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PubMedDate not supplied

Brillo pad crack screen aspiration and ingestion.

Crack cocaine is commonly smoked in a pipe with a metallic filter made from a steel wool scouring pad. We report an unusual complication of smoking crack cocaine: the aspiration and ingestion of a Brillo pad filter. A 34-year-old female presented 7 h after drinking beer and smoking crack. She was concerned that she might have inhaled the "screen" from her crack pipe, a piece of Brillo pad the size of her fingertip. She complained of "burning" in her throat, a foreign body sensation, and change in her voice, but no dyspnea, dysphagia, or abdominal pain. On physical examination, she was afebrile with a pulse of 105 beats/min and respiratory rate of 24 breaths/min. She was tearful and spoke in a whisper. There were no visible oropharyngeal burns and the lungs were clear to auscultation, but she had intermittent inspiratory stridor. The O2 saturation was 96%, and the ethanol concentration was 100 mg/dl. No foreign body or burn was seen on indirect laryngoscopy. A lateral neck x-ray study showed a normal epiglottis and no foreign body. Chest x-ray studies were unremarkable. Fiberoptic laryngoscopy showed left posterior arytenoid edema and swelling. An abdominal x-ray study revealed a foreign body in the right lower quadrant consistent with the Brillo pad filter. The next morning, the patient was asymptomatic and was discharged, recovering without sequellae. While crack pipe screen aspiration is a rarely reported event, physicians should be aware of the potential for foreign body aspiration and ingestion by this mechanism.

Adult↗
PubMed1999

Equine respiratory pharmacology.

Differentiation of diseases of the equine respiratory tract is based on history, clinical signs, auscultation, endoscopy, imaging, and sampling of airway exudate. Upper respiratory therapies include surgical correction of airway obstructions; flushing of localized abscesses (strangles), guttural pouch disease, or sinusitis; and oral or parenteral antibiotic and anti-inflammatory therapy if deemed necessary. Pneumonia usually is treated with antimicrobials, anti-inflammatories, and bronchodilators. Pleural drainage is indicated if significant pleural effusion is present. The most commonly used therapies for early inflammatory and chronic allergic obstructive conditions include bronchodilators and anti-inflammatories. Acute respiratory distress, particularly acute pulmonary edema, is treated with diuretics (usually furosemide), intranasal oxygen, bronchodilators, corticosteroids, and alleviation of the underlying cause. Furosemide also had been used in North America as a race-day preventative for exercise-induced pulmonary hemorrhage (EIPH), but recent data have shown that furosemide may be a performance-enhancing agent itself.

Animals↗
PubMed1996

Lower respiratory tract disease.

Lower respiratory tract disease is an important source of poor performance and exercise intolerance in racehorses and middle-aged sport horses. Horses that perform high-intensity exercise are predisposed to development of infectious and noninfectious respiratory disease. Diagnostic aids for investigation of lower respiratory tract disease include thorough thoracic auscultation with rebreathing, endoscopic examination, bronchoalveolar lavage (BAL), and thoracic radiographic examination. The therapeutic approach for horses with lower respiratory tract diseases often can be directed by cytologic evaluation of BAL fluid. Conservative management techniques may reduce the risk or severity of respiratory disease in horses performing high-intensity exercise.

Animals↗
PubMed1992

Examination of the upper and lower respiratory tract relevant to purchase.

The intent and extent of the respiratory tract examination relevant to purchase are dictated by numerous factors, including historical information, signs suggestive of respiratory tract abnormalities, intended use of the horse, and economic considerations. Following a thorough and systematic examination of the horse at rest, evaluation during and following exercise may be warranted. The physical examination should include evaluation of regional symmetry of the head, neck, and thorax; evaluation of nasal airflow and patency; palpation of the nasal septum, larynx, and trachea; examination for surgical scars; and auscultation and percussion. Special examination techniques, including endoscopy, stress evaluation, and radiography, may be indicated. Much has been learned about the URT in recent years, particularly regarding endoscopy of the region and the interpretation of endoscopic findings. The reader is referred to a generous list of references to gain further detailed information regarding the endoscopic diagnosis of other URT conditions.

Animals↗
PubMed1992

Medical examination of the digestive system relevant to purchase.

Routine examination of the digestive system relevant to purchase includes gross examination of the feces, auscultation of the abdomen, and examination of the oral cavity and teeth for verification of age and identification of any gross abnormality. Further examination is indicated only when there is a history of diseases such as colic, especially colic surgery, or esophageal obstruction. Special procedures that might be indicated, depending upon the history and findings on the routine physical examination, include rectal palpation of the abdominal viscera; endoscopic examination of the esophagus; abdominal paracentesis; radiographs of the teeth, esophagus, or abdomen; and transabdominal or transrectal ultrasound.

