When chest compressions and early defibrillation are not the most important interventions in cardiac arrest

6 Feb CFR 2A

CFR 2A

The chain of survival is well known and most of us work everyday to spread it’s use at every level. Chest compressions is, along with early defibrillation, the most important and evidence based intervention to save a cardiac arrest patient’s life.

But there is a group of cardiac arrest patient in whom chest compressions and early defibrillation are not the first and most important intervention to perform. 

When a trauma is at the base of a cardiac arrest we know that this patient is either hypovolemic or there is an obstruction at the blood flow at the base of the cardiac arrest,  so chest compressions (and vasoactive drugs) are not effective.

We also know that the most common ekg presentation rhythms are Asystole and PEA and early defibrillation is not required.

That’s why when advanced care is performed in traumatic cardiac arrest all the interventions are directed to resolve reversible causes and chest compressions or defibrillation are not indicated.

In brain trauma the most critical phase are the 10 min following the impact. In this phase some critical, but mostly neglected, events occur and the survival of the patients depends on their entity.

Brain impact apnoea and catecholamine surge are the early pato-physiologic processes that determine the life or death of a severely brain injured patient in the first phase of the trauma. Both are proportional to the entity of the impact and can be cause of most of the cardiac arrest in which prehospital providers intervene. 

Apnoea is a reaction to the impact and concussion of brain stem in trauma. Apnoea occurs even for obstrution of first respiratory tract due to head position and muscles relaxation following head trauma.

Apnoea cause hypoxia and cell death, but even hypercarbia who leads to vasodilatation and increased blood volume in the brain. All this induce brain swelling and cerebral edema with permanent neurological damage or death.

Catecholamine surge is a reaction of the sympathetic system to head trauma, as to many other stressful conditions, that produces a massive releasing of vasoactive principles who leads to systemic hypertension. This condition determines increasing ICP that, associated with vasodilatation and relative loss of vascular regulatory function, increase brain oedema and neurological damage.

Massive cathecholamine excretion leads also to increasing pre-load and after-load responsible for the secondary heart failure function and acute cardiovascular insufficiency often discovered in massive trauma patients, who develop profound and refractory  hypotension in absence of evident, external or internal, blood loss. Other phenomena can also occur as consequence of direct cahecholamine insult as gastric ischemic ulceration, neurogenic pulmonary oedema and myocardial necrosis. 

Unfortunately those early phenomena are less likely to be testified by prehospital providers even if an efficient dispatch policy is in place. That’s why there is not much in literature about those topics and all the evidence derives from studies on animal models.

Most of the times this early phase of brain trauma is testified by community responders who has to be aware and instructed that when respiratory or cardiac arrest happens following head trauma, the most effective intervention is opening the airway and supporting ventilation and not performing chest compressions.

Prehospital professionals as also to be aware of the physiologic and clinical implications when comes to deliver Advanced Care. Supporting ventilation and promoting oxygenation and normocarbia are the key features for those patients and have to be prioritized in regard to other interventions.

We also have to remark, when teaching and lecturing in professional and community settings, the difference of priority in interventions between medical and traumatic cardiac arrest.

GoodSam app is a new instrument for EMS and community responders, commonly used for prioritize C interventions (chest compressions and defibrillation) in medical cardiac arrest, but was originally intended to diffuse awareness of brain impact apnoea and to encourage bystanders to perform A (airway opening) and B (ventilation) interventions. 

In the future when, thanks to culture and technologies devolopment, everyone at every level will be well conscious about the importance of opening the airway and ventilation in the early phases of trauma  the morbidity and mortality associated with head injury will be reduced to a level not yet achieved.

References and resources

 

By Mario Rugna

 

 

 

The pregnant patient

30 Jan Cardiac Arrest in Pregnancy

The management of a pregnant women has been always a challenge for physicians.

The different physiology of pregnancy, makes clinical choices and treatment different than in usual adult patient, and needs attentions and practice that override standard care.

In emergency medicine, where standards and protocols are a way to think and to act, a change in routine care, together with the time dependency of the decision making process, makes the pregnant patient an effective challenge.

So here is the need of specific guidelines focused on pregnant patient for specific clinical emergency situations.

In this post we discuss two guidelines about the management of a pregnant trauma patient and cardiac arrest in a pregnant women, with an eye of regard on the aspects of the recommendations for prehospital care.

