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PICU Doc On Call: Daily Summaries Delivered
by Dr. Pradip Kamat, Dr. Rahul Damania, Dr. Monica Gray
PICU Doc On Call is the podcast for current and aspiring Intensivists. This podcast will provide protocols that any Critical Care Physician would use to treat common emergencies and the sudden onset of acute symptoms. Brought to you by Emory University School of Medicine, in conjunction with Dr. Rahul Damania and under the supervision of Dr. Pradip Kamat.
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- 6 days ago38 min
Pediatric Critical Care Board Review Board Part 3
A child with septic shock develops worsening oxygenation after initial fluid resuscitation. Another presents with seizures, hypotension, and a widened QRS following a suspected tricyclic antidepressant ingestion. What should happen next? Dr. Pradip Kamat and Dr. Rahul Damania tackle these questions and more in the final installment of their three-part pediatric critical care board review series.Through 21 rapid-fire, case-based questions, the hosts explore gastrointestinal emergencies, nutrition, toxicology, sepsis, trauma, sedation, medical ethics, and research interpretation. They explain why enteral nutrition is generally preferred in critically ill children, how ECG findings guide treatment in toxic ingestions, when early airway intervention is essential, and why a normal pulse does not exclude compartment syndrome.With practical clinical pearls and bedside-focused explanations, this episode offers a concentrated review for pediatric critical care trainees and clinicians preparing for certification or recertification.Show Highlights:• Gastrointestinal emergencies, including variceal bleeding, octreotide, and malrotation with volvulus• Enteral versus parenteral nutrition, indirect calorimetry, and nutritional markers• Toxicology emergencies involving tricyclic antidepressants, acetaminophen, salicylates, and toxic alcohols• Carbon monoxide and cyanide poisoning, serotonin syndrome, neuroleptic malignant syndrome, and malignant hyperthermia• Pediatric septic shock, vasoactive support, and the Phoenix Sepsis Criteria• Streptococcal toxic shock, chronic granulomatous disease, and invasive fungal infections• Trauma, burns, inhalation injuries, compartment syndrome, and environmental emergencies• Propofol infusion syndrome, neuromuscular blockade, sedation, and delirium assessment• Ethics involving emergency treatment, informed consent, end-of-life care, and pediatric research• Positive predictive value, Type I and II errors, statistical power, risk reduction, and number needed to treat• Choosing statistical tests and evaluating quality improvement outcomesResources:GI and Nutrition• APSPGHAN statement on endoscopic variceal bleeding hemostasis (2026): pediatric octreotide use and antibiotics in cirrhosis-associated variceal bleeding.• Fivez T, et al. Early versus Late Parenteral Nutrition in Critically Ill Children (PEPaNIC). N Engl J Med. 2016;374:1111–1122.• Evans DC, et al. The Use of Visceral Proteins as Nutrition Markers: An ASPEN Position Paper. Nutr Clin Pract. 2021;36:22–28.Toxicology• American Heart Association. 2023 focused update on life-threatening toxicity due to poisoning.• Dart RC, et al. Management of Acetaminophen Poisoning in the US and Canada: A Consensus Statement. JAMA Netw Open. 2023;6.Additional Board Review Resources• PICU Doc On Call — Podcast episodes, management cards, and board review equation sheets: https://picudoconcall.org/Equations and InterpretationRespiratory Quotient (RQ)Formula: RQ = VCO₂ / VO₂Interpretation: A measured value above 1 may reflect overfeeding or net lipogenesis. Measurement conditions and nonsteady-state physiology matter.Absolute Risk Reduction (ARR)Formula: ARR = Control Event Rate − Treatment Event RateInterpretation: Use absolute benefit for the defined outcome and follow-up period.Number Needed to Treat (NNT)Formula: NNT = 1 / ARRInterpretation: Enter ARR as a proportion. If adverse events fall from 20% to 10%, ARR = 0.10 and NNT = 10 over the study's follow-up. Round noninteger NNTs up.Positive Predictive Value (PPV)Formula: PPV = True Positives / All Positive TestsInterpretation: Lower prevalence generally lowers PPV when sensitivity and specificity are comparable.Statistical PowerFormula: Power = 1 − βInterpretation: The probability of rejecting the null hypothesis under a specified alternative and study assumptions. A nonsignificant result does not establish equivalence.Traditional Parkland EstimateFormula: 4 mL × Weight (kg) × % Total Body Surface Area (TBSA) Burned over 24 hoursInterpretation: This is a historical starting estimate, not a universal pediatric prescription. Follow the local burn-center protocol. Traditionally, half is allocated to the first 8 hours from injury and half to the next 16 hours. Account for fluids already administered and titrate to response. Pediatric protocols may use a different coefficient, and smaller children need separate maintenance
