Traumatic Intubation Research Articles

S2076 Consequences of Going over to the ‘Right’ Side in the Wrong Way: Impact of an Aberrant Subclavian Artery

Introduction: Tracheoesophageal fistulas (TEFs) in adults are uncommon and typically acquired. Traumatic or prolonged intubation account for up to 75% of acquired nonmalignant TEFs.1 No definitive guidelines exist for management of this complication which has poor prognosis without intervention. Case Description/Methods: A 68 year old male presented with SOB and fevers then had prolonged ICU course for COVID-ARDS. The hospital course was complicated by recurrent VAP and unsuccessful attempts to wean the ventilator. He was transitioned to tracheostomy after 34 days. GI was then consulted for PEG placement which was aborted after endoscopy showed what initially appeared to be an ulcer. Further inspection revealed that it was the tracheotomy cuff in the esophagus. (Image 1) PEG placement was deferred and patient underwent tracheostomy exchange for ETT, advanced distal to the site of the fistula, along with esophageal stent placement with CT surgery. Within days patient developed worsening hypoxia refractory to vent adjustments and profound shock then ultimately passed. Discussion: Prognosis for unrepaired TEF is poor with mean survival time 1-6 weeks.1 Risk factors for TEF in the setting of intubation include prolonged ventilation, immunosuppression, malnutrition, episodic hypotension, and NG/OG tube, thus, this patient was the ideal substrate. 2 Symptoms are non specific which delays diagnosis. Evaluation of TEF may include barium esophageal if patient is able to swallow or alternatively CT chest. Definitive diagnosis is made on endoscopy and/or bronchoscopy. Very rarely TEFs may close spontaneously without intervention.3 Strategies for repair include esophageal bypass, direct repair and stenting.2 Studies comparing esophageal stenting with other interventions are lacking. Furthermore, there is no data comparing intervention with esophageal stent by GI vs CT surgery. Approach to repair will depend on the clinical context and physician comfort level. Ideally, patients with TEFs should be extubated, if reasonable, since continued positive airway pressure after repair can increase the risk of dehiscence or stent migration.

MALIGNANT HEMISPHERIC INFARCTION AFTER SUBTLE TRACHEAL RUPTURE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Tracheal rupture after endotracheal intubation is a rare but life-threatening complication with an incidence of approximately 0.005%. Predisposing factor can be a weakness of the membranous trachea secondary to chronic illness or steroid use. Herein we present a case of a young woman who developed a distal tracheal rupture after emergent endotracheal intubation with devastating consequences. CASE PRESENTATION: A 48-year-old female with a medical history of hypertension, epilepsy, and panhypopituitarism secondary to a respected craniopharyngioma was admitted to the intensive care unit with a diagnostic impression of obstructive uropathy with septic shock and multiorgan failure. Supportive management with aggressive fluids resuscitation, antibiotics, dual vasopressor therapy, and endotracheal intubation was given. Hours later, the patient became hemodynamically unstable requiring increased vasopressor therapy with increased demand in ventilation parameters. Physical examination was positive for massive subcutaneous emphysema from her chest tracking through facial and neck planes. A chest computerized tomography (CT) scan was performed and showed a distal tracheal rupture as the most likely cause of the massive pneumothorax that progressed to tension subcutaneous emphysema. Upon acute neurological deterioration, a head CT scan was performed, revealing a left pan-hemispheric malignant ischemic stroke involving the left anterior, middle, and posterior cerebral arteries suggestive of a left internal carotid artery (ICA) complete occlusion. The patient had a National Institutes of Health Stroke Scale score above 20, a left hemisphere infarction, and a GCS 3/11, conferring a poor clinical outcome. As poor prognosis and poor quality of life were expected, the family members opted to withdraw life support. DISCUSSION: Malignant hemispheric infarction has a mortality rate as high as 80 percent with catastrophic neurologic sequelae. Its incidence is less than ten percent of all ischemic infarcts and it's generally caused by embolic occlusion of the ICA. CONCLUSIONS: To our knowledge, there are no malignant hemorrhagic strokes provoked by traumatic intubation resulted from tracheal rupture documented to this day. We presume the etiology of this event to be subcutaneous air that exerted enough pressure between the fascial and cervical planes to result in significant vascular compression. Tracheal rupture is one of the most feared immediate complications of intubation as it could result in increased morbidity and mortality. There is no established consensus for the treatment yet, but early surgical repair has been the mainstay of treatment. However, conservative management has been chosen in cases of small ruptures with similar outcomes. REFERENCE #1: JOSEPH, M. M., & LEWIS, S. (2002). Stroke after penetrating trauma of the oropharynx. Pediatric Emergency Care, 18(3), 179–181.doi:10.1097/00006565-200206000-00007 DISCLOSURES: No relevant relationships by Ian Da Silva Lugo, source=Web Response No relevant relationships by Juan Feliciano-FIgueroa, source=Web Response No relevant relationships by Hector Nunez Medina, source=Web Response No relevant relationships by Héctor Oliveras-Cordero, source=Web Response No relevant relationships by Juan Santiago, source=Web Response

