Canadian Association of Emergency Physicians Position Statement on Acute Ischemic Stroke

12 apr CJEM CJO masthead9

CJEM CJO masthead9Has been published in March 2015 on Canadian Journal of Emergency Medicine (CJEM), the Canadian Association of Emergency Physicians Position Statement on Acute Ischemic Stroke.

Let’s see what they say about thrombolitic therapy and administration timing.


Summary of Evidence

Seven trials either specifically addressed the efficacy of rt-PA in stroke within three hours of symptom onset or provided data on a subgroup of patients receiving therapy within three hours of symptom onset.
Fibrinolytic therapy administered within three hours of symptom onset increases the probability of survival with a favourable neurologic outcome (NNT 10).
This favourable effect appears to be independent of age, including patients aged 80 and older.
Pooled data from several clinical trials suggest an important relationship between time from symptom onset to treatment and outcome. Patients treated with rt-PA within 90 minutes to symptom onset were more likely to have a favourable neurologic outcome compared to those treated from 90 – 180 minutes to treatment onset.



1. Patients with acute ischemic stroke whose neuroimaging excludes contraindications, and who can be treated within three hours of symptom onset, should be offered rt-PA with the goal of improving functional outcome (STRONG RECOMMENDATION, HIGH QUALITY EVIDENCE)
2. Stroke patients meeting eligibility criteria for thrombolytic therapy should be treated as rapidly as possible, with a target door-to-needle time of less than 60 minutes (STRONG RECOMMENDATION, MODERATE QUALITY EVIDENCE)
3. Due to limited resources and practical constraints, the administration of thrombolytic therapy within 3 hours in rural hospital may not be feasible and hence not recommended in all of these settings but should fall to the discretion of the local decision making team (WEAK RECOMMENDATION, LOW QUALITY EVIDENCE)


The statement is fair enough. The 3 hrs time window, even with the controversy that all the 7 available studies evidenced, is pretty condivisible. I love the great emphasis on ” target door-to-needle time of less than 60 minutes” that has to be the real target of all Emergency Systems. Is also well thought the flexibility on rural hospital and the assumption that treatment in those situations is discretional. Very well done i feel to subscribe everything!

CJEM CJO masthead9


Summary of Evidence

A pooled analysis of all trials involving acute ischemic stroke patients treated in the 3.0 to 4.5 hour time window was published by Emberson et al. in 2014. Combing data from 7 studies that included 2768 patients, the likelihood of a favorable outcome was higher if patients were randomized to rt-PA. (Emberson J, Lees KR, Lyden P, et al; for the StrokeThrombolysis Trialists’ Collaborative Group. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet 2014;384(9958):1929-35)(.……) the latter figure (of the meta-analysis) showing significant imprecision and no difference in mortality, but a direction of effect towards a mortality increase with rt-PA in a dose-response relationship between time to treatment and 90-day mortality, suggesting a potential for increased mortality in those treated beyond 3 hours.
Included in this most recent systematic review is patient-level data from the IST-3 trial.

IST-3 suggested a 7-fold increase in symptomatic ICH associated with thrombolytic use (7% vs. 1%) as well as an expected increase in early mortality but no difference in disability or mortality at 6 months for those treated at 3–4.5 hours.



1. Thrombolytic therapy for acute ischemic stroke patients should not be routinely offered for the treatment of acute ischemic stroke for patients if administered beyond three hours of stroke symptom onset (WEAK RECOMMENDATION, MODERATE QUALITY EVIDENCE).
2. The administration of thrombolytic therapy for acute ischemic stroke beyond 3 hours from stroke symptom onset should be restricted to specialized stroke centers with advanced imaging capabilities or as part of a research protocol (WEAK RECOMMENDATION, LOW QUALITY EVIDENCE).


Even for this part of the statement my agreement is total.
IST 3 that is, at the moment, the largest study on thrombolytic therapy for ischemic stroke is a total contradiction in terms of evidence about benefit and major bleeding events.
Good outcome in the first 3 hrs, a majority of adverse events between 3 and 4,5 hrs and again beneficial between 4,5 and 6 hrs. Just one consideration: the results are not suitable for clinical practice.
So Thrombolytic therapy for acute ischemic stroke patients should not be routinely offered for the treatment of acute ischemic stroke for patients if administered beyond three hours of stroke symptom onset.

This is in contrast with the 2013 AHA/ASA Guidelines for the Early Management of Patients With Acute Ischemic Stroke that states:

Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is recommended for administration to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke onset (Class I; Level of Evidence B). The eligibility criteria for treatment in this time period are similar to those for people treated at earlier time periods within 3 hours, with the following additional exclusion criteria: patients >80 years old, those taking oral anticoagulants regardless of INR, those with a baseline NIHSS score >25, those with imaging evidence of ischemic injury involving more than one third of the MCA territory, or those with a history of both stroke and diabetes mellitus.

Bottom line:

I really like this Statement and think that is one of best available policy  about thrombolytic therapy and ischemic stroke.





Cricoid Pressure in DAS 2015 Intubation Guidelines: an update.

10 apr

Below you can read the answer to my question (Cricoid pressure in new DAS (Difficult Airway Society) Guidelines: still on?) from Chris Frerk, Chair of DAS guidelines group:




Thanks for your thoughtful comments

The website posting is necessarily brief and there will be more detail in the developing paper.

Your point is well made re cricoid pressure vs BURP and external laryngeal manipulation.

