Tripod Position Research Articles

6575 From Tonsils to the Thyroid: A Rare Case of Acute Suppurative Thyroiditis in an Immunocompetent Adult

Abstract Disclosure: F. Sajid: None. A. Mubashir: None. F. Mohsin: None. M. Sattar: None. Introduction: Acute suppurative thyroiditis (AST) is a rare infection of the thyroid gland due to its high vascularity, protective encapsulation, and high iodine content. Most AST cases occur in children with anatomical aberrations or in immunosuppressed adults. Here, we describe a case of AST in an immunocompetent woman. Case: A 54-year-old woman with no medical history presented to the emergency department due to dyspnea, dysphagia, and odynophagia for two days. She reported a four-day history of sore throat, fever, and chills. She was saturating well on room air but was sitting in a tripod position. She had erythema, swelling, tenderness to palpation in the anterior neck with a hoarse voice, and moderate trismus. Nasopharyngoscopy revealed no mass, but the scope could not pass beyond the velum due to edema. The patient’s condition quickly deteriorated, necessitating emergent intubation for acute hypoxic respiratory failure. After intubation, the patient had cardiac arrest with asystole requiring resuscitation and successful ROSC. The initial CT scan showed extensive soft tissue abnormalities in the nasopharynx and parapharyngeal tissues, extending to the thyroid gland and mediastinum with the possibility of developing abscesses. A thyroid ultrasound showed a heterogeneous thyroid gland without nodules or increased vascularity. Treatment commenced with ampicillin-sulbactam. Laboratory results showed Free T4 of 4.74 ng/dL (0.58-1.64), TSH 0.03 MCIU/mL (0.39-4.08), Total T3 1.56 ng/dL (0.72-1.35), WBC 19.3 K/UL (4.8-10.8), and elevated ESR and CRP levels. Thyroid-stimulating Immunoglobulin (TSI), Thyroid Peroxidase (TPO) Antibody, and Thyrotropin Binding Inhibitory Immunoglobulin (TBII) were negative, making AST the top differential. Methimazole was initiated due to concerns of thyroid storm, but it was quickly tapered due to a significant decrease in Free T4 levels and suspicion of AST. A repeat CT scan revealed more defined abscesses along the bilateral pharyngeal walls extending to the thyroid bed. The patient underwent bilateral tonsillectomy and drainage of the abscesses. She was extubated the following day. Cultures from the abscesses grew rare Klebsiella pneumoniae, susceptible to Ampicillin-sulbactam. A barium swallow on day 14 showed no evidence of a pyriform sinus fistula. She was discharged on day 15 with Augmentin for 7 days. On discharge, free T4 decreased to half (2.39 ng/dL), and Total T3 normalized (1.08ng/dL). Conclusion: This case presents a rare instance of AST in an immunocompetent patient without anatomical anomalies, stemming from the spread of peritonsillar and parapharyngeal abscesses into the thyroid bed. AST should be considered in cases of deep neck infections, as it is a potentially life-threatening disease. It is crucial to identify and treat AST early to prevent complications. The primary treatment involves antibiotics, incision, and drainage. Presentation: 6/1/2024

Combination of Tripod Position and Pursed Lip Breathing to Reduce Shortness of Breathing in Patients with Respiratory System Disorders

Background: Shortness of breath that is not treated immediately will result in several other health problems and threaten death. There are non-pharmacological treatments, namely tripod position techniques and pursed lip breathing. To determine the effectiveness of tripod position and pursed lip breathing on reducing shortness of breath in patients with impaired systems and respiration. Methods: The study design used in this case study is based on evidence-based practice of nursing (EBN) with sampling according to inclusion criteria of 5 respondents—ameasuring instrument used for the assessment of shortness of breath using oxygen saturation observation sheets. Respondents' intervention used SOPs for tripod position and pursed lip breathing. Results: Based on interventions that have been performed on patients, most oxygen saturation < 95% to 80%. Then, after the intervention, there was an increase in oxygen saturation to 96-100% as much as 100%, from the results of the spss test using the Wilcoxon test, p values (0.04) < (0.05) were obtained, which means that there is an effect of the application of tripod position and pursed lip breathing on reducing shortness of breath in patients. Conclusion: Tripod position and pursed lip breathing techniques can reduce shortness of breath in patients. This application can be done independently for 10-15 minutes, as much as two times, to reduce shortness of breath if you experience a recurrence.

