New 2015 ACEP Clinical policy on ischemic stroke downgrade tPA within first 3 hours to a Level B recommendation (and other condsiderations about this policy).

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On June 2015 ACEP updated the 2013 policy on ischemic stroke treatment.

The 2013 policy graded the tPA administration within 3 hours as a Level A recommendation and tPA administration between 3 to 4.5 hours as Level B recommendation

2013 Stroke tPA

2013 ACEP Clinical policy on ischemic stroke

In Jan 2015 ACEP published a Draft about the update of the 2013 clinical policy based on 2 critical questions:

  1. Is IV tPA safe and effective for patients with acute ischemic stroke if given within 3 hours of symptom onset?
  2. Is IV tPA safe and effective for patients with acute ischemic stroke treated between 3 to 4.5 hours after symptom onset?
2015 Draft

January 2015 Draft about ACEP Clinical policy on ischemic stroke

2015 draft 2

January 2015 Draft about ACEP Clinical policy on ischemic stroke

In June 2015 the definitive policy was released, based on the same critical questions. 

2015 stroke tpa

2015 ACEP Clinical policy on ischemic stroke

2015 def 2

2015 ACEP Clinical policy on ischemic stroke

Here is the most relevant changes:

  • TPA administration within 3 hours was graded as a Level B recommendation (NNT 8 with a 95% CI).
  • The statement says that tPA should be offered and may be given to selected patients” (“should be offered” alone in 2013 policy)
  • In the same Level B recommendation was incorporated consideration (that in the previously Jan Draft was Level A) about sICH risk (7% with a NNH of 17 and 95%CI).
  • TPA administration between 3 and 4.5 hours is still considered a Level B recommendation (NNT=14; 95% CI). The the risk of early sICH in this case correspond to a NNH of 23 (95% CI)
  • The recommendation statement begins mentioning and prioritizing the “known risk of sICH and the variability in the degree of benefit in functional outcomes”, and about tPA treatment says “may be given to carefully selected patients” (“should be considered” in in 2013 policy)

Some considerations on evidences supporting the recommendations in this 2015 policy:

  • TPA administration within 3 hours is supported by just 1 Class I study (NINDS part 2, 1995), a small study (n.333 ) that despite the benefit on functional outcomes, demonstrate no statistically significant difference in 3-month mortality, and was never been replicated. 
  • All the sub-analysis from NINDS study where considered of Class II or III evidences.
  • ECASS III study was downgraded (from 2013 policy) to a Class II evidence study cause of “baseline differences between groups and changes in the timing of tPA administration during the course of the study”.
  • IST-3 study is graded as a Class III study.
  • TPA Administration between 3 and 4.5 hours is supported just by 1 Class II study and some other Class III case series.

What I like about the policy:

  • Level B recommendation for tPA administration within 3 hours is fair enough
  • The panel who examined the available litterature put the right light on controversies and conflict of interest involved in most of the recent studies (ATLANTIS, IST-3, ECASS ecc…) and following statistical analysis,  grading most of them as Class III evidences, and leaving as Class I just NINDS part 2 (a 1995 study who yes demonstrate benefit on functional outcome but no difference in 3 months mortality, is a small study and has never been reproduced) .

What I don’t like about the policy:

  • Level B recommendation for tPA administration between 3 and 4.5 hours is too high cause is supported just by 1 Class II study (ECASS III) and a bunch of Class III evidences.
  • The authors in their final statement play with terms jumping between “should be offered and may be given” and “selected patients” for 3 hours treatment to “may be given” and “carefully selected patients”for the 3 to 4.5 hours treatment, to emphasize the difference between recommendations both graded as Level B but supported by such a different quality of evidences. These leave to clinician a wide margin of discretionality (“may be given” but also “may be not”) supporting them in their choices (whatever it is, and that is good), but from the other hand not giving a clear advice or any clinical tool to help the decision making process. This gonna result in a large variability of approach.
  • The risk of sICH is the only demonstrated and consistent evidence that appears trough the letterature in those years and is not clear why in the draft of Jan 2015 was classified as Level A and in the definitive policy was relegated as Level B with no new evidences added in the meantime, and no clear explaination.

Bottom line

I think thrombolysis is a beneficial treatment for a selected group of patients. The available evidences and policies (even this last one) based on time window alone, and not patient centered, don’t clearly indicate which group of patients really benefits from tPA administration.

This 2015 ACEP policy suggests physician to strongly consider the risk (evident)/benefit (maybe) ratio when offering tPA in acute ischemic stroke and to strongly involve patients in the final decision. It also leave the clinician a wide range of choice to decide which is the right patient to treat with tPA.

“When considering administration of IV tPA for a patient with acute ischemic stroke within 3 hours of stroke symptom onset, the physician and patient (and/or the surrogate) should weigh the potential benefit in terms of long-term functional outcome against the increased risk of sICH while recognizing that IV tPA does not alter 90-day mortality.

