Articles at the Top. Take home messages from 2017 (part 2).

19 Gen

Welcome to our annual review of the best articles from the finishing year.

This will be a weekly (or so..) appointment with the top (or so…) articles of 2017 divided by topic and chosen by me.

Here is the best (for me) about:

 Advanced Life Support

Here are the best 2017 articles:

My take home messages:

Pathophysiological bases in experimental swine models

  • In a swine model following primary cardiac arrest the respiration continues at least for 1 minute. and after that Gasping starts lasting for another minute.
  • In a swine model following primary cardiac arrest the blood shifts from high pressure compartment (arteries) to low pressure compartment (veins). 
  • In a swine model the PaO2 following primary cardiac untreated VF arrests PaO2 results 70 mmHg after 9 min with a saturation of 93% and decrease at 44 mmHg with a saturation of 61% after 14 min of CPR. In this period airway management with possible interruption of chest compressions and starting positive pressure ventilation (with decreased return to the thorax end depression of cardiac output) is not mandatory due to the low cost/beneficial ratio and the potential detrimental effect. 

Chest compressions

  • Chest compressione only CPR is associated with worst outcome in children under 8 yers. Always perform chest compression/ventilation (ratio 15:2) in children <8 years of age (only exception if the cardiac arrest is due to primitive cardiac causes). 
  • Chest compressione only CPR can be a valuable option in adult witnessed VF/pulseless VT primary cardiac arrest (delayed airway management and passive O2 administration is reasonable).
  • Mechanical chest compression (MCC) is the future of CPR. They still do not demonstrated evident superiority in terms of outcome respect to manual chest compressions, but are evidently not inferior with a similar rate of life treating lesions. For sure MCC avoid variability in quality and allows good quality CC during transport. 

Ventilation

  • Lower Tidal volumes following OHCA is independently associated with favourable neurocognitive outcome
  • Weak evidences demonstrate that the ideal rate for ventilation of intubated patients  during CPR is 10/min

Airway management

  • There is not beneficial effect on outcome with early intubation in Cardiac Arrest (CA)
  • Privilege High Quality CPR and Defibrillation (if needed).
  • Use Supraglottic Airway Devices (SAD) in first part (15 min) of resuscitation 
  • If Mechanical Chest Compressions is used, to optimise ventilation with SAD, use 30:2 ratio (because the intrathoracic pressure generated during MCC overrules that generated from SAD and impaires ventilation).
  • In prolonged Cardiac Arrest management converting SAD to Endotracheal Tube can be considered.
  • Experience provider only can perform endotracheal intubation in CA. They have a better chance of first passage rate, without interruption in chest compressions. First pass success rate is positively associated to survival and good neurological outcome.

Defibrillation

  • Escalating bilevel energy (150-200-360 Joule) is associated with more efficacy in termination of shock resistant VF/pulselessVT cardiac arrest
  • Dual Sequential Defibrillation is feasible and safe. Although the evidences on its beneficial effect on outcome are still lacking it has to be considered in case of CA with refractory shockable rhythm. 

Antiarrhythmics drugs

  • There has been no conclusive evidence that any antiarrhythmic agents improve rates of ROSC, survival to admission, survival to discharge or neurological outcomes.

Ultrasound

  • Ultrasound in PEA is a key tool to detect CA causes improving survivival.

Post Resuscitation Care

  • In post resuscitation phase avoid any arterial oxygen and carbon dioxide abnormality because are associated to increased mortality.
  • Centralisation of resuscitated patients toward an acute PCI/CABG capable Center  is associated to better outcome.

Targeted Temperature Management

  • Prehospital cooling does not improve faster in-hospital target temperature achieving and due to its costs is not recommended.
If you are interested on a daily update about the best emergency medicine literature follow me on Facebook, Twitter or give your like to MEDEST Facebook page.

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Articles at the Top. Take home messages from 2017 (part 1).

25 Dic

Welcome to our annual review of the best articles from the past year.

This will be a weekly (or so..) appointment with the top (or so…) articles of 2017 divided by topic and chosen by me.

At the end of the post I will also mention some take home points as summary of the evidences emerged from the articles. 