The Effect of Change Position on Cardiac Function Patterns on Patients with COVID-19 Diagnosis: A Clinical Trial Study.

Various methods are used to treat patients with coronavirus, including drug therapy and alternative and non-invasive therapies Research has been done on the effects of body position on cardiac function in patients with COVID-19 diagnosis. This study was performed on patients admitted with COVID-19 diagnosis. Patients with inclusion criteria were selected based on purpose and entered into the study. They were divided into three groups: Group A patients were placed in a semi-sitting position, group B patients were placed in a tripod position, and group C patients were placed in a prone position. After being placed in the relevant positions at 15 and 60 minutes were measured in terms of heart rate and blood pressure at the mentioned times in the relevant checklist. The results showed that there was no statistically significant difference in heart rate between the three groups before the intervention (P>0.05). In other words, changes in heart rate over time between the three groups (in several measurements) were statistically significant (P<0.05). Regarding Systolic Blood Pressure (SBP) and Diastolic Blood pressure patterns, the results showed that the three position groups was not statistically different before and 15 and 60 minutes after the intervention (P>0.05). According to the results, it can be concluded that placing the patient in all three positions of the tripod, prone and semi-sitting can be effective in improving the patient's heart rate pattern and lead to improving the patient's clinical condition.

Tripod Position and Pursed Lip Breathing on Respiration Rate in COPD Patients

Many people with COPD develop emphysema and chronic bronchitis. Both conditions cause obstruction of airflow in the respiratory system and cause an increase in the frequency of external respiration. One of the non-pharmacological management is tripod position and pursed lip breathing. This study aimed to determine the effect of giving a tripod position and pursed lip breathing on respiration rate in COPD patients. The design of this study used a one group pretest-post test design. The population in this study were all COPD patients at Bangil Hospital, Pasuruan in June 2021. The sampling technique of this study was consecutive sampling, the sample was obtained by 25 respondents. The instrument used observation and SOP. The results showed that the average respiration rate before giving the combination of tripod position and pursed lip breathing was 28.8x/minute, and the average value of respiration rate after giving the tripod position and pursed lip breathing was 23.2x/minute. Wilcoxon test results value = 0.000 on respiration rate before and after the combination of tripod position and pursed lip breathing, which means that tripod position and pursed lip breathing are proven to be effective on respiration rate in COPD patients. Tripod position and pursed lip breathing will loosen the chest cavity, provide positive pressure on the lungs so that air can go in and out more smoothly and reduce shortness of breath

COMBINATION EFFECT AMONG GIVING TRIPOD POSITION AND PURSED LIP BREATHING TO RESPIRATION RATE IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) PATIENTS

The purpose of this study was to analyze the effect of a combination of tripod position and pursed lip breathing on respiration rate in COPD patients at Bangil Hospital. In this study, a pre-experimental method was used to determine the effect of giving a combination of tripod position and pursed lip breathing on respiration rate in COPD patients at Bangil Hospital, Pasuruan. The population in this study were all COPD patients at Bangil Hospital Pasuruan in June 2021 as many as 30 people. The sampling technique in this study was consecutive sampling. The sample used in this study were some COPD patients at Bangil Hospital, Pasuruan. From the results of the research above, there are differences in the decrease in respiration rate , this can be caused by differences in the accuracy of respondents when doing pursed lip breathing , respondents who can do it correctly will get better results in reducing respiration rate . It can be concluded that there is an effect of giving a combination of tripod position and pursed lip breathing on respiration rate in COPD patients at Bangil Hospital, Pasuruan.

