A Day in Milan

16 mar Featured Image -- 4755

medest118:

Not just Emergency Medicine! If you planned to visit Italy for the great EXPO follow this amazing Blog.
Linda Sorgiovanni guide you through the most exciting travel experience.
Food, wine, art and much more from real italian culture.
Don’t miss it!

Originally posted on Italy Travel Designer:

With the expo just around the corner all eyes on on Milan. Typically known as the business hub of Italy not as romantic or as charming as its famous neighbours to visit.  Although Milan is actually a fabulous city to visit with historical and contemporary charm and probably the best restaurants in the entire country!

I was there a couple of weeks ago to meet up with our friends and collaborators. Heres is how I spent my day:
Just a short ride from Florence on Italo to arrive at the Porta Garibaldi Train Station a short walk over the road to Feltrinelli Cafe and Book Shop in Piazza Sigmund Fraud. This business district is known as Centro Direzione situated north west of the city centre.  After our cappuccino and introduction in to the business district we took a cab in the historical centre for lunch at L’Arte  an exceptional restaurant…

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RSI Basics Podcast with Minh Le Cong (@ketaminh on twitter)

16 mar

Originally posted on DOWNSTAIRS CARE OUT THERE BLOG:

A Podcast with Minh Le Cong on beginner RSI. Recorded for my own personal reference but its such a great resource for Paramedics, Paramedic Students and a good all round touch up on the subject with a person much more knowledgeable than I.

pharm-logo-1400x1400
If your not listening to Minh I highly suggest you start! His podcast was my first step into #FOAMed, so its an absolute honor to have him on my own.

You can find the Podcast over on I-Tunes:  https://itunes.apple.com/au/podcast/downstairs-care-outthere-podcast/id876296199c (please take time to leave a review or rating!!)

Below you will find some of the papers, trial and websites that we mention throughout, all are a good read. There’s also a number of different checklist ideas.

PHARM Podcast 61:
http://prehospitalmed.com/2013/02/19/pharm-podcast-61-rapid-sequence-intubation/

The Original RSII Article;

http://journals.lww.com/anesthesia-analgesia/Citation/1970/07000/Rapid_Induction_Intubation_for_Prevention_of.27.aspx

The study protocol for the Head Injury Retrieval Trial (HIRT): a single centre randomised controlled trial of physician prehospital management of severe…

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Let’s be clear! Not all trauma patients must be treated with spinal immobilization during prehospital resuscitation and transport.

9 mar

ems-backboardsSpinal immobilization is performed in all trauma patients from the rescuers in EMS systems all over the world, regardless the mechanism of injury and the clinical signs.
This kind of approach is nowadays been rebutted from the recents evidences and the actual guidelines.
ACEP, in Jan 2015, released a policy statement entitled :”EMS Management of Patients with Potential Spinal Injury” clarifying the right indications, and contraindications, for spinal immobilization in prehospital setting.
The lack of evidence of beneficial use of devices such as spinal backboards, cervical collars etc… is in contrast with the demonstrated detrimental effects of such instruments: airway compromise, respiratory impairment, aspiration, tissue ischemia,increased intracranial pressure, and pain, consequent to spinal immobilization tools, can result in increased use of diagnostic imaging and mortality.

Already in 2009 a Cochrane review demonstrated the lack of evidences on use of spinal restriction strategies in trauma.

Recently the out of hospital validation of Nexus criteria and Canadian C-spine rules, strongly driven to a revisited approach to spinal immobilization.

So in 2013 American Association of Neurological Surgeons and the Congress of Neurological Surgeons Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injurie”  and Faculty of Pre-Hospital Care “Pre-hospital Spinal Immobilisation: An Initial Consensus Statement” stated those changes.

Based on this statements:

  1. Spinal immobilization should not be used for patients with penetrating trauma without evidence of spinal injury.
  2. Spinal immobilization should be considered in all trauma patients with a cervical spine or spinal cord injury or with a mechanism of injury having the potential to cause cervical spinal injury.
  3. Spinal motion restriction should not be considered for patients with plausible blunt mechanism of injury and any of the following:
    • The patient is GCS 15 (normal lev el of alertness)
    • There is no posterior mid-line tenderness
    • There is no distracting injury (other painful injury)
    • There is no focal neurological signs and /or symptoms (e.g., numbness and/or motor weakness)
    • There is no anatomic deformity of the spine
    • There is no intoxication (alcohol or drugs, including iatrogenic)
  4. The long spinal board is an extrication device solely.
  5. Backboards should not be used as a therapeutic intervention or as a precautionary measure either inside or outside the hospital or for inter-facility transfers. For this purpose, a scoop stretch or vacuum mattress should be used.
  6. EMS providers ahs to be properly educated on assessing risk for spinal injury and neurologic assessment, as well as on performing patient movement in a manner that limits additional spinal movement in patients with potential spinal injury.

