Brainstem anaesthesia after retrobulbar block

AbstractRegional anaesthesia techniques in ophthalmology are usually utilized for day case surgery. During various procedures, profound akinesia of the eye and anaesthesia of the surgical site are required, both of which are achieved with retrobulbar block. Due to the anatomy of the eye, life-threatening complications are possible. An 82-year-old female with secondary post-herpetic uveitic glaucoma of the right eye presented at the Department of Ophthalmology for an elective trans-scleral laser cyclophotocoagulation. She was given a retrobulbar block to the right eye with 2 mL of 0.5% levobupivacaine and 2 mL of 2% lidocaine. The procedure was technically performed without any issues. 2-3 minutes after the injection she became lethargic and 5 minutes later she lost consciousness and developed severe hypotension with bradycardia and respiratory arrest. She was successfully intubated and resuscitated, using mechanical ventilation, vasoactive medications, fluid therapy and intravenous lipid emulsion. There are three mechanisms for local anaesthetic (LA) to reach the central nervous system after a retrobulbar block: systemic absorption of LA, direct intra-arterial injection and retrograde flow into the cerebral circulation, and injecting LA into the subdural space via puncturing the dural optic nerve sheath, the latter being most common. The clinical picture of our patient was very consistent with subdural anaesthesia after exposure of the pons, midbrain and cranial nerves to LA, i.e. brainstem anaesthesia. Following appropriate life support measures taken in our case, there was a successful outcome. To minimize the chance for brainstem anaesthesia after retrobulbar block, we recommend low volume with low concentration of LA and block performance by an experienced ophthalmologist or anaesthesiologist with proper technique. Patients receiving retrobulbar anaesthesia should be carefully monitored at least 20 minutes after the block. Life support equipment should be available before performing retrobulbar block.

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The Esophageal Detector Device: Accuracy and Reliability in Difficult Airway Settings

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00042369 ◽

1996 ◽

Vol 11 (1) ◽

pp. 60-62 ◽

Cited By ~ 5

Author(s):

Christopher E. Kapsner ◽

David C. Seaberg ◽

Charles Stengel ◽

Kaveh Ilkhanipour ◽

James Menegazzi

Keyword(s):

Emergency Medicine ◽

Pulmonary Edema ◽

Difficult Airway ◽

Laboratory Investigation ◽

Respiratory Arrest ◽

Tube Placement ◽

Mainstem Bronchus ◽

Anatomic Location ◽

The Right ◽

Attending Physician

AbstractIntroduction:The esophageal detector device (EDD) recently has been found to assess endotracheal (ET) tube placement accurately. This study describes the reliability of the EDD in determining the position of the ET tube in clinical airway situations that are difficult.Methods:This was a prospective, randomized, single-blinded, controlled laboratory investigation. Two airway managers (an emergency-medicine attending physician and a resident) determined ET-tube placement using the EDD in five swine in respiratory arrest. The ET tube was placed in the following clinical airway situations: 1) esophagus; 2) esophagus with 1 liter of air instilled; 3) trachea; 4) trachea with 5 ml/kg water instilled; and 5) right mainstem bronchus. Anatomic location of the tube was verified by thoracotomy of the left side of the chest.Results:There was 100% correlation between the resident and attending physician's use of the EDD. The EDD was 100% accurate in determining tube placement in the esophagus, in the esophagus with 1 liter of air instilled, in the trachea, and in the right mainstem bronchus. The airway managers were only 80% accurate in detecting tracheal intubations when fluid was present.Conclusions:The EDD is an accurate and reliable device for detecting ET-tube placement in most clinical situations. Tube placement in fluid-filled trachea, lungs, or both, which occurs in pulmonary edema and drowning, may not be detected using this device.

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Gasperini Syndrome: A Case Report and Systematic Review and Proposing a New Definition

Case Reports in Neurology ◽

10.1159/000510845 ◽

2020 ◽

Vol 12 (3) ◽

pp. 433-439

Author(s):

Riwaj Bhagat ◽

Siddharth Narayanan ◽

Marwa Elnazeir ◽

Thong Diep Pham ◽

Robert Paul Friedland ◽

...

