Iatrogenic Tracheal Rupture Caused by Emergency Intubation: A Case Report.

BACKGROUND: Iatrogenic tracheal rupture is a rare but life-threatening complication. If suspected by clinical examination or chest radiograph, a computed tomography scan can confirm the diagnosis, but the criterion standard is a bronchoscopy. There is no consensus on its management. CASE REPORT: A 52-year-old woman was intubated in a prehospital setting after cardiac arrest. A gradual appearance of subcutaneous emphysema was observed after intubation. A computed tomography scan revealed a complicated tracheal rupture, pneumomediastinum, and pneumothorax. The management was surgical. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intubation in emergency conditions increases the risk of tracheal rupture and a delay in management is an important prognostic factor.

Appropriateness and Complications of Peripheral Venous Catheters Placed in an Emergency Department.

BACKGROUND: The insertion of peripheral venous catheters (PVCs) is the invasive procedure most frequently performed in hospitals, and it could be associated with complications. The appropriateness of PVC placement, however, has not been carefully analyzed. OBJECTIVES: We conducted a study to assess the rate of PVC placement in our Emergency Department (ED), their use, their immediate or potential usefulness, and their complications. METHODS: In this descriptive prospective study, we recorded every PVC placed in our ED during 1 week and assessed its appropriateness in terms of its use and potential usefulness. We then followed the patients transferred to medical wards to determine the duration of PVC maintenance and any complications. RESULTS: PVCs (n = 210) were placed for 34% (n = 207) of the 605 patients admitted to the ED during the study period. Of these PVCs, 27% (n = 52) were not used and 43% (n = 91) were considered ineffective. Follow-up covered 92 patients with PVCs transferred to medical wards. We recorded seven episodes of phlebitis (8%) and no infections, local or systemic. The mean duration of PVS maintenance in the medical wards was 40 h from insertion. Of the PVCs with complications, 43% were ineffective. The mean duration of maintenance of the PVCs that led to complications was 80 h, compared with 35 h for those without complications (p < 0.02). CONCLUSION: In accordance with the literature, half of the PVCs inserted in our ED were ineffective; half the PVCs causing complications were avoidable.

Difficult Airway Management Algorithm in Emergency Medicine: Do Not Struggle against the Patient, Just Skip to Next Step.

We report a case of prehospital "cannot intubate" and "cannot ventilate" scenarios successfully managed by strictly following a difficult airway management algorithm. Five airway devices were used: the Macintosh laryngoscope, the gum elastic Eschmann bougie, the LMA Fastrach, the Melker cricothyrotomy cannula, and the flexible fiberscope. Although several airway devices were used, overall airway management duration was relatively short, at 20 min, because for each scenario, failed primary and secondary backup devices were quickly abandoned after 2 failed attempts, each attempt of no more than 2 min in duration, in favor of the tertiary rescue device. Equally, all three of these rescue devices failed, an uncuffed cricothyroidotomy cannula was inserted to restore optimal arterial oxygenation until a definitive airway was secured in the ICU using a flexible fiberscope. Our case reinforces the need to strictly follow a difficult airway management algorithm that employs a limited number of effective devices and techniques, and highlights the imperative for early activation of successive preplanned steps of the algorithm.