In-hospital and long-term prognosis of elderly patients requiring endotracheal intubation for life-threatening presentation of cardiogenic pulmonary edema.

OBJECTIVE: We studied the in-hospital course, long-term prognosis, and functional status of elderly patients with life-threatening cardiogenic pulmonary edema requiring mechanical ventilation. DESIGN: Semiprospective evaluation. SETTING: Twelve intensive care units and one emergency prehospital medical department in university hospitals. PATIENTS: Patients, aged >75 yrs, with life-threatening cardiogenic pulmonary edema requiring invasive airway management during the prehospital phase between January 1994 and January 1999 were included. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: A total of 79 patients were studied, of which 55 were included in the prospective phase and 24 during the retrospective phase. The age range was 75-99 yrs, with a mean age of 82.4 +/- 5.9. The male/female ratio was 35:44. The in-hospital mortality was 26.6%. The mean follow-up time for all 58 survivors was 23 months (range, 2-56 months). Among those discharged, survival at 1 yr was 69%. At 3 months after hospital discharge, 49 (87%) patients lived at home, 46 (82%) were able to bathe themselves, 35 (62%) could walk at least one block, and 34 (61%) could climb one flight of stairs. CONCLUSIONS: Mortality after severe pulmonary edema requiring endotracheal intubation in a very elderly cohort has a predictably high mortality, although not related directly to the degree of presenting respiratory compromise. However, approximately 50% of the overall cohort returned to relatively good functional status, despite advanced age and a severely compromised presentation. Aggressive airway management appears, therefore, justified in this select group of patients.

Headache: cortical vein thrombosis and response to anticoagulation.

Cerebral venous thrombosis (CVT) is being diagnosed more frequently with the use of advanced radiologic imaging. The presentation of CVT includes a wide spectrum of nonspecific symptoms with headache predominating. We present a case with acute, severe headache. The evaluation included a head computed tomography (CT) scan that was normal. The presence of opacified sinuses led to treatment for sinusitis. The patient returned the following day with a generalized tonic-clonic seizure. A magnetic resonance imaging (MRI) study identified an isolated cortical venous thrombosis. This patient was treated with anticonvulsant and anticoagulation therapy. A CVT is an unusual cause of headache and should be considered in patients with atypical presentation or associated seizure, or who are refractory to current therapy. Diagnosis may be made with MRI. Resolution and complete recovery are possible with appropriate therapy.

Relation of body position at the time of discovery with suspected aspiration pneumonia in poisoned comatose patients.

OBJECTIVE: The left lateral decubitus position is generally accepted as the position of choice to protect against aspiration pneumonia in comatose poisoned patients. We studied the relationship between initial body position during coma and subsequent development of suspected aspiration pneumonia (SAP). DESIGN: Observational, descriptive study. SETTING: Toxicology intensive care unit in a university hospital. PATIENTS: Acutely poisoned comatose patients admitted to our intensive care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Glasgow Coma Scale score (GCS) and body position were recorded in poisoned patients on discovery. Chest radiographs were examined for infiltrates suggesting SAP within 24 hrs of hospitalization. The prone positioned patients had a lower incidence of SAP than patients in the lateral decubitus and supine positions, despite similar GCS scores. Patients in the semi-recumbent position had an incidence of SAP similar to prone patients, but with higher GCS values. CONCLUSIONS: The prone position appears to be associated with a lower incidence of SAP than the lateral decubitus position in comatose poisoned patients.

A survey of sedation protocols used for emergency endotracheal intubation in poisoned patients in the French prehospital medical system.

The purpose of this study was to evaluate prehospital sedation protocols used by several French mobile intensive care units for difficult intubations in poisoned patients. This prospective, descriptive study was performed within the toxicological intensive care unit in a university hospital. Consecutive poisoned patients intubated during their airway management by prehospital medical teams were included. Intubating physicians completed a one-page checklist concerning the circumstances of endotracheal intubation. Intubation difficulty was significantly related to the nature of sedation protocols. The use of etomidate alone as an intubation sedative agent was associated with significantly poorer intubating conditions (47.2% difficult) than other sedative agents or neuromuscular blockade). Neuromuscular blockade with sedation in our series was associated with the lowest incidence of difficult intubations in poisoned patients. Sedation alone for intubation appears to be inadequate to achieve good intubating conditions in a significant proportion of patients.