Guidelines for the Management of a Pregnant Trauma Patient (Open Access)

Approved by Executive and Board of the Society of Obstetricians and Gynaecologists of Canada

J Obstet Gynaecol Can June 2015;37(6):553–571

Airway
  • Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C)
  • A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content.(III-C)
Breathing
  • Oxygen supplementation should be given to maintain maternal oxygen saturation >95% to ensure adequate fetal oxygenation. (II-1B)
  • If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C)
Circulation
  • Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B)
  • After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement (Lateral Uterus Displacement L.U.D.) of the uterus or left lateral tilt (obsolete n.d.r). Care should be taken to secure the spinal cord (if indicated n.d.r.) when using left lateral tilt. (II-1B)
Transfer to health care facility
  • Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life nor limb threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks’ gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B)
Perimortem Caesarean section
  • A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B)

Take home points on modifications of assessment of trauma patients in presence (or suspect) of pregnancy

  1. When indicated a thoracostomy tube should be inserted 1 or 2 intercostal spaces upper than usual.

  2. Vasopressors has to be avoided in pregnancy.

  3. Perform L.U.D (Lateral Uterus Displacement) to relieve Inferior Vena Cava compression.

  4. Transport the severely injuried pregnant patient to an hospital with maternal facility if fetus is viable (≥ 23 weeks).

Cardiac Arrest in Pregnancy. A Scientific Statement From the American Heart Association (Open Access)

Circulation. 2015;132:00-00. DOI: 10.1161/CIR.0000000000000300
Cardiac Arrest in Pregnancy1
Chest Compressions in Pregnancy
  • There is no literature examining the use of mechanical chest compressions in pregnancy, and this is not advised at this time
  • Continuous manual LUD (left uterus dispalcement) should be performed on all pregnant women who are in cardiac arrest in which the uterus is palpated at or above the umbilicus to relieve aortocaval compression during resuscitation (Class I; Level of Evidence C).
  • If the uterus is difficult to assess (eg, in the morbidly obese), attempts should be made to perform manual LUD if technically feasible (Class IIb; Level ofEvidence C)
  • Cardiac Arrest in Pregnancy
Transporting Pregnant Women During Chest Compressions
  • Because an immediate cesarean delivery may be the best way to optimize the condition of the mother and fetus, this operation should optimally occur at the site of the arrest. A pregnant
    patient with in-hospital cardiac arrest should not be transported for cesarean delivery. Management should occur at the site of the arrest (Class I; Level of Evidence C). Transport to a facility that can perform a cesarean delivery may be required when indicated (eg, for out-of-hospital cardiac arrest or cardiac arrest that occurs in a hospital not capable of cesarean delivery)
Defibrillation Issues During Pregnancy
  • The same currently recommended defibrillation protocol should be used in the pregnant patient as in the nonpregnant patient. There is no modification of the recommended application of electric shock during pregnancy (Class I; Level of Evidence C).
Advanced Cardiovascular Life Support
Cardiac Arrest in Pregnancy 3
Breathing and Airway Management in Pregnancy
Management of Hypoxia
  • Hypoxemia should always be considered as a cause of cardiac arrest. Oxygen reserves are lower and the metabolic demands are higher in the pregnant patient compared with the nonpregnant patient; thus, early ventilatory support may be necessary (Class I; Level of Evidence C).
  • Endotracheal intubation should be performed by an experienced laryngoscopist (Class I; Level of Evidence C).
  • Cricoid pressure is not routinely recommended (Class III; Level of Evidence C).
  • Continuous waveform capnography, in addition to clinical assessment, is recommended as the most reliable method of confirming and monitoring correct placement of the ETT (Class I; Level of Evidence C) and is reasonable to consider in intubated patients to monitor CPR quality, to optimize chest compressions, and to detect ROSC (Class IIb; Level of Evidence C). Findings consistent with adequate chest compressions or ROSC include a rising Petco2 level or levels >10 mm Hg (Class IIa; Level of Evidence C).
  • Interruptions in chest compressions should be minimized during advanced airway placement (Class I; Level of Evidence C).
Arrhythmia-Specific Therapy During Cardiac Arrest
  • No medication should be withheld because of concerns about fetal teratogenicity (Class IIb; Level of Evidence C).
  • Physiological changes in pregnancy may affect the pharmacology of medications, but there is no scientific evidence to guide a change in current recommendations. Therefore, the usual drugs and doses are recommended during ACLS (Class IIb; Level of Evidence C).
Epinephrine and vasopressine
  • Administering 1 mg epinephrine IV/IO every 3 to 5 minutes during adult cardiac arrest should be considered. In view of the effects of vasopressin on the uterus and because both agents are considered equivalent, epinephrine should be the preferred agent (Class IIb; Level of Evidence C).
Fetal Assessment During Cardiac Arrest
  • Fetal assessment should not be performed during resuscitation (Class I; Level of Evidence C).
Delivery durin cardiac arrest
  • During cardiac arrest, if the pregnant woman (with a fundus height at or above the umbilicus) has not achieved ROSC with usual resuscitation measures with manual uterine displacement, it is advisable to prepare to evacuate the uterus while resuscitation continues (Class I; Level of Evidence C)
  • PMCD (Peri Mortem Cesarean Delivery) should be strongly considered for every mother in whom ROSC has not been achieved after ≈4 minutes of resuscitative efforts (Class IIa; Level of Evidence C).
  • If maternal viability is not possible (through eitherfatal injury or prolonged pulselessness), the procedure should be started immediately; the team does
    not have to wait to begin the PMCD (Class I; Level of Evidence C).
  • Assisted vaginal delivery should be considered when the cervix is dilated and the fetal head is at an appropriately low station (Class IIb; Level ofEvidence C)