And now here is the best (for me) about:

 Airway management

Here are the best articles of the past year about Airway Management:

My take home messages about airway management:

  1. Risk factors for intubation related cardiac arrest are: overweight or obesity, age more than 75 years old, low SBP prior to intubation, hypoxemia prior to intubation, and absence of preoxygenation before intubation procedure.
  2. Preoxygenation is crucial (at least 2 minutes), before paralysing, to extend safe apnea time.
  3. Use apneic oxygenation during intubation attempts.
  4. Tracheal intubation is good in the hands of very well skilled professionals. Otherwise can improve mortality rate.
  5. Supraglottic devices perform well in cardiac arrest and are a valuable option for airway management. 
  6. Videolaryngoscopy improve glottic view but need training to improve first pass success.
  7. Always use paralytics when intubating a non cardiac arrest patient. It improves the chances fo first pass success.
  8. Rocuronium and Succynocholine are both valuable options for paralysis in airway management. 
  9. Dose Succynocholine, and other depolarising neuromuscular blockade drugs, based on actual body weight. Dose Rocuronium or Vecuronium based on ideal body weight.
  10. Use cuffed tracheal tubes even in paediatric patients. They perform well and  complications rate is the same. 
  11. The difficult airway is a myth. It’s not  a matter of technique but of decision making.
If you are interested on a daily update about the best emergency medicine literature follow me on Facebook, Twitter or give your like to MEDEST Facebook page.

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Chest compression point. Are we compressing in the right place? Probably NOT!

8 Dic

The objective of chest compressions in CPR is to compress the heart and in particular the Left Ventricle (LV) to generate a stroke volume (SV) trough the Left Ventricular Outflow Tract (LVOT) to perfuse the heart the brain and the rest of the organs.

Performing CPR we blindly compress the center of the chest on the sternum approximately at the level of intermammillar line (as recommended by the 2015 CPR Guidelines) but we risk to apply the Area of Maximum Compression (AMC) not only on the LV but also on the Aortic Valve (AV) and the Ascending Aorta (AA) closing them and generating less (or none) LV stroke volume but just an ineffective retrograde flow.

Radiological assessment of chest compression point and achievable compression depth in cardiac patients 1

Image Attribution: Nestaas et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2016) 24:54. Radiological assessment of chest compression point and achievable compression depth in cardiac patients.

Depending on how much the AMC is positioned on the left ventricle or on the aortic part of the heart chest compressions are respectively more or less efficacious to perfuse the brain the heart and the organs.

This is not just theory but was demonstrated in animal and human studies (See References links at the bottom).

In particular Sung Oh Hwang and coll. in the article “Compression of the Left Ventricular Outflow Tract During Cardiopulmonary Resuscitation” observe that”the magnitude of compression of the left ventricle is more significant when a maximal compression occurs at the LVOT than when a maximal compression occurs at the ascending aorta during external chest compression“. They also determined “that external chest compression at the hand position currently recommended by the AHA guidelines compresses the LVOT or the ascending aorta.” and conclude that “(….) the compression location currently recommended by the AHA guidelines may not be effective in generating forward blood flow during CPR.”(….) it is possible that compressing the caudal part of the sternum will improve the quality of CPR and reduce rescuer fatigue.

The investigators stated also that the Optimal Compression Point (OCP) cannot be definitively addressed because it depends on many variables and varies from patient to patient depending “on the configuration of the heart in the thorax.”

All those findings were assessed using Trans Esophageal Echocardiography (TEE) inserted during CPR in real cases scenarios to visualise the heart to measure the LV stroke volume in order to find the best OCP.

TEE in fact is a good method to study proposition but in a short future will be a good clinical instrument to individually and visually assess the OCP, to deliver biphasic shock and to pace the heart. It is of rapid insertion in the intubated patients, is remotely and in real time monitorizza from team leader doesn’t implicate chest compressions interruption and is safe.

In another study based on a real case series “Clinical pilot study of different hand positions during manual chest compressions monitored with capnography” published in 2013, Eric Qvigstad and coll. found “that the chest compression point generating the highest EtCO2 value was evenly distributed between the patients, indicate that there is no common optimal chest com-pression point within the area tested.” 

Clinical pilot study of different hand positions during manual chest compressions monitored with capnography

Image attribution: Qvigstad E, et al. Clinical pilot study of different hand positions during manual chest compressions monitored with capnography. Resuscitation (2013), http://dx.doi.org/10.1016/j.resuscitation.2013.03.010

They individually chosen the best hand position during chest compressions on the basis of EtCO2 values.