Pneumothorax and pneumomediastinum in COVID-19 acute respiratory distress syndrome

COVID-19 has involved numerous countries across the globe and the disease burden, susceptible age group; mortality rate has been variable depending on the demographical profile, economic status, and health care infrastructure. In the current clinical environment, COVID-19 is one of the most important clinical differential diagnoses in patients presenting with respiratory symptoms. The optimal mechanical ventilation strategy for these patients has been a constant topic of discussion and very importantly so, since a great majority of these patients require invasive mechanical ventilation and often for an extended period of time. In this report we highlight our experience with a COVID-19 patient who most likely suffered barotrauma either as a result of traumatic endotracheal intubation or primarily due to COVID-19 itself. We also aim to highlight the current literature available to suggest the management strategy for these patients for a favorable outcome. The cases described are diverse in terms of age variance and other comorbidities. According to the literature, certain patients, with COVID-19 disease and spontaneous pneumothorax were noted to be managed conservatively and oxygen supplementation with nasal cannula sufficed. Decision regarding need and escalation to invasive mechanical ventilation should be taken early in the disease to avoid complications such as patient self-inflicted lung injury (P-SILI) and barotrauma sequelae such as pneumothorax and pneumomediastinum Recent systematic review further supports the fact that the use of non-invasive ventilation (NIV) in certain patients with COVID-19 pneumonia may give a false sense of security and clinical stabilization but has no overall benefit to avoid intubation. While invasive mechanical ventilation may be associated with higher rates of barotrauma, this should not mean that intubation and invasive mechanical ventilation should be delayed. This becomes an important consideration when non-intensivists or personnel with less experience provide care for this vulnerable patient population who may rely too heavily on NIV to avoid intubation and mechanical ventilation.

The integral role of the clinical pharmacist in drug-assisted intubation at a newly established children\u2019s major trauma center

This commentary outlines how the clinical pharmacist can support the safe administration of emergency medications in trauma anesthesia for seriously injured children. Promoting the professional development of the clinical pharmacist provided an opportunity to strengthen a key step in our trauma care pathway. We describe the implementation of this process in a new hospital, which was to become the designated children’s trauma center for an entire country. Although the literature documents the use of pharmacists in emergency intubation, ours was a unique set of circumstances, where empowering the pharmacist in frontline clinical care provided additional quality assurance for rapid sequence induction and intubation in trauma. Medical simulation was a core part of socializing the advanced clinical practice role of pharmacy within the trauma team. It was our experience that the pharmacist helps to promote confidence and decision making among other members of the trauma team.

