Coté CJ, Wilson S; AMERICAN ACADEMY OF PEDIATRICS; AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics. 2019 Jun;143(6):e20191000. doi: 10.1542/peds.2019-1000. PMID: 31138666.x
4. Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006 Mar 4;367(9512):766-80. doi: 10.1016/S0140-6736(06)68230-5. PMID: 16517277.
5. Sharif S, Kang J, Sadeghirad B, Rizvi F, Forestell B, Greer A, Hewitt M, Fernando SM, Mehta S, Eltorki M, Siemieniuk R, Duffett M, Bhatt M, Burry L, Perry JJ, Petrosoniak A, Pandharipande P, Welsford M, Rochwerg B. Pharmacological agents for procedural sedation and analgesia in the emergency department and intensive care unit: a systematic review and network meta-analysis of randomised trials. Br J Anaesth. 2024 Mar;132(3):491-506. doi: 10.1016/j.bja.2023.11.050. Epub 2024 Jan 6. PMID: 38185564.
6. Smith, Heidi A. B. MD, MSCI (Chair)1,2; Besunder, James B. DO, FCCM3,4; Betters, Kristina A. MD1; Johnson, Peter N. PharmD, BCPS, BCPPS, FCCM, FPPA, FASHP5,6; Srinivasan, Vijay MBBS, MD, FCCM7,8; Stormorken, Anne MD9,10; Farrington, Elizabeth PharmD, FCCM11; Golianu, Brenda MD12,13; Godshall, Aaron J. MD14; Acinelli, Larkin CPNP-AC, ACHPN15; Almgren, Christina CPNP16; Bailey, Christine H. MD17; Boyd, Jenny M. MD18,19; Cisco, Michael J. MD20; Damian, Mihaela MD, MPH21,22; deAlmeida, Mary L. MD23,24; Fehr, James MD13,25; Fenton, Kimberly E. MD, FCCM14; Gilliland, Frances DNP, CPNP-AC/PC26,27; Grant, Mary Jo C. CPNP-AC, PhD, FAAN28; Howell, Joy MD29; Ruggles, Cassandra A. PharmD, BCCCP, BCPPS30; Simone, Shari DNP31,32; Su, Felice MD21,22; Sullivan, Janice E. MD33,34; Tegtmeyer, Ken MD, FAAP, FCCM35,36; Traube, Chani MD, FCCM29; Williams, Stacey CPNP-AC37; Berkenbosch, John W. MD, FAAP, FCCM (Chair)33,34. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatric Critical Care Medicine 23(2):p e74-e110, February 2022. | DOI: 10.1097/PCC.0000000000002873
7. Benzoni T, Agarwal A, Cascella M. Procedural Sedation. [Updated 2025 Mar 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551685/
8. Kerson AG, DeMaria R, Mauer E, Joyce C, Gerber LM, Greenwald BM, Silver G, Traube C. Validity of the Richmond Agitation-Sedation Scale (RASS) in critically ill children. J Intensive Care. 2016 Oct 26;4:65. doi: 10.1186/s40560-016-0189-5. PMID: 27800163; PMCID: PMC5080705.
9. Tel-Dan SF, Shavit D, Nates R, Samuel N, Shavit I. Emergency Physician-Administered Sedation for Thoracostomy in Children With Pleuropneumonia. Pediatr Emerg Care. 2021 Dec 1;37(12):e1209-e1212. doi: 10.1097/PEC.0000000000001975. PMID: 31929389.
10. Cosgrove P, Krauss BS, Cravero JP, Fleegler EW. Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation. Ann Emerg Med. 2022 Dec;80(6):485-496. doi: 10.1016/j.annemergmed.2022.05.002. Epub 2022 Jun 23. PMID: 35752522.
11. Cravero JP, Blike GT, Beach M, Gallagher SM, Hertzog JH, Havidich JE, Gelman B; Pediatric Sedation Research Consortium. Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics. 2006 Sep;118(3):1087-96. doi: 10.1542/peds.2006-0313. PMID: 16951002.

