On line le slide della mia presentazione al congresso nazionale SIS 118 2014 in svolgimento a Santa Margherita Ligure
L’uscita di nuove linee guida è sempre un’occasione importante per chi ogni giorno si prende cura di pazienti critici in regime di emergenza-urgenza.
Quando poi l’argomento di cui trattano è importante, e per alcuni aspetti anche controverso, fa ancora più piacere l’uscita di un documento di consenso che permette di avere un riferimento affidabile per la pratica clinica giornaliera.
D’altra parte per i professionisti sanitari le linee guida non devono essere una gabbia professionale, bensì il valore aggiunto che guida le scelte cliniche ma la cui interpretazione critica prelude anche a scelte diverse, ma conseapevoli, da quele indicate.
Le nuove linee guida NICE (National Institute for Healthcare and Ecellence) sulla diagnosi e cura dello scompenso cardiaco acuto (2014 Acute heart failure NICE Full text Guidelines) pongono da questo punto di vista alcuni spunti interessanti quando si tratta di indicazioni per il trattamento iniziale.
Avevamo già trattato in un precedente post il trattamento dell’edema polmonare acuto affrontando le evidenze attuali ed i retaggi culturali che ancora persistono nel suo trattamento.
Vediamo se queste linee guida accolgono o meno i cambiamenti culturali che le nuove evidenze ci propongono.
|S-nitrosylation of effector proteins (8,13)|
|Activates ryanodine receptors to improve myocardial contractility|
|Regulates endothelial function|
|Inhibits smooth muscle hyperplasia|
|Regulates blood flow with changes in tissue oxygen tension matching flow to demand|
|Protects myocytes by preventing oxidative damage|
|Scavenges superoxide anions|
|Regulates energy metabolism|
|Protects cells from apoptosis|
|Guanylyl cyclase activation (8,17)|
|Promotes venous and arterial smooth muscle relaxation decreasing preload and afterload|
|Inhibits platelet aggregation by inhibiting platelet adhesion to vascular endothelium|
|Has anti-inflammatory effects by preventing leukocyte adhesion to vascular endothelium|
|Has antiapoptotic effects|
|Has antiremodeling effects|
|Hemodynamic conditions (12,18,19)|
|Decreased pulmonary capillary wedge pressure|
|Decreased left ventricular end diastolic pressure|
|Decreased pulmonary vascular resistance and right ventricular afterload|
|Decreased systemic vascular resistance and left ventricular afterload|
|Increased venous capacitance|
|Decreased right atrial pressure|
|Decreases myocardial oxygen demand|
2014 AHA:ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes were published on September 23.
The new terminology, from Non STE Miocardial Infarction to Non STE Acute coronary Syndromes, establishes a pathophysiological continuum between unstable angina and Non STE Acute coronary Syndromes, and make those two identities indistinguishable and considered together in this 2014 Guideline.
The need of High Sensitive Troponin and the importance of risk stratification are just few of the many changes made in this 2014 update
You con find this and all the newst guidelines on MEDEST Guidelines section
Sono state pubblicate il 23 di Settembre le 2014 AHA:ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes
Trovate queste e tutte le nuove linee guida su MEDEST nella sezione dedicata
From 23 to 25 of September at Hunan Provincial People’s Hospital in Changsha (People’s Republic of China) was held the Xiao Xiang International Forum on Emergency and Critical Care Medicine and Reapiratory Therapy.
Many speakers from differents part of Asia and US talked about different and interesting topics. I was honored to be part of this group.
I want to thank my friend and colleague Zhang Yi Xiong for the great opportunity he gave me. I also thank him for the wonderful human experience I had meeting all the chinese colleagues who work in Emergency Depatment of Provincial People’s Hospital.
Here is my presentation
You can also watch the presentation on line at the link below
Clik the links below to download the pdf and ppt version of the presentation
We publish this contribute from Dott. Guido Parodi.
Guido is a good friend of MEDEST and an exceptional interventional cardiologist working at Careggi Hospital in Florence.
The passion for medical research made Guido one of the lead investigators in many studies about antiplatelets therapies in acute coronary syndromes.
His enthusiastic way to work and to talk about the things he does is contagious. So we had this wonderful connection from the first time we met many years ago.
In this post he talks about a brilliant intuition he had, on the possible drug-to-drug interaction between morphine and antiplatelets agents.
So let’s go to the post.
