Barotrauma in COVID-19 Patients

Clinical manifestations of COVID 19 is still unknown. We performed this study to determine the occurrence of pulmonary barotrauma as a complication of this disease. In this retrospective study, a total of 955 COVID 19 patients with respiratory insufficiency requiring oxygen support or invasive ventilation admitted to ICU of Sina Hospital from 20 March 2020 to 9 June 2021, were included and their chest imaging reviewed. Here, we report results of chest imaging of first 92 patients of this group. Barotrauma (pneumothorax, pneumomediastinum, pneumopericardium) occurred in 11 (11.9%) of 92 patients with coronavirus disease 2019 (COVID-19) infection requiring ICU admission for respiratory support and monitoring. It seems barotrauma is a common complication of COVID 19 disease. The role of increased respiratory efforts, patient or ventilation induced lung injury, viral and host response should be assessed. It needs to consider the occurrence of barotrauma in Patients with COVID-19, before expansion of dead space for treatment and limiting the ventilation effects.

Scuba diving-related fatalities in New Zealand, 2007 to 2016

Introduction: New Zealand (NZ) diving-related fatalities have been reported since the 1960s. The aim is to identify contributing risk factors, including medical, and to inform appropriate preventative strategies. Methods: NZ scuba diving fatalities from 2007 to 2016 were searched from multiple sources – the National Coronial Information System (NCIS); the NZ Chief Coroner’s office; Water Safety NZ Drownbase™ and the NZ Police National Dive Squad records. For inclusion, a victim must have been wearing a scuba set (which may include a rebreather). A key word search of the NCIS was made and the results matched to the other databases. An Excel® database was created and a chain of events analysis (CEA) conducted. Results: Forty-eight scuba diving fatalities were identified, 40 men and eight women, average age 47 years (range 17−68), 20 of Māori ethnicity. Thirty-five were classified as overweight (14) or obese (21). Pre-existing medical risk factors were identified, either pre dive or at autopsy, in 37 divers, the commonest being ischaemic heart disease (IHD, 20), left ventricular hypertrophy (LVH, 18) and hypertension (seven). IHD, LVH and obesity were variously associated with each other. The likely commonest disabling conditions, identified in 32 cases, were asphyxia (15), cardiac (nine) and pulmonary barotrauma/cerebral arterial gas embolism (five). Multiple environmental and diving practice breaches and poor planning were identified in the CEA, similar to those seen in other studies. Thirty-eight divers had not released their weight belt. Information on resuscitation was limited. Conclusions: Obesity and cardiovascular disease were common and Māori appear to be over-represented, both as previously reported.

Emergency Carotid Endarterectomy for Internal Carotid Artery Thrombosis in the Course of COVID-19

A case of successful emergency carotid endarterectomy (CEE) in the acute period of ischemic stroke (within an hour after the onset of symptoms) in a patient with acute occlusive thrombosis of the internal carotid artery in the course of moderate-severe COVID-19 with a positive result of the polymerase chain reaction of the nasopharyngeal smear for SARS-CoV-2. The diameter of the ischemic focus in the brain according to multispiral computed tomography did not exceed 2.5 cm. The course of ischemic stroke was characterized by mild neurological deficit (score 5 according to National Institute of Health Stroke Scale). It was demonstrated that the severity of the patient’s condition was associated with bilateral, polysegmental, viral penvmonia with 65% damage to the lung tissue, a decrease in SpO2 to 93%. Laboratory noted coagulopathy with an increase in D-dimer (2837.0 ng/ml), prothrombin according to Quick (155.3%), fibrinogen (14.5 g/l) and signs of a “cytokine storm” with leukocytosis (28.4 10E9/l), an increase in C-reactive protein (183.5 mg/l), ferritin (632.8 ng/ml), interleukin-6 (176.9 pg/ml). The patient underwent glomus-sparing eversional CEE. The intervention was performed under local anesthesia due to the high risk of developing pulmonary barotrauma when using mechanical ventilation. To prevent the development of acute hematoma, a double active drainage was used into the paravasal space and subcutaneous fatty tissue (SFT). In case of thrombosis of one of the drainages, the second could serve as a spare. Also, upon receipt of hemorrhagic discharge from the drainage located in the SFT, the patient would not need to be transported to the operating room. Removal of skin sutures with revision and stitching of the bleeding source could be performed under local anesthesia in a dressing room. The postoperative period was uneventful, with complete regression of neurological symptoms. Used anticoagulant (heparin 5 thousand units 4 times a day s/c) and antiplatelet therapy (acetylsalicylic acid 125 mg at lunch). The patient was discharged from the hospital on the 12th day after CEE in satisfactory condition.