References

  1. 2015 ACEP Policy statements: EMS Management of Patients with Potential Spinal Injury
  2. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. Oct-Dec 1999;3(4):347-352.
  3. Cochrane Rewiev Spinal immobilisation for trauma patients
  4. Test performance of the individual NEXUS low-risk clinical screening criteria for cervical spine injury.
  5. The Out-of-Hospital Validation of the Canadian C-Spine Rule by Paramedics
  6. Evaluation of the Safety of C-Spine Clearance by Paramedics
  7. 2013 American Association of Neurological Surgeons and the Congress of Neurological Surgeons Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injurie
  8. Faculty of Pre-Hospital Care “Pre-hospital Spinal Immobilisation: An Initial Consensus Statement”

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Hands Off The Ketamine!

6 mar

medest118:

MEDEST join and support the disappointment about Ketamine restriction and its potential effects on medical use in low income nations. We support the work of collegues that face everyday the challenge of working in countries where the lack of resources makes being an intensivist the hardest experience.
So Hands Off The Ketamine!
#handsoffketamine

Originally posted on PHARM:

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Trauma induced coagulopathy. Fixed Ratio or Goal Directed Therapy?

3 mar Coagulopathy pat

Trauma induced coagulopathy (TIC) is now recognized as one of the major contributors to mortality in bad injured patients.
Its pathophysiological pathways is debated and still not well known, but seem to be clear, and widely accepted, that the profibrinolytic state, triggered from many and different factors involved in trauma, leads to an acute Fibrinogen consumption.
Thrombin and Coagulation Factors in fact seems to be preserved and well functioning even in bad traumatized patients.
This lack of Fibrinogen, at least in the early phase of trauma, is the real cause of coagulopathy and has to be early recognized and treated to revert the altered coagulation asset existing in a great part of traumatic patients.

Coagulopathy pat

The substitution of massively deteriorated Fibrinogen is the therapy of choice in patients with acute TIC.
Two ways of achieving this goal are recently shown to be feasible, and from different point of view, effective.
The first is the Fibrinogen replacement with PRBC, FFP and PLT with a fixed ratio (1:1:1 or 1:1:2).
The second is a Goal Directed Therapy (GDT) with Fibrinogen concentrate administered on the base of thromboelastography profile of the clot, targeted to guide the Fibrinogen administration and monitoring the profile of clot formation.
The clinical challenge for physicians facing traumatic emergencies, both in prehospital and in-hospital field, is to early recognize the TIC in patients with low injurity score and well preserved physiologic parameters. The early recognition of coagulative system alteration leads to an early support of coagulation and hopefully to a better outcome.

There is no clear evidence and consensus on which hematologic or clinical indicators to use as acute coagulopathy risk stratification in trauma patients.

On Feb 20 and 21 in Bologna, some of major italian experts in trauma gave life to a consensus conference on this topic. The result of the conference leads to an initial, but not least important, consensus on the major implant of the theory at the base of recognition and treatment of TIC.

First step of this implant is the decision on when to treat the patients and when the treatment is futile. If the treatment is not futile the second step is to recognize, based on hematologic values and clinical parameters, the patients at risk of coagulopathy. Some values were identified as suitable for the stratification of the risk, but among the participants were not consensus on which is the most important and wich cut-off level to use.

BE, HB. SBP, Lactate levels were the most wanted indicators for recognizing of TIC. Next step, after recognizing the risk of coagulopathy is the choice of sustaining coagulation. The experts achieved the consensus on this statement but not on which was the best way to do it: Goal Directed Therapy (thromboelastography and targeted Fibrinogen replacement) or Fix Ratio supplement with PRBC FFP an PLT.

Till here the consensus.

Giuseppe Nardi, an intensivist working in Rome at Shock and Trauma Center of Azienda Ospedaliera S. Camillo Forlanini and widely recognized as one of the major experts in trauma, tried to go beyond this statement, designing a clear path for future investigations and hopefully new consensus.
Steady underlining the subjective value of the data, he identified a potential cut-off value for each of the most important indicators of early coagulopathy in trauma.
He indicated:

  • BE -6 
  • SBP ↓100 mmHg
  • HB  ↓10 mg/dl 
  • Lactate ↑ 5 mmol/L

Said that just one of this values is predictive of fibrinogen depletion (normal plasma fibrinogen levels range from 200 to 450 mg/dl, and current guidelines recommend maintaining the plasma fibrinogen level above 150 m g/dl) and on the base of those values he hypothesized that, with a good approximation, clinicians can identify the risk of trauma induced coagulopathy.