Take home points for resuscitation in trauma patient:

  1. The utilization of mechanical chest compressors is not recommended.

  2. Continuous LUD should be performed during resuscitation.

  3. No modification in energy level when electrical therapy is needed.

  4. No modification in timing and doses of ACLS drugs.

  5. Fetal assessment is not indicated during resuscitation.

  6. Peri Mortem Cesarean Delivery (PMCD) has to be performed without delay and at the site of cardiac arrest (no transport is indicated), after 4 minutes of ineffective resuscitation attempts.

 

References: 

Logo MEDEST2

 

 
 

ACEP policy: Out-of-Hospital Use of Analgesia and Sedation

22 Jan cropped-logo-medest-aussie.jpg

ACEP states that ” The relief of suffering is among the most common reasons for requesting EMS assistance. Pain and agitation are common causes of this suffering and are commonly encountered by EMS. There is a gap between the need for patient analgesia and the willingness of EMS personnel to provide it. There is a variety of medications available for the relief of pain and agitation.”

So let’s make the point on prehospital analgesia and sedation according with this policy.

Out of hospital analgesia

  1. Fentanyl for his short duration and rapid onset, multiple administration route (IV, IM, IN, and IO),   haemodynamic stability is the ideal narcotic agent for out of hospital use.
  2. Do not withhold narcotics in patients with abdominal pain for the myth of confounding the surgical assessment and so clouding the final diagnosis.
  3. Ketamine (at low doses) for analgesia (alone or in combination with narcotics) is safe, effective and haemodynamically stable without provoking respiratory drive and gag reflex suppression
  4. Concern about Ketamine effect on (increasing) intracranial pressure is misplaced

Out of hospital sedation and chemical restraint 

  1. Midazolam due to his rapid onset, short duration and multiple administration route (IV, IM, IN, and IO) is the ideal benzodiazepine for out of hospital sedation.
  2. Benzodiazepines, especially when administered in multiple doses can cause respiratory drive depression: use full monitoring of the patient when using benzodiazepines (MEDEST suggest waveform capnography). Consider other agents as butyrophenones (MEDEST suggest Aloperidol, Droperidol)
  3. Ketamine (in dissociative dose) is the ideal agent for patients with excited delirium (still not recognised as medical disorder in Italy!!!!!) cause of his rapid onset, safe haemodynamic profile and leave intact respiratory drive and gag reflex.

For full free open access text of this policy go to:

cropped-logo-medest-aussie.jpg

 

Influence of EMS-physician presence on survival after out-of-hospital cardiopulmonary resuscitation: systematic review and meta-analysis

11 Jan

Conclusions: The results of this meta-analysis show that CPR guided by EMS physicians is associated with improved rates of ROSC, hospital admission, and hospital discharge compared with CPR guided by paramedics in OOHCA patients

********Before citing those conclusions consider that this Metanalisys has several and important limitations

  1. No RCT exists (and probably never will) about this topic so just prospective and retrospective study were included
  2. Despite the big numbers(126,000 patients) 90% of patients included comes from two big study from Japan and no sensitivity analyses excluding these two studies was conducted.
  3. No RCT means selection bias. One example: EMS-physician-staffed ambulances have the capacity of declare futile the initiation of CPR which may have influenced the denominator of “potential cardiac arrests” in sense of more favourable outcomes in EMS physician staffed ambulances. 
  4. Geographic distribution of EMS systems is highly variable and is often influenced by many historical factors that all may have confounded the results of this meta-analysis.

********Despite the significant limitations this systematic review provides the only available evidence for the effectiveness of a paramedic versus EMS-physician-based emergency response system for prehospital cardiac arrest. 

What could EMS physicians provide beyond what paramedics already contribute? 

  1. It has been demonstrated that because of the limited number of invasive procedures performed by EMS crews (like airway management, tracheal intubation, etc.) in out-of-hospital patients, it is very difficult to obtain or maintain life-saving skills and physician presence increases invasive procedures and drugs delivery. 
  2. Physician presence during CPR has been reported to increase compliance with guidelines, resulting in less hands-off time during CPR.

References

Influence of EMS-physician presence on survival after out-of-hospital cardiopulmonary resuscitation: systematic review and meta-analysis

By Mario Rugna

Reflections at the beginning of a New Year

2 Jan hotel-jesolo-spiaggia-di-jesolo_5401f9297f52f

hotel-jesolo-spiaggia-di-jesolo_5401f9297f52f

  • The best quality for a medical professional is to know his limits. Until he works in this range he makes the best for his patients. If he exceed those limits he plays with the life of innocent and sick people just to improve his self-esteem

  • The challenge for every medical professional is to push forward his personal and cultural limits. The way to do this is by studying and training constantly. So his duty is to be always up to date and well trained trying to deliver a better care every day.