Assessment of Nonroutine Events During Intubation After Pediatric Trauma

BackgroundIntubation in the early postinjury phase can be a high-risk procedure associated with an increased risk of mortality when delayed. Nonroutine events (NREs) are workflow disruptions that can be latent safety threats in high-risk settings and may contribute to adverse outcomes. Materials and methodsWe reviewed videos of intubations of injured children (age<17 y old) in the emergency department occurring between 2014 and 2018 to identify NREs occurring between the decision to intubate and successful intubation (“critical window”). ResultsAmong 34 children requiring intubation, the indications included GCS≤8 (n = 20, 58.8%), cardiac arrest (n = 6, 17.6%), airway protection (n = 5, 14.7%), and respiratory failure (n = 3, 8.8%). The median duration of the “critical window” was 7.5 min (range 1.4-27.5 min), with a median of six NREs per case in this period (range 2-30). Most NREs (n = 159, 61.9%) delayed workflow, with 31 (12.1%) of these delays each lasting more than one minute. Eighty-seven NREs (33.9%) had a potential for harm but did not lead to direct patient harm. The most common NREs directly related to the intubation process were poor positioning for intubation (n = 23, 8.9%) and difficulty passing the endotracheal tube (n = 5, 1.9%), with most being attributed to the anesthesiologist performing the intubation (n = 51, range 0-7). ConclusionsWorkflow disruptions related to nonroutine events were frequent during pediatric trauma intubation and were often associated with delays and potential for patient harm. Interventions for improving the efficiency and timeliness of the critical window should focus on adherence to intubation protocol and improving communication and teamwork related to tasks in this phase.

In Search of Evidence for Using Noninvasive Ventilation for Severe Acute Asthma.

* Abbreviations: IMV — : invasive mechanical ventilation NIV — : noninvasive ventilation Noninvasive ventilation (NIV) is appealing for the treatment of severe asthma because it likely avoids the potential airway and lung trauma of intubation and invasive mechanical ventilation (IMV). In this issue of Pediatrics , Smith et al1 illustrate the compelling appeal of NIV in clinical use, showing that centers with high use of NIV in 2014 doubled their use of NIV in the next 4 years and that NIV is more common as a mode of respiratory support than IMV. … Address correspondence to Michael D. Johnson, MD, MS, Primary Children’s Hospital, 100 N Mario Capecchi Dr, Salt Lake City, UT 84108. E-mail: mike.johnson{at}hsc.utah.edu

