Complications associated with the Esophageal-Tracheal Combitube® in the pre-hospital setting

PURPOSE: The Esophageal-Tracheal Combitube (Combitube) is widely used for the management of the airway during cardiopulmonary resuscitation in the pre-hospital setting. Although serious complications have been reported with the Combitube, there is a paucity of data relative to the frequency and nature of such complications. The objective of this retrospective study was to determine the incidence and the nature of complications associated to the Combitube in the pre-hospital setting. METHODS: Since 1993, in the Quebec City Health Region, the basic life support treatment algorithm for emergency medical technicians has included the use of a Combitube as the primary airway device for management of all patients presenting with cardiac or respiratory arrest. The database of the emergency coordination services was searched for the period between 1993 and 2003 (2,981 patients). Only those patients who survived at least 12 hr were included. Medical records of these patients were reviewed to identify complications related to the use of the Combitube. RESULTS: Two-hundred-eighty (280) patients were identified. Fifty-eight (58) patients (20.7%, confidence interval (CI)95%=16.0%-25.4%) presented 69 complications: aspiration pneumonitis (n=31), pulmonary aspiration (n=16), pneumothorax (n=6), upper airway bleeding (n=4), esophageal laceration (n=3), sc emphysema (n=2), esophageal perforation and mediastinitis (n=2), tongue edema (n=2), vocal cord injury (n=1), tracheal injury (n=1), and pneumomediastinum (n=1). Thirteen of these complications (12 patients, 4.3%, CI95%=2.0%-6.3%) were judged as most likely resulting from trauma associated with insertion of the Combitube. CONCLUSION: The use of the Combitube in the pre-hospital setting is associated with a notable incidence of serious complications.     

Arthroscopic Chondral Cyst Excision in a Stiff Perthes’ Hip

Persistent hip stiffness in Perthes’ disease indicates a poor prognosis and is a therapeutic challenge. We report a case of a 13-year-old boy with a stiff Perthes’ hip that was nonresponsive to prolonged nonsurgical treatment. Imaging revealed Catterall group IV Perthes’ disease in an advanced reossification stage, with a focal defect in the weight-bearing area of the capital femoral epiphysis. A focal, compressible chondral elevation was detected on hip arthroscopy; on incision, flocculent fluid was released. After the cyst was excised, microfracture revascularization of the chondral defect was undertaken. Postoperatively, the patient had immediate pain relief, correction of deformity, and restoration of painless range of motion; this has continued for 4 years since surgery was performed. Persistence of an unhealed necrotic segment in Perthes’ disease has traditionally been associated with osteochondritis dissecans; however, in this case, the unhealed and nonossified segment produced an elevated painful chondral cyst that caused spasm and stiffness of the hip. Although 2 distinct types of chondral lesions have been described in Perthes’ disease, stiffness arising because of these lesions has not been reported. Patients with this unusual third type of chondral lesion of the capital femoral epiphysis, which causes persistent stiffness in Perthes’ hip, may be identified and successfully treated with the use of arthroscopic techniques.     

T-wave alternans: predicting the unpredictable?

Sudden cardiac death (SCD) due to ventricular arrhythmias hasa high morbidity and mortality. It is no wonder that cardiologists,rather than patching up survivors, are dedicated to findingpredictors of cardiac electrical instability to prevent SCD.The implantable cardiac defibrillator (ICD) has evolved as theultimate strategy for sudden arrhythmic death. In secondaryprevention, individuals are recognized by an aborted arrhythmicevent. By stratifying according to left ventricular ejectionfraction (LVEF) below 35%, SCD may also be prevented by an ICDin individuals without any prior arrhythmic event.¹ However,the relative SCD risk based