  • Every professional deserves to work in a well developed system to totally express his professionality. He has to contribute to improve his working environment, even with a constructive criticism, but much more with a positive attitude to propose solutions for clinical and management problems.

  • Private life and well being his a great part of every human been and medical professionals do not makes exceptions.

  • Before being a good professional is important being a good person.

IMG_1934

To my Family.

Happy New Year guys

cropped-logo-medest-xmas2.jpg

Rises and falls in 2015

1 Jan cropped-medest-xmas.jpg

This is my special classification of 2015 major changes in Emergency Medicine.

A simple way to review what happened in this year from an emergency physician point of view, and to wish everyone a wondeful 2016.

rising-graph1 copy

  • Tranexamic Acid in major trauma

  • Blood products for hemorrhagic shock

  • Ketamine in sedation and analgesia

  • Point of care Ultrasound

  • External Life Support

  • Capnography

  • Intranasal route for drug administration

  • FOAMED

  • Endovascular Therapy in Stroke

 

stock_graph_down_arrow copy

  • Hyperoxia

  • Spine motion restriction in Trauma

  • Hypothermia pre and post ROSC

  • Early Goal Directed Therapy in Sepsis

  • Volemic Resuscitation in Trauma and Septic Shock

  • Morphine in ACS

  • Thrombolysis in Stroke

  • Cricoid Pressure in Airway Management

 

cropped-logo-medest-xmas1.jpg

 

A wonderful FOAMED 2016 for everyone

 

Inappropriato utilizzo del sistema di emergenza sanitaria territoriale: La soluzione della Victoria Ambulance

27 Dec IMG_1655

Disclaimer,

This post is mainly directed to italian emergency audience, and is written in italian to give anyone is interested the chance of comprehending the deep meaning of this topic.

I usually do not address arguments regarding the political organization of prehospital emergency systems. I am daily involved in those kind of process and talking about them takes me to indirectly comment the politic of the organization I work for and this can generate bias and conflict of interests.

I made an exception this time, cause I am going to comment the virtuous process that Victoria Ambulance started on rationalizing the task of ambulances, trying to avoid non emergency interventions who risk to subtract resources to real emergency cases.

This is far different from italian view of reforming emergency systems, and for this reason worths a particular mention.

Thanks.

Mario Rugna

MEDEST lead author

Premessa

Non parlo mai, per scelta,  di organizzazione dei sistemi sanitari, in particolare di quelli territoriali. Sono personalmente/professionalmente coinvolto in questo tipo di processo e parlarne mi porterebbe a commentare, anche se indirettamente, le scelte politico-organizzative dell’Azienda Sanitaria per cui lavoro e questo comporterebbe inevitabili condizionamenti e conflitti d’interesse.

Faccio un’eccezione per questo post in cui riporto il processo di riforma intrapreso dalla Vittoria Ambulance (Australia) volto a razionalizzare l’invio dei mezzi di soccorso al fine di migliorare l’assitenza dei pazienti critici.

Mi sembra interessante analizzare un modello ed un concetto di riforma che potrebbe riguardare in un prossimo futuro anche sistemi d’emergenza più vicini a noi rispetto a quelli Australiani. Alcuni concetti sono infatti, sia pure nel rispetto delle diversità dei modelli organizzativi e delle figure professionali coinvolte, di stretta attualità anche da queste parti dell’emisfero.

Proverò a riferire il contenuto dei documenti (riportati nei riferimenti bibliografici con il link alle versioni integrali) nel modo più fedele possibile, inserendo i commenti personali in un paragrafo ben distinto e lasciando ogni ulteriore considerazione ai lettori di MEDEST

Le criticità del sistema Victoria Ambulance

Ambulance, Melbourne, Victoria, Australia

Ambulance, Melbourne, Victoria, Australia

Lo stato di Victoria nel sud-est dell’Australia è il più densamente popolato (secondo per popolazione totale) e la sua capitale, Melbourne è la seconda città per popolazione dell’intero continente.

Le criticità del sistema d’emergenza preospedaliera sono emerse dall’analisi di alcuni casi in cui l’arrivo ritardato del mezzo di soccorso ha aperto una riflessione sui tempi di risposta alle emergenze territoriali.

L’analisi ha evidenziato come la performance su questi indicatori tecnici era nettamente peggiorata negli anni, a fronte di un crescente aumento della richiesta da parte dei  cittadini.