Short-Term Outcomes of the Lapicotton Technique in the Treatment of Progressive Collapsing Foot Deformity

Category:Midfoot/ForefootIntroduction/Purpose:Medial column instability (MCI) in Progressive Collapsing Foot Deformity (PCFD) is not solely determined by forefoot varus (FV). First ray hypermobility, hallux valgus, midfoot arthritis, gapping at the tarsometatarsal joint and dorsal metatarsal migration are findings associated with MCI. Acknowledgement of this instability requires inclusion of a procedure to the medial column in order to correct the forefoot varus, stabilize the ray and bring the foot to a plantigrade tripod position. Cotton opening wedge medial cuneiform osteotomy and Lapidus tarsometatarsal arthrodesis are procedures of choice in these scenarios. We have combined these 2 procedures into one called Lapicotton. The purpose of this study was to present the short-term outcomes of this technique.We hypothesized that Lapicotton will improve both clinical and radiological outcomes.Methods:We performed an IRB-approved retrospective study comprising 3 PCFDs having benefited from a Lapicotton procedure. Clinical outcomes were assessed with the European Foot and Ankle Society Score (EFAS), the Foot Function Index Score (FFI) and the Pain Catastrophizing Scale (PCS). Radiographic outcomes were assessed using weight-bearing computed tomography (WBCT) assessments. Middle Cuneiform Floor distance, Forefoot Arch Angle, Middle Facet uncoverage percentage, Talonavicular Coverage angle and the Foot and Ankle Offset (FAO) were measured. All these data were both preoperatively and postoperatively collected. Comparison between preoperative and postoperative results were done as described below. The Kruskal-Wallis H-test for independent groups was used to compare median values of the EFAS. The Wilcoxon signed-rank test for paired samples was used to compare preoperative and postoperative variables of FFI and PCS. For the radiographic measurements, normality was assessed using Shapiro-Wilk test. Comparisons were made using Student tests for normal variables and Mann-Whitney for non-normals.Results:This small series included 2 female and 1 male, with a mean age of 56 and a mean BMI of 31.8 kg/m2. Mean follow up was 2.9+/-0.2 (range from 2.7 to 3.1) months. 2 out of 3 patients simultaneously benefited of a Medial Calcaneal Displacement Osteotomy (MDCO 10mm) and a Lateral Column Lengthening (LCL 8mm). The wedge sizes used for the Lapicotton were 8 mm in all cases. Regarding clinical outcomes, EFAS (p=0.79) and FFI (p=0.99) did not showed any significant improvement whereas PCS were significantly improved (Δ=-5.67[-9.2–2.2];p=0.03). Regarding radiological outcomes, fusion was present in all the cases at the maximal follow-up. Middle cuneiform floor distance and Forefoot Arch Angle were significantly increase (respectively Δ=6.9;CI95%=[6.4;7.4];p< 0.01 and Δ=7.5;CI95%=[4.3;10.8]p<0.05). Middle Facet uncoverage was significantly improved (Δ=- 28.8;CI95%=[-33.1;-24.5]p< 0.01). Statistical power of the serie did not allowed comparison regarding the Talonavicular Coverage Angle (Δ=-14;CI95%=[-24;-3.9]) and the FAO (Δ=-3.9;CI95%=[-10.7;2.9]).Conclusion:The Lapicotton procedure showed encouraging outcomes with fusion in all cases at 3 months postoperatively, improvement in pain, correction of forefoot varus and of the of the Peritalar subluxation represented by the Middle Facet Uncoverage. These results should be moderate because other procedures (MDCO and LCL) were performed in 2/3 of the patients, and the outcomes were issued from a small cohort with short-term follow-up. Longer follow-up and a larger cohort are needed to confirm these results.

THE EFFECTIVENESS OF CHEST PHYSIOTHERAPY WITH TRIPOD AND FOWLER POSITION TO INCREASING OXYGEN SATURATION

Chronic Obstructive Pulmonary Disease (COPD) is one of the three leading causes of death in the world in low and middle income countries up to 90%, characterized by airway obstruction making it difficult for the body to transport sufficient oxygen. This study examines chest physiotherapy with a tripod and Fowler's position in oxygen saturation. Quantitative analysis using quasi-experimental method and two-group pre-test-posttest design with 50 samples using accidental sampling technique. Statistical test using unpaired t test showed a significant difference in average oxygen saturation using a tripod position with a P-Value of 0.00. The tripod position showed better results as indicated by the increase in oxygen saturation from 93.40 to 97.64 compared to the Fowler position which increased from 92.64% to 95.52. Therefore, this study suggests chest physiotherapy using a tripod position is more effective in increasing oxygen saturation in COPD patients. This intervention can remove secretions, help reduce shortness of breath in patients, and affect the value of increasing oxygen saturation in COPD patients. This non-pharmacological action is a nursing intervention based on scientific evidence for independent nursing actions in providing nursing care to COPD patients

