Endotracheal Intubation For Airway Protection Research Articles

RAPID RECOVERY FROM MYCOBACTERIUM TB EPIGLOTTITIS REQUIRING ENDOTRACHEAL INTUBATION

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Laryngeal Tuberculosis (LTb) currently accounts for <1% of all Tb cases. Patients most often present with dysphonia, weight loss, and typically respond well to targeted antimicrobial regimens [1]. To our knowledge, there is minimal data regarding time to liberation from mechanical ventilation and the efficacy of corticosteroids in LTb. We present a case of LTb in a 37-year-old immunocompetent female requiring endotracheal intubation with a subsequent rapid recovery. CASE PRESENTATION: A 37-year-old female presented to the Emergency Department for a 2-week history of dyspnea, and 3 months of intermittent fevers, weight loss, and dysphonia. She had no known past medical history. The patient was febrile, tachycardic, and hypoxic requiring 100% oxygen via non-rebreather mask. Physical exam was remarkable for respiratory distress and mild stridor. Laboratory studies found a leukocytosis of 18.3 K/μL with a neutrophilic predominance to 84%. HIV screening was negative. A CXR revealed bilateral interstitial opacities. Chest CT angiography found diffuse, bilateral centrilobular nodules, tree-in-bud opacities, and bilateral upper lobe cavitary lesions measuring up to 3.9cm (Image 1). Contrast-enhanced Neck CT demonstrated marked swelling of the epiglottis and moderate narrowing of the airway (Image 2). Nebulized racemic epinephrine, albuterol, ipratropium, and IV dexamethasone resulted in mild improvement of her stridor. Transnasal flexible fiberoptic laryngoscopy revealed an enlarged epiglottis with >50% obstruction of the supraglottic airway. She underwent endotracheal intubation for airway protection, and a flexible bronchoscopy was performed. Bronchoalveolar lavage fluid analysis revealed 95% neutrophils, cultures grew Mycobacterium tuberculosis, and cytology was negative for malignant cells. Rifampin, isoniazid, pyrazinamide, ethambutol (RIPE), and pyridoxine were initiated. She also received dexamethasone 6mg IV daily for seven days. Twelve days after intubation, the patient was extubated without signs of stridor. DISCUSSION: LTb has two categories: primary, in which bacteria seed the larynx directly, and secondary, via invasion by advanced pulmonary Tb [1]. Diagnosis is often a combination of visualization of laryngeal lesions via laryngoscopy, tissue culture, and laryngeal histopathology [1]. A review of the literature identified 13 cases of LTb requiring mechanical ventilation, all via tracheostomy. Time to decannulation ranged from 2-6 months, with one case reporting 2 weeks [2]. Data regarding the efficacy of corticosteroids in LTb with airway compromise is limited. However, a recent retrospective study found steroid use in pulmonary Tb with acute respiratory failure to be beneficial [3]. CONCLUSIONS: When treated with appropriate antimicrobials along with consideration to adjunct corticosteroid use, LTb patients may demonstrate a rapid recovery obviating the need for tracheostomy. REFERENCE #1: Benwill JL, Sarria JC. Laryngeal tuberculosis in the United States of America: a forgotten disease. Scand J Infect Dis. 2014;46(4):241-249. doi:10.3109/00365548.2013.877157 REFERENCE #2: Gupta R, Fotedar S, Sansanwal P, et al. Obstructing mass lesion of epiglottis: it can be tubercular. Indian J Tuberc. 2008;55(2):100-103. REFERENCE #3: Yang JY, Han M, Koh Y, et al. Effects of Corticosteroids on Critically Ill Pulmonary Tuberculosis Patients With Acute Respiratory Failure: A Propensity Analysis of Mortality. Clin Infect Dis. 2016;63(11):1449-1455. doi:10.1093/cid/ciw616 DISCLOSURES: No relevant relationships by Nathaniel Allison, source=Web Response No relevant relationships by Christopher Lee, source=Web Response No relevant relationships by John Prudenti, source=Web Response No relevant relationships by Lourdes Sanso, source=Web Response