- 1 weeks ago35 min
Pediatric Critical Care Board Review Part 2
A child with DKA develops a worsening headache, altered mental status, and bradycardia: the hosts explain why suspected cerebral injury should be treated before imaging. Dr. Pradip Kamat and Rahul Damania bring that same bedside focus to a rapid-fire pediatric critical care board review, covering medication dosing, kidney and electrolyte emergencies, endocrine crises, and liver failure. Along the way, they explain why a normal anion gap can hide acidosis when albumin is low, how a dangerously wide QRS in hyperkalemia changes the treatment order, and why acute liver failure can meet criteria even without obvious encephalopathy. Short cases, clear answers, and practical physiology make this a focused review for the PICU and the boards.Show Highlights:Medication dosing in acute kidney injury, including loading versus maintenance dosesPhenytoin’s nonlinear kinetics and extended-infusion beta-lactam antibioticsKidney and electrolyte disorders, including metabolic alkalosis, hypokalemia, and anion-gap interpretationHyponatremia, sodium correction, cerebral salt wasting, and pseudohyponatremiaHyperkalemia management, rhabdomyolysis, and kidney replacement therapyDiabetic ketoacidosis and suspected cerebral injuryEndocrine emergencies, including adrenal crisis, thyroid storm, and hypoglycemiaMetabolic disorders, including urea cycle disorders and hyperammonemiaPediatric acute liver failure and lactulose’s role in ammonia managementNutrition assessment and the effects of inflammation on albumin and prealbuminReferences: Medication questionsFDA Dilantin prescribing information: saturable metabolism and interpretation of unbound phenytoin in hypoalbuminemia and renal/hepatic disease.Fuhrman & Zimmerman’s Pediatric Critical Care, 6th edition: background pharmacology, renal physiology, acid–base, and endocrine chapters.Electrolytes and kidney supportRoyal Children’s Hospital clinical guideline: Hyponatraemia.Royal Children’s Hospital clinical guideline: Hyperkalaemia.Gaudry S, Palevsky PM, Dreyfuss D. Extracorporeal Kidney-Replacement Therapy for Acute Kidney Injury. N Engl J Med. 2022;386:964–975. doi:10.1056/NEJMra2104090.Stanski NL, Fuhrman D, Basu RK. Controversies in paediatric acute kidney injury and continuous renal replacement therapy. Curr Opin Crit Care. 2021;27:604–610. doi:10.1097/MCC.0000000000000888.Endocrine and metabolic questionsGlaser N, et al. ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2022;23:835–856. Full guideline.Kuppermann N, et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med. 2018;378:2275–2287. The trial did not find significant neurologic outcome differences among the fluid regimens studied.American Thyroid Association: Hyperthyroidism in Children and Adolescents; 2016 ATA guideline.Additional background and references are provided in the linked hypoglycemia and hyperammonemia episodes.Liver and nutrition questionsSquires JE, et al. NASPGHAN Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pedi
- 2 weeks ago47 min
Pediatric Critical Care Board Review Part 1
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 reasoningOxygen delivery, oxygen content, and hemoglobin’s roleCardiac shunts, Qp:Qs, and duct-dependent congenital heart diseaseCardiopulmonary interactions, ventilation, and hemodynamicsRhythm disturbances, CPR, and ECMO perfusion conceptsGas exchange, alveolar gas equation, and oxygenation indicesVentilator pressures, waveforms, time constants, and dead spaceCerebral perfusion, traumatic brain injury, and neurologic emergenciesNeuromuscular respiratory failure, seizures, and brain death assessmentAnticoagulation, transfusion complications, sickle cell disease, and other hematologic emergenciesResources:American Board of Pediatrics. Pediatric Critical Care Medicine Content Outline. https://www.abp.org/sites/abp/files/outline-critical-care-updated.pdfFuhrman & 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-supportKapur 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.