IATROGENIC TRACHEAL RUPTURE POST ENDOTRACHEAL INTUBATION CAUSING PNEUMOMEDIASTINUM IN A DOWN SYNDROME PATIENT

SESSION TITLE: Medical Student/Resident Procedures Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Tracheal rupture is a rare, infrequent complication associated with endotracheal intubation. The complication rate is approximately 1:20,000, and is associated with significant increased morbidity and mortality. Our case describes the importance of early recognition and intervention, which can lead to improved clinical outcome. CASE PRESENTATION: Patient is a 77 year-old female with Down’s syndrome and atrial fibrillation who presented with decreased appetite, hypoxia, hypothermia, and hypotension. She was found to have pulmonary edema secondary to acute pancreatitis. CT chest showed bilateral pleural effusions and bibasilar pneumonia. She was started on broad spectrum antibiotics, norepinephrine, and oxygen. Patient subsequently required mechanical ventilation for worsening respiratory distress. Post intubation CXR noted appropriate ET tube placement, without any subcutaneous emphysema. However, she was difficult to oxygenate and ventilate. Repeat CT chest was obtained which showed bilateral subcutaneous emphysema. Bronchoscopy at bedside revealed a 2 cm tracheal tear secondary to traumatic intubation leading to significant pneumomediastinum. Bilateral thoracostomy tubes were placed with initial improvement in her oxygenation. Over the next day, she was unable to be liberated from the ventilator. Another CT chest showed progressive pneumomediastinum and thoracostomy tubes were found to be kinked. Subsequently, thoracostomy tubes were removed and pigtail catheters were inserted. Interventional pulmonology then evaluated the patient and had been planning for a tracheostomy inferior to the site of rupture, however after the placement of the pigtail catheters, the patient’s clinical status markedly improved. Further imaging showed resolution of the emphysema. She was further extubated and discharged back to her facility. DISCUSSION: Upon reviewing post intubation CXR, there were subtle signs of subcutaneous air outside the trachea, which reinstates the importance of reviewing all images closely. However, as noted, this patient continued to have poor oxygenation, which should raise a concern for tracheal injury post intubation. Patients with Down’s Syndrome also have several anatomical abnormalities that can lead to difficult intubation, including macroglossia, short neck, and narrower tracheas. The pediatric literature suggests that an ETT 2 sizes smaller than normal should be considered, however to the best of our knowledge, there are no guidelines in the adult patient with Down’s Syndrome CONCLUSIONS: Our case is uncommon, as the incidence of airway injury is estimated to be 0.005% for all ET intubations. This case conveys the need to have high suspicion for tracheal injury in the setting of clinical symptoms after intubation, despite initial review of the imaging appearing normal. Early recognition of traumatic complications can lead to early intervention and favorable outcomes Reference #1: Aboussouan LS, O'Donovan PB, Moodie DS, Gragg LA, Stoller JK. Hypoplastic trachea in Down's syndrome. Am Rev Respir Dis. 1993;147(1):72-75. doi:10.1164/ajrccm/147.1.72 Reference #2: Shott SR. Down syndrome: analysis of airway size and a guide for appropriate intubation. Laryngoscope. 2000;110(4):585-592. doi:10.1097/00005537-200004000-00010 Reference #3: Singh S, Gurney S. Management of post-intubation tracheal membrane ruptures: A practical approach. Indian J Crit Care Med. 2013;17(2):99-103. doi:10.4103/0972-5229.114826 DISCLOSURES: No relevant relationships by Kia Ghiassi, source=Web Response No relevant relationships by Prateek Juneja, source=Web Response No relevant relationships by Jack Kanoff, source=Web Response No relevant relationships by Sunil Ramaswamy, source=Web Response

A Randomized Controlled Trial of Dexamethasone as a Prophylactic Treatment for Subglottic Stenosis in a Rabbit Model.

Iatrogenic injury is a common cause of subglottic stenosis (SGS). We investigated the role of pre-injury dexamethasone as a preventive treatment for iatrogenic subglottic stenosis. 16 New Zealand White rabbits were used in an IACUC approved study. Subjects were divided into two groups: intramuscular dexamethasone (DEX) at a dose of 2 mg/kg 15 minutes prior to an endoscopic injury to create SGS, and the same injury creation with a preoperative intramuscular saline (SAL) injection. Three independent, blinded raters evaluated endoscopic images to obtain cross sectional area (CSA) airway measurements. Rabbit airways were measured just prior to injury and at one week post-injury. All subjects were provided as-needed postoperative steroids and buprenorphine for symptoms of respiratory distress. Data analysis was performed using Student t-test. Intraclass correlation coefficients were used to assess inter-rater agreement. All subjects survived to the one-week post-injury airway evaluation. There was no difference in airway size between groups prior to injury (P = .28). Subjects in the DEX group demonstrated an average stenosis of 20.3% (95% CI 10.2-30.5) at one week compared to 60.6% (95% CI 40.3-80.9) in the SAL group (P = .01). Subjects in the control group required significantly more doses of postoperative dexamethasone (P = .02). Inter-rater agreement for between raters was excellent (ICC = .88). This is the first study to examine the role of pre-injury glucocorticoids in preventing iatrogenic subglottic stenosis. In our model, a single dose of intramuscular dexamethasone given prior to a subglottic injury resulted in a statistically significant reduction in airway stenosis. This research suggests that administering systemic dexamethasone should be considered prior to any procedure that may injure the subglottis, including traumatic intubation, to prevent iatrogenic subglottic stenosis.