Epiglottitis in four – year- old boy caused by COVID-19 infection

Introduction: Epiglottitis is an inflammatory disease involving the epiglottis, vallecula, aritenoid cartilage, and aryepiglottic wrinkles. Acute epiglottitis is relatively rare but can quickly lead to life-threatening airway obstruction. Diagnosis of epiglottitis is clinical, but radiography and direct vision of the epiglottis can also help with the diagnosis. Clinical manifestations of epiglottitis include fever, sore throat, and in the event of imminent airway obstruction, also may present with muffled sound, falls, tripod position, and stridor. Epiglottitis can be caused by some bacterial agents or viruses such as adenovirus and measles.COVID-19 was first detected in December 2019 in a group of patients with severe respiratory symptoms in Hubei Province, China. Common symptoms include fever, cough, fatigue, difficulty breathing, and loss of smell and taste. Although COVID-19 disease has a variety of manifestations, only one case of epiglottitis following COVID-19 disease has been reported in adults. Case presentation: The patient, a 4-year-old boy, came to our center and the patient's family complained of shortness of breath and progressive lethargy of the child 10 days ago. Since last week, he has been sleeping in a sitting position due to the aggravation of shortness of breath. On physical examination, respiratory distress, tachypnea, subcostal retraction, tail stridor, and crackle was heard in both lungs. Diagnosed with suspected bronchoscopy epiglottitis, a large, swollen, and cherry-red epiglottis was observed. Based on the patient's history of respiratory symptoms and the prevalence of COVID-19, a reverse pharyngeal polymerase (RT-PCR) transcript test was requested for COVID-19 and the COVID-19 infection was positive. Conclusion: In this article, we reported an 4-year-old child with epiglottitis in the context of COVID19.

SARS-CoV-2 pneumonia succesfully treated with cpap and cycles of tripod position: a case report

BackgroundPneumonia induced by 2019 Coronavirus (COVID-19) is characterized by hypoxemic respiratory failure that may present with a broad spectrum of clinical phenotypes. At the beginning, patients may have normal lung compliance and be responsive to noninvasive ventilatory support, such as CPAP. However, the transition to more severe respiratory failure - Severe Acute Respiratory Syndrome (SARS-CoV-2), necessitating invasive ventilation is often abrupt and characterized by a severe V/Q mismatch that require cycles of prone positioning. The aim of this case is to report the effect on gas exchange, respiratory mechanics and hemodynamics of tripod (or orthopneic sitting position) used as an alternative to prone position in a patient with mild SARS-CoV-2 pneumonia ventilated with helmet CPAP.Case presentationA 77-year-old awake and collaborating male patient with mild SARS-CoV-2 pneumonia and ventilated with Helmet CPAP, showed sudden worsening of gas exchange without dyspnea. After an unsuccessful attempt of prone positioning, we alternated three-hours cycles of semi-recumbent and tripod position, still keeping him in CPAP. Arterial blood gases (PaO2/FiO2, PaO2, SaO2, PaCO2 and A/a gradient), respiratory (VE, VT, RR) and hemodynamic parameters (HR, MAP) were collected in the supine and tripod position. Cycles of tripod position were continued for 3 days. The patient had a clinically important improvement in arterial blood gases and respiratory parameters, with stable hemodynamic and was successfully weaned and discharged to ward 10 days after pneumonia onset.ConclusionsTripod position during Helmet CPAP can be applied safely in patients with mild SARS-CoV-2 pneumonia, with improvement of oxygenation and V/Q matching, thus reducing the need for intubation.