- Sep 6, 202623 min
128: Beta Blocker Toxicity in the PICU: Slow Heart, Fading Mind, and Falling Sugar
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 ingestionBeta-blocker toxicity and its clinical featuresDifferentiation between beta-blocker and calcium channel blocker toxicityKey physiological concepts related to cardiac action potentials and beta receptor functionClinical presentation and diagnostic workup for beta-blocker toxicityManagement strategies for beta blocker overdose, including airway control and fluid resuscitationSpecific toxicologic profiles of common beta-blockers (e.g., propranolol, sotalol, metoprolol)Importance of recognizing hypoglycemia and CNS effects in beta-blocker toxicitySummary of critical management steps and take-home points for pediatric intensivistsEncouragement for further learning and engagement on related topicsReferences:Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 126. Toxidromes and their treatment. Joshi P. Pages 1504-1505Reference 1: Rogers textbook of Pediatric Intensive Care: Chapter 36: Poisoning. Nares M, Jeyapalan A, Weisman R: pages 525-543Reference 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.
- Aug 23, 202621 min
Hello From the Otherside! Transport Calls
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 trainingImportance of transport medicine in the PICU settingFramework for handling transport calls effectivelyKey considerations for assessing patient stability during transportImportance of vital signs and current patient status in decision-makingStrategies for communicating with referring providersDiscussion of a specific case involving a pediatric patient with asthma exacerbationDecision-making process for mode of transport (ground vs. air)Role of critical care transport teams in patient transferTips for preparing the receiving ICU team for incoming patientsWe welcome your feedback and reviews. Please visit our website at https://picudoconcall.org/, where you can find our episodes.
- Aug 9, 202620 min
Metformin Overdose in the Pediatric ICU | A Case of Low pH
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 agentPresentation of severe lactic acidosis, hypoglycemia, acute kidney injury, and cardiac arrestDiscussion of the pharmacology and toxicology of metformin and empagliflozinMechanisms of metformin toxicity and its effects on metabolic processesDifferentiation between types of lactic acidosis related to metforminImportance of early recognition and management of metformin toxicitySupportive care strategies for managing severe metformin overdoseRole of extracorporeal therapies, including ECMO and dialysis, in treatmentMultidisciplinary approach involving intensivists, nephrologists, and toxicologistsClinical implications and outcomes of severe metformin toxicity in pediatric patientsResources:Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter: Nothing foundReference 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.
- Jul 26, 202621 min
Capnography in the PICU | Take My Breath Away
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 AUse of capnography for confirming endotracheal tube placement and assessing ventilation statusDetection of cardiac arrest and guidance for CPR quality through ETCO2 monitoringOverview of capnography physics and physiology, including terminology distinctionsTypes of capnography: mainstream vs. sidestream, and their applications in pediatric patientsAssumptions for accurate ETCO2 approximation of arterial CO2 and conditions affecting this relationshipAnalysis of capnography waveform phases and their clinical significancePrognostic value of ETCO2 during cardiac arrest and its correlation with patient outcomesPractical applications of ETCO2 monitoring in critical care, focusing on airway, breathing, and circulation managementReferences:Noninvasive respiratory monitoring and assessment of gas exchange. David F. Butler; Kenneth A. Schenkman. Fuhrman and Zimmerman's Pediatric Critical Care, 43, 483-491.e3Humphreys 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.14208Lasa 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):e2025074351O'Flaherty. Capnography: principles and practice. London: BMJ Publishing Group; 1994.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.
- Jul 12, 202618 min
Start Off Strong: Tips and Tricks for 1st-year PICU Fellows
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 HighlightsIntroduction to pediatric critical care fellowship for new fellows and learnersKey insights and advice for first-year fellows in pediatric intensive careImportance of understanding logistics in the PICU environmentStrategies for effective communication and collaboration within the PICU teamManaging mental health and self-care during fellowshipTechniques for absorbing and retaining vast knowledge in pediatric critical careRecommendations for organizing study materials and resourcesEmphasis on lifelong learning and accessing information effectivelyPractical tips for time management and responsibility organizationSuggested resources for mindfulness and emotional support in medical trainingResource:PICU Doc on Call Episode 31
About PICU Doc On Call
PICU Doc On Call is the podcast for current and aspiring Intensivists. This podcast will provide protocols that any Critical Care Physician would use to treat common emergencies and the sudden onset of acute symptoms. Brought to you by Emory University School of Medicine, in conjunction with Dr. Rahul Damania and under the supervision of Dr. Pradip Kamat.
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