SESSION TITLE: Miscellaneous Case Report Posters I
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: The hemodynamic compromise caused by a large aspirated particle producing high auto-PEEP, can become the focus of medical attention, and a distraction from rare but fatal complications of Heimlich maneuver (HM), increasing morbidity and mortality in the setting of acute food aspiration.
CASE PRESENTATION: An 84 year old man was brought to the emergency department after choking in a restaurant. The patient was hypotensive and required immediate resuscitation upon arrival. While on mechanical ventilation, evidence of persistent large food particle in the main airway was seen on the Flow/Time monitor, showing an auto-PEEP with a notched expiratory flow curve that appeared as an inverted square root sign (Figure 1). A large piece of steak was extracted by rigid bronchoscopy. Despite relieving the airway obstruction, the patient developed severe refractory shock and lactic acidosis. Repeated laboratory tests showed a significant drop in the hemoglobin level. CT scan of the abdomen and pelvis (Figure 2) revealed a lacerated liver with a large subcapsular hematoma and hemoperitoneum caused by the HM attempts at the time of aspiration. Blood products were transfused, and the lacerated liver was treated conservatively with a favorable outcome.
DISCUSSION: A ball-valve effect caused by the large food particle in the main airway demonstrated an auto-PEEP on the Flow/Time monitor of the mechanical ventilator, with a notched expiratory flow curve, as the particle completely occludes the expiratory airflow at the end of expiration, when the point of equalization of pressures meets the level of obstruction. Auto-PEEP can cause circulatory collapse when the increased intrathoracic pressure reduces venous return, as well as the increased pulmonary vascular resistance that can precipitate right ventricular failure. Improperly performed HM can lead to rare but life-threatening complications. Liver laceration is a rare complication of HM with only one previously described case in literature.
CONCLUSIONS: This case report highlights the mechanisms of altered airway dynamics and circulatory compromise caused by high auto-PEEP when a large particle occludes the main airway. It further emphasizes the necessity of early identification of HM complications after the event of acute aspiration.
Reference #1: Laghi F, Goyal A. Auto-PEEP in respiratory failure. Minerva Anestesiol. 2012 Feb;78(2):201-21
Reference #2: Chillag S, Krieg J, Bhargava R. The Heimlich maneuver: breaking down the complications. South Med J. 2010 Feb;103(2):147-50
DISCLOSURE: The following authors have nothing to disclose: Basheer Tashtoush, Jonathan Schroeder, Eduardo Oliveira, Anas Hadeh, Michael Medina, Jose Ramirez, Laurence Smolley
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