Il ministro della salute dello stato di Victoria (Australia), On. Jill Hennessy, ha quindi istituito e presieduto una commissione composta da professionisti sanitari (paramedici), rappresentanti della Victoria Ambulance e rappresentanti di organizzazioni attive sul territorio, con lo scopo di razionalizzare l’invio dei mezzi di soccorso e supportare lo sviluppo della carriera dei professinisti dell’emergenza sanitaria territoriale.

ambulance-reform-victoria

Il lavoro del comitato si è concretizzato nella stesura di un documento Victoria’s ambulance action plan tra i cui obiettivi qualificanti ci sono:

  1. Miglioramento della qualità del dispatch
  2. Miglioramento della soddisfazione professionale e del training dei professionisti sanitari

Miglioramento della qualità del dispatch

Image13

"The interim report identified that there was a common view among 
paramedics that many non-urgent patients were being incorrectly 
categorised as needing an urgent lights and sirens response".

Tra le argomentazionie che vengono riportate alla base delle necessità di tale piano, oltre a quelle legate ai tempi di risposta, di trasporto e di stazionamento in ospedale, ci sono quelle legate alla qualità del dispatch dei mezzi da parte della centrale operativa.

"Ambulance Victoria’s prioritisation system had classified almost 
60 per cent of all emergency incidents as 
Code 1 (il nostrocodice rosso n.d.r.), 
requiring an urgent lights and sirens response. 
But on arrival, paramedics often found that a 
Code 1 response 
was not required"

Si evidenzia quindi una larga discrepanza tra la gravità dei codici d’invio (determinati dal dispatch telefonico dell’operatore di centrale) e la situazione non grave e non tempo dipendente constata dai paramedici all’arrivo sul paziente.

Tale situazione viene stigmatizzata come critica dal punto di vista organizzativo, in quanto distoglie dai pazienti più gravi risorse umane ed economiche, ma anche dal punto di vista professionale in quanto demotiva i professionisti che operano nel sistema.

"Change the dispatch grid, to ensure that 
only patients with life threatening emergencies receive a 
lights and sirens response. 
We are currently sending too many ambulances to non emergency cases. 
This change will free up ambulances to provide a faster response to 
the sickest patients".

Il piano di miglioramento che riguarda questo particolare aspetto del piano di riorganizzazione prevede:

  • Cambiamenti tecnici nel sistema di dispatch tali da far in modo che si possano identificare e dare risposte efficienti alle emergenze più gravi, ma al tempo stesso dia indicazione chiare perchè le chiamate per problemi non tempo dipendenti (“callers with non-urgent needs” “non-time-critical needs”) siano indirizzate verso servizi alternativi che possano fornire risposte più appropriate (General Praticioners o GP, medici di base).
  • Rafforzamento delle relazioni e dei protocolli condivisi con tutti gli organismi territoriali che si occupano di una serie di pazienti con necessità non urgenti.
  • Organizzazione di un trasposto non urgente efficiente mediante nuove regolamentazioni.
  • Miglioramento della governance, l’efficienza e l’affidabilità del processo di dispatch.
  • Creazione di strumenti migliori sia per il training che per l’operatività dei dispatcher.

Individua inoltre delle azioni di miglioramento da attuare sulla popolazione destinataria del servizio:

  • Campagne di sensibilizzazione sul reale valore ed utilizzo del sistema d’emergenza.
  • Campagne d’informazione sull’esistenza e sul funzionamento di sistemi alternativi, non d’emergenza, per l’accesso alle cure, che garantiscono allo stesso tempo efficienza e risposte adeguate.

Il sistema d’emergenza (ed i suoi dirigenti appena insediati) verrà quindi valutato in modo rigoroso attraverso il monitoraggio di alcuni indicatori clinico-organizzativi

  • Sopravvivenza dei pazienti in arresto cardiaco
  • Trattamento del dolore
  • Corretta centralizzazione di pazienti affetti da ictus o sindrome coronarica acuta

Miglioramento della soddisfazione professionale e del training dei professionisti sanitari.

AmbVIC

L’impiego sistematico delle doti professionali del personale giornalmente coinvolto nell’assistenza preospedaliera su codici a bassa priorità non di pertinenza del sistema d’emergenza, viene individuato come uno dei maggiori fattori contribuenti allo stato di insoddisfazione percepito.

"Ambulance Victoria’s workforce experienced unacceptable 
levels of dissatisfaction and disengagement, workplace fatigue, 
injury and violence, which impact on their health and wellbeing"

Era quindi doveroso affrontare da parte delle istituzioni il miglioramento delle condizioni di lavoro verso una migliore e più razionale utilizzo delle competenze professionali a disposizione.

Di pari passo va l’attenzione alla salute del personale in servizio.