Nardi based his assumption on some good articles present in letterature, but he mentioned one in particular:

Estimation of plasma fibrinogen levels based on hemoglobin, base excess and Injury Severity Score upon emergency room admission.

This is a retrospective study of major trauma patients (ISS ≥16) with documented plasma fibrinogen analysis upon ER admission. Plasma fibrinogen was correlated with Hb, BE and ISS, alone and in combination.

The study, being retrospective, is at risk of confounding bias even if regression analysis was conducted.

The authors concluded:”Upon ER admission, FIB of major trauma patients shows strong correlation with rapidly obtainable, routine laboratory parameters such as Hb and BE. These two parameters might provide an insightful and rapid tool to identify major trauma patients at risk of acquired hypofibrinogenemia. Early calculation of ISS could further increase the ability to predict FIB in these patients. We propose that FIB can be estimated during the initial phase of trauma care based on bedside tests.”

Nardi, together with Osvaldo Chiara, Giovanni Gordini and other well known experts in trauma, is part of the Trauma Update Network (TUN) and elaborated the Early Coagulopathy Support (ECS) protocol:

“The protocol aims to avoid the use of plasma in the patients who will need a limited number of PRBCs, reduce the plasma related complications, and improve coagulation support in patients requiring massive transfusion through the early restoration of fibrinogen blood concentration. The ECS protocol has been developed assuming to have a point of care monitoring of coagulation, but can also be applied if a viscoelastic monitoring is not available. The ECS will be adopted by the TUN trauma centers with strict monitoring of economic impact and clinical results” (from: Giuseppe Nardi, Vanessa Agostini, Beatrice Rondinelli Maria et al. Prevention and treatment of trauma induced coagulopathy (TIC). An intended protocol from the Italian trauma update research group)

The basic principles of ECS can be so summarized:

  • All hemorrhagic patients (or bleeding risk) should receive early anti-fibrinolytic therapy (within the first 3 hours of injury)
  • The severity of hypoperfusion and the risk of coagulopathy correlate with the levels of Lactate and BE and pH as well as with the values of PA and Hb.
  • In case of bleeding fibrinogen is the most critical factor in the coagulation process and should be early replaced
  • The remaining coagulation factors are significantly decreased only later, and only in response to massive hemorrhage
  • Platelets decreased significantly only after massive hemorrhage but their functionality may be significantly limited by hypothermia
  • The control and correction of hypothermia is essential
  • Fluid challenge can be granted using crystalloids in patients with bleeding who do not requires massive transfusion (≤6 PRBC within 24 hours)
  • Transfusions of plasma and PTL to patients who do not have a massive hemorrhage should be avoided
  • In case of massive bleeding, it is desirable to transfuse plasma early in relation Plasma / PRBC in 1: 2 or 1: 1 ratio.
  • It is not necessary to start the transfusion of platelets it immediately after the admission of the patient (except in cases of anti-aggregation therapy)
  • Coagulation monitoring should be guaranted by viscoelastic methods (ROTEM / TEG); in the absence of these tools coagulation parameters (INR, PTT) over a, fibrinogen and platelets, must be monitored at close intervals.
But how those assumption can be related to practical clinical world?
The identification of parameters and cut-off values to recognize TIC can be a great step forward on the choice of the right patients in whom starting an early hemostatic resuscitation, avoiding both the risk of exposure to unneeded side effects than the possibility of wasting precious clinical resources.
The achievement of target level of plasmatic fibrinogen (with Fresh Frozen Plasma in fix ratio or with the goal directed administration of concentrated Fibrinogen ) can be the next level for treating trauma patients.
In term of treatment, damage control resuscitation and early support of coagulation must guide our clinical gestalt when treating trauma patients.

References:

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Endovascular Treatment of Ischemic Stroke

14 feb merci01

merci01

Thrombolysis is nowadays the preferred therapy for ischemic stroke management.
Many controversies on his safety and discussion on evidences that support benefits on long term outcomes, aroused from most of the studies supporting the use of alteplase in stroke patients.
New technologies has been recently developed for endovascular therapy and this made possible a steady step forwar for its use in targeted treatment of obstructed cerebral vessels.
Imaging detection of the lesion, targeted vessels treatment has been applied to a selected group of patients avoiding blind systemic thrombolytic administration.
New studies and good evidences support this technique. Selecting patients with advanced imaging techniques, using the latest stent retriever devices, and performing the intervention earlier is the key of a revolving way to investigate endovascular theraphy in ischemic stroke.

The addition of this tecnique when one of the major cerebral artery is obstructed almost double, according some investigators, the chance of good neurological outcome comparing to tPa alone.