Animals↗
PubMed1985

Equine heart disease. An overview.

The clinician must appreciate unique aspects of equine cardiovascular physiology in order to distinguish normal variation from a pathophysiologic state. Cardiovascular problems in the horse include auscultation of cardiac murmurs, identification of cardiac arrhythmias, and recognition of congestive heart failure. A cardiac data base including history, general and cardiovascular examination, and resting and postexercise electrocardiogram are necessary to evaluate most horses for significant heart disease. Additional studies, such as echocardiography and cardiac catheterization, are useful in selected cases. Because some types of heart disease are amendable by therapy, an accurate diagnosis is needed to direct treatment and offer a realistic prognosis.

Age Factors↗
PubMed1993

[Recurrent selective bronchial intubation in laparoscopic cholecystectomy].

Selective endobronchial intubation occurred three times in a 38-year-old female patient undergoing laparoscopic cholecystectomy. She weighed 58 kg and was 165 cm tall. Anaesthesia was obtained with propofol, fentanyl and vecuronium. Endotracheal intubation was carried out with a Mallinckrodt tube, size 7.5. It was attached to the cheeks with the 22 cm marking at the teeth. The diagnosis of endobronchial intubation was made when he SpO2 fell abruptly to 79, 87 and 93% respectively. Simultaneously, the peak inspiratory pressure increased and PetCO2 decreased. The third time, both lung fields were auscultated; no breath sounds were found on the left side. The first two incidents were cured by exsufflating the artificial pneumoperitoneum. Pulling out the tube 4 cm definitely solved the problem. These endobronchial intubations were due to the tube being too close to the carina. During insufflation of the pneumoperitoneum, the carina is pushed upwards with the corresponding part of the mediastinum.

Adult↗
PubMed1994

[Bronchopleural fistula after transbronchial passage of a feeding tube].

Inadvertent transbronchial insertion of a narrow-bore feeding tube using a metallic wire resulted, twice in less than 24 hours, in a right pneumothorax complicated by a bronchopleural fistula. This accident occurred in a conscious patient but with central neurologic chronic disorders recently aggravated by a postoperative Gayet-Wernicke syndrome. The incidence of transbronchial insertion is relatively important [2 to 4%]. Risk factors include a previous endotracheal intubation and an altered mental status. The insertion may be especially hazardous when the patient is uncooperative or unconscious or has lost the cough reflex. The presence of a cuffed endotracheal tube should not be considered as a safeguard for tracheobronchial penetration. Recommendations for prevention are presented. The usual procedure of testing for proper location of the tube following its insertion consisting in the injection of air through the tube with auscultation for gastric borborygmi, is inadequate and should no longer be used.

Acute Disease↗
PubMed1987

[Pulmonary edema after laryngospasm].

A case is reported of rapidly resolving pulmonary oedema following post-extubation laryngospasm in a 23 year-old healthy man who underwent emergency resection of a rectal polyp. The laryngospasm occurred immediately after extubation and resolved after administration of curare. The patient was reintubated and auscultation disclosed bilateral coarse and moist rales. Chest X-ray displayed a right pulmonary opacity. Because of the deteriorating respiratory status, mechanical ventilation was used with positive end-expiratory pressure for 18 h. Chest examination, chest X-ray and arterial blood gas levels improved steadily and the patient was discharged 24 h later. Pulmonary oedema associated with upper airway obstruction seems to be related to hypoxic pulmonary vasoconstriction and the largely subatmospheric transpulmonary pressure gradients generated while trying to breathe against a closed glottis. In addition, this increased negative intra-alveolar pressure was responsible for significant changes in cardiovascular function: right ventricular blood volume, right ventricular ejection fraction and left ventricular after-load increased, while left ventricular ejection fraction decreased. These changes favoured a rise in left atrial and pulmonary blood volumes, with transudation of fluid from the capillaries into the alveoli. Because of the severe consequences of respiratory failure, any patient who suffers acute upper airway obstruction should be observed in the recovery room for at least 3 h in order not to miss this rarely developing, but fortunately rapidly reversible, syndrome.

Adult↗
PubMed1997

[Gas embolism during endonasal YAG laser surgery].