Cito solo alcuni dei passaggi (scusate la traduzione con termini mutuati dal nostro gergo organizzativo/sindacale, ma ritengo renda il tutto più comprensibile) :

  • Adeguamento delle piante  organiche per permettere riposi e sostituzioni senza gravare sul carico di lavoro del personale.
  • Rafforzamento dei gruppi di Consueling e di prevenzione che si occupano della salute del personale.
  • Ammodernamento dei veicoli di soccorso con installazione di barelle elettromeccaniche
  • Implementazione delle possibilità di cariera legate a parametri di merito e non solo di anzianità

Commenti dell’autore

Alcune riflessioni personali, ed assolutamente non riferibili, se non casualmente, a contesti che non siano quello analizzato nella parte precedente del post.

  1. Rispetto ad un evento in cui un ritardo del mezzo di soccorso ha verosimilmente causato un danno alla salute del paziente,  ci si è chiesti, oltre se quello era il mezzo più appropriato come capacità assistenziale e tempo di risposta che in quel momento la rete proponeva, anche dove erano finiti il resto dei mezzi a disposizione del sistema che avrebbero potuto rispondere in modo clinicamente e temporalmente adeguato a quell’emergenza.
  2. Le risposte alla riflessione precedente potevano essere 2:
    1. La rete non è adeguata
    2. La rete è adeguata ma gestita male
  3. Le istituzioni dello stato di Victoria hanno valutato che l’aspetto da migliorare era la gestione della rete territoriale di soccorso.
  4. Risulta chiaro infatti come venga correlato l’allungamento dei tempi di risposta (di una rete adeguata come dimensioni) all’invio di mezzi di soccorso verso pazienti inizialmente triagiati come gravi ma che poi, all’arrivo sul posto, risultavano non critici.
  5. La naturale, ed eticamente corretta sovrastima (overtriage) con cui devono lavorare i sistemi d’emergenza, viene valutata confrontando l’attinenza delle priorità indicate dai codici d’invio, con quelle effettivamente riscontrate dai mezzi di soccorso intervenuti sul posto.
  6. Quando la discrepanza supera un margine fisiologico (e di sicurezza per i pazienti) essa viene ritenuta lesiva per la salute dei pazienti effettivamente critici.
  7. Oltre al potenziale pericolo clinico-organizzativo, l’analisi evidenzia come la sistematica assitenza fornita a pazienti non critici si ripercuote in negativo sulla soddisfazione professionale, sulle motivazioni lavorative e sulla salute del personale sanitario ingenerando un potenziale pericolo per l’assistenza dei pazienti effettivamente critici.
  8. Dalle misure proposte come correttivo si desume che non può esserci riforma organizzativa che non passi dal miglioramento delle condizioni di lavoro del personale coinvolto. Miglioramento che va dal clima lavorativo alle prospettive professionali ed economiche all’adeguatezza dei mezzi a disposizione sul territorio.

Conlcudo riportando un inno alla trasparenza che cito integralemente:

“Increased transparency of ambulance performance by publicly releasing local ambulance response times each and every quarter, in line with the government’s commitment to openness and transparency”.

Mario RugnaIMG_1655

 

References

  1. Victoria’s Ambulance Action Plan
  2. Ambulance Performance and Policy Consultative Committee

 

 

 

 

 

Neonatal Resuscitation Guidilenes 2015 update

20 Dec Neo resus

Even if neonatal cardiac arrest is not a common clinical scenario, it is a big concern for all the professionals involved in emergency medicine practice.

While on adult and pediatric cardiac arrest updated guidelines much (despite few key changes) was said or written, on neonatal part of the updated guidelines there is not much to read or to hear.

I think this particular aspect of cardipulmonary resuscitation worths a specific focus (see references for full free text of the guidelines).

So here is a brief summary of the key recommendations:

  • Usual care (remaining with the mother) is applicable to all term infants who are breathing or crying and have good tone.
  • Infants not meeting those criteria should be warmed (36.5o–37.5oC), dried, and stimulated. Suctioning should only be performed if is present airway obstruction is present or suspected .
  • Pressure ventilation by self-inflating bag, flow-inflating bag, or other ventilatory device, initially by room air, shoul be performed on labored or ineffective respirations or heart rate <100/min. after 60 seconds . Supplemental oxygen has to be started and targeted to preductal pulse oximetry norms.
  • Intubation is indicated only after ineffective or prolonged bag-mask ventilation, chest compressions, or congenital diaphragmatic hernia.
  • Laryngeal masks are an alternative to intubation for newborns at ≥34 weeks of gestation.
  • If despite effective positive pressure ventilation heart rates remains <60/min. chest compressions using the 2-thumb-encircling-hands technique has to be started at a 3:1 compressions/ventilation ratio.
  • Consider induced therapeutic hypothermia for infants born at >36 weeks of gestation with moderate-to-severe hypoxic-ischemic encephalopathy.
  • Termination of resuscitative efforts has to be considered if the 10-minute Apgar score is 0 associated with undetectable heart rate.
By Mario Rugna

cropped-medest-xmas.jpg

References:

  1. 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care- Free full text

2015 ALS Guidelines update. Is there something new (and good)? What really changes in our daily practice.

8 Dec IMG_1655

Who read the pervious post, Evidence Based Medicine. Beyond the dogma, can understand how my attention is focused on applicability of EBM based guidelines in my clinical context, so I want to underline some controversy of these guidelines, and at the same time, to introduce which are the most relevant statements for my clinical practice and for the way we want to evolve our local prehospital emergency system.