Important readings:

Evidence class

Litterature classification schema of Evidence Class

Recomm class

Recommendation Level Classification

References:

Unmissible resources:

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FOAMed Italy: time to rise up!

15 lug SMACC DUB 2016

SMACC DUB 2016Next year SMACC, the Conference of the Conferences, will come in Europe.

Dublin 13-16 Jun 2016.

Italian Emergency Medicine and Critical Care bloggers rise up! There is the chance to submit your topics, idea, talks and whatever you have in mind for evaluation by organising committee.

Fill the form at smaccDUB Speaker Suggestions and get the chance to participate as speaker to one of the most exciting event of the year.

Here is the original message from the SMACC Organising Committee:

The SMACC Organising Committee are currently crafting plans for the next SMACC event. It will be in Dublin from Monday June 13th to Thursday 16th June 2016. We get plenty of suggestions about who should join the SMACC faculty as speakers and workshop instructors and have created this form to make the process easier. We can’t make every wish a reality, but we will do our damnedest to make smaccDUB the event of 2016 for anyone in critical care who wants to learn, to meet and be inspired.

All the best,
Chris Nickson, Oli Flower, Roger Harris and the SMACC Organising Committee
http://smacc.net.au
http://twitter.com/smaccteam

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#DeathIsAWanker

4 lug CJEhXPhWgAAPSFi.jpg_large
CJEhXPhWgAAPSFi.jpg_largeToday a great loss hit the world of Emergency Medicine.
Doctor John Hinds teacher and inspirational emergency doctor passed away.
He was a prehospital emergency enthusiastic and I have personally learned a lot from his talks and writings.
We all lost one of the greatest voices in FOAMed family.

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Is the supine position associated with loss of airway patency in unconscious trauma patients? A systematic review and meta-analysis

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medest118:

Supine is the recommended position in a trauma patient. In this #FOAMed article from Norway, this long standing concept is challenged from some old and new evidences.
Thanks to PHARM for sharing.

Originally posted on Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds:

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View original 24 altre parole

Endovascular therapy in Stroke: the 2015 AHA/ASA Updated Guidelines establish new eligibility criteria.

30 giu merci01

New evidences aroused in treatment of ischemic stroke from early 2015. Large and well conducted trials demonstrated the benefit of endovascular therapy (in association with thrombolysis) on primary clinical endpoints.

MEDEST post on Endovascular Treatment of Ischemic Stroke

Today AHA and ASA  updated the 2013 Stroke Guidelines for the Early Management of Patients With Acute Ischemic Stroke regarding Endovascular Treatment on the basis of this recent evidences.

Let’s resume the recommendations on Endovascular Interventions:

  • Patients who are elegible for intravenous r-tPA should receive r-tPA and in addition endovascular therapy with a stent retriever if they meet all the following criteria (Class I; Level of Evidence A). (New recommendation):
  1. Prestroke modified Ranking Scale score 0 to 1
  2. Acute ischemic stroke receiving intravenous r-tPA within 4.5 hours of onset according to guidelines from professional medical societies
  3. Causative occlusion of the internal carotid artery or proximal MCA (M1)
  4. Age ≥18 years
  5. NIHSS score of ≥6
  6. ASPECTS of ≥6
  7. Treatment can be initiated (groin puncture) within 6 hours of symptom onset
  • To ensure benefit, reperfusion should be achieved as early as possible and within 6 hours of stroke onset (Class I; Level of Evidence B-R). (Revised from the 2013 guideline); if treatment is initiated beyond 6 hours from symptom onset, the effectiveness of endovascular therapy is uncertain (Class IIb; Level of Evidence C). (New recommendation)
  • The benefits are uncertain, on carefully selected patients with acute ischemic stroke in whom treatment
    can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the M2 or M3 portion of the MCAs, anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries. (Class IIb; Level of Evidence C). (New recommendation)
  • Endovascular therapy with stent retrievers may be reasonable for some patients <18 years of age with acute ischemic stroke who have demonstrated large vessel occlusion in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset, but the benefits are not established in this age group (Class IIb; Level of Evidence C). (New recommendation)

Read the full text on AHA/ASA website:

2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment

Read also:

Medscape article: Groups Issue Guidance on Endovascular Repair of Ischemic Stroke (subscription required)

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EZDrugID: International campaign to improve the distinctiveness of medication packaging

28 giu WheresWally_1

“Look-alike Drugs”is a present concern for all the emergency medicine professionals. EZDrugID Campaign address this topic with a petition a survey and suggesting strategies to prevent medication errors.

Go to the website http://ezdrugid.org/EZDrugID/About_EZDrugID.html and sign the petition, take the survey but most importantly introduce in your working place the awareness of “Look-alike drugs” danger for medication errors.

NMBD One of these things Pregnancy SuxPanc WheresWally_1

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Updated Guidelines for Treating Spontaneous Intracerebral Hemorrhage

24 giu American-Heart-Association-logo

American-Heart-Association-logo

Busting new and old myths on treating ICH.