Uno degli skill importanti per la gestione del paziente critico in emergenza è il settaggio e la gestione del ventilatore polmonare.
La scelta della modalità di ventilazione ed il settaggio consapevole dei parametri ventilatori spesso scoraggia l’uso di uno strumento fondamentale, per chi fin dalla fase preospedaliera deve gestire il malato critico che necessita di assistenza ventilatoria.
La familiarità con concetti base, ma non per questo scontati, di fisiopatologia polmonare, ma anche un piano operativo predefinito da applicare ed adattare volta per volta alle varie situazioni cliniche, sono di basilare importanza per il settaggio in emergenza del ventilatore.
Recenti concetti come la Lung Protective Ventialtion, hanno inoltre reso necessaria una rivoluzione critica di quelli che erano i vecchi cardini della ventialzione meccanica.
Sono liberamente disponibili in rete risorse preziose che illustrano in modo chiaro ed autorevole questi nuovi concetti.
Sono inoltre disponibili alcuni simulatori e tutorial molto utili per poter interagire e settare in modo virtuale, ma anche realistico, il ventilatore polmonare e comprendere la ventilazione polmonare.
A novel publication goes to enrich the long-living debate on direct laryngoscopy (DL) vs video laryngoscopy (VL) efficacy in emergency intubation.
The recent article, pubblished on JEMS and titled “Deploying the Video Laryngoscope into a Ground EMS System” ,compares the success rate beetwen DL vs VL in a ground EMS Service. The device used was the King Vision with channeled blade. The partecipants had a prior training on the divide, consisting in didactic orientation and practical skills on manikins.
The result of the study shown that “Within the first 100 days of the study, the video laryngoscope utilizing the channeled blade has shown to be at least as effective as DL in relation to first-attempt success” and considering that “the mean experience in our group with DL is nine years, yet the success rate remains unacceptable” “It’s time to consider transition from a skill that’s difficult to obtain and maintain to one that appears to have a quicker learning curve and will likely result in decreased episodes of multiple attempts at intubation and associated complications.”
So is direct laryngoscopy dead?( Or will be so in a few years)
There are some fundamental differences in VL tecnique respect the DL tecnique, that makes the DL more intuitive to pass the tube trough the cords.
We have basically 3 main axis in the airways
When we manage the airways we first put the head in “sniffing position” aligning the pharyngeal axis with the laryngeal one
Then we use the laryngoscope to align the mouth axis having so a direct view of the cords. This view coincide with the way to pass the tube, making this step intitive and easy.
When using the videolaryngoscope we take our eyes right in front of the larynx, having a perfect “video” view of the vocal cords, but also minimally modifying the axis of the mouth.
For this reason passing the OTT is not straight forward, so we need the stylet, the Bougie/Froban or the external glottic maneuvers, to facilitate the intubation.
This difference in tecnique makes the VL not so intuitive due to the contrast between the perfect laryngeal view and the not intuitive passage of the tube trough the cords.
In fact the available evidences almost accordingly demonstrate an equivalent success first pass rate beetwen traditional laryngoscope an video but a prolonged intubation time in VL groups.
As the previously cited article demonstrate the learning curve for VL is short and easy to perform, and this make this tecnique surely suitable for emergency intubation.
But for emergency professionals well trained and familiar with DL I think this has to be the first choice approach when managing an emergent airway.
Emergency field is not the place to make trianing or experience with novel devices or drugs.
The still not widely availability of video-laryngoscope makes this device a perfect alternative in all the casess when is not possible to obtain a good laryngela view with DL, but still not the gold standard tecnique.
In the future the increasingly diffusion of videoleryngoscopes (due mostly to more affordable prices), will chenge the airway management scenario. Novel emergency medicine operators will grown up parallel experience wid DL and VL so the latter will be more suitable as first choice device.
Wich way you prefer to go home?
The quickest and the shorter one for sure!
Do you use the GPS to go home?
Agree, me neither!
And when you use it?
Right! When you are lost!
So that’s why Direct Laryngoscope il still my Plan A
My straight way home!
Steroid-Pressor Cocktail for In-Hospital Cardiac Arrest? – See more at: http://www.jwatch.org/na31719/2013/09/24/steroid-pressor-cocktail-hospital-cardiac-arrest#sthash.qZBir4Aa.dpuf
Learning everything I can from everywhere I can. This is my little blog to keep track of new things medical, paramedical and pre-hospital from a student's perspective.
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