SPONTANEOUS CORONARY ARTERY DISSECTION: A RARE SEQUELA OF COVID-19

TOPIC: Cardiovascular Disease TYPE: Fellow Case Reports INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a rare coronary event, mostly associated with autoimmune and inflammatory conditions. We share a case report of a patient admitted to the Creighton University Medical Center, Omaha, Nebraska with the clinical presentation and diagnostics suggestive of SCAD after coronavirus disease 2019 (COVID-19). CASE PRESENTATION: A 43-year-old caucasian woman with a history of atrial fibrillation (AF) during pregnancy, was brought to the hospital after she had a syncopal episode due to ventricular fibrillation (VF) leading to cardiac arrest requiring defibrillation on site. She had been tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) by PCR with mild symptoms, about 12 weeks prior to this episode and she recovered within a week after self-quarantine at home. In the emergency room, she had AF with a rapid ventricular response, hypothermia, bilateral decreased breath sounds, a non-tender abdomen, and equal pulses. She required endotracheal intubation for airway protection. Her initial laboratory studies revealed normal complete blood counts, CRP 71.2 mg/L, and initial Troponin I 2.55 ng/mL (with a peak of 21 ng/mL). Subsequently, she progressed to refractory cardiogenic shock necessitating four vasopressor agents. A transthoracic echocardiogram revealed a left ventricular ejection fraction of 20% with new-onset global hypokinesis and myocardial wall thickness. The coronary angiogram revealed SCAD in the left circumflex artery. An Impella device was placed for cardiovascular support initially, but she ultimately required Veno-arterial (VA) ECMO. She was also given pulse dose IV methylprednisone due to concerns for myocarditis as a late inflammatory sequela of COVID-19. She was managed conservatively without coronary intervention. The follow-up TTE one week later showed improvement in her LVEF to 60%. DISCUSSION: SCAD should be kept in the differential diagnosis in the patients who have COVID-19 infections within the past 2-12 weeks and noted to have symptoms of an acute coronary syndrome (ACS) or new-onset cardiac arrhythmias. So far there are very few reported cases of SCAD after COVID-19, all having a variable clinical course (1–3). Overall, SCAD is an underreported coronary event and has a prevalence of around 4%, mostly associated with autoimmune and inflammatory diseases. Various mechanisms of SCAD have been proposed including infection-related endothelial dysfunction and intra-plaque hemorrhage leading to an intra-adventitial hematoma, followed by longitudinal spread along the coronary artery and eventually dissection. Even though SCAD can be due to other contributory factors in critical illness, however, the association of SCAD with COVID-19 needs to be further elaborated. CONCLUSIONS: COVID-19 may lead to various cardiovascular disorders ranging from ACS to SCAD and management protocols need further research. REFERENCE #1: Kumar K, Vogt JC, Divanji PH, Cigarroa JE. Spontaneous coronary artery dissection of the left anterior descending artery in a patient with COVID-19 infection. Catheter Cardiovasc Interv [Internet] 2021;97(2). Available from: https://onlinelibrary.wiley.com/doi/10.1002/ccd.28960 REFERENCE #2: Aparisi Á, Ybarra-Falcón C, García-Granja PE, Uribarri A, Gutiérrez, and H, Amat-Santos IJ. COVID-19 and spontaneous coronary artery dissection: causality? REC Interv Cardiol (English Ed [Internet] 2021;Available from: https://www.recintervcardiol.org/en/?option=com_content&view=article&id=548&catid=41 REFERENCE #3: Shojaei F, Habibi Z, Goudarzi S, et al. COVID-19: A double threat to takotsubo cardiomyopathy and spontaneous coronary artery dissection? Med Hypotheses [Internet] 2021;146:110410. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0306987720333016 DISCLOSURES: No relevant relationships by Faran Ahmad, source=Web Response No relevant relationships by Arslan Ahmed, source=Web Response No relevant relationships by Austin Loranger, source=Web Response Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Pharmaceuticals, Inc. Please note: $5001 - $20000 by Doug Moore, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Genentech Please note: $1001 - $5000 by Doug Moore, source=Web Response, value=Honoraria No relevant relationships by Sanu Rajendraprasad, source=Web Response No relevant relationships by Renuga Vivekanandan, source=Web Response

