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The dangers of playing with sharp sticks

The dangers of playing with sharp sticks. Cheryl Pirozzi, MD Pulmonary Grand Rounds October 13, 2011. Case. 43 yo woman presented to OSH with SOB, productive cough with hemoptysis, and weakness. PMH. CVID with ↓ IgG and IgM, treated with monthly IVIG

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The dangers of playing with sharp sticks

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  1. The dangers of playing with sharp sticks Cheryl Pirozzi, MD Pulmonary Grand Rounds October 13, 2011

  2. Case • 43 yo woman presented to OSH with SOB, productive cough with hemoptysis, and weakness

  3. PMH • CVID with ↓ IgG and IgM, treated with monthly IVIG • Multiple recent hospitalizations (x7 in 2011), mult for pneumonia, most recent 8/8-9/2011 • Adrenal insufficiency due to chronic steroids: unclear why • Chronic hypoxemia: 3LPM • Asthma • PFTs 12/10: mildly reduced FEV1, nl DLCO • Chronic pain, narcotic abuse • Psych issues: bipolar d/o, borderline personality d/o, prior overdoses on narcotics, tricyclics, atarax • Papillary thyroid Ca, s/p thyroidectomy • VRE skin and UTI infections • DM2 • ? Crohns disease – negative biopsy

  4. PMH • PSH: gastric bypass, CCY, tonsillectomy, sinus surgeries x2, hiatal hernia repair, PFO closure • SH: on disability, married. Denies EtOH, tobacco, IDU

  5. Meds • Prednisone 20 mg qd • Lortab 10 q4 hrs • Tapentadol 100 mg q4h • Albuterol • Budesonide • Lasix • Atarax • Synthroid • cytomel • IVIG 30 g q mo • Nexium • Lunesta • Seroquel 800 mg qHS • Metoprolol • Zofran • Cymbalta

  6. Case • PE • T 38.5, p116, 85/40 → 111/56, R 18, 84%/3L • Ill-appearing, alert but tangental • Bilateral crackles and rhonchi • Labs: • WBC 16, 20% bands, hgb 11, plt 266 • Lactate 3.7, BUN 22, Cr 0.8

  7. Initial CXR OSH 8/30/11

  8. Hospital Course • Initially treated for HCAP with Zosyn, Levaquin, and Vancomycin • Stress dose steroids • IVIG

  9. CXR 8/31/11

  10. 9/1/11 • Reportedly, patient’s husband sneaks her extra antihistamine, dramamine, seroquel and tapentadol, and she has an aspiration event • Acute hypoxic respiratory failure • Emergent intubation

  11. CXR 9/1/11

  12. 9/1/11 • Soon after intubation, patient has bronch with BAL • “proximal airways were normal in appearance” • BAL grows MRSA • A few hours later, she is noted to acutely decompensate and “blow up”

  13. 9/1/11

  14. 9/1/11

  15. 9/4/11 • Patient again decompensates, with increased hypoxia and subcutaneous emphysema, and transfer to IMC is requested

  16. 9/4/11 transfer to IMC • T 38.1, p123, 122/87, R 24 FiO2 100%, PEEP 11, Vt 6 ml/kg • Diffuse subcutaneous emphysema, crackles, edema

  17. What would you do next?

  18. CT 9/4/11

  19. CT 9/4/11

  20. CT 9/4/11

  21. CT 9/4/11

  22. CT 9/4/11

  23. What is going on?

  24. Bronch 9/8/11

  25. Bronch 9/8/11

  26. CT 9/8/11

  27. CT 9/8/11

  28. Hospital Course • Recurrent infectious complications and intermittent septic shock: • Acromobacter PNA • Persistent MRSA tracheobronchitis • C.diff colitis • VRE UTI • Treated with Vanc, linezolid, zosyn, ceftaroline, flagyl • Severe ARDS • Self extubation with emergent re-intubation on 9/13 • Eventually stabilizes, but unable to wean from vent

  29. Bronch 9/24/11

  30. Hospital Course • Trach on 9/27/11

  31. Bronch 9/28/11

  32. Tracheal injury associated with endotracheal intubation • Clinical presentation • How often does this happen? • What are the risk factors? How do we avoid it? • What is the treatment?