The paper is predominantly aimed at anaesthesia for surgery in the UK though we recognise that the existing 2004 guidelines are referred to in ED and ITU settings. Current UK practice does endorse cricoid pressure for RSI (which includes most ED intubations) though we are aware this is not the case in other countries – we’ve taken the stance so far that this paper isn’t the place to debate RSI techniques but we do have a developing section on RSI.

 I think we do need to be more explicit about when cricoid pressure would be expected to be applied – we are already clear in the paper  that if it is applied and laryngoscopy is difficult the pressure should be removed (with suction at hand). In the elective scenario (with no cricoid pressure) then we say BURP / external laryngeal pressure (different from cricoid pressure) should be tried to see if view improves.

The group meet again soon and we’ll be discussing your thoughts in more detail then.

Thanks for taking the time to contribute”

Chris Frerk

Chair of DAS guidelines group

Now is only a matter of time.
We wait for the release of the new DAS Guidelines on intubation and, as Chris anticipated, on RSI.

Stay tuned on MEDEST and all the FOAMED community to be up to date on this and all the news from the Emergency Medicine World


Cricoid pressure in new DAS (Difficult Airway Society) Guidelines: still on?

9 apr

DAS Difficult Airway Society

Background story:

This is the post I wrote about the DAS April 2015 draft on intubation Guidelines:

DAS (Difficult Airway Society) released a draft of its intubating Guidelines for evaluation and comment before definitive update.

Previuos 2007 Guidelines are available here DAS Intubation Guidelines

This is the link to download the Update (April 2015) on DAS intubation guidelines 2015

What’s new on this draft:

Plan A (face mask ventilation and intubation)

  • Preoxygeneation is now included (to mantain even during the intubation, O2 nasal cannula).
  • VL is considered as standard approach (same leve than DL).
  • Cricoid pressure is no longer mentioned and replaced with BURP.
  • BURP has to be released if difficult intubation(laryngoscopy is predicted.

The authors invite all to send suggestions and comments to

Last night (Italy time at least) on Twitter a debate about the presence on less of cricoid pressure aroused:

23:06 @MyEmergencyMed: Difficult Airway Society 2015
 intubating Guidelines vía
 23:12 @MDaware: cc @ketaminh MT @MyEmergencyMed: DAS
 2015 intubating Guidelines vía

23:13 @ketaminh: @MDaware @MyEmergencyMed
 @MEDEST118 have u checked original source
 23:13 @MDaware: @ketaminh @MyEmergencyMed
 @MEDEST118 nope in a meeting
23:18 @ketaminh: @MDaware @MyEmergencyMed
 @MEDEST118 ok let me help you then
 23:22 @MDaware: @ketaminh @myemergencymed @medest118
 interestingly the guidelines say "Remove cricoid
 pressure" — not use it!
 23:23 @ketaminh: @MDaware @MyEmergencyMed
 @MEDEST118 stick to social media, editor! cricoid
 pressure still advocated by DAS as far as I can tell .
 remove prn
 23:29 @ketaminh: @MDaware @MyEmergencyMed
 @MEDEST118 well…you have to use it if you are to
 remove it

So let’s see what the released material from DAS says about cricoid pressure?

On the algorithm:


And then on the Highlights:


Pretty controversial.

So let’s ask directly to DAS wich is their position on cricoid pressure.

Screen Shot 2015-04-09 at 09.41.06And let’s wait for their answer.

Stay in touch!


Difficult Airway Society 2015 intubating Guidelines

6 apr Logo MEDEST2

DAS Difficult Airway Society

DAS (Difficult Airway Society) released a draft of its intubating Guidelines for evaluation and comment before definitive update.

Previuos 2007 Guidelines are available here DAS Intubation Guidelines

This is the link to download the Update (April 2015) on DAS intubation guidelines 2015

What’s new on this draft:

Plan A (face mask ventilation and intubation)

  • Preoxygeneation is now included (to mantain even during the intubation, O2 nasal cannula).
  • VL is considered as standard approach (same leve than DL).
  • Cricoid pressure is no longer mentioned and replaced with BURP.
  • BURP has to be released if difficult intubation(laryngoscopy is predicted.

Plan B (Oxygenation/ventilation with Supraglottic Airway Devices)

  • ILMA is no longer mentioned as preferred device
  • 2nd generation SAD is suggested as default devices

Plan C (Think and revert to face mask oxygenation/ventilation before surgical approach)

  • No main changes
  • Focus on reverting neuromuscolar blockade action

Plan D (surgical approach)

  • Scalpel Bougie Tube (finger????) technique suggested as standard approach
  • Cannula techniques only for skilled operators

The authors invite all to send suggestions and comments to


VL tecnique in suspect intracranial bleeding

31 mar

62 yrs old male found unconscious GCS 6 (E1,V1, P4). Sign of vomiting and inhalation. Profoundly hypoxic, hypertensive (BP 200 over 110). Pupils were miotic with anisocoria dx>sx.

The team, after aspiration of gastric material from the airway, decided for airway control, before transport. The patient is overweight with a “taurine” neck so VL was chosen as first choice for airway management.

RSI (Fentanyl. Midazolam, Sux) performed. In the video you can see a detailed explanation of the VL technique that is slightly different from DL technique.

 Post-intubation management included ventilation optimization (EtCO2 35-38 mmHg in suspected intracranial hypertension) oxygenation and haemodynamic management.



A Day in Milan

16 mar Featured Image -- 4755


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


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.

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: (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:

The Original RSII Article;

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.


  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”


Hands Off The Ketamine!

6 mar


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!

Originally posted on PHARM:

photo (26)

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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 antifibrinolytic 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.



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