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Recognition, treatment, and prevention of systemic allergic reactions and anaphylaxis *
Published in Richard F. Lockey, Dennis K. Ledford, Allergens and Allergen Immunotherapy, 2020
Emma Westermann-Clark, Stephen F. Kemp, Richard D. deShazo
Severe laryngeal edema may occur so quickly during anaphylaxis that endotracheal intubation becomes impossible. Therefore, an endotracheal tube should be quickly inserted if laryngeal edema is not reversed promptly with epinephrine. An endotracheal tube measuring at least 7.5 mm in diameter is preferred in adults since larger sizes reduce resistance to airflow. Aerosolized epinephrine, along with supplemental oxygen and extension of the neck, may be helpful for difficult endotracheal intubation. If intubation fails, a cricothyrotomy is next since it is more easily accomplished than is an emergency tracheostomy. To do so, the subject's neck is hyperextended, and the area of the cricothyroid membrane is palpated below the thyroid cartilage and above the cricoid cartilage. A small incision is made, the membrane is punctured, and the opening is enlarged with a blunt instrument such as a scalpel handle. Finally, a small diameter (4–5 mm) endotracheal tube is inserted. Alternatively, high-flow oxygen delivery through an 11-gauge needle or polyethylene catheter may suffice for the short term if an endotracheal tube is not available. Potential complications of cricothyrotomy include vocal cord injury, bleeding, and subcutaneous emphysema [122]. This procedure is not part of the training of allergy/immunology subspecialists and is performed in emergency/critical care units by specialists trained to do so.
Anaesthesia for Paediatric Otorhinolaryngology Procedures
Published in John C Watkinson, Raymond W Clarke, Christopher P Aldren, Doris-Eva Bamiou, Raymond W Clarke, Richard M Irving, Haytham Kubba, Shakeel R Saeed, Paediatrics, The Ear, Skull Base, 2018
There are few occasions in anaesthesia and surgery where the surgeon and anaesthetist work so closely together as in paediatric ENT procedures. Many of these involve a shared airway, and it must be accepted that, in the case of any deterioration in the condition of the patient, the anaesthetist must be allowed instant and full access to the patient to deal with the immediate problem. The surgeon’s role in this circumstance is to provide assistance to the anaesthetist, which may extend in life-threatening circumstances to the provision of an emergency surgical airway. It therefore follows that any surgeon undertaking an operating list that includes patients likely to need emergency care must be capable of performing such a procedure. Unlike the adult situation, cricothyroid membrane puncture on children is difficult and has a high failure rate irrespective of how it is done, so in extremis a surgical cricothyrotomy or tracheostomy may need to be carried out urgently.7
Head, neck and vertebral column
Published in David Heylings, Stephen Carmichael, Samuel Leinster, Janak Saada, Bari M. Logan, Ralph T. Hutchings, McMinn’s Concise Human Anatomy, 2017
David Heylings, Stephen Carmichael, Samuel Leinster, Janak Saada, Bari M. Logan, Ralph T. Hutchings
The gland's iodine-containing secretion, thyroxine, is a general metabolic stimulant. Occasionally, a pyramidal lobe extending upwards towards the floor of the mouth can be found attached to the isthmus. This reflects the development of the gland from an outgrowth from the floor of the primitive oral cavity. This variation is not in itself pathological, but can contain pathology or a bleeding hazard when performing an emergency cricothyrotomy.
Acute epiglottitis due to Pasteurella multocida after contact with a feral cat
Published in Baylor University Medical Center Proceedings, 2019
Lauren Sisco, Lizbeth Cahuayme-Zuniga
On arrival the patient appeared acutely ill. He was febrile and dyspneic with a muffled voice. His temperature was 101.1°F; heart rate, 113 beats per minute; blood pressure, 180/115 mm Hg; and respiratory rate, 25 breaths per minute. Scratches and erythema were visible on both hands and forearms. The skin over the neck and chest was flushed. Cervical lymphadenopathy was present. Lung auscultation revealed rhonchi in the left lower lobe. He had no stridor but developed worsening shortness of breath and difficulty swallowing. Racemic epinephrine and dexamethasone were administered due to concern for airway edema, but his respiratory distress progressed. Laryngoscopy was then performed. This revealed an erythematous and edematous epiglottis with leftward deviation, edema, and erythema of the supraglottic tissues with purulent drainage in the oropharynx. Endotracheal intubation was unsuccessful due to severe oropharyngeal edema. An emergent cricothyrotomy was performed.
Randomized Comparative Assessment of Three Surgical Cricothyrotomy Devices on Airway Mannequins
Published in Prehospital Emergency Care, 2019
Jillian M. Dorsam, Steven R. Cornelius, Julie B. McLean, Gregory J. Zarow, Alexandra C. Walchak, Sean P. Conley, Paul J. D. Roszko
To ensure standardization between participants, the cricothyrotomy devices were used as designed by the manufacturer, without adding or mixing parts. SC products were unassembled and in original packaging at the time of evaluation. Tactical CricKit® (TCK, North American Rescue, Greer, SC) uses a tracheal-hook to open a gap between the thyroid cartilage and the cricoid cartilage and the tracheal tube insertion is guided with an obturator (Figure 2). The Control-Cric™ System (20) (CC, Pulmodyne, Indianapolis, IL) features a pre-shaped stylet key and knife with integrated tracheal-hook for insertion (Figure 3). Finally, the bougie-assisted technique (BAT) utilizes the Introducer Adult Bougie (SunMed, Largo, FL), an endotracheal introducer with a curved coudé tip to aid in tracheal tube insertion and placement (Figure 4). Each of these methods is fully described in Table 1.
A rare presentation of angioedema with isolated retropharyngeal and supraglottic involvement
Published in Journal of Community Hospital Internal Medicine Perspectives, 2019
In the ED, patient was given 0.5 mg of 1:1000 Epinephrine IM, 120 mg Methylprednisolone IV, 25 mg Diphenhydramine IV, and 20 mg Famotidine IV. CT scan of the neck with contrast was obtained, which demonstrated marked supraglottic and retropharyngeal edema with severe compromise of the supraglottic airway (Figures 1 and 2). As the patient remained stable, otolaryngology consultation was requested for direct visualization and controlled fiberoptic-guided intubation. Fiberoptic laryngoscopy showed severe edema of the supraglottic and glottic larynx with 90% obstruction of airway along with no visualization of true vocal cords due to severe edema. Due to these findings, along with the possibility of worsening of airway compromise leading to complete obstruction, emergency cricothyrotomy was performed to secure the patient’s airway. The ACE inhibitor was stopped, and the blood pressure managed with hydralazine IV as needed.