1/58. Upper airway obstruction.A large number of diseases may present with respiratory distress. In adults, upper airway obstruction (UAO) is relatively rare. Consequently, UAO may initially be overlooked in the differential diagnosis of the dyspneic patient. Because it may progress rapidly, delays or errors in diagnosis can be critical. During an eight-month period in one emergency department, seven adult patients with potentially life-threatening diseases of the upper airway were seen. To reacquaint physicians with the syndrome of mechanical obstruction of large airways, several illustrative cases are presented and the syndrome is discussed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/58. Laryngeal papillomatosis presenting as acute airway obstruction in a child.Upper airway obstruction, regardless of cause, can masquerade or be misdiagnosed as lower airway disease in children. In such cases, therapeutic trials of antibiotics, bronchodilators, and over-the-counter medications for symptom relief routinely fail; however, the original diagnosis often goes unchallenged. If the obstructive process is progressive, then acute occlusion of the airway may occur, rapidly leading to suffocation and death if resuscitation is unsuccessful. Outlined in this report is the case of a young female with a history of asthma, poorly responsive to outpatient treatment, who presented with respiratory arrest. The cause of the respiratory collapse was later identified as a large laryngeal papilloma, a condition rarely encountered by emergency physicians.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/58. Lingual tonsillectomy for refractory paroxysmal cough.Historically, the lingual tonsils are the most neglected members of Waldeyer's ring. They are often overlooked even in a thorough head and neck exam because of their anatomic location and the ambiguous constellation of symptoms which they produce when they are diseased or enlarged. The lingual tonsils have been reported to be associated with a variety of upper aerodigestive tract symptoms including odynophagia, dysphagia, otalgia, globus, halitosis, chronic cough, and dyspnea. Many patients with lingual tonsillar pathology may undergo extensive work-up for some of these non-specific upper airway complaints by their primary physician before referral to an otolaryngologist. Consequently, the diagnosis of lingual tonsillar disease requires a high index of suspicion and a thorough physical exam including evaluation of the tongue base and hypophaynx with indirect mirror or fiberoptic exam. In order to draw attention to this frequently unrecognized entity, we present a case report of a child with chronic cough resulting from lingual tonsillar hypertrophy.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/58. Breath-holding-like spells in an infant: an unusual presentation of lingual thyroglossal duct cyst.The authors report the case of an infant with a lingual thyroglossal duct cyst who presented with breath-holding-like spells, which actually represented life-threatening ball-valve obstruction of the larynx, leading to hypoxemia and transient cerebral dysfunction. When evaluating apparent breath-holding spells in young infants, physicians should include dynamic, episodic upper airway obstruction in the differential diagnosis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/58. Late presentation of upper airway obstruction in Pierre Robin sequence.A retrospective review was carried out of 11 consecutive patients with the Pierre Robin sequence referred to a tertiary paediatric referral centre over a five year period from 1993 to 1998. Ten patients were diagnosed with significant upper airway obstruction; seven of these presented late at between 24 and 51 days of age. failure to thrive occurred in six of these seven infants at the time of presentation, and was a strong indicator of the severity of upper airway obstruction. growth normalised on treatment of the upper airway obstruction with nasopharyngeal tube placement. All children had been reviewed by either an experienced general paediatrician or a neonatologist in the first week of life, suggesting that clinical signs alone are insufficient to alert the physician to the degree of upper airway obstruction or that obstruction developed gradually after discharge home. The use of polysomnography greatly improved the diagnostic accuracy in assessing the severity of upper airway obstruction and monitoring the response to treatment. This report highlights the prevalence of late presentation of upper airway obstruction in the Pierre Robin sequence and emphasises the need for close prospective respiratory monitoring in this condition. Objective measures such as polysomnography should be used, as clinical signs alone may be an inadequate guide to the degree of upper airway obstruction.