Subglottic stenosis imitating the carina - a case report of airway mimicry.

We present a case of awake tracheal intubation with flexible bronchoscopy which resulted in incorrect tracheal tube placement. The presence of a stenotic subglottic lesion with an appearance similar to the carina led to the tube being positioned with only the tip within the trachea whilst the cuff was located between the vocal cords. A capnography trace was identified before induction of anaesthesia; however, visual confirmation of the carina was undertaken in a rushed manner due to the patient becoming agitated. Once the incorrect tracheal tube placement was identified, the decision was made to wake the patient. Thereafter, a more experienced operator successfully performed awake tracheal intubation with flexible bronchoscopy using a smaller tracheal tube, which easily passed through the subglottic stenosis. This report emphasises the importance of performing the 'two-point check' every time awake tracheal intubation is undertaken: to confirm correct tube placement, both a capnography trace and view of the tracheal lumen including the carina and main bronchi is required. This must be properly performed before induction of anaesthesia; safety should not be compromised by a stressful environment or time pressure.

European Resuscitation Council COVID-19 guidelines executive summary.

Coronavirus disease 2019 (COVID-19) has had a substantial impact on the incidence of cardiac arrest and survival. The challenge is to find the correct balance between the risk to the rescuer when undertaking cardiopulmonary resuscitation (CPR) on a person with possible COVID-19 and the risk to that person if CPR is delayed. These guidelines focus specifically on patients with suspected or confirmed COVID-19. The guidelines include the delivery of basic and advanced life support in adults and children and recommendations for delivering training during the pandemic. Where uncertainty exists treatment should be informed by a dynamic risk assessment which may consider current COVID-19 prevalence, the person's presentation (e.g. history of COVID-19 contact, COVID-19 symptoms), likelihood that treatment will be effective, availability of personal protective equipment (PPE) and personal risks for those providing treatment. These guidelines will be subject to evolving knowledge and experience of COVID-19. As countries are at different stages of the pandemic, there may some international variation in practice.

[Care for severely injured persons : Update of the 2016 S3 guideline for the treatment of polytrauma and the severely injured]. / Versorgung von Schwerverletzten : Update der S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung 2016.

In 2011 the first interdisciplinary S3 guideline for the management of patients with serious injuries/trauma was published. After intensive revision and in consensus with 20 different medical societies, the updated version of the guideline was published online in September 2016. It is divided into three sections: prehospital care, emergency room management and the first operative phase. Many recommendations and explanations were updated, mostly in the prehospital care and emergency room management sections. These two sections are of special interest for anesthesiologists in field emergency physician roles or as team members or team leaders in the emergency room. The present work summarizes the changes to the current guideline and gives a brief overview of this very important work.

The benefit of multislice CT in the emergency room management of polytraumatized patients.

The early treatment of polytraumatized patients needs an effective and standardized approach. Reducing time requirements for the primary diagnostic evaluation is a major concern in the early phase of polytrauma management. Multislice-CT (MSCT) is a quick and reliable method for the initial diagnostic evaluation. Computed tomography provides more detailed and more consistent information than conventional radiography. It has the great advantage of allowing rapid examination of the head, vertebral column, chest, abdomen and pelvis during one single examination. The CT-suite needs to be adequately equipped for resuscitation and reanimation, which is done parallel to the radiological investigations. Since polytrauma management is based on a multidisciplinary approach characterized by a coordinated interaction between trauma surgeons, anaesthesiologists and radiologists, members of all involved disciplines need adequate teaching. Guidelines and algorithms contribute to optimize the early management.

Suprascapular nerve block in chronic shoulder pain: are the radiologists better?