AORTOESOPHAGEAL FISTULA PRESENTING AS HEMATEMESIS AFTER UPPER ENDOSCOPY

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Aortoesophageal fistulas (AEFs) are a rare and deadly cause of upper gastrointestinal bleeds. Prior repair of the thoracic aorta, primary aortic aneurysms, foreign body ingestion and thoracic cancer account for more than 90% of AEFs. Here we present the case of a patient developing AEF after a diagnostic esophagogastroduodenoscopy (EGD). CASE PRESENTATION: A 72-year-old male smoker with a history lung cancer status post right lobectomy presented with months of progressive solid dysphagia. In the past months he underwent two EGDs with balloon dilation of esophageal strictures, of which the most recent one was complicated by a distal esophageal perforation requiring an esophageal stent. Weeks after stent removal his dysphagia returned, prompting a repeat EGD to obtain biopsies of his stricture [Figure 1A-B]. The post-operative course was complicated by a small episode of hematemesis, for which the patient was offered admission for observation but declined. After eating his first meal at home, the patient had a second episode of hematemesis which prompted him to present to the emergency department. On admission, the patient was noted to have hematemesis necessitating a rapid response activation. He underwent emergent endotracheal intubation for airway protection and was started on pantoprazole and octreotide infusions. A massive transfusion protocol was initiated, and the patient was transferred to the intensive care unit where he was started on multiple vasopressors for his hypovolemic shock. A stat computed tomography angiogram (CTA) of the chest was suspicious for an underlying aorto-esophageal fistula [Figure 2A-C]. Thoracic surgery was consulted and given the patient’s age and complexity of the procedure; he was deemed a poor surgical candidate. Ultimately the patient’s family decided to pursue comfort care and the patient passed shortly thereafter. DISCUSSION: The presentation of AEF is characterized by a triad of midthoracic pain, sentinel arterial hemorrhage, and massive hemorrhage after a symptom-free interval. While initial clot formation tamponades the fistula, GI contents rapidly weaken this clot. Evaluation for AEF should done with a CTA-Chest as it has been found to be more sensitive than EGD. Initial therapy should focus on achieving hemodynamic stability via thoracic endovascular aneurysm repair or aortic graft replacement. AEF outcomes are improved when the esophageal pathology can be addressed with esophagectomy, stenting, or fistula repair, and with use of post-operative broad-spectrum antibiotics. Prompt surgical intervention increases one-year survival up to 50%. CONCLUSIONS: AEF should be included in the differential of hematemesis after instrumentation for an EGD. Limited time exists between the herald bleed and massive hemorrhage to confirm the diagnosis and plan for a surgical approach. CTA-Chest should be obtained first, followed by an EGD when imaging is inconclusive. Reference #1: Takeno S, Ishii H, Nanashima A, Nakamura K. Aortoesophageal fistula: review of trends in the last decade. Surg Today. December 2019:1-9. Reference #2: Uittenbogaart M, Sosef MN, van Bastelaar J. Sentinel bleeding as a sign of gastroaortic fistula formation after oesophageal surgery. Case Rep Surg. 2014;2014:614312. Reference #3: Vu QDM, Menias CO, Bhalla S, Peterson C, Wang LL, Balfe DM. Aortoenteric fistulas: CT features and potential mimics. Radiographics. 2009;29(1):197-209. DISCLOSURES: No relevant relationships by Hareen Chela, source=Web Response No relevant relationships by Ethan Karle, source=Web Response No relevant relationships by Adam Letvin, source=Web Response No relevant relationships by Tarang Patel, source=Web Response No relevant relationships by Shyam Shankar, source=Web Response

Early tracheostomy is associated with better prognosis in patients with brainstem hemorrhage.

Brainstem hemorrhage is presumed to be invariably associated with a poor prognosis in people with spontaneous hypertensive cerebral hemorrhage. The optimal timing of tracheostomy placement in brainstem hemorrhage patients, who generally require endotracheal intubation for airway protection, remains uncertain. Our research aim was to analyze the impact of early tracheostomy versus late tracheostomy on brainstem hemorrhage patients related outcomes and prognostic factors at 30 days. We identified early tracheostomy and how it could benefit the patients with brainstem hemorrhage and ameliorate the predictors of functional recovery at 30 days. Data on 136 patients with brainstem hemorrhage and Glasgow Coma Scale score ≤ 8, were retrospectively collected from 2012 to 2019. Patients were divided into the early tracheostomy group and the late tracheostomy group. Patients in the early tracheostomy group had a significantly lower neurosurgical intensive care unit stay (both overall and survival) compared with the late tracheostomy group (15.6 days vs. 19.0 days, P = 0.041, overall and 14.5 vs. 19.5 days, P = 0.023, survival). Also, the good outcomes (modified Rankin Score ≤ 3) were higher in the early tracheostomy group (P = 0.036). Multivariate analysis demonstrated that less hemorrhagic volume, high Glasgow Coma Scale score on admission, young age, and early tracheostomy were significantly associated with a better 30-day functional outcome. In conclusion, an early tracheostomy in patients with brainstem hemorrhage can reduce neurosurgical intensive care unit stay, and in addition to improvements in prognosis at 30 days.