So which are the clinical implications for our current clinical practice?

I would like to divide the clinical take home points in two different categories:

  1. Actual applications 
  2. Future development 

Actual applications for clinical practice

  • The recommended chest compression point can be ineffective to generate enough outflow because the Area of Maximum Compression is not on the Left Ventricle but either on the Aortic Valve or the Ascending tract of the Aorta
  • Emergency providers can adjust the compression point based on EtCO2 values.
  • If, despite technically correct chest compressions, the EtCO2 remains below 10, try to adjust the compression point.
  • In those cases, the Optimal Compression Point is usually positioned caudally to the recommended one on the lower third of the sternum

Future development for clinical practice

  • TEE is a clinical useful instrument to
    • individually and visually assess the OCP
    • deliver biphasic shock
    • pace the heart
  • TEE is of rapid insertion in the intubated patients, can be remotely and in real time controlled from team leader, doesn’t implicate chest compressions interruption and is safe.

To lear  more…..

Link to reference folder

IMG_1655

AIRWAY MANAGEMENT. DECISION MAKING, STRATEGIES AND CLINICAL OPTIONS

20 Lug

This talk was recorded live at Arezzo Cadaver Lab on June 5 2017.

 

The Slides

Prehospital Emergency Procedures: Scalpel, Finger, Bougie. That’s all you need!

13 Lug

In Emergency Medicine “Simplicity” is synonymous of efficiency, efficacy and reproducibility.

More the time frame is stressful more we need procedures that are efficient, efficacious and standardised, in one word SIMPLE.

Critcothyrodotomy and chest drain are procedures usually performed in high stressing scenarios and more simply they are more chance of success they have.

I don’t like complicate kits. They need training of course but even a calm and protected environment, and the middle of a street or a busy ER room aren’t nothing like that. 

I don’t like blindly performed procedures but prefer trusting my own senses and sensibility when performing high invasive procedures that, mostly of the times, are a lifesaving last chance.

So this is the best way I know to perform a surgical access to the airway and to drain a highly unstable tense pneumo: using simple instruments, always present in every emergency pack, and trusting my own tactile sensitivity.

surgical-airway-sfb

In those following videos you can see live records of the procedures. They were captured during a recent cadaver lab where I had the honour to join Jim DuCanto, Yen Chow, Carmine Della Vella and Fabrizio Tarchi in teaching airway management and clinical emergency procedures.

Hope you enjoy.

 

 

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Prehospital POCUS: Why I love it! Real Clinical Scenario.

10 Lug

73 yrs old male found unconscious by his wife. CPR started by a neighbour with pre arrival CPR instructions provided by dispatcher. We found him in asystolic cardiac arrest. Established mechanical chest compressions (MCC), ventilated through an 8.0 ET tube, placed an intraosseus access, 10 min of ALS and 2 mg of epinephrine later, on the monitor appears an organised rhythm at 40 bpm (narrow junctional shape), NO CENTRAL PULSE. After 2 min (CPR still going) same rhythm stil NO CENTRAL PULSE but this time, during the MCC pause, a subcostal view of the heart was obtained (sorry for the quality of the images but were recorded during the code and I’m not an expert but just an ultrasound user) 

As you can see the heart is moving and the right ventricle is almost the double of the left one. Due also to the clinical history of a recent surgical knee replacement the most probable origine of the cardiac arrest is PE. We decided to continue chest compressions, but to stop epinephrine at 1 mg dose, starting push doses of 0,1 mg till the return of a central pulse. After 5 min a strong carotid pulse appeared and this is the ultrasound view of the heart at that moment

  

The patient arrived to the hospital sedated and paralysed in assisted pressure control ventilation. You can see on the monitor the rest of vital signs.

No follow up yet.

You can read more about PEA and Pseudo-PEA on MEDEST

Forget ACLS guidelines if you are dealing with Pulseless Electric Activity. Part 1.

Forget ALS Guidelines when dealing with PEA. Part 2.