BACKGROUND: Suprascapular nerve block is a safe and effective treatment for chronic shoulder pain in arthritis, which can be performed either by direct imaging (CT guided) or in the clinic using anatomical landmarks to determine needle placement. OBJECTIVE: To compare a CT guided versus an anatomical landmark approach in a randomised, single blind trial examining the efficacy of suprascapular nerve block for shoulder pain in patients with degenerative joint/rotator cuff disease. METHODS: 67 patients with chronic shoulder pain from degenerative disease participated in the trial. 77 shoulders were randomised. The group randomised to receive the block through the anatomical landmark approach received a single suprascapular nerve block. Those in the CT guided group received an injection of methylprednisolone acetate and a smaller volume of bupivacaine around the suprascapular nerve. The patients were followed up for 12 weeks by a "blinded" observer and reviewed at weeks 1, 4, and 12 after the injection. RESULTS: Significant improvements were seen in all pain scores and disability in the shoulders receiving both types of nerve block, with no significant differences in the improvement in pain and disability between the two approaches at any time. Improvements in pain and disability scores were clinically and statistically significant. No significant adverse effects occurred in either group. Patient satisfaction scores for pain relief using either approach were high. CONCLUSION: The CT guided control and landmark approaches to performing suprascapular nerve blocks result in similar significant and prolonged pain and disability reductions; both approaches are safe.

Hyperbaric chamber-related decompression illness in a patient with asymptomatic pulmonary sarcoidosis.

An asymptomatic 46-yr-old male sustained an acute neurologic insult, appearing during the decompression phase of a 50-m dry hyperbaric chamber dive. The right hemisyndrome was most probably related to diving, since symptoms responded rapidly to the early commenced recompression therapy. Further diagnostics revealed a previously unknown pulmonary sarcoidosis with bilateral pulmonary opacities and pleural adhesions that might have predisposed to arterial gas embolism secondary to pulmonary barotrauma. This case may illustrate a potential risk of decompression illness even during dry chamber dives in patients suffering from asymptomatic pleuro-parenchymal pulmonary disease. The value of chest X-ray in the medical assessment of fitness to dive is therefore emphasized.

Stroke--a medical emergency.

Stroke is the third leading cause of death and number one cause of disability in industrialised countries. A number of new therapeutic approaches are currently in development for use in the acute phase of ischaemic stroke and all trials have, to date, demonstrated the importance of early diagnosis and subsequent initiation of treatment. It is well known that, for most patients, there is a long delay between the onset of symptoms and the start of treatment. A number of factors are responsible for this time delay: signs and symptoms often go unrecognised by patients, relatives, and bystanders and, unlike trauma or myocardial infarction, stroke is not given a high priority by medical staff. Studies into the pathophysiology of acute ischaemic stroke have indicated that treatment options are likely to be optimised when early signs of stroke are recognised and treatment is initiated within six hours of symptom onset. Although a small number of stroke patients are treated as emergencies and attended to by the emergency medical services within this time window, this number could easily be increased by intensified public and emergency personnel education. In the future, it is hoped that treatments which must be administered within the first few hours of acute stroke will be able to be initiated by the emergency medical services. In the same way that hospitals are notified and prepared in advance to receive trauma victims, early notification by the emergency medical services about stroke patients would enable stroke teams to be present at admission, thus improving the likelihood of a better outcome for patients.

Integration of chiropractic in the Armed Forces health care system.

Congress has approved the commissioning of chiropractors in the various medical branches of the armed services. Currently, the Department of Defense is conducting a 3-year demonstration program at 10 military sites in which chiropractors are hired on a contractual basis to treat military personnel. This paper presents a brief history of chiropractic and a discussion of a major court case involving the AMA and other professional medical associations. A survey of legal, professional, and organizational issues that must be resolved prior to, or in conjunction with, the full integration of chiropractic in the armed services health care delivery system (if directed by Congress) is included. Prompted by the identified issues, recommended policies and actions are offered to ensure that this alternative health care service is effectively utilized by patient beneficiaries.

Legal interfaces in telemedicine technology.