2405 Even When All Hell Breaks Loose…We Have a Plan!

INTRODUCTION: Acute variceal bleeding is a severe complication of portal hypertension. Endoscopic banding successfully controls the vast majority of acute variceal bleeding. Refractory variceal bleeding refers to a small percentage of acute variceal bleeding not controlled by endoscopic therapy, requiring more aggressive modalities such as a Sengstaken–Blakemore tube. We present a case series of two patients with hematemesis secondary to varices, requiring the use of Self-expandable metal stents (SEMS) with successful hemostasis. CASE DESCRIPTION/METHODS: Patient 1: A 38-year-old male with decompensated cirrhosis in the setting of alcohol use complicated by esophageal varices presented with hematemesis. On presentation, he was hypotensive and tachycardic with several large bouts of hematemesis prompting endotracheal intubation for airway protection. He required a massive transfusion protocol and was started on vasopressor support. Initial upper endoscopy showed five columns of large varices (&gt;5 mm) in the middle third and lower third of the esophagus. One varix was actively spurting at about 38 cm from the incisor, for which four bands were successfully placed with resolution of the active bleeding. The patient had a repeat episode of massive hematemesis the following day requiring upper endoscopy during which active bleeding was appreciated but a source could not be accurately identified. Due to lack of visualization, banding could not be repeated and a fully covered 23 mm × 105 mm esophageal stent was placed starting at 30 cm from the incisor to the GE junction with excellent hemostasis. The patient had no further episodes of hematemesis and was transferred for liver transplant evaluation. Patient 2: A 30-year-old male with incompletely treated hepatitis B complicated by hepatocellular carcinoma invading the portal vein and extending to the Superior Mesenteric Vein presented with hematemesis. He was intubated and required upper endoscopies on two consecutive days for management of active bleeding from esophageal varices with banding. He was considered not to be a candidate for TIPS. On day 3, he had another episode of hematemesis causing hypotension. An upper endoscopy was performed and a fully covered esophageal stent was placed to tamponade the varices. He did not have any more episodes of bleeding in the remaining hospitalization. DISCUSSION: SEMS should be considered as an option for management of refractory variceal bleeding.

Does Procalcitonin “Get High” on Flakka? A Case of Extreme Procalcitonin Elevation Due to Psychostimulant Abuse

SESSION TITLE: Poisoning and Drug Overdose 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: We present the first reported case of cathinone associated procalcitonin elevation in the absence of infection. These agents may warrant consideration as potential confounders of procalcitonin values. CASE PRESENTATION: A 42 year-old Caucasian male presented to the emergency room after being found on the street by law enforcement while hallucinating and exhibiting violent behavior. He reported using amphetamines, cocaine, MDMA and “flakka” within a 24-hour period. Further history at that time was limited by agitation. He required 10 mg haloperidol, 4 mg lorazepam, restraints, and ultimately endotracheal intubation for airway protection. Pertinent vitals included hyperthermia to 39.8 Celsius and tachycardia to 136 beats/minute. No leukocytosis was present on complete blood count (WBC=9,700 cells/mcL). Procalcitonin (PCT) was elevated to 7.23 ng/mL. Rhabdomyolysis was diagnosed: total creatinine kinase=46,149 U/L, AST=893, ALT=201. Acute kidney injury (AKI) secondarily presented with serum creatinine=5.15 mg/dL and estimated GFR=12 mL/min/1.73 m2. Imaging was unrevealing: chest x-ray showed no acute cardiopulmonary disease, KUB non-obstructive bowel gas pattern and CT head without contrast had no mass or infarct. Cultures revealed no signs of infection with two negative blood cultures and negative urine culture. Urine toxicology was positive for amphetamines, cocaine, opiates, and benzodiazepines. The following day he was extubated. Fever resolved and renal function slowly returned to baseline with aggressive IV fluids. DISCUSSION: PCT production increases in neuroendocrine cells of the lung and intestines during infection as a response to inflammatory cytokines and bacterial endotoxins. Because of this, PCT has established itself as a useful biomarker for antibiotic de-escalation. Despite utility as a marker for sepsis and systemic inflammation, clinicians must be wary of confounding factors that increase PCT. For example, there are case reports of cocaine and amphetamine associated PCT elevations. Extensive literature review shows no documented cases of flakka associated PCT elevation. Alpha-Pyrrolidinopentiophenone, known colloquially as flakka, is a relatively new street drug in the cathinone class. It has powerful psychostimulant effects including hallucinations, sympathetic stimulation and agitation. Cathinone’s biochemical effects on PCT are unknown. CONCLUSIONS: PCT should be regarded as a sensitive but not specific tool. This case demonstrates PCT elevation without infection, which can thus be attributed to sympathomimetics including the novel drug flakka. Reference #1: A. Lovas, et al., (2014). Extreme Procalcitonin Elevation without Proven Bacterial Infection Related to Amphetamine Abuse. Case Reports in Critical Care, 2014. Reference #2: C. Wacker, et al., “Procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis,” The Lancet Infectious Diseases, vol.13, no.5, pp.426-435, 2013. DISCLOSURE: The following authors have nothing to disclose: Grant Nelson, Stuart Shah, James Cury No Product/Research Disclosure Information

Effect of Early Versus Late Tracheostomy or Prolonged Intubation in Critically Ill Patients with Acute Brain Injury: A Systematic Review and Meta-Analysis.

