F.A.R. in E.M. (Focus Assessed Review in Emergency Medicine ) #4: Stroke. Bonus feature, 2015 ACEP Clinical Policy on Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department

27 gen
MEDEST F.A.RAnd here we are with the 4th episode of the F.A.R. series. If you accidentally lost the first two episodes you can find them here:
#1 Cardiac Arrest
#2 Airway Management
In this episode we’ll explore the best articles of 2014 about:

Stroke

Before starting we have to declare (if you are not aware of) that MEDEST is quite skeptical about the previous studies that are at the basis of thrombolytic therapy (Lo strano caso del trombolitico nell’ictus cerebrale ischemico, Pubblicate le nuove linee guida AHA/ASA sul trattamento precoce dello Stroke: nessuna nuova ed ancora qulache dubbio!, L’uso del trombolitico nello stroke. Stiamo giocando con la salute dei nostri pazienti?, rt-PA e Stroke: IST-3 l’analisi dei risultati). This can represent a potential bias on the choice of the articles. We also think that the actual evidences, and the consequent guidelines, are strongly influenced by commercial interests and not well supported from evidences that demonstrates how benefits outweight harms. We hope that 2015 will be the first year of a new era for stroke management, an era of well done studies producing strong evidences to achieve good neurological targets in all stroke patients.

In the first part we mention the litterature about thrombolytic therapy

And then the articles about endovascular therapy:

And now as anticipated in the title the 2015 ACEP Clinical Policy on Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department. Those freshly published guidelines give answer at two of most recurrent questions on stroke treatment:

  1. Is IV tPA safe and effective for acute ischemic stroke patients if given within 3 hours of symptom onset?
  2. Is IV tPA safe and effective for acute ischemic stroke patients treated between 3 to 4.5 hours after symptom onset?
Download and read the full policy to discover the recommendations made and based on the strength of the available data.
DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.
Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).
So download the full text and read it carefully to have a clear and complete opinion of the related topics.


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F.A.R. in E.M. (Focus Assessed Review in Emergency Medicine ) #3: Trauma

10 gen
MEDEST F.A.RAnd here we are with the 3th episode of the F.A.R. series. If you accidentally lost the first two episodes you can find them here:
#1 Cardiac Arrest
#2 Airway Management
In this episode we’ll explore the best articles of 2014 about:

Trauma

Before approaching specific arguments about trauma here are some fundamental articles to read about new emerging concepts in trauma care. Those are the clinical and physiological bases to understand what is happening in the actual trauma management scene.

And now let’s go to specific area of interest:

  • Spine immobilization

Spine immobilization in trauma is changing.

After years of dogmatic approach to strict spine immobilization for all trauma patients regardless any other factor, is now pretty clear that not all the trauma patients benefits from this all or nothing way of thinking. MEDEST already faced the argument in previous posts (The Death of the Cervical Collar?) as also did some prehospital consensus guidelines (Faculty of Pre-Hospital Care Consensus Statements).

In 2014 many articles treated this topic in a critical and modern way of re-thinking spinal immobilization, in particular the widespread use of cervical collar. The lessons we learned is that:

  1. Widespread use of cervical collar in neck trauma has to be carefully evaluated (and even avoided) due to the low incidence of unstable spinal lesions.
  2. Routine use of cervical collar is of unclear benefit and supported by weak evidences. A new selective approach has to be implemented based on prehospital clearance protocols.

What is “revolution” in clinical practice? We don’t have the answer to this dilemma, but what is happening in fluid resuscitation for trauma patients seems likely to be revolutionary. Restrictive strategies and new blood products are the future for the treatment of trauma patients (read also Fluid resuscitation in bleeding trauma patient: are you aware of wich is the right fluid and the right strategy?).

But much more happened in 2014 about trauma….

Resuscitative throacotomy is now a reality not only “in” but even “out” of hospital, so read all about it

An evergreen topic is TBI but new concepts are arousing so read here the latest updates

New drugs and new protocols for airway and pain management: a rationale guide to choose the right drug for the right patient.

DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.
Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).
So download the full text and read it carefully to have a clear and complete opinion of the related topics.


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F.A.R. in E.M. (Focus Assessed Review in Emergency Medicine ) #2

5 gen cropped-logo-medest-aussie.jpg
MEDEST F.A.RThe second episode of this focus reviews will deeply assess a topic that is very “hot” for every emergency professional.
Before reading this episode give a look at the first of the series about the best of 2014 literature on  Cardiac Arrest
And now enjoy the very best of 2014 articles on:

Airway Management

Not all is CRASH! Especially when it comes to airway management. RSI is the gold standard when we talk about intubating a spontaneously breathin patient but DSI is becoming a classic. And is recommended by Scott Weingart and Seth Trueger, not properly two “new kids on the block”….
Caution! You are about to perform an invasive maneuver on a previously spontaneously breathing patient. So remember to carefully avoid desaturation and hyper-inflation!
This disclaimer should be written on the handle of every laryngoscope to remember two of the most frequent fault to avoid when managing the airways.
Always rewarded as a nightmare for the emergency professional, surgical airway is most of the time a real no through road for the patient. So here is a complete guide on how to approach in the best way such a difficult skill.
Does the aggressive management of the airways gets benefits on critically ill patients or a more conservative approach gives best results on clinical outcomes? Facts (few) and doubts (many) in this year literature.

 

DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.
Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).
So download the full text and read it carefully to have a clear and complete opinion of the related topics.


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Going Down….Under!

4 gen cropped-logo-medest-aussie.jpg

cropped-logo-medest-aussie.jpgMEDEST yearly trip in Australia finally arrived.

Next two weeks MEDEST will post from Perth. So don’t worry, running in King’s Park, cycling along the South Coast Highway or swimming in Cottesloe, will just enhance inspiration and concentration on everything happens in the #FOAMED world.

Stay tuned to hear about us and about the latest news in Emergency Medicine World.

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F.A.R. in E.M. (Focus Assessed Review in Emergency Medicine ) #1

2 gen
MEDEST F.A.RThis is the first (of a series) of literature reviews dedicated to a particular topic of Emergency Medicine clinical life.
We tried to give a deep look to all the articles that had a relevance for a particular argument in this year, and made some considerations regarding the emerged evidences . All the articles are full text end ready to be downloaded.
The first edition is focused on the “king argument” for an emergency medicine and critical care professional:

Cardiac Arrest

Chest compressions

This year the importance of chest compressions in CA was confirmed and even emphasized as one of the few (along with defibrillation) really wothy intervention to perform during CPR.

Mechanical Devices

The “black year” for mechanical devices saw 3 major trials finding no difference in outcome between mechanical and (good quality) manual chest compressions. Still remains the subjective (personal) impression that mechanical devices are of some utility for the human resources management and  transport during CPR.

Vasoactive (and other) drugs

Like (and perhaps more) than for mechanical devices, 2014 signed a really bad year for epinephrine.

Lack of evidence on his utility and emerging ones on detrimental effects, accompanied this “historical” drug through the year that preludes to new 2015 CA Guidelines. Will epinephrine still be there at the end of this 2015? Or new emerging trends on use of steroids and vasopressin will prevale at the end?

ECLS

And after interventions that are loosing evidence in the years, new future prospectives for the management of CA patients, comes from Extra-Corporeal Membrane Oxygenation that gives renewed hopes of better survival and good neurological outcome, despite initial difficulties and skepticism.

Outcome and prognostication

Therapeutic Hypothermia

New era for the post-resuscitative care! Less oxygen, lower tidal volume and last, but not least, less cooling. And, while this year will give us some answers about intra-arrest cooling, now we know that 33°C is equally effective as 36°C and is no longer recommended in post ROSC patients! Maybe….

Other

Hypotermia (accidental not therapeutic), highlights from ERC 2014 Congress and decision on non starting CPR: what changes and what remains in our daily practice.

DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.
Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).
So download the full text and read it carefully to have a clear and complete opinion of the related topics.

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MEDEST Review 30. One year in Review.

