The 4th year elective in pediatric critical illness provides the student with an opportunity to bridge many aspects of the preclinical basic sciences with clinical pathophysiology. The goals and objectives of the rotation are outlined below with this in mind. Obtainment of these objectives is the responsibility of the medical student and the teaching faculty.

The critically ill infant

• Appreciate the unique physiologic state of transition that occurs in the  neonatal period.
• Describe key anatomic and physiologic differences between the small infant and older child and how they may affect critical care management (see The Approach to the Critically Ill infant Powerpoint)
• Describe the rapid cardiopulmonary assessment and stabilization of the infant presenting in extremis.
• Utilizing key physical examination findings be able to quickly narrow diagnostic possibilities to allow the timely initiation of specific therapies.
• Provide an initial laboratory and imaging assessment in all critically ill infants and subsequent testing based on specific diagnostic considerations.
• Provide brief clinical summaries of the following critical illnesses that may present in neonates and infants. (i.e. neonatal sepsis, congenital heart disease, shaken baby impact syndrome, inborn errors of metabolism, infantile botulism methemoglobinemia)

Airway

• Appreciate the anatomic differences in the airways of an infant, small child and adolescent and how those differences impact laryngoscopy and intubation (see Airway powerpoint).
• List and clinically differentiate common causes of pediatric upper airway obstruction.

Respiration

• Revisit the oxygen cascade. Describes the physiologic steps required for atmospheric oxygen to be transported to the mitochondria. Key elements of the cascade that require review and understanding include pulmonary biomechanics (how air gets in), dead space and alveolar ventilation, alveolar endothelial barrier mechanics, ventilation-perfusion relationships, diffusion, oxygen uptake, O2-Hgb dissociation curve and oxygen release at the tissue level. (see Physiology of Gas Exchange power point)
• Using the above information discuss the causes of hypoxia and hypercarbia.
• Appreciate the fundamentals of positive pressure mechanical ventilation. Describe the different applications of mechanical ventilation based on different pulmonary disease processes (i.e. ARDS, asthma, upper airway obstruction).
• How are episodes of life-threatening asthma managed in the PICU?
• Describe the roles of adjunctive pulmonary therapies such as bronchodilators, corticosteroids, heliox, and noninvasive ventilation.

Cardiovascular

• Describe the difference between cyanotic and acyanotic congenital heart disease. Give examples of each.
• What congenital heart lesions have single ventricle physiology and how are they corrected ?
• What are the determinants of cardiac output and how are they manipulated in the PICU (see Pediatric Hemodynamics)
• What are the determinants of oxygen delivery (DO2) and how are they manipulated in the PICU?
• Define shock on a cellular level. Describe the major categories of shock. Give example of types of pediatric shock states (see Pediatric Shock) in each category  (i.e. cardiogenic shock- acute myocarditis, refractory SVT).
• Describe the types of pharmacologic myocardial support (i.e. inotrope, pressor, inopressor, inodilator).
• How does sepsis produce cardiovascular dysfunction (see Pediatric Sepsis powerpoint)?

Neurological

• What are common analgesic (opioids), sedatives (benzodiazepines) and neuromuscular blockers (nondepolarizing agents) use in the management of critically ill children? What are their mechanisms of action?
• Describe the intracranial vault anatomically and physiologically. What is the Monro Kellie doctrine?
• How is cerebral blood flow regulated? How does traumatic brain injury affect cerebral autoregulation?
• Describe management strategies for raised intracranial pressure (see Guideline for the treatment of traumatic brain injury in children).
• What is status epilepticus? What are the initial management priorities?

Metabolic

• Review the etiology and treatment of common electrolyte disorders seen in the PICU.
• What are the causes and treatment of acute hyper and hypoglycemia.
• What are the modes of nutritional support available to the critically ill child? Which is optimal?
• Why is the diagnosis of hypoadrenalism important in critically ill children?
• What inborn errors of metabolism may produce critical illness outside the neonatal period?

Trauma

• What are the ABCDs of initial trauma care?
• How is hemorrhagic shock classified and treated?
• What are common causes of traumatic hemorrhagic shock in the infant and older child?
• Describe historical, examination and imaging findings suggestive of trauma due to abuse? (see Child abuse powerpoint)