PICU Doc On Call

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

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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:
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
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
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
O'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.

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