First of all the things you already heard almost everywhere over the blogsphere.

Minor, and not so relevant, changes. Minor influence on clinical practice. Just a reinforcement to key messages issued on the previous version of the guidelines. 

quality-of-recomendations

Let’s get deep into the guidelines :

The quality of chest compressions is now well specified. Push at least 5 cm but no more than 6 cm. Rate at least 100, maximum 120 per minute. So to assess quality of compressions (and of the whole CPR) you need a metronome and a commercial feedback device (acoustic or visive) to calculate compressions rate and deepness. I suggest capnography as alternative method to monitor chest compression quality.

not-too-fast-not-too-hard

Attribution:First 10EM.

 

Great emphasis is given to minimising interruption of chest compressions. So why not to introduce the hands only CPR at least at the beginning of resuscitation? There are good evidence for good neurological outcomes with this technique (associated to unsynchronised ventilation) and these guidelines lost the chance to make a real change on the way to a better patient centred care. 

Epinephrine at 1 mg dose every 3-5 minutes is still on board despite no evidence on improving outcome (and some signal toward the detrimental side of the story). For sure such a massive dose of vasoactive drug in a patient with low flow state and low metabolic activity, when circulation restart is a big issue for the heart and the brain. Pramedic 2 trial is ongoing and will give us more definitive answers. 

PEA and asystole are still considered similar entity and have a common algorithm. This is wrong, and we already treated this topic (Forget ACLS guidelines if you are dealing with Pulseless Electric Activity. Part 1. Forget ALS Guidelines when dealing with PEA. Part 2.). 2015 Guidelines reiterated this controversy. 

Capnography is reinforced as a useful companion to guide resuscitation along all its duration, but just a shy recommendation was released about is use as tool to guide the termination of resuscitation efforts. Guidelines stated that a value of less than 10 mmHg after 20 min is strongly predictive of bad outcome but “End-tidal CO2 values should be considered only as part of a multi-modal approach to decision-making for prognostication during CPR.”But why not mentioning the combination of US (not beating heart) and low EtCO2(<10mmHg), that gives specificity and sensitivity (I just found 1 case report who mentioned ROSC in such a situation) to the prediction rule and is commonly use as parameter for termination of resuscitation? 

Those, from my point of view, the most controversial point of the guidelines.  

Let’s talk now about the new and game changing points of this 2015 ALS Guidelines. They are not new to the majority of FOAMED world inhabitants. But now those statements can be spread to the vast population of emergency medicine professionals. 

POCUS is now integral part of the ALS algorithm. It is the gold standard for the determination of reversible causes of PEA. So why don’t make a step forward and differentiate PEA and pseudo-PEA via ultrasonography!  

External Life Support is a recommended option for selected group of patients. Mechanical  devices for chest compressions are not the standard when comes to conventional CPR. They became unmissable in particular circumstances like when transporting patients toward the ECMO center for external life support or for prolonged resuscitation scenarios. 

Traumatic cardiac arrest is not the poorest twin of medical cardiac arrest anymore, but finally he as a specific algorithm. This is not a complete news (already many of prehospital emergency services have operative procedure in that sense) but is important that also the normally conservative AHA and ERC stated this different approach. What they say. In case of trauma and cardiac arrest, if you decided to start CPR, do not waste time to compress the chest but treat reversible causes. Use US to help the diagnose. Consider to stop resuscitation efforts if there is not contractile activity of the heart at the end of the protocol. As previously mentioned, the case of PEA associated with a rising in EtCO2 values, even in absence of a detectable central pulse, that indicates great chance of ROSC (despite a condition of profound shock) is not mentioned.

Read more about this topic at: Mind of Resuscitation in Traumatic Cardiac Arrest

But what we really changed in our practice?
From March 2015 Florence EMS published a best practice that anticipated new guidelines trends.
External life support is part of our daily practice, mechanical chest compressors have been adopted for that reason in our emergency vehicles and our personalized US algorithm to detect reversible causes of CA is being taught to many colleagues who attended the prehospital US course in those months.
Use of capnography was already a standard practice in case of CA but we don’t missed the chance to reinforce the message about its use as marker of good quality CPR, restoration of spontaneous circulation and predictive of bad outcome when combined with a non beating heart.


Follow MEDEST to know more about ELS local protocol (and hopefully some case reports) and how to use POCUS  during the scheduled conduction of a ALS scenario. 