Telemedicine, an emerging technology which seeks to use advanced telecommunications equipment to enhance medical care, is progressing rapidly in the Department of Defense health care delivery system. This paper recommends that a cautious, preventive law approach be simultaneously initiated to ensure that the technology does not abridge patients' rights to confidentiality or security of medical records, and that agreement on practice parameters be developed. Seven interfaces, in the areas of informed consent, physician liability, non-physician liability, costs, practice parameters, physician-patient relationships, and ergonomics, are discussed in the context of telemedicine. The author recommends that telemedicine pioneers include the legal community's early input in the application of telemedicine technology to help avoid needless litigation.

The case for mandatory HIV testing of active duty sex offenders.

As of May 1993, at least 23 states had passed laws permitting, or requiring, human immunodeficiency virus testing of sexual offenders. Several others have recently passed, or are considering, such legislation. At present, no such specific requirement exists under the Uniform Code of Military Justice. This paper presents an overview of the competing Fourth Amendment privacy rights of accused/convicted offenders, victims' rights, the usefulness and validity of such testing, and the public health mission of the military medical services. In addition, potential tort liability of the armed services is discussed. The author presents arguments supporting mandatory testing of accused offenders meeting minimal "probable cause" requirements, and sharing test results with the physician of complainants/ victims.

Classification and correlates of ethical dilemmas in hospital social work.

The authors used categories based on the NASW Code of Ethics to code hospital social workers' descriptions of ethical dilemmas according to the specific principles in conflict. They also developed codes to identify discharge destination and medical care issues involved in the ethical dilemma. Most ethical dilemmas were found to involve conflicts between client self-determination and client best interest. Ethical dilemmas were more likely when patient mental status was impaired and when decision making was problematic. Ethical dilemmas were related to delayed discharge, in-hospital mortality, and less-than-adequate postdischarge care. The study enhances understanding of ethical dilemmas and advances a methodology for studying their occurrence and consequences.

Draft registration of health care personnel.

A chronic shortage of health care personnel in the active and reserve forces continues to be of concern, particularly in planning for national emergencies or war. Congress has authorized the Selective Service System to establish a system to register and classify health care personnel rapidly in the event a national emergency requires implementation of a draft for the armed services. This paper describes the creation of the Health Care Personnel Delivery System. It provides a brief history of previous military drafts for health care personnel and describes the principal differences in the way a draft registration program may operate in the future.

Detection of articular defects using magnetic resonance imaging: an experimental study.

This study evaluates magnetic resonance imaging (MRI) in the detection of surgically created articular defects in bovine knees. A total of 26 articular defects was created in 2 fresh cadaveric cows' knees. The defects created include chondromalacic grade 2 defects, chondral and osteochondral defects from 3 to 15 mm in diameter. The knee joints were repaired in a normal saline bath to exclude air in the joint prior to MR scanning. T1 weighted spin echo (SE) images and 3D gradient echo (FISP 40 degrees 3D) images were obtained. The T1 weighted SE imaging technique detected 15 defects (57.7%) compared with FISP 3D imaging technique detection of 17 defects (65.4%). The two techniques combined enable 21 of 26 defects (80.8%) to be detected. The imaging techniques used in this study were not able to detect chondromalacic defects less than 10 mm in diameter, nor chondral defects less than 5 mm in diameter. However, small osteochondral defects of 3 mm in diameter are detectable provided the depth of the defect is not less than 10 mm. The FISP 3D imaging technique alone is more sensitive in detecting chondral defects. Both imaging techniques have similarly high sensitivities in detecting osteochondral defects. The imaging time for combined T1 weighted SE and FISP 3D sequence is short (16.5 mm) and this combined technique may be useful for MR scanning of knee joints suspected to have articular defects.

Temporomandibular joint arthrography: dynamic study by videorecording.

Temporomandibular joint symptoms are common. Patients not successfully treated by conservative methods require accurate assessment of the internal derangements of the joint. Temporomandibular joint arthrography using only videorecorded intensifier fluorography displays the anatomy and function accurately with a low radiation dose.