Inability to ventilate or oxygenate can be catastrophic. Critical tracheal stenosis may present as a life-threatening airway emergency. We report a 25-year-male who presented to the Emergency Department in respiratory arrest. After endotracheal intubation, there was no tidal volume delivery despite generating high peak airway pressures. Unfortunately, even an emergency surgical airway did not succeed in providing adequate ventilation. Postmortem examination revealed near-total occlusion of the distal tracheal lumen. When a patient has refractory ventilatory failure due to possible airway obstruction, the acute care provider should consider distal tracheal stenosis as one among the differential diagnosis. Conventional approach to airway management, including surgical airway, may not be of help in the presence of distal tracheal stenosis. A skilled emergency physician should possess the ability to think out-of-the-box and be aware of novel techniques to achieve oxygenation and ventilation in a 'failed airway' of this nature. Though appropriate, fibreoptic intubation, extracorporeal membrane oxygenation or emergency thoracotomy may not be readily available or practically feasible options to manage a failed airway due to distal tracheal stenosis.
Introduction: Coronavirus disease 2019 (COVID-19) is a highly contagious disease transmitted by contact, droplets, and aerosols. Front line health-care workers (HCWs), particularly emergency physicians and acute care providers, are vulnerable to being exposed while treating their sick patients. Despite appropriate personal protective equipment use, HCW gets infected, suggesting the need for multiple layers of protection such as barrier devices. Methods: We aimed to determine the effectiveness of our novel “Resuscitation Cover All”(RCA) in reducing the exposure of HCW to simulated respiratory particles and its feasibility during cardio pulmonary resuscitation (CPR). This was a pilot simulation-based study. Five CPR simulation sessions were performed in Standard and RCA protocols, individually. Exposures through contact, droplets, and aerosols were simulated using a standardized volume of liquid detergent. Under Wood's lamp illumination, exposures of participants were compared between the protocols. Rate and depth of chest compressions, time taken to intubate, interruptions in CPR, and first-pass success were analyzed. Results: Overall mean exposure in standard protocol was 4950.4 ± 1461.6 (95%confidence interval [CI]:3135.7–6765.2) sq.pixels and RCA protocol was 2203.6 ± 1499.0 (95%CI: 342.4–4064.9) sq.pixels ( P = 0.019). In standard, chest compressor had the highest exposure of 3066.6 ± 1419.2 (95%CI: 2051.3–4081.9) sq.pixels followed by defibrillator assistant 1166.4 ± 767.4 (95%CI: 617.4–1715.4) sq.pixels. Chest compressor of RCA had reduced exposure compared to that of standard ( P < 0.001). Hands were the most frequently exposed body part. Airway manager of RCA had no exposure over head and neck in any session. No significant difference in CPR performance metrics was observed. Conclusion: This pilot simulation-based study shows that the novel RCA device could minimize the exposure of HCW to simulated respiratory particles during CPR. Also, it might not alter the high-quality CPR performance metrics. We need more real-life evidence.
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