Keyword(s):

Systematic Review ◽

Brain Mri ◽

Cranial Nerves ◽

Clinical Manifestations ◽

The Other ◽

Neurological Deficits ◽

Brainstem Stroke ◽

Neurological Features ◽

The Right ◽

Core Features

Gasperini syndrome (GS), a rare brainstem syndrome, is featured by ipsilateral cranial nerves (CN) V–VIII dysfunction with contralateral hemibody hypoesthesia. While there have been 18 reported cases, the GS definition remains ambiguous. We report a new case and reviewed the clinical features of this syndrome from all published reports to propose a new definition. A 57-year-old man with acute brainstem stroke had right CN V–VIII and XII palsies, left body hypoesthesia and ataxia. Brain MRI showed an acute stroke in the right caudal pons and bilateral cerebellum. After a systematic review, we classified the clinical manifestations into core and associate features based on the frequencies of occurring neurological deficits. We propose that a definitive GS requires the presence of ipsilateral CN VI and VII palsies, plus one or more of the other three core features (ipsilateral CN V, VIII palsies and contralateral hemibody hemihypalgesia). Additionally, GS, similar to Wallenberg’s syndrome, represents a spectrum that can have other associated neurological features. The revised definition presented in this study may enlighten physicians with the immediate recognition of the syndrome and help improve clinical localization of the lesions and its management.

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Terminal Sedation: Palliative Care for Intractable Pain, Post Glucksberg and Quill

American Journal of Law & Medicine ◽

10.1017/s0098858800002331 ◽

2003 ◽

Vol 29 (1) ◽

pp. 45-76

Author(s):

Rob McStay

Keyword(s):

Palliative Care ◽

Supreme Court ◽

Assisted Suicide ◽

Life Support ◽

Intractable Pain ◽

Terminal Sedation ◽

Physician Assisted Suicide ◽

The Right ◽

Artificial Life Support ◽

Unconscious State

In 1997, the U.S. Supreme Court tacitly endorsed terminal sedation as an alternative to physician-assisted suicide, thus intensifying a debate in the legal and medical communities as to the propriety of terminal sedation and setting the stage for a new battleground in the “right to die” controversy. Terminal sedation is the induction of an unconscious state to relieve otherwise intractable distress, and is frequently accompanied by the withdrawal of any life-sustaining intervention, such as hydration and nutrition. This practice is a clinical option of “last resort” when less aggressive palliative care measures have failed. Terminal sedation has also been described as “the compromise in the furor over physician-assisted suicide.”Medical literature suggests that terminal sedation was a palliative care option long before the Supreme Court considered the constitutional implications of physician-assisted suicide. Terminal sedation has been used for three related but distinct purposes: (1) to relieve physical pain; (2) to produce an unconscious state before the withdrawal of artificial life support; and (3) to relieve non-physical suffering.

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PATENT DUCTUS ARTERIOSUS WITH REVERSAL OF FLOW

PEDIATRICS ◽

10.1542/peds.18.3.410 ◽

1956 ◽

Vol 18 (3) ◽

pp. 410-423

Author(s):

Ray C. Anderson ◽

Paul Adams ◽

Richard L. Varco

Keyword(s):

