The unilateral absence of ribs leads to poor development of subatmospheric pressure in the thorax and paradoxical respiration, and may cause inadequate pulmonary ventilation and hypoxia. In the present case, positive pressure ventilation was chosen to maintain ventilation during the procedure.
Purpose: To describe control of the airway in a patient with severe maxillo-facial injury using intubating laryngeal mask guided awake fibreoptic intubation.Clinical features: A 110 kg man presented with a severe facial injury due to a horse kick. Local examination showed a large transverse gaping laceration just beneath the nose, exposing the lower nasal cavities through to the posterior nasopharynx. It was planned to perform a surgical tracheostomy before surgical fixation of the maxilla and nasal bones. Considering the patient's weight, short neck and difficulty in lying flat, surgical tracheostomy under general anesthesia was considered the best option. Under topical anesthesia, an intubating laryngeal mask was introduced followed by a fibreoptic bronchscope. The endotracheal tube was threaded over the bronchoscope and airway control achieved.
Conclusions:The use of an intubating laryngeal mask avoids the need for manipulation of the head and neck and acts as a 'shield' for the fibreoptic bronchoscope from surrounding blood in patients with maxillo-facial injury. The use of the fibreoptic bronchoscope ensures intubation under vision.Objectif : Décrire la maîtrise des voies aériennes, dans le cas d'une lésion maxillo-faciale sévère, en utilisant le masque laryngé d'intubation comme guide d'intubation fibroscopique vigile.Éléments cliniques : Un homme de 110 kg présentait une lésion faciale sévère causée par un coup de sabot de cheval. L'examen a montré une importante lacération transverse béante, juste sous le nez, ouvrant les fosses nasales inférieures sur le nasopharynx postérieur. On a planifié une trachéotomie avant la fixation chirurgicale des os du maxillaire et du nez. Dans les circonstances, la trachéotomie sous anesthésie générale a été considérée comme le meilleur choix, vu le poids du patient, le cou court et la difficulté de s'allonger. Sous anesthésie topique, un masque laryngé d'intubation a été introduit, suivi d'un fibroscope bronchique. Le tube endotrachéal a été enfilé sur le bronchoscope pour ainsi réaliser le contrôle des voies aériennes.Conclusion : L'utilisation du masque laryngé d'intubation élimine la nécessité de manipuler la tête et le cou. Ce masque sert de «bouclier» au fibroscope bronchique au moment de contenir le sang chez des patients qui présen-tent des lésions maxillo-faciales. Le fibroscope bronchique assure une bonne vision pendant l'intubation.
The use of synthetic colloids for resuscitation and volume replacement is common in the intensive care unit. Although adverse reactions have been reported to colloid solutions, the incidence of severe reactions to the starch derivatives is low. We report a case of an anaphylactoid reaction to pentastarch (200/0.5) in a young asthmatic who received it as a fluid challenge in the intensive care unit. The pathogenesis and implications of such a reaction in an asthmatic are discussed.
This report describes the case of an otherwise healthy young adult female, who presented with a 12-h history of progressive bluish discolouration of lips and limbs. She denied ingesting or inhaling any drug or substance. A high PaO2 in the presence of 'cyanosis' and 'dark blood' led to suspicion of methaemoglobinaemia. Co-oximetry revealed the methaemoglobin level to be 47%. A urinary screen for drugs of abuse was negative and blood methaemoglobin reductase activity was within the normal range. The aetiology was traced to dapsone detected in the urine by gas chromatography/mass spectrometry. The therapeutic and diagnostic approach in such patients is discussed.
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