  33. Tracheal injury/rupture • Rare condition with high morbidity and mortality • Most common cause is head and neck injury • Most common iatrogenic cause is orotracheal intubation; also can occur with tracheostomy, bronchoscopy, placement of stents, esophagectomy • Usually longitudinal rupture in distal third of membranous trachea Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

  34. Tracheal injury associated with endotracheal intubation • Clinical presentation: • Most common: subcutaneous emphysema, pneumomediastinum, pneumothorax, respiratory distress • dyspnea, dysphonia, cough, hemoptysis, and pneumoperitoneum • signs often develop immediately or soon after intubation, but can take several days to appear Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

  35. Diagnosis • Requires high clinical suspicion based on clinical s/sx • Confirmed by direct visualization of lesion with bronchoscopy • CT

  36. Radiographic signs • Subcutaneous emphysema • Pneumomediastinum • Overdistended ETT cuff • On CT tracheal defect/perforation Am J Emerg Med 2004;22:289-293.

  37. J Bras Pneumol. 2009;35(8):809-813

  38. Tracheal injury associated with endotracheal intubation • How often does this happen? • Case reports, several case series and reviews • Incidence estimates from 0.005% - 0.37% of intubations, more common with double lumen tubes Medina et al. J Bras Pneumol. 2009;35(8):809-813 Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

  39. Tracheal injury associated with endotracheal intubation • Miñambres et al. Tracheal rupture after endotracheal intubation. Eur J Cardiothorac Surg. 2009;35(6):1056-62 • 182 cases of postintubation tracheal rupture. • mortality 22% • 86% women • Intubations: 14% “difficult”, 27% emergent • Increased mortality associated with age ( p = 0.015) and emergency intubation (RR = 3.11; p = 0.001)

  40. Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

  41. Variables associated with mortality Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

  42. Risk factors / mechanism for tracheal rupture with intubation Am J Emerg Med 2004;22:289-293.

  43. Risk factors for tracheal injury with intubation • Why women? • Shorter, with use of improperly long tubes • Smaller tracheal diameters- more vulnerable to cuff overinflation Anesth Analg 2001;93:1270–1

  44. How do I avoid tracheal injury with emergent intubation? • Recommendations for emergent intubation: • Select the proper size of endotracheal tube • Check all equipment before intubation • Check position of stylet (tip not beyond murphy’s eye) • Intubate gently and use RSI when necessary • Retract the stylet when balloon cuff passes through vocal cords • Inflate the cuff slowly with proper volume and pressure • Fix ETT tightly to reduce the possibility of tube movement • Deflate the cuff first when repositioning the tube Am J Emerg Med 2004;22:289-293.

  45. Management of tracheal laceration or rupture • Traditionally early surgical repair was mainstay • Now many recommend conservative treatment if rupture < 2 cm, and if minimal non-progressive sxs and no air leak • If > 2 cm, surgical vs conservative is debated. • In Miñambres et al. meta-analysis, surgical repair was associated with a 2x increased mortality • Meyer et al. case series: surgical repair in critically ill pts is high risk, mortality up to 71%. Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062 Meyer M. Thorac Cardiovasc Surg 2001;49:115—9.

  46. Management of tracheal laceration or rupture • Most recent studies recommend conservative management if • stable pt, no air leakage, no esophageal damage, minimal mediastinal collections, no clinical progression, no sign of infection • Conservative management = intubation with cuff distal to lesion, continuous tracheal aspiration, pleural drain, empiric abx • Surgical repair if unstable, large defect (>4cm), any evidence of mediastinitis Medina et al. J Bras Pneumol. 2009 Aug;35(8):809-13 Miñambres et al. European Journal of Cardio-thoracic Surgery 35 (2009) 1056—1062

  47. Management of tracheal laceration or rupture Am J Emerg Med 2004;22:289-293.

  48. Management of tracheal laceration or rupture Am J Emerg Med 2004;22:289-293.

  49. In retrospect, had we known what was going on, would probably have at least evaluated for surgical repair earlier. • Small rupture, but distal to ETT and with demonstrated clinical deterioration

  50. Questions/comments?

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