The authors describe a case of air embolism during an endonasal YAG laser surgery in a 10-year-old child. This accident was caused by the coaxial air cooling system of the laser ruby tip. The importance of end tidal CO2 monitoring and precordial auscultation during laser surgery even in patients without risk factors is underlined.

Carbon Dioxide↗
PubMed2001

Verification of endotracheal tube position.

The goals of tracheal intubation are to place the tube in the trachea and to position the tube at an appropriate depth inside the trachea. Various clinical signs and technical aids are described to verify tracheal intubation and to diagnose esophageal intubation. Many of these methods fail under certain circumstances. Not all these methods can be applied in every intubation, but it is essential that the clinician involved in tracheal intubation have the necessary airway management skills, perform these tests accurately, and interpret the results correctly. Prioritization of these tests depends on many factors, including familiarity, availability of monitors, and the location of intubation. Viewing the tube passing between the cords during direct laryngoscopy and visualization of the tracheal rings and carinae with a fiberoptic scope after intubation are the only fullproof methods of confirming tracheal intubation. In the nonarrested patient, carbon dioxide monitoring quickly can differentiate tracheal from esophageal intubation. In the arrested patient, however, carbon dioxide monitoring can be unreliable, although it can be useful as a prognostic indicator of the efficacy of resuscitation. Devices such as [figure: see text] the self-inflating bulb and esophageal detector device may be more useful in patients with cardiac arrest, but they also can yield false results. Placing the distal tip of the tube in the middle of the trachea can be accomplished by positioning the upper end of the cuff 2 cm below the cords during direct laryngoscopy or by placing the distal tip of the tube 4 cm above the carinae with the aid of a fiberoptic scope. The position of the tube always should be verified by clinical assessment (e.g., auscultation). If direct visualization cannot be done, referencing the marks on the tube, transillumination techniques, or cuff maneuvers can be helpful. In the emergency and critical care settings, a chest radiograph easily can detect malpositioned tracheal tubes that may not be detected by routine clinical assessment. Other techniques (e.g., use of fiberoptic scopes, cuff maneuvers, transillumination) can decrease the need for frequent chest radiographs. Based on available information, two algorithms are proposed: one for emergency intubation (Fig. 9) and the other for verification of tracheal tube position in elective intubation (Fig. 10). These algorithms are designed [figure: see text] to assist the clinician and should not be substituted for clinical judgment. Under no circumstances should clinical signs be ignored in the presence of conflicting information from monitors and technical aids.

Carbon Dioxide↗
PubMedDate not supplied

Visualization of coronary artery fistula with transesophageal echocardiography.

Coronary artery fistulas are relatively uncommon and are usually initially suspected on auscultation of a continuous murmur. Long-term complications include congestive heart failure, endocarditis, ischemia, and atrial arrhythmias. The role of echocardiography in visualization and diagnosis of these fistulas is expanding. We report two cases in which transesophageal echocardiography was used to visualize and better define proximal coronary arteries and coronary artery fistulas.

Adult↗
PubMed2002

Blood pressure, hypertension, and ambulatory blood pressure monitoring in children and adolescents.

Fixed essential hypertension in children is uncommon. Confusion surrounding the definitions and tools used in measuring blood pressure (BP), and the variable capacity to apply the definitions despite the device used explains this in part. In children, hypertension is defined statistically, based on a large normative population that is ethnically diverse. The standards were developed from the first BP measurement obtained in large studies, and the measurements were obtained using standard auscultatory sphygmomanometry. Technologic advances have seen the widespread introduction of oscillometric devices, which determine BP in a different fashion from auscultation, and the two values are not identical. In fact, as oscillometric devices use proprietary algorithms to calculate the BP, results are not readily interchangeable. Ambulatory BP devices have been added to this mix and offer unique opportunities for accurate diagnosis, and more effective therapies. Most ambulatory BP devices have neither been validated for use in children, nor have passed the validation process. A consensus document may be needed to optimize use and interpretation of data from ambulatory BP monitoring.

Adolescent↗
PubMed2003

Bedside placement of small bowel feeding tubes in hospitalized patients: a new role for the dietitian.