25 dic

MEDEST-review

 

 

 

DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.
Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).
So download the full text and read it carefully to have a clear and complete opinion of the related topics.

The latest Review of the year is dedicated to a collection of the most important (for us) articles of this 2014.

This is MEDEST way to wish you all Merry Xmas.

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Enjoy the reading:

Cardiac Arrest

Chest compression

Mechanical Devices

Vasoactive drugs

ECLS

Outcome and prognostication

Therapeutic Hypothermia

Other

Trauma

Spine immobilization

Fluids and blood products

Other

Airway management

Sepsis

ACS

Stroke

Guidelines

Emergency Pharmacology

Mechanical Ventilation

Other clinical conditions

Non Clinical

 

 

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The “3 SIMPLE Rules”: an easy and accurate tool for recognizing VT

17 dic
Following the discussion on ectopy and aberrancy (view Ectopy or aberrancy? Google Ecg+ community comments on a clinical case.)  Ken Grauer, EKG master and author of many EKG books, gave us the permission to share his “3 SIMPLE Rules” to recognize VT in a simple ad accurate way.
 
  • Rule #1 Is there extreme axis deviation during WCT

Extreme axis deviation is easy to recognize. The QRS complex will be entirely negative in either lead I or lead aVF. The presence of extreme axis deviation during a WCT rhythm is virtually diagnostic of VT.
  • Rule #2 Is lead V6 all (or almost all) negative?

IF ever the QRS in lead V6 is either all negative (or almost all negative)  then VT is highly likely.
  • Rule #3 Is the QRS during WCT “ugly”?

The “uglier” the QRS the more likely the rhythm is. VT originates from a ventricular focus outside of the conduction system. As a result VT is more likely to be wider and far less organized (therefore “uglier”) in its conduction pattern
 
The “3 simple rules” is an extract from ACLS 2013 Arrhythmias  where you can find the complete explanation and much more on arrhythmias.
Visit Ken Grauer Amazon page to find out more and discover all the amzing EKG books he wrote. They are accurate and reliable for use in many emergency situation.
I’ll include Ken’s reply in the main script of the post cause it contains some very important adjuncts and expalnations. At the end of the replay you’ll find the link to download the full text of the section regarding the WCT topic. You’ll also appreciate the perfect Ken’s italian. I’m amazed….
Molto grazie Mario per la pubblicazione del mio consiglio su le tre semplici regole per diagnosticare VT! I’ll make a few brief additions to what Mario wrote. RULE #1 – Remember that slight or even moderate axis deviation is of no help. The QRS complex must be ALL negative in either lead I or in lead aVF. If it is – then the rhythm is almost always VT. RULE #2 – Again, moderate negativity in lead V6 is common and means nothing. But if the QRS complex in lead V6 is either all negative or shows no more than a tiny r wave – then VT is likely. This is because such marked negativity in lead V6 implies that the impulse is moving away from the apex – and that almost always means VT. RULE #3 – Supraventricular rhythms with either preexisting bundle branch block or aberrant conduction typically resemble some form of conduction defect (ie, either RBBB, LBBB or RBBB with LAHB and/or LPHB). However, if the QRS complex is amorphous (ie, very “ugly” and formless) – then it is much more likely to be originating from the ventricles. Occasionally, patients may have unusual forms of IVCD – so this rule is not 100% accurate – but it is a helpful supportive point in the differential diagnosis. For those wanting more complete description of the 3 Rules (and other pointers in assessing wide tachycardias) – feel free to download these Sections from my ACLS-2013-ePub – GO TO – https://www.dropbox.com/s/8bc9h5cumo7e4vy/8.0%2C9.0%2C10.0-%20ACLS-2013-e-PUB-WCT-Criteria-%2810-13.11-2014%29-LOCK.pdf?dl=0 – Detailed description of the 3 Simple Rules begins in Section 08.17. Spero che questo vi aiuta.”
Ken Grauer
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Ectopy or aberrancy? Google Ecg+ community comments on a clinical case.