Visit MEDEST ALS 2015 Guidelines page for full text, posters adn video links to AHA and ERC Guidelines

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Evidenced Based Medicine (EBM): Beyond the dogma

16 Nov evidence-based-medicine-word-collage-concept-vector-illustration-42380553 copy

A disclosure on reading EBM based guidelines (and interpreting statistical analysis)evidence-based-medicine-word-collage-concept-vector-illustration-42380553 copy

Before presenting my comments on 2015 ALS Guidelines I wanna share my thoughts on EBM based guidelines and interpretation of statistical analysis as a “disclosure” for all MEDEST followers and to clarify some concepts on this two methodological approach.

Evidence Based Medicine External Validation and applicability.

EBM is based on RCTs (randomized and controlled) studies as maximum expression of quality of evidences.

The original spirit of EBM was to improve the quality of care for real patients in the real world (external validation). RCT studies are mostly based on controlled group of patients and regional organizations, expressions of local contexts and not always applicable to a more wide population of patients.

So in the years the concern about GRADE score of evidence (where RCTs trials are the highest expressions of evidence), made EBM based guidelines more focused on internal validation than external validation and applicability in widest clinical contexts.

Everyone of us when comes to clinical practice have to consider this potential bias.

Local context, individual clinical experience and local experts opinion can be the bridge between internal and external validation of RCT studies and EBM based guidelines.

Statistical Analysis

Similar considerations can be done on statistical analysis and statistical significative results.

To better explain this concept consider the result of this trial, Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Childrenrecently published in NEJM.

Results: The proportion of survivors with VABS-II scores of 70 or more at 12 months was not significantly different between the two groups (20% in the hypothermia group vs. 12% in the normothermia group; relative likelihood, 1.54; 95% confidence interval [CI], 0.86 to 2.76; P=0.14)

Authors conclusions: In conclusion, in comatose children who survive of out-of-hospital cardiac arrest, therapeutic hypothermia, as compared with therapeutic normothermia, did not confer a significant benefit with respect to survival with good functional outcome at 1 year. Survival at 12 months did not differ significantly between the treatment groups.

The authors conclusions are based on a P value of 0,14 that effectively is not relevant froma a statistical point of view. But what about ethic and clinical side of the picture? Can we ignore such a numerical difference on the base of a statistical interpretation?

In an other article (see in the references Difficulty interpreting the results of some trials: the case of therapeutic hypothermia after pediatric cardiac arrest.)  is well illustrated this dilemma, simulating a conversation between a physician and a parent of a post cardiac arrest comatose child.

From the article:

Doctor: I’m really sorry, but your child may have serious brain damage as a result of his cardiac arrest.

Parent: That’s terrible! Isn’t there anything we can do?

Doctor: I’m afraid not. There are some interventions that have been suggested, but they’ve not been shown to be effective.

Parent: What interventions?

Doctor: Well, cooling the body for a couple of days, for example. It’s been tried in neonates with birth asphyxia and adults after cardiac arrest.

Parent: But … if this intervention is used in neonates and adults, how can you say it won’t work in children?

Doctor: Well, in a recent study including almost 300 children, 20 % of those who were cooled survived with good brain function versus just 12 % of those who weren’t cooled. Neurological status improved in 38 % of the cooled children compared with only 29 % of the non-cooled. And, 28 days after the arrest, the mortality rate was 10 % lower in cooled children (57 % versus 67 %). Unfortunately, when the researchers applied the standard statistical rules that we use to interpret all scientific research, there was more than a 10 % possibility that these differences were due to chance, so we can’t recommend it.

Parent: But those results are really encouraging. Even if statistics tell you that this may be due to chance, there’s still the possibility that it wasn’t and I’d like my child to have that opportunity. Maybe the treatment’s expensive?

Doctor: No, that’s not the issue.

Parent: Was it dangerous then?

Doctor: Quite safe actually. Potassium and platelet levels went down a little, but with no harmful consequences. There is a risk that the heart rhythm can be affected; some of these abnormalities can even be quite dangerous. In the same study, serious abnormalities of the heart rhythm occurred in 11 % of the cooled children and 9 % of the others. Reduction in body temperature also increases the risk of infections; the investigators of this study reported that 46 % of cooled children developed an infection, compared with 39 % of the other children.

Parent: So, the treatment is associated with some risk but can still improve the chances of my child surviving… how can you balance the benefits and the risks for my boy?

Doctor: Honestly, I don’t know. If I just have to use numbers… 12 children would need to be cooled instead of kept at normal temperature in order to have one additional child with a good clinical outcome. And, 15 children would need to be cooled for one child to develop an infection.

Parent: Please, try this treatment on my child.

Statistical analysis is not the only determinant in daily clinical practice such as in real life. Reading the results of clinical trials beyond statistical analysis is important when we arrive to apply those results in our clinical practice.

Again, clinical gestalt and local experiences has to be considered when interpreting statistical analysis of clinical trials.

References

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