Highlits on new and revised reccomendation in patients presenting with Spontaneous Intracerebral Hemorrage (ICH).

Safety of Early Intensive BP-Lowering Treatment
  • For ICH patients presenting with SBP between 150 and 220 mm Hg and without contraindication to acute BP treatment, acute lowering of SBP to 140 mm Hg is safe (Class I; Level of Evidence A) and can be effective for improving functional outcome (Class IIa; Level of Evidence B) (Revised from the previous guideline)
  • For ICH patients presenting with SBP >220 mm Hg, it may be reasonable to consider aggressive reduction of BP with a continuous intravenous infusionand frequent BP monitoring (Class IIb; Level of Evidence C). (New recommendation)
Because the speed and degree of BP reduction will vary according to the agent and method of delivery (bolus versus infusion) and clinical features, the choice of agent should take into account the practicability, pharmaco logical profile, potential side effects, and cost.
Glucose Management: Recommendation
  • Glucose should be monitored. Both hyperglycemia and hypoglycemia should be avoided (Class I; Level of Evidence C).(Revised from the previous guideline)
Temperature Management
  • Treatment of fever after ICH is reasonable
Seizures and Antiseizure Drugs Recommendations
  • Clinical seizures should be treated with antiseizure drugs (Class I; Level of Evidence A). (Unchanged from the previous guideline)
  • Prophylactic antiseizure medication is not recommended (Class III; Level of Evidence B). (Unchanged from the previous guideline)
ICP Monitoring and Treatment: Recommendations
  • Corticosteroids should not be administered for treatment of elevated ICP in ICH (Class III; Level of Evidence B). (New recommendation)

Those are just few of many changes introduced in this revision of the Guidelines. Discover more!

You can find the link to download the full text of this (and may other) guidelines on MEDEST at:

Guidelines page

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GINA and GOLD Guidelines 2015 Updates

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Global Initiative for Asthma (GINA) and Global Initiative for Chronic Obstructive Lung Disease (GOLD) updated their statements for 2015?
You can find the links to the documents on MEDEST Guidelines page.

GINA Guidelinesgina-asthma-guidelines

GOLD Guidelines

GOLD

MEDEST you tube

The 3-3-2 rule. A pratical tool for predicting the difficult airway on the field

31 mag 3_3_2_rule

3_3_2_ruleThe 3-3-2 rule is part of the evaluation in a patient for a predicted difficult airway. This evaluation can be done on an unconscious patient in supine position and is reliable tool for the anticipation of a difficult BVM ventilation and intubation out of the hospital.

In the video you can see the 3-3-2- rule application on a patient with a predicted difficult airway. .

This patient was difficult to BVM ventilate (cause of the “sloopy” chin) and was intubated in VL with the aid of a bougie.
In this case the predicted difficulty of the airway, determined the choice of VL bougie aided intubation as first choice for the airway management, avoiding so multiple attempts. This choice was of more importance view the difficulty of BVM ventilation that would have conducted to a critical desaturation during the intubation attempts.

The invasive airway management is a critical skill in out of hospital emergency medicine and, when indicated, not avoidable. Predicting in advance the difficulty is important to choose the right plan and avoiding multiple attempts.

View in Prezi.com

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Eco-ALS and mechanical chest compressions: that’s the way I like to run a code!

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47 ysr old male collapsed on the field. First ALS unit found him arrested in VF.
Shocked 3 times he regained a palpable central pulse.
When we arrived the patient arrested again. VF on the monitor. Shocked 4 times. Mechanical chest compression and tracheal intubation on board. He received Epi, Amio (300+150), Calcium Gluconate and Bicarb (suspected iper K in kidney insufficiency) before the ROSC.
15 minutes passed from the collapse to ROSC,  7 of wich were of “no flow” (no chest compressions, no AED from bystanders).
PMH: Hypertension, kidney insufficiency, heavy smokers. Medication history unknown.
He had chest pain before collapsing, as referred from bystanders.

Vitals at ROSC: GCS 3 T, RR 10 MV, SaO2 100%, EtCO2 35,  HR 70 bpm. NIBP 100/70 12 lead EKG at ROSC is shown below

ROSC IMA

An echo of the heart performed on the field (in the ambulance running to the ED, so I apologize for the low quality of the images) confirmed the lateral wall MI and shown distended IVC, B lines in both lungs and no sign of aortic dissection. No free fluid was present in the abdomen.

After administration of Heparin and Aspirin the patient arrived in ED and taken straight to cat-lab where a PTCA was performed 50 min after the collapse.

I think that increasing the use of ultrasonography on the field, and using it when really makes the difference, with a Point Of Care approach, is a big step for the care of critical patients out of the hospital.

Every prehospital emergency system have to instruct their professionals on how to use POC Ultra Sonography on the field and need specific “problem solving” protocols to help it’s diffusion.

MEDEST you tube


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