Effectiveness Active Cycle of Breathing Technique (ACBT) with Pursed Lips Breathing Technique (PLBT) to tripod position in increase oxygen saturation in patients with COPD, West Sumatera

Chronic Obstructive Pulmonary Disease (COPD) is a chronic lung disease characterized by obstruction or obstruction of airflow in a reversible or partial nonreversible airway. Dyspnea is a common symptom in COPD sufferers; this can cause problems with oxygen saturation, or the oxygen saturation value is below normal. Non-pharmacological actions given in the form of breathing exercises can be done by a nurse to help reduce shortness of breath in COPD patients. The exercise is given by adjusting the resting position that is comfortable and comfortable so that the extra breath muscles can work well. The position that can do the position of the tripod with Active Cycle of Breathing and Pursed lips are breathing so that shortness of breath is reduced and SaO2 can have increased so that more oxygen has obtained in Lung Hospital, West Sumatra. This research is quantitative research, with quasi-experimental research methods. They used two pre-test-posttest design groups. The sample in this study amounted to 30 people with quota sampling technique. In this study showed that there was a difference in the increase in oxygen saturation of COPD patients which was effective in the tripod position group with Active Cycle Breathing Technique (ACBT) with a p-value of 0.00 while in the tripod position group with the Active Respiratory and Lip Cycle there was a difference of p-value 0.023. It has concluded that the tripod position with ACT and PBLT could increase oxygen saturation and nasal breathlessness reduced, but the tripod position with ACT is more effective in COP patients because with chronic respiratory patients who are short of breath due to sputum buildup, then with ACT will clean the airway and the flow of the road effective breathing so that shortness of breath have reduced and oxygen saturation increases. Furthermore, it has recommended that in hospitals, especially nurses, in dealing with COPD patients in addition to the correct position of breathing exercises with ACT to help patients.

Medical Management of Epiglottitis.

Epiglottitis is most commonly caused by bacterial infection resulting in inflammation and edema of the epiglottis and neighboring supraglottic structures. Acute infection was once found predominantly in children ages 2 to 6 years old, but with the introduction of the Haemophilus influenzae B (HiB) vaccine the incidence of cases in adults is increasing. Typical clinical presentation of epiglottitis includes fever and sore throat. Evidence of impending airway obstruction may be demonstrated by muffled voice, drooling, tripod position, and stridor. Radiographs can be helpful in diagnosing epiglottitis; however, they should not supersede or postpone securing the airway. An airway specialist such as an otolaryngologist, anesthesiologist, or intensivist should ideally evaluate the patient immediately to give ample time for preparing to secure the airway if necessary. All patients with epiglottitis should be admitted to the intensive care unit for close monitoring.

The Effectiveness of Tripod Position And Pursed Lips Breathing to Enhance Oxygen Saturation in Patients With COPD

Background: COPD is a pulmonary disease characterized by air obstruction in respiratory tract from bronchi to the bronchioles, which continuously occur progressively, and irreversible, and related with the inflammatory response due to toxic gases (cigarette smoke, factory pollution and vehicle pollution) so it can cause a desaturation oxygen (SpO2). This impact will caused in concentration decreased, functional activity reduction, hypoxemia, hypoxia until cyanosis. To prevent this impact, there are two non-pharmacological methods that can be applied, a tripod position and pursed lips breathing exercise. Purpose: To determine the effectiveness of tripod position and pursed lips breathing to enhance oxygen saturation in patients with COPD.Methods: The research used queasy experimental with pre-posttest design. This research used total sampling that have 34 samples COPD patient which is include in inclusion criteria in working area of Puskesmas Padangsari Semarang. The samples are divided into 2 treatment groups (tripod position groups and pursed lips breathing groups) that gives 15 minutes therapy 3 times within 3 continuous days. This research will begins from February until March 2019. Statistical test to determine the affectivity of each groups using non-parametric test (Mann-Whitney test). Results: the result of this research shows differences effectiveness between tripod position and pursed lips breathing with p value 0.00 with mean deviation before and after therapy of tripod position 0.29 and pursed lips breathing 1.23.Conclusion: in this research shows that pursed lips breathing is most effective to enhance oxygen saturation in COPD patient compare with tripod position.