The optimal timing of tracheostomy placement in acutely brain-injured patients, who generally require endotracheal intubation for airway protection rather than respiratory failure, remains uncertain. We systematically reviewed trials comparing early tracheostomy to late tracheostomy or prolonged intubation in these patients. We searched 5 databases (from inception to April 2015) to identify randomized controlled trials comparing early tracheostomy (≤10days of intubation) with late tracheostomy (>10days) or prolonged intubation in acutely brain-injured patients. We contacted the principal authors of included trials to obtain subgroup data. Two reviewers extracted data and assessed risk of bias. Outcomes included long-term mortality (primary), short-term mortality, duration of mechanical ventilation, complications, and liberation from ventilation without a tracheostomy. Meta-analyses used random-effects models. Ten trials (503 patients) met selection criteria; overall study quality was moderate to good. Early tracheostomy reduced long-term mortality (risk ratio [RR] 0.57. 95% confidence interval (CI), 0.36-0.90; p=0.02; n=135), although in a sensitivity analysis excluding one trial, with an unclear risk of bias, the significant finding was attenuated (RR 0.61, 95% CI, 0.32-1.16; p=0.13; n=95). Early tracheostomy reduced duration of mechanical ventilation (mean difference [MD] -2.72days, 95% CI, -1.29 to -4.15; p=0.0002; n=412) and ICU length of stay (MD -2.55days, 95% CI, -0.50 to -4.59; p=0.01; n=326). However, early tracheostomy did not reduce short-term mortality (RR 1.25; 95% CI, 0.68-2.30; p=0.47 n=301) and increased the probability of ever receiving a tracheostomy (RR 1.58, 95% CI, 1.24-2.02; 0<0.001; n=377). Performing an early tracheostomy in acutely brain-injured patients may reduce long-term mortality, duration of mechanical ventilation, and ICU length of stay. However, waiting longer leads to fewer tracheostomy procedures and similar short-term mortality. Future research to explore the optimal timing of tracheostomy in this patient population should focus on patient-centered outcomes including patient comfort, functional outcomes, and long-term mortality.

Lidocaine-Induced Cardiac Arrest in the Emergency Department: Effectiveness of Lipid Therapy

BackgroundLocal anesthetics are commonly used in the emergency department (ED). Overdoses can lead to disastrous complications including cardiac toxicity and arrest. Recognition of local anesthetic systemic toxicity (LAST) is important; however, prevention is even more critical. Knowledge of proper lidocaine dosage can prevent LAST. LAST may be effectively treated with lipid emulsion therapy. Although the mechanism is not well understood, its use may have a profound impact on morbidity and mortality. Case ReportFifty milliliters of 2% lidocaine was infiltrated for local anesthesia in a 35-year-old woman during the incision and drainage of a labial abscess. Following the procedure, the patient complained of vomiting, with rapid progression to an altered mental state and seizure requiring endotracheal intubation for airway protection. Suspecting lidocaine toxicity, intralipids were ordered. While waiting for the intralipids, the patient decompensated and suffered pulseless electrical activity (PEA) cardiac arrest. A 100-mL bolus of 20% intralipids was administered 3 minutes into the resuscitation, after which return of spontaneous circulation occurred. The intralipid bolus was then followed by a continuous infusion of 0.25 mL/kg/minute, for an infusion dose of 930 mL. Despite a complicated hospital course, the patient was discharged home neurologically intact. Why Should an Emergency Physician Be Aware of This?We believe this patient's cardiovascular collapse was secondary to an iatrogenic overdose of lidocaine. This is one of the first cases to support the efficacy of intravenous lipids in the treatment of LAST in humans in the ED.

Sliding to Safety

A 56-year-old man was brought to the ED after being found unconscious on the street. The initial neurologic exam resulted in a Glasgow Coma Scale score of 3. After endotracheal intubation for airway protection, a CT scan of the head revealed a large left-side intracranial hemorrhage with a 5-mm midline shift and the patient was transferred to our medical ICU for management. Soon after arrival, central venous access was attempted via a left subclavian vein approach because of insufficient peripheral access sites. Immediately after the procedure, severe hypotension (BP =62/46) and desaturation (oxygen saturation =65%) developed. Concern for an iatrogenic tension pneumothorax led to immediate preparation for needle decompression and chest thoracostomy-tube placement. During preparation, a team member performed a physical examination and a left-side chest ultrasound survey. Physical examination revealed presence of equal, bilateral breath sounds and the symmetric appearance of hemithorax dimensions. Ultrasound findings are shown in Videos 1-3.

