Evaluation of esophageal injuries after defibrillation with transesophageal ultrasound probe in the mid-esophagus in pigs.

OBJECTIVE: Transesophageal echocardiography (TEE) is becoming increasingly utilized by emergency medicine providers during cardiac arrest. Intra-arrest, TEE confers several benefits including shorter pauses in chest compressions and direct visualization of cardiac compressions. Many ultrasound probe manufacturers recommend against performing defibrillation with the TEE probe in the mid-esophagus for fear of causing esophageal injury or damage to the probe, however no literature exists that has investigated this concern. To assess this, we performed cardiopulmonary resuscitation (CPR) and multiple defibrillations in 8 swine with a TEE probe in place. METHODS: We performed TEE on 8 adult swine during CPR and performed multiple 200 J defibrillations with the TEE probe in the mid-esophagus. Post-mortem, esophagi were dissected and inspected for evidence of injury. RESULTS: On macroscopic inspection of 8 esophagi, no evidence of hematoma, thermal injury, or perforation was noted. CONCLUSION: Our study suggests that performing defibrillation during CPR with a TEE probe in place in the mid-esophagus is likely safe and low risk for significant esophageal injury. This further bolsters the use of TEE in CPR and would enable continuous visualization of cardiac activity without the need to remove the TEE probe for defibrillation.

Epistaxis.

Most anterior epistaxis originates primarily from the Kiesselbach plexus, whereas posterior epistaxis is less common and originates from branches of the sphenopalatine artery. Risk factors include local trauma, foreign body insertion, substance abuse, neoplasms, inherited bleeding diatheses, or acquired coagulopathies. Assessment of airway, breathing, and circulation precedes identification of bleeding source, pain control, and achieving hemostasis. Management options include topical vasoconstrictors, direct pressure, cautery, tranexamic acid, nasal tampons, Foley catheters, or surgical intervention. Specialty consultation may be pursued if interventions fail. Disposition is typically to home unless posterior epistaxis or significant comorbidities exist that warrant admission.

Sulf1 modulates BMP signaling and is required for somite morphogenesis and development of the horizontal myoseptum.

Heparan sulfate proteoglycans (HSPGs) are glycosylated extracellular or membrane-associated proteins. Their unbranched heparan sulfate (HS) disaccharide chains interact with many growth factors and receptors, modifying their activity or diffusion. The pattern of HS sulfation can be altered by the enzymes Sulf1 and Sulf2, secreted extracellular 6-O endosulfatases, which remove specific sulfate groups from HS. Modification by Sulf enzymes changes the binding affinity of HS for protein such as ligands and receptors, affecting growth factor gradients and activities. The precise expression of these sulfatases are thought to be necessary for normal development. We have examined the role of the sulf1 gene in trunk development of zebrafish embryos. sulf1 is expressed in the developing trunk musculature and as well as in midline structures such as the notochord, floorplate and hypochord. Knockdown of sulf1 with antisense morpholinos results in poor differentiation of the somitic trunk muscle, loss of the horizontal myoseptum, lack of pigmentation along the mediolateral stripe, and improper migration of the lateral line primordium. sulf1 knockdown results in a decrease in the number of Pax7-expressing dermomyotome cells, particularly along the midline where the horizontal myoseptum develops. It also leads to decreased sdf1/cxcl12 expression along the mediolateral trunk musculature. Both the Pax7 and cxcl12 expression can be restored by inhibition pharmacological inhibition of BMP signaling, which also restores formation of the myoseptum, fast muscle development, and pigmentation patterning. Lateral line migration and neuromast deposition depend on sdf1/cxcl12 and FGF signaling respectively, both of which are disrupted in sulf1 morphants. Pharmacological activation of FGF signaling can rescue the spacing of neuromast deposition in these fish. Together this data indicate that sulf1 plays a crucial role in modulating both BMP and FGF signaling along the developing myoseptum to coordinate the morphogenesis of trunk musculature, associated pigment cells, and lateral line neuromasts.