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/58. Complications of a retrograde intubation in a trauma patient.The authors report the case of an elder woman involved in a motor vehicle collision (MVC) requiring emergent intubation using the technique of retrograde intubation (RI). Since RI is a blind technique, potential complications arising from its use are numerous and may result in increased morbidity and mortality. Such was the case of this RI that involved incorrect placement of the endotracheal tube (ETT), resulting in suboptimal ventilation and increased morbidity. Additionally, this case illustrates how the failure to detect this error in multiple settings (ambulance, helicopter, emergency department) led to unnecessary and potentially deleterious procedures and significant delay in providing the basics of trauma care, oxygenation and ventilation. Although theoretical complications of RI have been addressed in the past, there have been very few published reports of actual complications. The emergency physician must be aware of difficult airways, options available to establish alternative airways, and methods to confirm appropriate placement of the ETT. The authors also discuss the indications, procedures, and complications involved in performing an RI.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/58. Gastric rupture after heimlich maneuver and cardiopulmonary resuscitation.Choking is a common emergency problem. The heimlich maneuver is unquestionably effective in relieving airway obstruction. Serious and life-threatening complications may arise, however, if the maneuver is applied incorrectly. Two cases of gastric rupture after heimlich maneuver are reported. Lay public, paramedics and the medical professionals should be educated with the correct technique of heimlich maneuver and its potential complications. All patients receiving heimlich maneuver should be examined by an experienced physician.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/58. Poststreptococcal glomerulonephritis presenting as impending airway obstruction.The presence of poststreptococcal glomerulonephritis in the pediatric patient remains a diagnostic challenge to the emergency physician. The variability of both patient presentation and laboratory parameters often obscures the diagnosis. We describe a child who presented to the emergency department with subglottic edema and the possibility of impending airway compromise. The child was admitted to the hospital under close observation, and several days later, the diagnosis of poststreptococcal glomerulonephritis was made.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/58. A technique for maintenance of airway access in infants with a difficult airway following tracheal extubation.Tracheal extubation of patients with a difficult airway represents a challenge to anaesthesiologists and intensive care physicians. While a variety of techniques designed to maintain access to the airway in case of the need for tracheal reintubation have been described in adults, no reports have been published in infants and young children. We describe an approach to this issue in a young child with severe micrognathia.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/58. Fatal angioedema associated with lisinopril.OBJECTIVE: To report a case of fatal angioedema associated with the use of lisinopril, a long-acting angiotensin-converting enzyme (ACE) inhibitor. DATA SOURCES: case reports, review articles, short reports, and pertinent information from the patient's medical record. DATA EXTRACTION: Data was collected from contemporary medical journals and reviewed by both authors. DATA SYNTHESIS: angioedema associated with ACE inhibitors (captopril and enalapril) is well documented in the literature. With increased prescribing of newer, longer-acting agents, this potentially lethal adverse reaction is of even greater concern. Because angioedema associated with ACE inhibitors is a class-related event, the number of reported cases would be expected to increase with increasing numbers of prescriptions written for these drugs. This report, describing a patient who developed angioedema following therapy with lisinopril, illustrates the severity of this adverse reaction. PATIENT: A 66-year-old man presented to the emergency room complaining of increased swelling of the back of his throat and difficulty breathing. Despite treatment with epinephrine, antihistamines, and corticosteroids, the patient's condition progressed from that of severe laryngeal edema to total laryngospasm and complete airway obstruction. Emergency measures to intubate the patient were complicated by severe swelling of his neck and oropharynx, forcing the physician to perform a grossly traumatic tracheotomy. The difficulty encountered during intubation deprived the patient of oxygen for a significant amount of time, precipitating cardiopulmonary arrest. The anoxic episode resulted in hypoxic, ischemic encephalopathy and, ultimately, death. CONCLUSIONS: angioedema is a serious, potentially life-threatening adverse effect associated with the use of ACE inhibitors. Clinicians need to be aware of this effect when prescribing ACE inhibitors to treat hypertension and congestive heart failure, and when assessing patients presenting to the emergency room with complaints of tongue or pharyngeal swelling. patients should be instructed to report immediately to an emergency room for medical attention if they experience any unexplained shortness of breath or swelling of the throat or tongue.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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