RESPIRATORY ALKALOSIS FROM HYPERVENTILATION SECONDARY TO MODAFINIL: WHEN STIMULANTS GO AWRY

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Modafinil is a psychostimulant medication that is approved for shift work disorder, narcolepsy, and other sleep disorders. While studies have shown modafinil raises blood pressure and heart rate, little is known of its effects on the respiratory drive. Here we present a patient who had primary hyperventilation suspected to be secondary to modafinil use. CASE PRESENTATION: A 36 year-old female with a history of mild asthma (as needed albuterol inhaler), anxiety, and shift work sleep disorder presented to the emergency department in acute respiratory distress. One week prior to presentation she had a prodrome of cough and congestion while returning from a road trip. Her home medications include albuterol and modafinil as needed. She took modafinil prior to presentation for her long drive. On physical exam, she was tachypneic with a respiratory rate of 30-50 breaths/min and in obvious distress. She was sitting leaning forward in tripod position with accessory muscle use and inability to complete full sentences. Of note, she had bilateral breath sounds with good air entry and no wheezes, rales, or rhonchi. Laboratory values at time of examination included pH 7.52, pCO2 15, pO2 156 on 4L oxygen, chemistry bicarbonate is 9, potassium 2.9, lactic acid 7.2 with no other derangements. Chest radiograph and computed tomography angiogram of chest were unremarkable. She was placed on bilevel positive airway pressure (BIPAP) to assist her work of breathing but she remained tachypneic. Respiratory viral panel and echocardiogram were within normal limits. Dexmedetomidine was initiated with significant improvement in her work of breathing and resolution of tachypnea. A repeat arterial blood gas showed pH 7.37, pCO2 35, pO2 67% on 35%. She was weaned off BIPAP to room air. DISCUSSION: Modafinil acts upon the arousal state of the brain via the dopaminergic and sympathetic nervous system pathways. The theory of its effect, as seen in our patient, is through the brainstem respiratory system, resulting in its stimulation. The end pharmacologic result is increased wakefulness and increased respiratory drive. Taneja et al demonstrated that modafinil causes a strong central adrenergic response, resulting in increased catecholamines and an increase in respiratory drive. Dexmedetomidine is a centrally acting sympatholytic agent that was used in our patient for respiratory drive suppression with great success and resolution of symptoms. Modafinil use likely stimulated our patient’s sympathetic drive resulting in hyperventilation causing respiratory alkalosis and lactic acidosis. CONCLUSIONS: Early recognition and targeting treatment of central hyperventilation is crucial to treat secondary metabolic derangements. While there is a need for more research regarding modafinil’s effects on the ventilatory drive, It is prudent that clinicians are aware of the side effects of this medication as seen in our patient. Reference #1: Taneja I, Haman K, Shelton RC, Robertson D (2007). A randomized, double-blind, crossover trial of modafinil on mood. J Clin Psychopharmacol 27: 76–78. DISCLOSURES: No relevant relationships by Thomas Blair, source=Web Response No relevant relationships by Lakshmi Kallur, source=Web Response No relevant relationships by Poorvi King, source=Web Response No relevant relationships by JENNIFER Stahl, source=Web Response

Assessing physical and respiratory distress in children with bronchiolitis admitted to a community hospital emergency department: A retrospective chart review.

IntroductionBronchiolitis is a leading cause of infant hospitalization with wide variation in its diagnosis and management, especially in smaller community hospitals. The objective of this study is to describe children admitted to a community-based hospital emergency department (ED) for bronchiolitis and explore alternate assessments of illness severity.MethodsA retrospective chart review (January to September 2014) of 100 children, < 2 years old and meeting International Classification of Diseases 10 for bronchiolitis. Outcomes included demographics, symptoms, and interventions. In addition, the Respiratory Distress Assessment Instrument (RDAI) score was calculated using documented assessments of wheezing and retractions. Descriptive and comparative statistics were completed with p < 0.05 considered significant.ResultsThe mean (standard deviation) age 10.6 (8.4) months, n = 41 females. Sixty-seven percent had a chest X-ray (CXR), 17% oral antibiotics, 65% bronchodilators, and 19% oral steroids; 19% were admitted in hospital. There was a significant difference in RDAI score between those given oral antibiotics (mean (95% CI), 6.35 (4.96–7.75)) versus not (4.70 (4.20–5.20)), p = 0.01. Those who received a CXR had a significantly higher oxygen flowrate (1.4 (0.6–2.1) litres per minute (lpm)) and worse physical appearance (tri-pod position, head bobbing) versus those who did not (0.15 (–0.05 to 0.35) lpm), p = 0.002 and p = 0.04, respectively.ConclusionsA large number of children admitted to a community-based ED for bronchiolitis received unnecessary CXR and medications. Assessing physical and respiratory distress may be more effective at determining illness severity compared with radiological or laboratory testing. Local clinical practice guidelines may aid in optimal management of bronchiolitis for community-based EDs.