16 dic
 75 yrs old female, confused, chest pain and hypotensive. Below ypu can see the 12 leads EKG pre and post cardioversion

TVCardioversion

EK post cardio

The question about ectopy and aberrancy, even if of minor influence on theraphy that was based on clinical presentation, was interestingly debated in ECG+ community.

Prof. Ken Grauer and other members of community gave the solution on why the above 12 leads EKG was, with good approximation, referrable to a VT and not to a SVT conducted with aberrancy.

Those are the EKG criteria they individuated:

  1. Extreme axis “northwest axis”: (neg in lead I, positive in lead aVR);
  2. Lead V1 is amorphous
  3. Lead V6 is almost all negative
  4. No diphasic RS complexes in any of the precordial leads
  5. Monophasic R-wave in lead V1(taller left “rabbit-ear”)
  6. Diphasic QR complexes in leads V2 and V3.
  7. Monophasic QS complexes in leads V4, V5, and V6.
  8. Josephson’s sign (notching on the nadir of S wave)

Those criteria, even if present in this case, are universally valid.

If you want to discover more on this topic MEDEST already posted on this topic in a previous post

There you can find alle the references on EKG criteria for differential diagnosis between ectopy and aberrancy in wide comples tachycardia.

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M(orphine)O(xygen)N(itrates)A(SA) in STEMI. New evidences indicates that is time to change our practice

26 nov

In a previous post we already told about a possible interaction between Morfine and antiplatelets therapy, proposing, on the base of the new evidences, a different approach to analgesia in AMI with a more caution morphine administration in STEMI patients.

Courtesely from Dott. Guido Parodi

Courtesely from Dott. Guido Parodi

A recent published study, presented at American Heart Association (AHA) 2014 Scientific Sessions, also questioned oxygen use in non hypoxic STEMI patients.

The Air Versus Oxygen in ST-Elevation Myocardial Infarction (AVOID) trial compared supplemental oxygen vs no oxygen unless O2 fell below 94%.

“The AVOID study found that in patients with ST-elevation myocardial infarction who were not hypoxic, there was this suggestion that, potentially, oxygen is increasing myocardial injury, recurrent myocardial infarction, and major cardiac arrhythmia and may be associated with greater infarct size at 6 months,” lead author Dr Dion Stub (St Paul’s Hospital, Vancouver, BC, and the Baker IDI Heart and Diabetes Institute, Melbourne, Australia) concluded.

A previous Cochrane review Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev 2013 concluded that “current evidence neither supports nor clearly refutes the routine use of oxygen in people with AMI”, so after AVOID trial the ideal balance is more and more weighing on avoiding supplemental oxygen in STEMI non hypoxic patients.

We can affirm now that 50% of MONA acronym is, at least, reasonably questionable, and a new era in the treatment of STEMI patients is probably coming.

References:

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A great Twitter day!

24 nov
TwitterI’m more and more convinced of the power of spreading informations and resources trough social media.
Twitter is something that you can’t miss if you want to stay on the line of medical education. Conferences, articles, discussions and much more flows on twitter line everyday.
So give a look at MEDEST timeline of today and read text articles treating different aspects of emergency medicine.

24’th November, 2014 @medest118

08:10 Improved Survival After Out-of-Hospital Cardiac Arrest and Use of Automated External Defibrillators

08:15 Treatment for Out-of-Hospital Cardiac Arrest Is the Glass Half Empty or Half Full?t

08:27 More commorbidities and increasing age of OHOCA. Is Time for changing approach and terminology?

08:33 It is time to embrace an era in which transparency and responsible data sharing are common values. 

08:35 Glucocorticoids as an Emerging Pharmacologic Agent for Cardiopulmonary Resuscitation

08:42 Sedation in non-invasive ventilation: do we know what to do (and why)?

08:50 Diagnosis and acute management of anaphylaxis

08:54 Are you ready for running Florence marathon on 30 Nov?

14:38 Il ventilatore polmonare vi spaventa? avete sempre desiderato utilizzarlo ma non avete mai osato?

If you don’t already have one, get a Twitter profile and

Follow MEDEST on Twitter @medest118

You can also follo us on Facebook

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