OBJECTIVE: The benefits of enteral nutrition when compared with parenteral nutrition are well established. However, provision of enteral nutrition may not occur for several reasons, including lack of optimal feeding access. Gastric feeding is easier to initiate, but many hospitalized patients are intolerant to gastric feeding, although they can tolerate small bowel feeding. Many institutions rely on costly methods for placing small bowel feeding tubes. Our goal was to evaluate the effectiveness of a hospital-developed protocol for bedside-blind placement of postpyloric feeding tubes. METHODS: The Surgical Nutrition Service established a protocol for bedside placement of small bowel feeding tubes. The protocol uses a 10- or 12-French, 110-cm stylet containing the feeding tube; 10 mg of intravenous metoclopramide; gradual tube advancement followed by air injection and auscultation; and an abdominal radiograph for tube position confirmation. In a prospective manner, consults received by the surgical nutrition dietitian for feeding tube placements were followed consecutively for a 10-mo period. The registered dietitian recorded the number of radiograph examinations, the final tube position, and the time it took to achieve tube placement. RESULTS: Because all consults were included, feeding tube placements occurred in surgical and medical patients in the intensive care unit and on the ward. Of the 135 tube placements performed, 129 (95%) were successfully placed postpylorically, with 84% (114 of 135) placed at or beyond D3. Average time for tube placement was 28 min (10 to 90 min). One radiograph was required for 92% of the placements; eight of 135 (6%) required two radiographs. No acute complications were associated with the tube placements. CONCLUSIONS: Hospitalized patients can receive timely enteral feeding with a cost-effective feeding tube placement protocol. The protocol is easy to implement and can be taught to appropriate medical team members through proper training and certification.

Cost-Benefit Analysis↗
PubMed2006

Outcome of percutaneous transarterial coil occlusion in patients with isolated patent ductus arteriosus using an upstream-and-push maneuver.

BACKGROUND: There are limited data on the outcome of percutaneous transarterial coil occlusion for isolated patent ductus arteriosus (PDA) in Taiwan. This study evaluated the 2-year outcome of 52 patients with isolated PDA who received percutaneous transarterial coil occlusion by an upstream-and-push maneuver. METHODS: From July 1997 to June 2002, a total of 52 patients (25 infants, 27 children) underwent occlusion of PDA with standard Gianturco coils. There were 39 females and 13 males. Patient age ranged between 7 days and 14 years, and weight was between 3 and 45 kg. Percutaneous transarterial coil occlusion was performed by an upstream-and-push maneuver. Chest auscultations, chest radiographs, and Doppler echocardiography were performed in all patients within 24 hours, and 1, 3, 6, 12 and 24 months after coil occlusion. RESULTS: Mean PDA diameter at the pulmonary end was 2.34 +/- 1.00 mm (range, 1.00-4.80 mm). Angiographic classification was megaphone type in 32 patients, window type in seven, tubular type in six, aneurysmal type in three, and elongated conical type in four. Complete PDA occlusion was performed with a single coil in 41 (79%) patients and with multiple coils in 11 (21%). The mean ratio of pulmonary to systemic blood flow was 1.95 +/- 0.95 (range, 1.10-5.80) before the procedure, and 1.02 +/- 0.04 (range, 1.00-1.20) after the procedure (p < 0.001). Immediate occlusion of the ductus was achieved 15 minutes after the procedure in 44 (85%) patients. Occlusion was achieved in 92% of patients within 24 hours and in 100% of patients by the 1-month follow-up. Follow-up at 24 months after the procedure revealed no complications. CONCLUSION: Percutaneous transarterial coil occlusion with 5-loop Gianturco coils can be effectively and safely achieved in patients with a PDA minimum diameter < 5 mm.

Cardiac Surgical Procedures↗
PubMed2001

[Early management of neonates with suspected congenital heart disease].

Congenital heart diseases may remain asymptomatic for days or weeks after birth. Early diagnosis of prenatally undiagnosed congenital heart diseases rests upon familial history of congenital heart disease and clinical signs such as cyanosis intrauterine growth retardation, tachypnea, excessive sweating, feeding difficulties, or abnormal cardiac auscultation. Hyperoxia test, blood gas determination, chest x-ray and electrocardiogram are the most useful complementary tests before the anatomical evaluation by the pediatric cardiologist. The initial medical management includes mechanical ventilation and oxygen supplementation, insertion of a good quality central or peripheral vascular line, correction of metabolic disorders, sedation, and prostaglandin administration in order to maintain the opening of the ductus arteriosus.

Diagnosis, Differential↗
PubMed1987

Intrapartum fetal monitoring.