Patent Ductus Arteriosus ◽

Ductus Arteriosus ◽

Diagnostic Value ◽

Successful Outcome ◽

Exertional Dyspnea ◽

Artery Segment ◽

Pulmonary Arterial ◽

The Right ◽

Patent Ductus

Ten cases are presented of children having patent ductus arteriosus with reversal of shunt. Cyanosis, often greater in the toes, was present in all. Exertional dyspnea developed early. Murmurs were of no diagnostic value, but an accentuated pulmonic second sound was uniformly present. Right ventricular preponderance was found in all cases on the electrocardiogram. Cardiac size varied on roentgenography, but there was usually prominence of the pulmonary artery segment. Six cases showed evidence of bi-directional shunts, one showed only a reversed shunt, while data were insufficient to determine this point in the remaining three. Three patients had surgery, one with a successful outcome. The latter was a 1-year-old infant in whom lung biopsy at surgery revealed only minimal pulmonary arterial changes. Forty-five cases are reviewed from the literature. The majority of these occurred in adults. Twenty-two have been subjected to surgery, four with good results, three of the latter being children. The differential diagnosis is briefly discussed. The safest and simplest diagnostic test to perform is the determination of oxygen saturation of samples of blood obtained simultaneously from the right brachial and femoral arteries. Angiocardiography and cardiac catheterization also provided helpful information. The diagnosis will not be made unless the examiner keeps the entity in mind. The entity can no longer be considered rare. Surgical treatment of the condition has been very disappointing, especially in the adult. There is reason to believe that surgical intervention very early in life will yield a higher salvage rate.

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A forgotten life-threatening medical emergency: myxedema coma

Emergency Care Journal ◽

10.4081/ecj.2016.5790 ◽

2016 ◽

Vol 12 (2) ◽

Author(s):

Elisa Pizzolato ◽

Alberto Peano ◽

Letizia Barutta ◽

Emanuele Bernardi ◽

Elena Maggio ◽

...

Keyword(s):

Life Support ◽

Neurological Status ◽

Medical Emergency ◽

Myxedema Coma ◽

Emergency Department Stay ◽

Life Threatening ◽

Appropriate Therapy ◽

Alithiasic Cholecystitis ◽

The Right ◽

Tomography Scan

Nowadays myxedema coma is a rare medical emergency but, sometimes, it still remains a fatal condition even if appropriate therapy is soon administered. Although physical presentation is very non-specific and diversified, physicians should pay attention when patients present with low body temperature and alteration of neurological status; the presence of precipitating events in past medical history can help in making a diagnosis. Here we discuss one such case: an 83-year-old female presented with abdominal pain since few days. Laboratory tests and abdomen computed tomography scan demonstrated alithiasic cholecystitis; she was properly treated but, during the Emergency Department stay she experienced a cardiac arrest. Physicians immediately started advance cardiovascular life support algorithm and she survived. Later on, she was admitted to the Intensive Care Unit where doctors discovered she was affected by severe hypothyroidism. Straightway they started the right therapy but, unfortunately, the patient died in a few hours.

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Extreme Lateral Supracerebellar Infratentorial Approach to the Lateral Midbrain

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1669981 ◽

2018 ◽

Vol 79 (S 05) ◽

pp. S415-S417

Author(s):

M. Kalani ◽

William Couldwell

Keyword(s):

Cranial Nerves ◽

Sudden Onset ◽

Superior Cerebellar Artery ◽

Entry Zone ◽

Cerebellar Artery ◽

Sensory Disturbances ◽

History Of ◽

Supracerebellar Infratentorial Approach ◽

The Right ◽

Piecemeal Resection

This video illustrates the case of a 52-year-old man with a history of multiple bleeds from a lateral midbrain cerebral cavernous malformation, who presented with sudden-onset headache, gait instability, and left-sided motor and sensory disturbances. This lesion was eccentric to the right side and was located in the dorsolateral brainstem. Therefore, the lesion was approached via a right-sided extreme lateral supracerebellar infratentorial (exSCIT) craniotomy with monitoring of the cranial nerves. This video demonstrates the utility of the exSCIT for resection of dorsolateral brainstem lesions and how this approach gives the surgeon ready access to the supracerebellar space, and cerebellopontine angle cistern. The lateral mesencephalic safe entry zone can be accessed from this approach; it is identified by the intersection of branches of the superior cerebellar artery and the fourth cranial nerve with the vein of the lateral mesencephalic sulcus. The technique of piecemeal resection of the lesion from the brainstem is presented. Careful patient selection and respect for normal anatomy are of paramount importance in obtaining excellent outcomes in operations within or adjacent to the brainstem.The link to the video can be found at: https://youtu.be/aIw-O2Ryleg.