Efficacy and safety of videolaryngoscopy versus direct laryngoscopy in paediatric intubation: A meta-analysis of 27 randomized controlled trials

ObjectiveAnatomical and physiological differences in paediatric and adult airways make intubation of paediatric patients a challenge. This study aimed to compare the efficacy and safety of video laryngoscopy (VL) to direct laryngoscopy (DL) on intubation outcomes in paediatric patients. DesignSystematic review and meta-analysis. SettingOperating room. PatientsPaediatric patients who needed tracheal intubation. InterventionVideo laryngoscopy or direct laryngoscopy. MeasurementsElectronic searches in PubMed, Embase, and the Cochrane Library were performed to identify relevant randomized controlled trials published through January 2020. Outcomes included time to intubate, intubation failure at first attempt, Cormack-Lehane laryngeal view grade, intubation difficulty scale (IDS), percentage of glottic opening score (POGO), optimal external laryngeal manipulation (OLEM), and complications. Relative risks and weighted mean difference (WMD), with 95% CI, were employed to calculate summary results using a random-effects model. Main resultsOverall, 27 trials including 2461 paediatric patients were analysed. Children with video laryngoscopy intubation required longer time to intubate than direct laryngoscopy intubation (WMD 3.41, 95% CI: 1.29–5.53, P = 0.002), whereas infants receiving video laryngoscopy and direct laryngoscopy intubation experienced similar time to intubate (WMD 1.72, 95% CI: −1.09-4.54, P = 0.230). No significant differences were observed on intubation failure at first attempt between video laryngoscopy and direct laryngoscopy intubations in children and infants, respectively. Video laryngoscopy improved the POGO and intubation trauma but not Cormack-Lehane laryngeal view grade, IDS, external laryngeal manipulation, hoarseness, or oxygen desaturation. ConclusionsCompared with direct laryngoscopy intubation, there were no benefits for paediatric patients with video laryngoscopy on time to intubate and failure at first attempt, but there were benefits with regard to POGO and intubation trauma.

Idiopathic nonhistaminergic acquired angioedema in a patient with coronavirus disease 2019

Idiopathic nonhistaminergic acquired angioedema in a patient with coronavirus disease 2019

Videolaryngoscopy versus direct laryngoscopy for double-lumen endotracheal tube intubation in thoracic surgery - a randomised controlled clinical trial

BackgroundDouble-lumen tube (DLT) intubation is necessary for thoracic surgery and other operations with the need for lung separation. However, DLT insertion is complex and might result in airway trauma. A new videolaryngoscopy (GVL) with a thin blade might improve the intubation time and reduce complexity as well as iatrogenic airway complications compared to conventional direct laryngoscopy (DL) for DLT intubation.MethodsA randomised, controlled trial was conducted in 70 patients undergoing elective thoracic surgery using DLT for lung separation. Primary endpoint was time to successful intubation. The secondary endpoints of this study were number of intubation attempts, the assessment of difficulty, any complications during DLT intubation and the incidence of objective trauma of the oropharynx and supraglottic space and intubation-related subjective symptoms.Results65 patients were included (DL group [n = 31], GVL group [n = 34]). Median intubation time (25th–75th percentiles) in GVL group was 93 s (63–160) versus 74 (58–94) in DL group [p = 0.044]. GVL resulted in significantly improved visualisation of the larynx (Cormack and Lehane grade of 1 in GVL group was 97% vs. 74% in DL Group [p = 0.008]). Endoscopic examinations revealed significant differences in GVL group compared to DL group showing less red-blooded vocal cord [p = 0.004], vocal cord haematoma [p = 0.022] and vocal cord haemorrhage [p = 0.002]. No significant differences regarding the postoperative subjective symptoms of airway were found.ConclusionsVideolaryngoscopy using the GlideScope®-Titanium shortly prolongs DLT intubation duration compared to direct laryngoscopy but improves the view. Objective intubation trauma but not subjective complaints are reduced.Trial registrationGerman Clinical Trial Register DRKS00020978, retrospectively registered on 09. March 2020.

