The evaluation of a better intubation strategy when only the epiglottis is visible: a randomized, cross-over mannequin study.

BACKGROUND: The Cormack-Lehane (C-L) grade III airway is considered to be a challenging airway to intubate and is associated with a poor intubation success rate. The purpose of this study was to investigate whether the holding position, shapes, bend angles of the endotracheal tube (ET) and the stylet-assisted lifting of the epiglottis could improve the success rate of intubation. METHODS: Thirty-two participants, 26 physicians, 2 residents, and 4 nurse practitioners, with 12.09 ± 5.38 years of work experience in the emergency department and more than 150 annual intubation events, were enrolled in this randomized, cross-over mannequin study. We investigated the effects of straight-to-cuff ET shapes with 35° and 50° bend angles, banana-shaped ET with longitudinal distances of 28 cm and 26 cm, two methods of holding the ET (either on the top or in the middle), and lifting or not the epiglottis, on the intubation duration, its success rate, and its subjective difficulty. The aim of the study is to provide optimized intubation strategies for difficult airway with C-L IIb or III grades, when the inlet of the trachea cannot be visualized. RESULTS: The two groups that lifted the epiglottis using the stylets, in bend angles of 35° and 50°, had the shortest duration of intubation (23.75 ± 14.24 s and 20.72 ± 6.90 s, hazard ratios 1.54 and 1.85 with 95% confidence intervals [95% CI] of 1.01-2.34 and 1.23-2.78, respectively) and a 100% success rate in intubations. In the survival analysis, lifting of the epiglottis was the only significant factor (p < 0.0001, 95% CI 1.34-2.11) associated with the success rate of intubation. CONCLUSIONS: The use of the epiglottic lift as an adjunctive technique can facilitate the intubation and improve its success rate without increasing procedure difficulty, in C-L III airway, when only the epiglottis is seen. TRIAL REGISTRATION: ClinicalTrials Registry ( https://clincaltrials.gov , identifier NCT03366311).

Disco spotlight sign: A sign that may be useful for diagnosis of pneumomediastinum.

The use of ultrasonography for the investigation of pneumomediastinum is limited by the presence of air artifacts. Air accumulation in the mediastinum obscures the heart, sometimes leading to misinterpretation as lung tissue. We found that cardiac apical swinging during the heart cycle, however, can create a uniquely characteristic squeezing of mediastinal free air, producing a sonographic B-line that flashes in and out. We named this dynamic finding, the "disco spotlight" sign. This finding may be useful to confirm the diagnosis of pneumomediastinum.

Acute aortic dissection (AAD) in the elderly.

AAD is a relatively uncommon yet catastrophic disease. Though the relationship between AAD and age has been discussed in several previous studies, many facets of the relationship between AAD and the elderly still remain unclear. From a retrospective review of charts from January 1, 2005 to December 31, 2010, we collected data of 132 spontaneous AAD cases in a medical center in Taiwan, 83 of which were enrolled in our study. We divided patients into two groups: one above 65 years old (elderly), and a second, non-elderly group. Data collected for statistical analysis included: clinical manifestations on arrival, time of onset, type of AAD, width of mediastinum, whether or not the patient underwent an operation, number of days spent hospitalized, and in-hospital mortality rates. We found that in the elderly group there were more instances of hyperglycemia (p=0.0001), more neurologic defects (p=0.001), less chest pain (p=0.001), and less abdominal pain (p=0.003). SBP was also lower in the elderly group (139±48mmHg, p=0.0001), while there was no difference in mediastinal width between these two groups. In both groups, most AAD cases were DeBakey type III, but type I AAD was more commonly seen in the elderly (p=0.0011). We found that there were both lower SBP and higher rate of diabetes in the elderly group. The elderly group also had longer hospital stays (14.6±16.3 days, p=0.0001) and almost twice the mortality rate (31.1% vs. 15.8%, p=0.0001).

Treatment and prognosis of pyogenic liver abscess.

BACKGROUND: There are many combinations of treatments for pyogenic liver abscess (PLA). Different treatments are indicated for different clinical courses of PLA. AIMS: To realize the current prevalence, clinical course, trend of treatment, and prognosis of pyogenic liver abscess (PLA) in Taiwan. METHODS: We retrospectively reviewed the medical records of 126 patients with PLA. We divided them into four groups: M, MD, MS, and MDS, represented as parenteral antibiotic only, parenteral antibiotic with drainage, parenteral antibiotic with surgical intervention, and parenteral antibiotic with surgical drainage. We analyzed data by commercial statistical software (SPSS for Windows, version 11.0, SPSS Ltd., Chicago, IL). We used Student's t-test and χ(2) test for statistical analyses, and significance was set at a p value less than 0.05. RESULTS: PLA patients who were treated only with parenteral antibiotics had early diagnosis of PLA with a mean fever period of 3.3 days (p = 0.043). Patients who needed surgical drainage were highly associated with shock presentation in the clinical course (35.7% versus 14.3%, p = 0.007). CONCLUSION: The earlier we can diagnose PLA, the shorter the patient's hospital stay (20.6 days) will be. In PLA patients with shock, a higher rate of surgical intervention is mandatory to save their lives.