The case of a misleading EKG trace

24 Giu
This post was inspired by Carmine Della Vella and I want to thank him for the great contribution.
Is a hot afternoon of a summer day. You are on duty in an EMS local station and your Physiocontrol LP 12 looks like to have some trouble. You decide to make a try on an healthy volunteer. So pick up the first local guy passing by from the station that happens to be a 20 yrs old young male with no medical history. Set you LP 12 on, attach the 12 leads and print the EKG trace. BOOM!!!
It doesn’t look any good!!!!!
So you wonder how to find an explanation of this terrible trace: STEMI, Brugada like pattern, Spoddik sign, Wellens ????
Doesn’t sound good at all, it look likes we are missing something.
And when you just t bring to the unaware guy the terrible news here comes the light!!
The LP12 was in monitoring mode and not in diagnostic 12 lead EKG mode!!!
What that means ?
When the LP 12 is on monitoring mode the low frequency filter (also called high-pass filter because signals above the threshold are allowed to pass) is set at either 0,5 Hz or or 1 Hz and the high-frequency filter (also called the low-pass filter because signals below the threshold are allowed to pass) is set at 40 Hz. This limits artifacts for routine cardiac rhythm monitoring. In diagnostic mode, the high-pass filter is set at 0.05 Hz, which allows accurate ST segments to be recorded. The low-pass filter is set to 40, 100, or 150 Hz. As a consequence, the monitor mode ECG display is more filtered than diagnostic mode, because its passband is narrower.

Remember that the ST segment is a very low frequency part of the EKG tracing (the slope of the line is very flat) and so in monitor mode with the lower filter set to 0.5 or 1 Hz, it’s not low enough to accurately obtain the tracing. Diagnostic mode with a lower filter of 0.05 will produce an accurate tracing.

This is true even for LP 15 as reported on Operating instructions

Anyway the 12 lead EKG was repeated in diagnostic mode and resulted totally normal.

References

HEMS vs GEMS: by ground or by air, which is the best way to take care of traumatized patients

25 Apr

HEMS

Take home points:

Speed

Mission Time

  • –In case of simultaneous activation HEMS is competitive for distance >10 miles from Trauma Center
  • In case of non simultaneous activation HEMS is faster  for distances >45 miles from Trauma Center

 

On scene time

 

  • –HEMS > GEMS

Severity

  • –HEMS patients are generally more severely injured than GEMS patients

Trauma Center Access

  • –HEMS transported patients have more chances to be referred to a level I Trauma Center

Crew

  • –More time on scene (beyond the golden hour)
  • –More procedures performed
  • –The accuracy of prehospital documented diagnoses was not increased in HEMS compared to GEMS rescue

Survival 

  • –No definitive evidences on HEMS benefits on survival rate
  • –Recent literature points on a trend toward an increased chances of survival in some categories of trauma patients transported by HEMS

 

 

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Yes We Can

4 Mar

 

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Quality, education, clinical competence and other amenities about Emergency Medicine

17 Feb

Competence

“The degree to which the individual can use the knowledge, skills and judgment associated with the profession to perform effectively in the domain of possible encounters defining the scope of professional practice.”

Kane MT. The assessment of professional competence. Eval Health Prof 1992;15:163-82.

Clinical Quality

If someone asks why a medical professional deserve to work in a public emergency medical system, despite a degree (as many others in different fields), experience (subjective) and a fist of courses (mostly individually chosen and not institutionally validated) there is nothing objective that demonstrates that this professional was, and still is, eligible for this kind of job in terms of competence.

Certification of clinical quality is something missed in action in the jungle of Health Systems in general and in Emergency Medical Services in particular. 

We have generic admission criteria but no instruments to monitor on a regular basis the adequacy of clinical competence for medical professionals who work in emergency field.

Education

We spread education, giving competences equally distributed to all medical professionals, despite any specific  need.

Cultural needing are not a question of democracy.

They are specific for each person who works in a certain field and are conditioned by different personal attitudes and everyday clinical practice. 

We waste time, money and human resources giving, in large part of cases, unuseful informations to the wrong persons at the wrong time of their working careers. 

Competence

The fact is that we do not have a clear idea of who and which competences are needed to be a good medical emergency professional.

None stated which skills and which clinical practices, in quality and quantity, are needed to achieve a minimum level of competence.

The future?

  1. Personal record of clinical competences for every emergency medicine professional.
    • Self-constructed (self-certified) on the base of daily clinical practice  and individually acquired education. Externally and institutionally validated.
  2. Specific targeted education based on personal needing.
    • Targeted to complete the personal competence record when both, clinical practice and self-acquired education, are not sufficient or when new clinical instances come into the system
  3. Quality assessment.
    • All the professionals who work in the emergency medical system respond to minimum required clinical competency standard. 

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