Predicting postoperative tracheostomy requirement in children undergoing surgery for posterior fossa tumors.

Posterior fossa tumor (PFT) resection can be associated with postoperative respiratory failure. We aimed to identify risk factors predicting tracheostomy dependence in children after PFT resection. Retrospective chart review of all children undergoing PFT resection from April 2007 to May 2017 at our institution was performed. A total of 197 patients were included; 12 (6.1%) required tracheostomy placement at a mean 69.1days postoperatively (SD 112.7, range 7-388). Patients requiring tracheostomy were younger (3.4 vs. 6.8years, p < 0.01), more likely to have postoperative dysphagia (91.7% vs. 17.3%, p < 0.01), and more likely to have an ependymoma (41.7% vs. 15.1%, p < 0.01) or astrocytoma (25.0% vs. 8.1%, p < 0.01). Patients with eventual tracheostomy were less likely extubated immediately postoperatively (45.5% vs. 79.6%, p < 0.01), had longer intubation duration postoperatively (5.7 vs. 0.5days, p < 0.01), and had higher rates of reintubation within 48h (63.6% vs. 1.3%, p < 0.01). Patients requiring tracheostomy had longer hospital length of stay (45.8 vs. 15.3days, p < 0.01) and ICU stay postoperatively (13.5 vs. 2.1days, p < 0.01). Of those requiring tracheostomy, three (25.0%) were decannulated by 1year postoperatively. Decannulation rates did not vary by age (p < 0.47), extubation failure (p < 0.24), duration of intubation (p < 0.10), tumor histology (p < 0.23), or tumor grade (p < 0.13). Lower cranial neuropathy following PFT resection is common. Identifying risk factors correlated with need for tracheostomy can help identify patients who may benefit from early tracheostomy, reducing prolonged intubation trauma, time on mechanical ventilation, and length of stay.

Is there a rationale for direct dosing of chemicals to nursing pups in the EOGRTS (OECD 443)?

In OECD guideline 443 – Extended One Generation Reproductive Toxicity Study (EOGRTS) – to be used for testing industrial and agrochemicals, it has been indicated that careful consideration of benefits and disadvantages should be made prior to conducting direct-dosing studies in nursing pups. Nursing pups will not be directly dosed in dietary and drinking water studies whereas in oral gavage studies this possibility exists. Besides the risk of intubation trauma and overdosing due to direct exposure and exposure via the mother's milk, direct dosing could lead to a different hazard assessment of chemicals depending on the choice of the route of administration. In addition, in case of industrial and agrochemicals used in industrial or professional settings only, there will never be direct exposure of newborns. Moreover, direct dosing of nursing pups is an artificial, non-physiological, route of exposure and as such it would hamper risk assessment. It should therefore only be considered in exceptional cases and justified on a case-by-case approach.

The Role of laryngeal ultrasound in comparison with cuff leak test in prediction of post extubation stridor

