Neck-stoma airway anatomy, lower-risk BRUE assessment, duct-focused paediatric pancreatic trauma and cardiac causes of seizure-like collapse.
A patient with a total laryngectomy can only be oxygenated and ventilated through the neck stoma.
Acute-care material today spans neck-stoma emergencies, infant events, abdominal trauma and unexplained collapse. A total laryngectomy disconnects the mouth and nose from the lungs, so oxygenation and ventilation must occur through the neck stoma. Most tracheostomy patients retain an upper-airway connection, although the tube, cuff or original pathology may restrict airflow. When the anatomy is uncertain, oxygen should initially be applied to both the face and stoma. Removing speaking valves, humidification devices and the inner cannula can rapidly correct obstruction, while failure to pass a soft suction catheter suggests tube blockage or displacement. Major bleeding is different: an inflated cuff may be providing tamponade and should not be deflated or removed without specialist airway and haemorrhage support.
Paediatric material includes BRUE and blunt pancreatic injury. BRUE is diagnosed only after careful history and examination fail to identify an explanation for a brief, resolved change in colour, breathing, tone or responsiveness. Lower-risk infants may avoid blanket blood tests, imaging and mandatory admission when age, gestation, event duration, recurrence, CPR history and examination are reassuring. Choking, gagging or suck-swallow-breathe difficulty should instead prompt focused feeding assessment. After handlebar or focal epigastric trauma, the management question is whether the main pancreatic duct is disrupted. Early examination, pancreatic enzymes and CT may be falsely reassuring, so MRCP or ERCP becomes important when duct integrity will determine observation, stenting or surgery.
The collapse case challenges automatic attribution of convulsive movements to epilepsy. Recurrent seizure-like events with negative EEG findings, prolonged QTc and structural heart disease should prompt rhythm monitoring and cardiology assessment. Dynamic left ventricular outflow obstruction worsens when preload or afterload falls or contractility rises, making dehydration and adrenergic stimulant exposure clinically important. Acute management is therefore directed towards cautious volume restoration and beta blockade rather than inotropes that may intensify obstruction.
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Rheumatology, rehabilitation and palliative-care clinicians get a multi-system view of Ehlers-Danlos syndrome. Joint instability, chronic pain, fatigue, gastrointestinal symptoms and eye or vascular complications are linked to pacing, bracing, occupational therapy, disability-aware communication and preservation of meaningful activity at the end of life.
Paediatric emergency, trauma and surgical teams get a duct-focused approach to blunt pancreatic injury. Handlebar trauma, initially subtle CT findings, main pancreatic duct disruption, MRCP or ERCP, endoscopic stenting, pseudocyst surveillance and distal pancreatectomy are connected to the child’s stability and clinical trajectory.
Cardiology, neurology and emergency clinicians get a diagnostic-reasoning case in which seizure-like activity represents possible convulsive syncope from malignant arrhythmia. Negative EEG findings, prolonged QTc, stimulant exposure and hypertrophic obstructive cardiomyopathy reinforce the importance of ECG review, rhythm monitoring and physiology-specific management.
Primary-care, cardiology and nephrology clinicians get a cardiovascular risk-stratification update involving PREVENT, LDL targets, lipoprotein(a), apolipoprotein B and coronary artery calcium. The episode uses a calculate, personalise and reclassify framework to connect risk enhancers with statin and non-statin treatment decisions.
A brief professional-development announcement for clinicians considering structured support around burnout, career resilience and sustainable practice. It introduces a live webinar and contrasts interactive cohort learning with asynchronous course delivery, while encouraging clinicians to identify the workplace problem they want a programme to address.
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Paediatric and emergency clinicians get a structured approach to brief resolved unexplained events in infants. Careful event reconstruction, lower-risk criteria, feeding assessment, targeted investigation, family communication and safety-netting are prioritised over automatic admission or broad test panels.
Clinician educators and supervisors get practical career-planning tools involving ikigai, Schlossberg’s four S framework, mentorship networks and job crafting. The discussion connects protected time, hidden institutional expectations, productivity, role transitions and professional meaning with sustainable academic work.
Emergency, prehospital and ENT teams get a practical neck-stoma airway framework. It distinguishes tracheostomy from total laryngectomy and covers oxygen delivery, removal of external devices and inner cannulas, soft suction-catheter patency checks, cuff deflation and preservation of tamponade during major tracheostomy bleeding.
In any neck-stoma deterioration, establish whether the patient has a tracheostomy or total laryngectomy before choosing the ventilation route. If the anatomy is uncertain, apply oxygen to both the face and stoma, remove external devices and the inner cannula, then test tube patency with a soft suction catheter. Preserve cuff tamponade during major bleeding while escalating to senior airway, ENT and haemorrhage teams. In seizure-like collapse, obtain an ECG and review the QTc before assuming primary epilepsy.
A patient with a permanent neck stoma becomes cyanosed, and a carer confirms a previous total laryngectomy. Where must emergency oxygenation and ventilation be delivered?
Through the neck stoma. Total laryngectomy separates the upper airway from the lungs, so face-mask ventilation, supraglottic devices and oral intubation do not ventilate the patient.
A stable 7-year-old develops worsening epigastric pain after falling onto bicycle handlebars. CT shows subtle pancreatic swelling but does not define the main pancreatic duct. What investigation best addresses the management question?
MRCP or ERCP should be used to assess duct integrity when the result will determine observation, endoscopic stenting or operative management. Normal pancreatic enzymes or an equivocal early CT do not exclude duct disruption.
A 70-day-old term infant has a first brief episode of pallor and irregular breathing lasting less than one minute. No CPR is given, the event has resolved, and history and examination identify no explanation or concerning features. What management approach is appropriate?
The presentation is consistent with a lower-risk BRUE after clinical assessment. Shared decision-making, proportionate observation, clear safety-netting and follow-up are appropriate, without routine blanket testing or mandatory admission.
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