CPAP delivered outside critical care during the second wave of COVID-19: outcomes from a UK respiratory surge unit

BackgroundNHS England recommends non-invasive continuous positive airway pressure (CPAP) as a possible treatment for type 1 respiratory failure associated with COVID-19 pneumonitis, either to avoid intubation or as a ceiling of care. However, data assessing this strategy are sparse, especially for the use of CPAP as a ceiling of care, and particularly when delivered outside of a traditional critical care environment. We describe a cohort of patients from Liverpool, UK, who received CPAP on a dedicated respiratory surge unit at the start of the second wave of the COVID-19 pandemic in UK.MethodsRetrospective cohort analysis of consecutive patients receiving CPAP for the treatment of respiratory failure secondary to COVID-19 on the respiratory surge unit at the Royal Liverpool Hospital, Liverpool, UK from 21 September until 30 November 2020.Results88 patients were included in the analysis. 56/88 (64%) were deemed suitable for escalation to invasive mechanical ventilation (IMV) and received CPAP as a trial; 32/88 (36%) received CPAP as a ceiling of care. Median age was 63 years (IQR: 56–74) and 58/88 (66%) were men. Median SpO2/FiO2 immediately prior to CPAP initiation was 95 (92–152). Among patients for escalation to IMV, the median time on CPAP was 6 days (IQR 4–7) and survival at day 30 was 84% (47/56) with 14/56 (25%) escalated to IMV. Of those patients for whom CPAP was ceiling of care, the median duration of CPAP was 9 days (IQR 7–11) and 18/32 (56%) survived to day 30. Pulmonary barotrauma occurred in 9% of the cohort. There were no associations found on multivariant analysis that were associated with all-cause 30-day mortality.ConclusionsWith adequate planning and resource redistribution, CPAP may be delivered effectively outside of a traditional critical care setting for the treatment of respiratory failure due to COVID-19. Clinicians delivering CPAP to patients with COVID-19 pneumonitis should be alert to the dangers of pulmonary barotrauma. Among patients who are for escalation of care, the use of CPAP may avoid the need for IMV in some patients. Our data support the NHS England recommendation to consider CPAP as a ceiling of care.

Inhalation of helium in plastic bag suffocation with suicidal purpose: Observation and differences of two cases

The use of helium in plastic bag suffocation is a suicide method recently found in forensic cases. Although it is not common practice, there has been a strong increase in its use during the past 20 years, thanks to the accessibility of information on the web and materials needed to implement it. From a pathophysiological point of view, there are various theories on how helium can change the timing and, also, the cause of death when the head is inside a plastic bag. We report two cases where we believe that the action of helium, whose unequivocal use is demonstrated by the circumstantial data, has unfolded in a different way. In the first case, the discovery of an intense cyanosis of the face, blood leakage from the respiratory orifices and the destruction of numerous alveolar septa with histologically demonstrated blood extravasation, was left for a longer agonic period and a no negligible rate of pulmonary barotrauma in determination of death. In the second case, the total absence of external pathological phenomena, internal and histological, allows us to hypothesise an onset of death that is faster and catalysed by helium and explained by the known sympathetic hyperactivation and consequent cardiac arrhythmic death described in similar plastic bag suffocation cases.