In this episode of *PICU Doc on Call*, Dr. Monica Gray and Dr. Pradip Kamat are joined by fellow Dr. Hope Vancleve to discuss a complex case of a 12-year-old with MRSA septic shock requiring VA ECMO. The conversation covers sepsis-induced myocardial dysfunction, including its pathophysiology, diagnosis, and management. The hosts also explore differential hypoxia, or Harlequin syndrome, a serious VA ECMO complication causing upper body deoxygenation, and discuss monitoring strategies and circuit reconfiguration to prevent cerebral and myocardial ischemia.

Show Highlights:

• Clinical case discussion of a 12-year-old male patient with MRSA septic shock.
• Complications of sepsis, including sepsis-induced myocardial dysfunction and refractory shock.
• Management strategies for septic shock, including antibiotic therapy and fluid resuscitation.
• Use of venoarterial ECMO support in pediatric patients with severe cardiac dysfunction.
• Pathophysiology of sepsis-induced myocardial dysfunction and its impact on cardiac function.
• Differential hypoxia (North-South syndrome) in patients on femoral VA ECMO.
• Diagnostic approaches for sepsis-induced myocardial dysfunction, including echocardiography and biomarkers.
• Importance of monitoring and managing end-organ function in septic patients.
• Strategies for addressing differential hypoxia in ECMO patients, including circuit reconfiguration.
• Discussion of the risks and benefits of various ECMO configurations and management techniques.

References:

• Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter
• Reference 1: Torre DE, Pirri C. Harlequin Syndrome in Venoarterial ECMO and ECPELLA: When ECMO and Native or Impella Circulations Collide - A Comprehensive Review. Rev Cardiovasc Med. 2025 Aug 26;26(8):39992. doi: 10.31083/RCM39992. PMID: 40927093; PMCID: PMC12415751.
• Reference 2 : Cove ME. Disrupting differential hypoxia in peripheral veno-arterial extracorporeal membrane oxygenation. Crit Care. 2015 Jul 22;19(1):280. doi: 10.1186/s13054-015-0997-3. PMID: 27391473; PMCID: PMC4511033.

In this episode of PICU Doc on Call, hosts Dr. Monica Gray and Dr. Pradip Kamat discuss a 15-year-old girl who attempted suicide by ingesting rat poison, acetaminophen, ibuprofen, and amlodipine. The episode focuses on long-acting anticoagulant rodenticides (LAARs), such as brodifacoum, which inhibit vitamin K epoxide reductase, causing delayed coagulopathy. Key topics include clinical presentation, diagnostic evaluation, and management, emphasizing vitamin K1 as the primary antidote and prothrombin complex concentrate or fresh-frozen plasma for major bleeding. The patient stabilized with aggressive supportive care, including vasoactive agents and NAC therapy, alongside psychiatric intervention. Listen to learn more!

Show Highlights

• Clinical case of a 15-year-old girl who attempted suicide through polypharmacy ingestion
• Ingestion of multiple substances, including chewable rat poison, acetaminophen, ibuprofen, and amlodipine
• Discussion of toxicology related to long-acting anticoagulant rodenticides (LAARs) like brodifacoum
• Symptoms and clinical presentation following acute ingestion, including metabolic acidosis and elevated lactate
• Diagnostic evaluation and laboratory findings, including coagulation studies and liver function tests
• Management strategies for LAAR poisoning, including the use of vitamin K and supportive care
• Importance of monitoring for delayed coagulopathy and serial INR testing
• Consideration of calcium channel blocker toxicity in the context of the patient's clinical instability
• Overview of the mechanisms of action of LAARs and their impact on vitamin K-dependent clotting factors
• Key take-home points regarding the recognition and management of rodenticide ingestion in pediatric patients

References

Reference: King N, Tran MH. Long-Acting Anticoagulant Rodenticide (Superwarfarin) Poisoning: A Review of Its Historical Development, Epidemiology, and Clinical Management. Transfus Med Rev. 2015 Oct;29(4):250-8.

Reference 2: Feinstein DL, Akpa BS, Ayee MA, et al. The emerging threat of superwarfarins: history, detection, mechanisms, and countermeasures. Ann N Y Acad Sci. 2016 Jun;1374(1):111-22.