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Isolated Congenital Absence of Cranial Nerves: Report of Two Cases

Neuropediatrics ◽

10.1055/s-0038-1669923 ◽

2018 ◽

Vol 49 (06) ◽

pp. 405-407

Author(s):

Vivek Agarwal ◽

Sumeet Dhawan ◽

Naveen Sankhyan ◽

Sameer Vyas

Keyword(s):

High Resolution ◽

Mr Imaging ◽

Cranial Nerve ◽

Clinical Presentation ◽

Cranial Nerves ◽

Rare Condition ◽

Congenital Absence ◽

The Third ◽

Seventh Cranial Nerve ◽

The Right

AbstractIsolated cranial nerve absence is a rare condition that can be diagnosed using high-resolution cranial nerve magnetic resonance (MR) imaging. Thorough clinical examination with proper knowledge of the course of cranial nerves may help diagnose this rare condition. We describe two cases, one each of, isolated congenital absence of the third and seventh cranial nerve with their clinical presentation. High-resolution T2-weighted MR imaging was done in both patients which revealed absence of cisternal segment of the right-sided third nerve and cisternal with canalicular segment of the right-sided facial nerve.

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Refusal to travel in the National Ambulance Service: A retrospective examination of calls from 2017.

Irish Journal of Paramedicine ◽

10.32378/ijp.v3i2.149 ◽

2018 ◽

Vol 3 (2) ◽

Author(s):

Eamonn Byrne ◽

Sasha Selby ◽

Paul Gallen ◽

Alan Watts

Keyword(s):

Emergency Department ◽

Life Support ◽

Advanced Life Support ◽

Light Response ◽

Respiratory Arrest ◽

Ambulance Service ◽

Quality Improvement Initiative ◽

Southern Area ◽

Course Of Action ◽

Rate Of Increase

Introduction When a member of the public calls for an ambulance through the 999/112 system, the only permitted course of action for the responding National Ambulance Service (NAS) staff is to convey the patient to an emergency department. Regardless of the clinical level, NAS staff do not have the authority or scope of practice to discharge the patient from the scene or make any other arrangements for the treatment of that person(1). The patient, meeting certain criteria, can refuse treatment or transport (RTT) of their own volition(1). Mortality rates for non-conveyed patients vary from 0.2%-3.5% within 24hours and are twice those of patients discharged from an emergency department(2, 3). In 2017, the refusal to travel rate in Ireland jumped from 7-8% of calls (2012-2014) to a national average of 11.3% (24,735) of total AS1 calls(4). Although this level of non-conveyance would still be below international norms the rate of increase was concerning(3).Aim.A quality improvement initiative necessitated identification of baseline RTT information.MethodsRetrospective data collection was conducted on all calls closed with a ‘refusal to travel’ or ‘refusal of treatment’ occurring between 1st Jan 2017 and 9th Nov 2017 and was gathered from the National Emergency Operations Centre (NEOC).ResultsThe top three dispatch classification that resulted in RTT were falls, unconsciousness or near fainting, and generally unwell patients. This was followed by chest pain, seizures, traffic incidents and breathing problems. It was noted that the time at which RTT calls occurred peaked nationally between 2000 and 2059. In the Southern area, peak RTT occurred between 2000-2059h and 0000-0100. 33.6% of RTT calls in the Southern Area were designated as Delta calls. This designation requires an advanced life support and a blue light response and is the call level with the second highest acuity below an Echo call, the designation for Cardiac or Respiratory arrest.ConclusionsThe NAS specifically utilises a risk adverse triage system. Examination of dispatch priorities may be warranted. The peak close of RTT calls between 2000-2059 may align with a shift changeover at 2000. Further study is required.