Altered thoracolumbar position during application of craniocaudal spinal mobilisation in clinically sound leisure horses

Manual therapy techniques are commonly used by physiotherapists in the management of back pain to restore a pain-free range of motion and function in humans. However, there is a lack of research to support the proposed kinematic effects of manual therapy in the horse. This study investigated the kinematic effects of craniocaudal spinal mobilisation (CCSM) on the thoracolumbar spine in asymptomatic leisure horses. Markers were fixed to T10, T13, T17, L1, L3, the highest point of the wither and the tuber sacrale on thirteen horses that were positioned squarely. The CCSM technique consisted of two parts: (1) carpal flexion of either forelimb to 90° to maintain the horse in a tripod position, and (2) the application of a cranial to caudal force to the forehand via the ipsilateral point of the shoulder. Movement changes of the thoracolumbar markers from baseline to maximum flexion when the CCSM was applied was recorded as ‘depth’ (mm) relative to a fixed line drawn from the tuber sacrale to the maximal point of the withers. The change in angle (°) of each marker relative to the same markers was also recorded. Data were collected via video and analysed with Dartfish™ software. Increases in maximum thoracolumbar angle (P&lt;0.05) and reductions in thoracolumbar depth (P&lt;0.05) were found with CCSM. These results indicate CCSM induced flexion in the thoracolumbar spine, supporting its potential to improve range of motion and function in horses. Further studies to understand whether the changes observed during CCSM translate to treatment of back pain are warranted.

Abdominal muscle activity during breathing in different postural sets in healthy subjects

This study aims to evaluate the effect of different postural sets on abdominal muscle activity during breathing in healthy subjects. Twenty-nine higher education students (20.86±1.48 years; 9 males) breathed at the same rhythm (inspiration: 2s; expiration: 4s) in supine, standing, tripod and 4-point-kneeling positions. Surface electromyography was performed to assess the activation intensity of rectus abdominis, external oblique and transversus abdominis/internal oblique muscles during inspiration and expiration. During both breathing phases, the activation intensity of external oblique and transversus abdominis/internal oblique was significantly higher in standing when compared to supine (p≤0.001). No significant differences were found between tripod position and 4-point-kneeling positions. Transversus abdominis/internal oblique activation intensity in these positions was higher than in supine and lower than in standing. Postural load and gravitational stretch are factors that should be considered in relation to the specific recruitment of abdominal muscles for breathing mechanics.