Abstract Background Endotracheal intubation is commonly used in (ICU) for different causes. However, intubation/extubation may lead to the development of complications such as post-extubation stridor (PES), one of the most frequent causes of reintubation, prolonged mechanical ventilation, and increased morbidity in the ICU patients. PES and upper-airway obstruction are multifactorial in etiology and can occur as a result of laryngotracheal edema, intubation trauma, excessive cuff pressure with mucosal ulceration, and prolonged intubation with secondary inflammation and granuloma formation. Objective: The aim of this study was to evaluate the value of laryngeal ultrasonography versus cuff leak test in predicting post-extubation stridor. Patients and Methods Our study included fifty patients admitted to the critical care department, Misr University for Science and Technology Hospitals from the period of November 2017 to July 2018 intubated for different causes for a minimum of 24 h. excluded patients primarily intubated for the upper airway obstruction, patients with laryngeal carcinoma, Previous tracheostomy, neck radiotherapy. All patients will undergo for laryngeal ultrasonography versus cuff leak test to predict post-extubation stridor. Results In our study CLT identified PES patients with a sensitivity of 75%. But with low PPV of 50% for leakage volume of (132.5 mm ) . Laryngeal ultrasound showed a sensitivity of 50% for those patients with air column width before deflation less than 10.955 mm and ACWD 0.905 mm with PPV of 11.8% and 14.3% for air column width and ACWD respectively Conclusion Both CLT (Cuff leak test) and laryngeal US (ultrasound) might have sensitivity in predicting PES and should be used with caution in this regard.

Intubation of emergency traumatic head injury patient outside the operation theatre: Cross-sectional study

IntroductionImmediate and effective airway management is a priority to save the victim's life. Maintaining a patent airway and ensuring adequate oxygenation is vital to protect the patient from secondary injury due to hypoxia.This study was aimed to assess the practice of emergency traumatic brain injury patient intubation outside the operation theatre. MethodsThis study was conducted from 1st September 2018 to February 28, 2019. All trauma patients that were admitted to the emergency department were included. The data was collected by a standardized questionnaire prepared from the recommendations of an Eastern Association for the surgery of trauma practice, by direct observation while performing the procedure and reviewing the patient's chart for any drug given and any documented procedure. ResultA total of 75 trauma patients intubation was observed during the study period. All of the patients were successfully intubated but the standards of maintaining hemodynamic stability, administration of vomiting prophylaxis, and application of capnograph had nil performance. Rapid sequence intubation and maintenance of cervical spine mobility were underperformed. ConclusionEven though emergency intubations were successfully performed most of the standards of intubation did not meet the criteria, and it needs improvement. Regarding the findings of this audit emergency, traumatic patient intubation needs to be improved in line with the standards for a better patient outcome to avoid secondary injury.

1951 Not All Diverticular Bleeds Are Colonic: A Rare Case of Zenker's Diverticulum Bleeding and Endoscopic Treatment

INTRODUCTION: Zenker's diverticulum (ZD) is a retropharyngeal pouch formed with herniation through Killian’s triangle. The diverticulum is thought to be developed through traction &amp; pulsion but precise mechanism is unknown. Prevalence estimated to be 0.01–0.11%; ZD is predominantly in adults age &gt;60. ZD is associated with dysphagia, halitosis, regurgitation &amp; cough. But very rarely associated with bleeding - only 7 cases reported in the literature. Aspirin irritation is theorized as the etiology, as all reported cases involved aspirin or other anti-platelet medication. CASE DESCRIPTION/METHODS: A 73 year-old male with history of obesity, GERD, former smoker, &amp; coronary artery disease presented with hematemesis &amp; hemoptysis. 1 week prior to onset of bleeding, he was hospitalized for STEMI requiring intubation which was traumatic with minor bleeding, &amp; he underwent drug eluting stent placement to the left anterior descending artery. He was discharged home on aspirin &amp; clopidogrel. Patient had awakened due to the sensation of liquid pooling in the back of his throat; he cleared this with a cough &amp; noted the liquid to be gross blood. He then had ongoing small volume hemoptysis &amp; hematemesis. He denied dysphagia, NSAID usage &amp; breakthrough reflux symptoms on daily PPI. On exam, tachycardic to 120s, otherwise vitals normal; diaphoretic &amp; pale but otherwise benign exam. Patient’s hemoglobin had decreased from 13.3 g/dL at discharge to 8.7 g/dL in the ER; also notable for blood urea nitrogen of 45 mg/dL. ENT evaluated initially due to complaint of hemoptysis &amp; recent traumatic intubation. Laryngoscopy revealed blood pooling at the esophageal inlet; this could be cleared voluntarily by patient, but it immediately reaccumulated. Otherwise the oropharyngeal exam was normal. EGD was subsequently performed &amp; this revealed large ZD which was filled with fresh blood. This area was lavaged &amp; small ulcer seen at base; multiple clips were placed with successful hemostasis. Further exam of esophagus, stomach &amp; proximal duodenum revealed no additional source. Patient’s bleeding stopped &amp; tolerated resumption of aspirin &amp; clopidogrel without further incident. DISCUSSION: ZD bleeding is an extremely rare event, so treatment modalities may not be readily familiar to most medical staff. We report the third case of ZD bleeding treated with endoscopic hemostasis; all cases have been successful &amp; well tolerated. Traditionally, ZD bleeding has been treated surgically, but this may not be an option in certain populations or situations.