Tracheal Perforation from Primary Thyroid Lymphoma

Objective: To describe a rare case of tracheal perforation due to invasive primary thyroid lymphoma and suggest that expectant management with temporary airway protection is an option to invasive interventions such as tracheotomy and tracheal stent placement. Method: We report a case of primary B-cell thyroid lymphoma causing acute airway obstruction in an elderly female who required emergency endotracheal intubation for airway protection. Results: After receiving one cycle of chemotherapy with rapid response in terms of tumor size reduction, she was found to have extensive anterior tracheal wall necrosis and perforation on both radiologic imaging and direct bronchoscopic examination. She was able to be quickly extubated and survived without intervention. Conclusion: There is currently no standard of care in terms of management of invasive thyroid lymphoma causing airway obstruction due to its rare incidence. We propose that expectant management with temporary airway protection is an option to procedures such as tracheotomy or tracheal stenting, even in the scenario of airway perforation.

Superselective Microcatheter Embolization of Hemorrhage after Buccal Lipectomy

Superselective microcatheter angiography and embolization has been shown to be an effective modality for prompt treatment of bleeding from traumatic facial injury and refractory epistaxis when local methods fail to achieve hemostasis. It obviates the need for further surgical exploration and provides precise diagnostic and therapeutic modalities in a minimally invasive manner. Despite this successful profile, its use in treatment of hemorrhagic complications after facial aesthetic surgery is underreported. This report is a unique case of life-threatening hemorrhage after buccal fat pad lipectomy that was successfully treated with superselective microcatheter embolization of internal maxillary artery branches. A 31-year-old male was transferred to our emergency room from an outside facility with an active intraoral hemorrhage after a buccal lipectomy in which severe bleeding was encountered deep within the buccal space that persisted despite further attempts at surgical exploration. On arrival to the emergency room, the patient demonstrated signs of significant blood loss and had intraoral packing in place tamponading further hemorrhage. The patient underwent resuscitation and stabilization with endotracheal intubation for airway protection and was sent emergently to the angiography suite. Superselective angiography was used to study branches of the internal maxillary artery. Superselective embolization using microspheres was then performed on target vessels to control the bleeding. The surgical packing was then removed with no evidence of active bleeding. The patient was transferred to the surgical intensive care unit for further monitoring and was discharged the following day in stable condition. In the case of refractory surgical measures, superselective microcatheter angiography and embolization provides an alternative to both precisely localize and control severe small-artery bleeding. This may be ideal in cases that otherwise would require extensive dissection and in regions of complex anatomy, both of which can compromise aesthetic outcomes. We demonstrated the use of this method in a case of refractory bleeding after facial lipectomy. The expanding role of superselective angiography and specifically designed embolic agents may play an invaluable role in treatment of arterial injury after aesthetic surgery when local methods fail. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Intra-Arterial Nicardipine for the Treatment of Cerebral Vasospasm in Postpartum Cerebral Angiopathy: A Case Study and Review of Literature

ABSTRACTIntroduction: Postpartum cerebral angiopathy is one of the many neurological complications seen during pregnancy and the postpartum period. Management of these patients consists of optimal blood pressure control, and general supportive critical care. We present a case of diffuse cerebral vasospasm, which improved with intra-arterial nicardipine. This brief report addresses the utility of interventional management in cases of postpartum cerebral angiopathy. Case report: A 28-year-old female presented 1 week after cesarean delivery with altered mental status, endotracheal intubation for airway protection, thrombocytopenia, and hypofibrinogenemia. Cerebral angiogram revealed anterior and posterior circulation vasospasm, which responded to repeated selective intra-arterial injections of nicardipine. This treatment coupled with optimal blood pressure control resulted in complete recovery. Discussion: Our case report highlights the importance of cerebral angiography for the diagnosis and treatment of patients with postpartum cerebral angiopathy. Although nicardipine is used in patients with aneurysmal subarachnoid hemorrhage for the treatment of cerebral vasospasm, this agent has the potential to be used in patients with cerebral vasospasm due to other etiologies. Summary: Intra-arterial nicardipine is one of the therapeutic measures available to physicians in the management of patients with cerebral vasospasm. In patients with postpartum cerebral angiopathy, early cerebral angiography should be considered to quantify and treat cerebral vasospasm with either angioplasty or selective intra-arterial injections of nicardipine.