The Case Files

The Case Files

Medical Error. The Personal Cost

On a beautiful summer day the July after I finished my fellowship, I prepared for an inaugural ride on a new bike. The bike was a gift to myself to celebrate the end of my formal training in pulmonary and critical care medicine. The sky was clear, a deep “Carolina” blue. There was no wind to warn of a change in weather, no premonition of just how ugly this beautiful day might become. Then, a seemingly insignificant event: a slight irritation on my left toe and a tiny honeybee stuck to my sock. I had no allergy to bees. My breathing was fine. But as the erythema crept up my foot and past my ankle, I grudgingly drove to the emergency department. I parked my car in the deck across the street and started to walk. The entrance to the emergency department felt like it was miles away. I vomited profusely, and sweat dripped down my brow. Despite my “training,” I had underestimated the situation. At triage, I was tachycardic and febrile. I was ushered to a hallway bed (whichmeant I was too sick for the waiting room, but not sick enough for a resuscitation bay). A corticosteroid and an antihistamine were administered intravenously. A repeat pulse oximetry measurement demonstrated that my oxygen saturation had dropped. As I was moved to the resuscitation bay, I remembered the patients I had met there: patients on ventilators, patients with tubes in their noses, their throats, their bladders, and/or their chest. The seriousness of the situation settled into me. In a trauma room, in the ED, at a teaching hospital, in July. My very busy nurse registered me to the new room, moved me to a new bed, hooked me up to telemetry, called for a respiratory therapist, and left to get epinephrine for subcutaneous injection. When she returned with the drug, I noticed that the syringe contained a very small volume. It looked like concentrated epinephrine for an intramuscular injection, but she hooked up the syringe to my IV. I considered asking her about the route of administration, but I said nothing. I had not made good decisions or good assessments aboutmy condition so far that day. A sense of impending doom overwhelmed me. I attributed this to a “fight or flight” response from the epinephrine. I looked for reassurance to the heart monitor, expecting sinus tachycardia. I saw a wide complex tachycardia. I called out for help. The attending physician arrived quickly, shouting to the nurse to administer epinephrine subcutaneously, as he had already ordered. “I received the epinephrine intravenously,” I shouted. “Intravenously”? he questioned. The nurse turned quickly. She glared at me intently, and stated, “I gave it intramuscularly.” Before we resolved that issue, I was intubated. During rounds two days later, the attending physician shared her plan to liberate me from mechanical ventilation. The ache in my chest suggested that extubation would fail. I have a chronic neuromuscular disease that predisposes me to respiratory failure. From previous experience, I had learned to be aware of the pain that was building in my chest. I communicated my concern using the writing tablet provided by the nurse, but was overruled by the team. I was extubated. Within a few hours, I struggled again to breathe. I sat upright and leaned forward into a tripod position in an attempt to catch my breath. The nurse replaced the sweatdrenched bed sheets. The emergency airway team was summoned to reintubate me. When they arrived, the medicine team communicated that I should not receive succinylcholine because of my underlying condition. Rocuronium and etomidate were ordered. Unfortunately, it seemed that the anesthesiologist did not remind the medicine house staff about the different half-lives of these two drugs, drugs that these physicians had probably never ordered or used. I awakened some time later, paralyzed. The endotracheal tube scraped the back of my throat, but I could not cough. I felt restraints around my wrists. Cognitively, I knew why I could not move. As if fierce motivation could overcome neuromuscular blockade, I tried to move anyway. First, my toes and then my eyebrows. To no avail. Next, I tried to communicate distress by thinking of something scary to raise my heart beat (which usually runs in the 50s). When I was finally able to open my eyes, I saw that my curtain was pulled closed. My nurse was gone, probably to lunch after a long morning. My bed was flat—leftover from reintubation. I was

The Heat Is on … Thermal Epiglottitis As a Late Presentation of Airway Steam Injury

BackgroundThermal epiglottitis is a rare but potentially life-threatening disease. Diagnosis requires a thorough history and high clinical level of suspicion, particularly in children. Thermal epiglottitis from steam inhalation can have a slow onset without oropharyngeal signs of thermal injury, findings that can hide the clinical diagnosis. ObjectiveOur aim was to review the pathophysiology and clinical presentation of thermal epiglottitis and the challenges involved in diagnosis and management of this form of atypical epiglottitis. Case ReportWe describe the case of a 22-month-old male presenting to the pediatric emergency department after a scald burn from steam and boiling water resulting in 12% body surface area burns to his chin, chest, and shoulder, with no obvious oropharyngeal or neck injuries. At the time of presentation, he was afebrile and well appearing. Six hours after the injury, he was sitting in the “tripod position,” drooling, with pooled saliva in his mouth and inspiratory stridor. Intubation in the operating room using conventional direct laryngoscopy was not successful and he was intubated using an operative endoscope. Laryngoscopy demonstrated thermal epiglottitis. A tracheostomy was performed to secure the airway, and he was admitted to the pediatric intensive care unit. He was discharged home and decannulated 4 weeks later, when airway endoscopy showed complete recovery with normal airway structures. ConclusionA thorough history and physical examination together with a high level of suspicion and aggressive, collaborative airway management is vital in preventing catastrophic airway obstruction in atypical forms of epiglottitis.

EFFECT OF TRIPOD POSITION ON OBJECTIVE PARAMETERS OF RESPIRATORY FUNCTION IN STABLE CHRONIC OBSTRUCTIVE PULMONARY DISEASE

PURPOSE: To measure changes in respiratory dynamics in patients with chronic obstructive pulmonary disease (COPD) sitting leaning forward with hands supported anteriorly on the knees (tripod position), a posture frequently assumed by patients in respiratory distress.