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Eversion carotid endarterectomy with nerve-sparing component in a case of high location of common carotid artery bifurcation

Patologiya krovoobrashcheniya i kardiokhirurgiya ◽

10.21688/1681-3472-2021-3-94-99 ◽

2021 ◽

Vol 25 (3) ◽

pp. 94

Author(s):

I. V. Makarov ◽

A. S. Borisenkov ◽

I. A. Migunov

Keyword(s):

Carotid Artery ◽

Carotid Endarterectomy ◽

Common Carotid Artery ◽

Preoperative Evaluation ◽

Cranial Nerves ◽

Hospital Medicine ◽

Nerve Sparing ◽

Left Internal Carotid Artery ◽

Brachiocephalic Trunk ◽

The Right

We performed carotid endarterectomy on a patient with 75% stenosis of the left internal carotid artery (ICA), 70% stenosis of the left common carotid artery (CCA), 60% stenosis of the right ICA and 55% stenosis of the right CCA after a transient ischaemic attack on the premises of the surgical unit of Russian Railways Hospital–Medicine (Samara), which is the clinical site for the care of surgical diseases at Samara State Medical University. During the preoperative evaluation and physical examination, we determined that the chance of high CCA bifurcation was high because the patient had a brachymorphic physique and his neck was short and broad. In fact, during the surgical exploration of the carotid triangle area, the CCA bifurcation was identified 7 ± 0.5 cm higher than the shield-like cartilage rim; thus the CCA bifurcation area crossed the stems of the glossopharyngeal (IX), vagus (X) and hypoglossal (XII) nerves, which precluded classic carotid endarterectomy. We then decided to perform carotid endarterectomy, using the eversion method and transposing the ICA above the rami of the cranial nerves. Through this method, we minimised traction and nerve stem trauma during the process of reconstructing brachiocephalic trunk arteries, prevented morbidities involving the cranial nerves during postsurgical period, accelerated the patient’s recovery and improved the patient’s quality of life. With further patient monitoring during the early and late postoperative periods, no abnormalities of peripheral innervation occurred.Received 26 March 2021. Revised 6 May 2021. Accepted 11 May 2021.Funding: The study did not have sponsorship.Conflict of interest: The authors declare no conflicts of interests.Contribution of the authors: The authors contributed equally to this article.

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Extracorporeal life support with an integrated left ventricular vent in children with a low cardiac output

Cardiology in the Young ◽

10.1017/s1047951113001017 ◽

2013 ◽

Vol 24 (4) ◽

pp. 654-660 ◽

Cited By ~ 4

Author(s):

Stany Sandrio ◽

Wolfgang Springer ◽

Matthias Karck ◽

Matthias Gorenflo ◽

Alexander Weymann ◽

...

Keyword(s):

Cardiac Output ◽

Cardiac Failure ◽

Life Support ◽

Extracorporeal Life Support ◽

Left Ventricular ◽

Neurological Dysfunction ◽

Left Heart ◽

Low Cardiac Output ◽

Cardiac Thrombus ◽

The Right

AbstractBackground: The aim of this study was to evaluate our experience in central extracorporeal life support with an integrated left ventricular vent in children with cardiac failure. Methods: Eight children acquired extracorporeal life support with a left ventricular vent, either after cardiac surgery (n = 4) or during an acute cardiac illness (n = 4). The ascending aorta and right atrium were cannulated. The left ventricular vent was inserted through the right superior pulmonary vein and connected to the venous line on the extracorporeal life support such that active left heart decompression was achieved. Results: No patient died while on support, seven patients were successfully weaned from it and one patient was transitioned to a biventricular assist device. The median length of support was 6 days (range 5–10 days). One patient died while in the hospital, despite successful weaning from extracorporeal life support. No intra-cardiac thrombus or embolic stroke was observed. No patient developed relevant intracranial bleeding resulting in neurological dysfunction during and after extracorporeal life support. Conclusions: In case of a low cardiac output and an insufficient inter-atrial shunt, additional left ventricular decompression via a vent could help avoid left heart distension and might promote myocardial recovery. In pulmonary dysfunction, separate blood gas analyses from the venous cannula and the left ventricular vent help detect possible coronary hypoxia when the left ventricle begins to recover. We recommend the use of central extracorporeal life support with an integrated left ventricular vent in children with intractable cardiac failure.

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