Transglottic corticosteroid injection for treatment of soft post-intubation subglottic stenosis: a retrospective analysis of 26 children.

Surgical treatment is generally recommended for severe subglottic lesions following traumatic endotracheal intubation in children. An alternative approach is early transglottic corticosteroid administration to reduce scar formation and prevent the need for subsequent surgical intervention. This technique has been practiced successfully for several decades at the Children's Hospital of Cologne and the outcomes of 26 subsequent patients reviewed in this analysis. All patients who underwent transglottic corticosteroid injection for treatment of post-intubation stridor and dyspnoea between 2012 and 2018 were identified and their records and endoscopy images analysed. Severity of the endoscopic findings was assessed using the Myer-Cotton classification (MCC) and an Expected Need for Surgical Intervention (ENSI) score (1 = inevitable; 2 = very likely necessary; 3 = probably avoidable and 4 = most likely not necessary) was recorded. Treatment was considered successful if the children had a complete resolution of clinical symptoms. A total of 26 patients with a median (range) age of 1.9 (0.02-7.2) years and weight of 9.8 (1.8-25) kg were identified and included into the analysis. Endoscopic images were available for 22 children. All children underwent transglottic corticosteroid injection prior to any potential surgical treatment. A total of 22 patients (85%) improved following transglottic corticosteroid injection including 4 of 5 patients with a MCC = 3 and ENSI = 1 avoiding surgical intervention. None of the patients experienced a deterioration of clinical symptoms or endoscopic findings. Transglottic corticosteroid injections as first-line treatment in children with severe post-endotracheal intubation trauma can successfully resolve symptoms and prevent invasive surgery.

Subglottic stenosis due to an unexpected foreign body diagnosed after emergency tracheostomy in a child

BackgroundSubglottic stenosis is a known complication of traumatic and prolonged endotracheal intubation. It is rare that the causes of severe subglottic stenosis are revealed to be an unexpected foreign body after airway securement in a child. Subglottic stenosis in a child is often associated with airway emergency, and management of difficult airway may be required.Case presentationWe report the case of an 8-year-old girl with severe subglottic stenosis who required emergency tracheostomy. Emergency tracheostomy was performed under regional anesthesia. Sevoflurane was administered with sufficient titration to maintain spontaneous breathing. At first, the cause of severe subglottic stenosis was thought to be a traumatic event that had occurred 1 month previously; however, subsequent laryngoscopy revealed that the cause of subglottic stenosis was a foreign body.ConclusionsManagement of the airway in a child with severe subglottic stenosis should be selected according to each patient’s individual circumstances.

Comments on "Prehospital Ground Transport Rapid Sequence Intubation for Trauma and Traumatic Brain Injury Outcomes".

Comments on "Prehospital Ground Transport Rapid Sequence Intubation for Trauma and Traumatic Brain Injury Outcomes".

Prehospital Ground Transport Rapid Sequence Intubation for Trauma and Traumatic Brain Injury Outcomes

Prehospital Ground Transport Rapid Sequence Intubation for Trauma and Traumatic Brain Injury Outcomes