Managing airways in TBI

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Load-Play-Go in Out of Hospital Cardiac Arrest. The “6 minutes approach”.

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In the Prehospital Emergency System where I work (from late 1996) we are historically used to manage cardiac arrest events with a deep “Stay and Play”, except for some sporadic cases (mostly pediatric patients) . The rising of A-V ECMO era (and in Florence there is a major ECMO center) and lastly of mechanical chest compression devices, took us to rethink the whole approach to the management of cardiac arrest.

Is there now a role for a “Load-Play and Go” approach in some selected patients.

Let’s try to figure out some of the major challenges that this new approach can pose to emergency physician working in a prehospital environment.

  • Which are the inclusion criteria to choose, in a so urgent and confusing situation (as OHCA is), the right patient with a reasonable hope of good functional recovery.
  • Do we have to change our ALS schedule and management in those selected cases?

Wich is the right patient

The all V-A ECMO process is a really expensive stuff in term of both, human and financial resources. So the development of criteria to predict wich patient is potentially a candidate to good neurological outcome is oriented to spare money (for the collectivity) and to avoid futility (for the patients).

For sure a relatively young age, and the absence of invalidant comorbidities can play a role in these decision. But also the no flow” time, intended as the time from when the CA happened to the start of chest compressions in the witnessed CA and a shockable rythm finding or a potential reversible cause in non witnessed CA are sign of predictable good outcome.

The V-A ECMO, last but not least, needs a strict time schedule from the CA to the cannulation process to be effective and so the transport time to ECMO Center plays also a fundamental role in the decision making.

Putting all together these specification we can, with a good approximation, describe the right candidate for External Cardiac Life Support (ECLS).

But what about the pratical approach to those patients. Is still the classical ALS protocol the way to follow?

The six minutes approach to Load-Play and Go in OHCA

The basic skills are not different, but the real difference is the mind of the resuscitationist (S. Weingarth dixit) in these cases.

If you already decided this is the right patient the right time, we propose a six minute approach to manage all the features you need to perform in the first phase of a OHCA before “loading” the patients, “playing” during the “going” phase toward ECMO Center.

PROTOCOLLO ELS da plastificare_eng

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!

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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

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

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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

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“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

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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.

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