From the fetal viewpoint, labour is a prolonged contraction stress test which most pass without incident. Labour also represents the obstetrician's last opportunity to influence perinatal outcome and ensure that those fetuses who have suffered chronic hypoxia antenatally are recognized promptly, so that labour is supervised in a way that does not place them at increased risk of either death or birth asphyxia. In the case of the fetus who enters labour healthy, with normal reserves, labour is managed with the same aim in mind, but with the foreknowledge that visualization of a normal volume of clear amniotic fluid and reasonable duration of labour makes the development of hypoxia and asphyxia unlikely. Those at increased risk of hypoxia should be monitored electronically, but, for the remainder, intermittent auscultation is satisfactory until labour lasts in excess of 5 hours, or if the patient requires oxytocin, or if an epidural is placed. If EFM is used, then it is important to provide adequate education in trace interpretation, with particular emphasis on the importance of short-term variability. Widespread use of EFM has provided us with an immense amount of knowledge about fetal physiology, but it is critically important for the practising obstetrician to understand that, in the low-risk patient, EFM is not more effective than IA in preventing death from asphyxia, that EFM does protect against asphyxial seizures, but that widespread use of the technique has not been associated with a significant reduction in the population of permanently handicapped infants. This information is particularly relevant in developing nations where money spent on sophisticated monitoring equipment might be better spent in other areas. From the maternal point of view, intensive fetal monitoring has profound implications by virtue of its usual effect on incidence of Caesarean birth, although the Dublin trial results, with regard to incidence of Caesarean section, emphasize the importance of considering intrapartum fetal monitoring as just one part of the overall supervision of labour. Finally, it must be emphasized that the method of fetal monitoring chosen may be strongly influenced by factors other than scientific evidence, as in the United States where the medicolegal climate is such that failure to rigorously document absence of fetal distress/true birth asphyxia may result in a harrowing lawsuit. It is a position this author has developed considerable sympathy with in recent years.

Amniotic Fluid↗
PubMed1997

Positive pressure ventilation with the size 5 laryngeal mask.

STUDY OBJECTIVE: To obtain data about the safety and efficacy of the size 5 laryngeal mask airway (LMA), which is a scaled-up version of the size 4 and is generally recommended for patients over 90 kg, for positive pressure ventilation (PPV), ease of insertion, oropharyngeal and gastric insufflation pressures, fiberoptic positioning, and complication rates. DESIGN: Prospective survey. SETTING: Teaching hospital. PATIENTS: 179 patients undergoing PPV with the size 5 LMA. INTERVENTIONS: The clinical criteria for using the size 5 LMA and the PPV technique were weight above 90 kg or an inadequate seal with a size 4 LMA and surgery estimated to last longer than 45 minutes. Anesthesia was standardized and included fentanyl/propofol for induction, N2O/O2/isoflurane 0.5% to 2% for maintenance, and atracurium for muscle relaxation. Two 20-second attempts were allowed with the standard recommended technique, followed by a single attempt with the Guedel technique. The LMA cuff was then inflated and the airway pressure at which either oropharyngeal leak or gastric insufflation occurred was determined by closure of the expiratory valve and anterior neck followed by epigastric auscultation. MEASUREMENTS AND MAIN RESULTS: The age and weight range were 15 to 82 years and 46 to 153 kg, respectively. 29% of patients had a body mass index (BMI) above 30 kg/m2. On 31 occasions the size 5 was used following an inadequate seal with the size 4. The weight range of this subgroup was 46 to 87 kg. The device was placed within 20 seconds in 94% and there were no failed placements within three attempts. Gastric insufflation was detected before oropharyngeal leak in 17% and oropharyngeal leak was detected first in 73%. In 10% of patients there was no leak at an inspiratory pressure of 45 cm H2O. Mean (range) for gastric insufflation pressure was 31 (range 23-45) cm H2O. Mean (range) for oropharyngeal leak was 33 (range 8-44) cm H2O. The mean (range) airway pressure was 17 (range 13-26) at tidal volumes of 10 ml/kg. At this tidal volume, 97.2% of patients could be ventilated without gastric insufflation and 98.3% without an oropharyngeal leak. At tidal volumes of 8 ml/kg no patient had gastric insufflation and 0.7% had an oropharyngeal leak. Oropharyngeal leak pressure of less than 15 cm H2O occurred in 11 patients. There was no correlation between fiberoptic score or Mallampati score and either gastric insufflation or oropharyngeal leak. The incidence of problems was 3% and the oxygen saturation remained above 94%. There was no correlation between problems, leak pressures, and BMI. CONCLUSIONS: Positive pressure ventilation with the size 5 LMA is safe and effective with a low failure/problem rate using tidal volumes of 8 to 10 ml/kg, even in those patients who are moderately obese. The device is suitable for patients weighing under 90 kg in whom the seal with the size 4 is inadequate.

Adolescent↗