Here is a short review of the 4 most recent studies on this topic:

500 patients where enrolled at 16 medical centers in Netherlands were assigned to intra-arterial treatment or to usual care alone. The primary outcome was the odds ratio of achieving a lower score on the modified Rankin scale at 90 days with endovascular therapy. There was an absolute difference of 13.5 percentage points in the rate of functional independence in favor of the intervention (32.6% vs. 19.1%). There were no significant differences in mortality or the occurrence of symptomatic intracerebral hemorrhage.

Patients with a proximal intracranial occlusion in the anterior circulation were included up to 12 hours after symptom onset. Participants where randomly assigned to receive standard care (control group) or standard care plus endovascular treatment with the use of available thrombectomy devices (intervention group). Patients with a proximal intracranial occlusion in the anterior circulation were included up to 12 hours after symptom onset. Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded.

The trial was stopped early because of efficacy. The primary outcome favored the intervention, and the intervention was associated with reduced mortality (10.4%, vs. 19.0% in the control group). Symptomatic intracerebral hemorrhage occurred in 3.6% of participants in intervention group and 2.7% of participants in control group (P=0.75).

Patients with ischemic stroke who were receiving alteplase less than 4.5 hours after the onset of ischemic stroke where randomly assigned either to undergo endovascular thrombectomy with the Solitaire FR (Flow Restoration) stent retriever or to continue receiving alteplase alone. All the patients had occlusion of the internal carotid or middle cerebral artery and evidence of salvageable brain tissue and ischemic core of less than 70 ml on computed tomographic (CT) perfusion imaging.

The trial was stopped early because of efficacy after 70 patients had undergone randomization. The percentage of ischemic territory that had undergone reperfusion at 24 hours was greater in the endovascular-therapy group than in the alteplase-only group.

The study is to determine if patients experiencing an Acute Ischemic Stroke due to large vessel occlusion, treated with combined IV t-PA and Solitaire FR within 6 hours of symptom onset have less stroke-related disability than those patients treated with IV t-PA alone.

The Primary endpoint is 90-day global disability assessed via the blinded evaluation of modified Rankin score (mRS).

The primary endpoint showed a substantial shift to lower disability levels on the modified Rankin scale. The proportion of patients alive and free of major disability at 3 months also significantly improved, along with mean improvement of National Institutes of Health Stroke Scale (NIHSS) score at 27 hours.

Read also Medscape commentary at:

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My favourite VL view to increase first pass intubation

8 feb

A debate is ongoing among #FOAMED social media about increasing first passage rate in tracheal intubation and some difficulties when using VL.

At the beginning of my experience with VL I experienced some difficulties, but with a radical change in technical approach I reached a good security on first pass success.

Here are my consideration and I hope will be useful for anyone is starting using VL

 

There are some fundamental differences in VL technique respect to DL, that makes the DL more easy and intuitive to pass the tube trough the cords.

3axys

The 3 axys theory for airway management

“Sniffing position” align the pharyngeal axis with the laryngeal one

Sniffing position

Sniffing position

Perfoming Direct Laryngoscopy with the laryngoscope we align the mouth axis to have a direct view of the cords.

DL view

DL VIEW

 

 

 

 

 

 

 

 

 

 

This view coincide with the route for passing the tube, making this step intuitive and easy.

 

When using a Video Laryngoscope 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.

Visione in videolaringoscopia

VL VIEW

This difference makes the act of passing the tube not so easy and not so intuitive, cause of the contrast between the perfect video laryngeal view and the not easy passage of the tube trough the cords.

In those cases the stylet, the Bougie/Froban or the external glottic maneuvers, are useful to facilitate the video-intubation.

tubo stylet

Golf stick shape of the tube+stylet

But the first goal is to reach this view on the screen of the videolaryngoscope.

IMG_1278

I want to have the epiglottis right at the center of the screen and this comes prior of a good view of the larynx.

Epiglottoscopy is the key point of my management of the airways in general and when prforming VL in particular.

Having the epiglottis in central position on the screen allow to:

  • lower the glottic plane facilitating intubation
  • decrease  the force to apply on the airways minimizing traumatism and neck movement in case of trauma.
  • fits all the difficult airway situations because a poor view of the cords is what you are looking for!

If you agree, memorize my favorite view and reach for it when using a video device to mange the airways.

All comments are welcome so please let me know your thoughts.

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Ketamine Fight Club: Ketamine in TBI

5 feb

medest118:

From Taming the SRU Blog a collection of systemtic reviews on Ketamine and intracranial pressure. You will also find a really interesting podcast and some #FOAMed resources on this topic.

Originally posted on PHARM:

20130907-144533.jpg

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Ketamine and intracranial pressure – literature update

29 gen

medest118:

Repetita iuvant. From PHARM a litterature update on Ketamine and intracranial pressure.

Originally posted on PHARM:

photo (26)

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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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