Traumatic Hemoptysis Treated With Recombinant Human Factor VIIa

Blunt thoracic trauma resulting in massive hemoptysis is rare. Although there are several indications for the administration of recombinant factor VIIa, we are unaware of a report of its utilization in the treatment of hemoptysis following chest trauma. We report a case of the successful use of factor VIIa in the treatment of life-threatening hemoptysis secondary to blunt force thoracic injury and traumatic coagulopathy.

Model for end-stage liver disease (MELD) exception guidelines: Results and recommendations from the MELD exception study group and conference (MESSAGE) for the approval of patients who need liver transplantation with diseases not considered by the standard MELD formula

Richard B. Freeman Jr., Robert G. Gish, Ann Harper, Gary L. Davis, John Vierling, Leslie Lieblein, Goran Klintmalm, Jamie Blazek, Robert Hunter, and Jeffrey Punch Division of Transplantation, Department of Surgery, Tufts–New England Medical Center, Boston, MA; Departments of Medicine and Transplantation and the Division of Hepatology and Complex GI, Physicians Foundation, California Pacific Medical Center, San Francisco, CA; United Network for Organ Sharing, Richmond, VA; Baylor Regional Transplant Institute, Baylor University Medical Center, Dallas, TX; Department of Medicine, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, CA; Ochsner Multi-Organ Transplant Center, New Orleans, LA; and Department of Surgery, University of Michigan, Ann Arbor, MI

Successful resuscitation of a verapamil intoxicated child with a dextrose-insulin infusion

Objective: To report the use of dextrose-insulin infusion in the successful resuscitation of an adolescent following an overdose of sustained-release verapamil that was refractory to traditional medical management.Case summary: A 13-year-old female with depression and post-traumatic stress disorder ingested 25–30 120-mg tablets (120–140 mg/kg) of sustained-release verapamil in a suicide attempt. Gastric lavage was performed, and activated charcoal and sorbitol were given for gastric decontamination. She developed atrial-ventricular (A-V) dissociation, bradycardia, hypotension and somnolence. Initial interventions included endotracheal intubation for airway protection, fluid resuscitation, high-dose intravenous calcium chloride, and glucagon. Hypotension and A-V block continued despite the addition of dopamine, epinephrine, and norepinephrine infusions. Normal sinus rhythm and hemodynamic stability occurred only after an infusion of regular insulin (0.1 U/kg/hr) and dextrose (0.5 g/kg/hr) was started. She ...

Deep Fascial Space Infection of the Neck: A Continuing Challenge

We present our clinical experience with two complex cases of deep fascial space infections of the neck. The first was a case of cervical necrotizing fasciitis involving the submental space. The second was an infection beginning at the soft palate and extending to the anterior mediastinum. Both infections emanated from an oral source in patients with diabetes mellitus, and both patients required multiple surgical debridements and endotracheal intubation for airway protection. Despite the declining incidence of deep space neck infections, our cases illustrate the challenging diagnostic and treatment dilemmas for the clinician managing patients with diabetes.

Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage

Background: Aspiration of blood may cause significant morbidity during emergent endoscopy for severe upper GI bleeding. Endotracheal intubation is widely performed for airway protection in this setting, but there are few data regarding its efficacy. Methods: Outcomes were compared for intensive care unit patients with upper GI bleeding for 1 year (1988) during which prophylactic endotracheal intubation was seldom performed before endoscopy, with outcomes during a subsequent year (1992) in which endotracheal intubation was routine for airway protection before or during EGD when there was hematemesis, altered mentation, unstable cardiopulmonary status, or large amounts of blood in the proximal GI tract, or before endoscopic treatment of lesions at high risk for bleeding. Results: Background variables were similar for intensive care unit patients in 1988 (n = 101) and 1992 (n = 119) with respect to number of patients who had shock (respectively, 66.3% vs. 67.2%), cirrhosis (34.7% vs. 38.6%), variceal/portal hypertensive bleeding (22.8% vs. 33.6%), and endoscopic therapy (37.6% vs. 42.0%). Although use of endotracheal intubation specifically for EGD increased significantly between 1988 and 1992 (3.0% vs. 15.1%; p < 0.05), there were no significant changes in endotracheal intubation at any time during hospitalization (24.8% vs. 28.6%), in all EGD-related cardiopulmonary complications (5.0% vs. 3.4%), in new pulmonary infiltrates after EGD (12.9% vs. 15.1%), in mean number of intensive care unit days (7.1 vs. 6.4), or in mortality (15.9% vs. 11.8%). New infiltrates developed in 10 (48%) of 21 patients after EGD despite endotracheal intubation specifically for airway protection. However, in 1992 there were no fatal episodes of aspiration during EGD (2.0% vs. 0%; p = 0.21), no emergent post-EGD endotracheal intubation (6.0% vs. 0%; p < 0.05), and fewer in-hospital cardiopulmonary arrests (12.9% vs. 5.0%; p < 0.05). Conclusion: Frequent use of endotracheal intubation for airway protection during EGD for upper GI bleeding requiring intensive care unit admission did not significantly change the relatively high frequency of acquired pneumonia or cardiopulmonary events, but may have prevented the rare fatal episode of massive aspiration. Endotracheal intubation may benefit selected patients with upper GI bleeding, but its specific role remains unclear, and alternative methods of airway protection should be investigated. (Gastrointest Endosc 2003;57:58-61.)

Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage

Background: Aspiration of blood may cause significant morbidity during emergent endoscopy for severe upper GI bleeding. Endotracheal intubation is widely performed for airway protection in this setting, but there are few data regarding its efficacy. Methods: Outcomes were compared for intensive care unit patients with upper GI bleeding for 1 year (1988) during which prophylactic endotracheal intubation was seldom performed before endoscopy, with outcomes during a subsequent year (1992) in which endotracheal intubation was routine for airway protection before or during EGD when there was hematemesis, altered mentation, unstable cardiopulmonary status, or large amounts of blood in the proximal GI tract, or before endoscopic treatment of lesions at high risk for bleeding. Results: Background variables were similar for intensive care unit patients in 1988 (n = 101) and 1992 (n = 119) with respect to number of patients who had shock (respectively, 66.3% vs. 67.2%), cirrhosis (34.7% vs. 38.6%), variceal/portal hypertensive bleeding (22.8% vs. 33.6%), and endoscopic therapy (37.6% vs. 42.0%). Although use of endotracheal intubation specifically for EGD increased significantly between 1988 and 1992 (3.0% vs. 15.1%; p < 0.05), there were no significant changes in endotracheal intubation at any time during hospitalization (24.8% vs. 28.6%), in all EGD-related cardiopulmonary complications (5.0% vs. 3.4%), in new pulmonary infiltrates after EGD (12.9% vs. 15.1%), in mean number of intensive care unit days (7.1 vs. 6.4), or in mortality (15.9% vs. 11.8%). New infiltrates developed in 10 (48%) of 21 patients after EGD despite endotracheal intubation specifically for airway protection. However, in 1992 there were no fatal episodes of aspiration during EGD (2.0% vs. 0%; p = 0.21), no emergent post-EGD endotracheal intubation (6.0% vs. 0%; p < 0.05), and fewer in-hospital cardiopulmonary arrests (12.9% vs. 5.0%; p < 0.05). Conclusion: Frequent use of endotracheal intubation for airway protection during EGD for upper GI bleeding requiring intensive care unit admission did not significantly change the relatively high frequency of acquired pneumonia or cardiopulmonary events, but may have prevented the rare fatal episode of massive aspiration. Endotracheal intubation may benefit selected patients with upper GI bleeding, but its specific role remains unclear, and alternative methods of airway protection should be investigated. (Gastrointest Endosc 2003;57:58-61.)

Efficacy of fiberoptic laryngoscopy in the diagnosis of inhalation injuries.

A significant proportion of burn patients with inhalation injuries incur difficulties with airway protection, dysphagia, and aspiration. In assessing the need for intubation in burn patients, the efficacy of fiberoptic laryngoscopy was compared with clinical findings and the findings of diagnostic tests, such as arterial blood gas analysis, measurement of carboxyhemoglobin levels, pulmonary function tests, and radiography of the lateral aspect of the neck. To determine if these patients were at risk for aspiration or dysphagia, barium-enhanced fluoroscopic swallowing studies were performed. Prospective study. Burn intensive care unit in an academic tertiary referral center. Need for endotracheal intubation and potential for aspiration. Six (55%) of 11 patients had clinical findings and symptoms that indicated, under traditional criteria, endotracheal intubation for airway protection. Visualization of the upper airway with fiberoptic laryngoscopy obviated the need for endotracheal intubation in all 11 patients. These patients also failed to evidence an increased risk of aspiration or other swallowing dysfunction. In comparison with other diagnostic criteria, fiberoptic laryngoscopy allows differentiation of those patients with inhalation injuries who, while at risk for upper airway obstruction, do not require intubation. These patients may be safely observed in a monitored setting with serial fiberoptic examinations, thus avoiding the possible complications associated with intubation of an airway with a compromised mucosalized surface. In these patients, swallowing abnormalities do not manifest.

Endotracheal intubation for airway protection in endoscopy for severe upper gastrointestinal hemorrhage: Effect on patient outcome

Endotracheal intubation for airway protection in endoscopy for severe upper gastrointestinal hemorrhage: Effect on patient outcome