Chest
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In patients with blunt chest trauma, early diagnosis of mediastinal hematoma is important, because it could be associated with thoracic vessel injury. Mediastinal hematoma is generally evoked because of a widened mediastinum on chest radiograph, but radiologic diagnosis may lead to excessive angiography being performed. Transesophageal echocardiography (TEE) provides accurate views of the mediastinum and can be rapidly performed at the bedside. ⋯ We described three different TEE signs of mediastinal hematoma: (1) an increased distance between the probe and the aortic wall; (2) a double contour of the aortic wall; and (3) visualization of the ultrasound signal between the aortic wall and the visceral pleura. The distance between the esophageal probe and the aortic wall was the most accurate sign because it could be easily obtained; the threshold value for this distance was 3 mm. TEE appears to be an accurate method to diagnose traumatic mediastinal hematoma.
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This was a prospective study of 52 patients that were extubated in our medical intensive care unit. Rapid shallow breathing, represented by a ratio of frequency to tidal volume (f/VT) of more than 105, was evaluated either on continuous positive airway pressure or pressure support prior to extubation as a marker of extubation outcome. Twelve out of 13 patients (92 percent) with rapid shallow breathing (f/VT ratio > 105) were successfully extubated. ⋯ A measured f/VT ratio of less than 105 had a sensitivity and specificity of 72 and 11 percent, respectively, for extubation success. Patients who had unsuccessful outcomes were ventilated for a significantly more prolonged period (9.6 +/- 6.8 d vs 4.6 +/- 3.9 d, unpaired t test, p = 0.004). We conclude that the presence of rapid shallow breathing during a weaning trial with the patient on partial ventilatory support does not necessarily preclude successful extubation.
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Case Reports
Endotracheal tube and tracheobronchial obstruction as causes of hypoventilation with high inspiratory pressures.
Two cases of difficult ventilation are presented, the first caused by endotracheal tube obstruction with nasal turbinate, and the second caused by tracheobronchial obstruction with blood clots. The clinical presentation in each case was characterized by extreme difficulty in ventilating and severe hypercapnia despite vigorous ventilatory efforts with either a mechanical ventilator or resuscitator bag. A simple manipulation of the endotracheal tube cuff helped to differentiate between increased impedance caused by endotracheal tube obstruction as opposed to increased respiratory system impedance beyond the tip of tube. In the second patient, in whom even a short interruption of ventilation was poorly tolerated, simultaneous rigid bronchoscopy (for removal of intratracheal masses) and ventilation via endotracheal tube were successfully performed.