A & A case reports
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A 67-year critically ill patient suffered from a hypertensive crisis (200 mm Hg) because of a norepinephrine overdose. The overdose occurred when the clinician exchanged an almost-empty syringe and the syringe pump repeatedly reported an error. ⋯ Testing this hypothesis in vitro showed significant peak dosing errors (up to +572%) but moderate overdose (0.07 mL, +225%) if a clamp was used on the intravenous infusion line and a large overdose (0.8 mL, +2700%) if no clamp was used. Clamping and awareness are advised.
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Airway management in trauma is a crucial skill, because patients are at risk of aspiration, hypoxia, and hypoventilation, all of which may be fatal in the setting of increased intracranial pressure. The King Laryngeal Tube reusable supraglottic airway (King Systems, Noblesville, IN) allows for temporary management of a difficult airway but poses a challenge when an attempt is made to exchange the device for an endotracheal tube, often managed by emergency tracheostomy. We describe a novel fiberoptic, video laryngoscope-assisted approach to intubation in a difficult trauma airway with an in situ King Laryngeal Tube.
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We placed a superficial serratus anterior plane catheter in an elderly woman with dementia and elevated clotting times who presented with multiple rib fractures after a mechanical fall. She was not a surgical candidate, and treatment consisted of conservative management with physical therapy and pain control. ⋯ Given her elevated international normalized ratio, thoracic epidural and paravertebral analgesia was also contraindicated. We placed an ultrasound-guided serratus anterior plane catheter, allowing titratable continuous infusion in a trauma patient, resulting in excellent analgesia without adverse effects.
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We experienced difficulty inserting cuffed inner diameter (ID) 4.5- and 5.0-mm endotracheal tubes (ETTs) in a 5-year-old boy. Postoperative ultrasound investigations showed that the internal transverse width of the cricoid cartilage was 8.0 mm. ⋯ The OD of an uncuffed ID 5.5-mm ETT was 7.6 mm; this tube passed the cricoid cartilage. Hence, the transverse width of the cricoid cartilage and ETT diameter including cuff folds should be considered when selecting cuffed ETTs.
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In some cases of cerebral aneurysm clipping, direct clip application to the aneurysm neck may be difficult or the aneurysm may rupture unexpectedly. In these cases, a clip may be temporarily applied to the parent artery to reduce aneurysmal wall tension, facilitate permanent clip placement, or control bleeding if the aneurysm ruptures. ⋯ We present a case in which the aneurysm ruptured and IV administration of adenosine was required to facilitate clipping. This case suggests that administering multiple consecutive precalculated doses of adenosine may be a safe method to manage aneurysmal rupture.