La “constatazione” di decesso. Storia presunta e non-fondamento legislativo di una leggenda metropolitana.

27 Ago

La “constatazione del decesso” è stata in questi anni frequente motivo d’invio di mezzi medicalizzati (automedica o ambulanza medicalizzata) da parte della CO 118. 

La più o meno fondata convinzione che la diagnosi ed il successivo accertamento della morte è  prerogativa della sola professione medica ha spesso giustificato l’utilizzo in emergenza territoriale di tale figura professionale per “constatare” la morte anche di quei pazienti in cui, per vari motivi clinici ed etici, non esisteva alcuna indicazione alla  rianimazione cardiopolmonare

Facciamo chiarezza esaminando i riferimenti di legge disponibili.

L’accertamento di morte e’ prerogativa della professione medica

Il fondamento legislativo dell’accertamento di morte risale al Testo Unico delle Leggi Sanitarie (TULS) approvato con Regio Decreto nel 1934 che all’articolo 103 tra le prerogative delle professioni sanitari recita che “Gli esercenti la professione di medico-chirurgo, oltre a quanto e’ prescritto da altre disposizioni di legge, sono obbligati a denunziare al podestà le cause di morte entro ventiquattro ore dall’accertamento del decesso.”

In esso sia pur indirettamente la figura medica veniva individuata come unica responsabile dell’accertamento e della comunicazione della morte alle autorità.

In epoca più recente la legge n. 578 del 29 dicembre 1993 “Norme per l’accertamento e la certificazione di morte”all’articolo 1 comma 1 stabilisce che “La morte si identifica con la cessazione irreversibile di  tutte le funzioni dell’encefalo.

La morte dell’ encefalo a tutti i suoi livelli infatti determina l’irreversibile disgregazione funzionale del classico “tripode vitale di Bichat”, che consiste nella contemporanea presenza della funzionalità respiratoria, cardiocircolatoria e del sistema nervoso centrale.

La medesima legge infatti all’articolo 2 comma 1 chiarisce cheLa  morte  per  arresto  cardiaco si intende avvenuta quando la respirazione e la circolazione sono  cessate  per  un  intervallo  di tempo  tale  da  comportare  la  perdita  irreversibile  di  tutte le funzioni dell’encefalo e puo’ essere accertata con le modalita’ definite con decreto emanato dal Ministro della sanita’.

Per le modalità di accertamento si rimanda quindi al decreto n. 582 del 22 agosto 1994, “Regolamento recante le modalita’ per l’accertamento e la certificazione di morte.”  che all’articolo 1 comma 1 stabilisce:  “In conformita’ all’art. 2, comma  1,  della  legge  29  dicembre 1993,  n.  578,  l’accertamento della morte per arresto cardiaco puo’ essere effettuato da  un  medico  con  il  rilievo  grafico  continuo dell’elettrocardiogramma protratto per non meno di 20 minuti primi.

Ma allora cos’e’ la “constatazione di decesso”? 

In effetti tale termine non ha alcun riferimento nel complesso legislativo che regola l’accertamento e la certificazione della morte e  non compare in nessuna parte dei regolamenti di polizia mortuaria. E’ quindi un termine derivato dalla consuetudine operativa, si confonde con la diagnosi e l’accertamento di morte ed è stato alimentato dalla trasmissione aneddotica/orale con sporadico riscontro nei  regolamenti locali. 

Ma per capire che un paziente e’ in arresto cardiaco serve un medico?

Sulla “diagnosi” di arresto cardiaco il BLS e la comune pratica ci hanno da anni insegnato che essa è clinica e non strumentale e può essere effettuata anche da personale laico addestrato e non addestrato sia pure se guidato anche in modo remoto da un professionista sanitario. Questo estendere una “diagnosi” a personale non sanitario ha contribuito in modo fondamentale ai progressi in termini di sopravvivenza nei pazienti colpiti da morte improvvisa  diffondendo la cultura e delle rcp di base e della defibrillazione precoce.

Abbiamo quindi oramai universalmente stabilito che i laici possono  individuare la presenza di criteri clinici di arresto cardiaco tanto che essi sono autorizzati ad effettuare un massaggio cardiaco ed utilizzare un defibrillatore. 

L’arresto cardiaco nei pazienti in cui non e’ indicata la RCP

A maggior ragione tale “diagnosi” può essere effettuata da familiari o astanti in pazienti a fine vita, affetti da patologie in fase terminale  in cui sono esauriti i margini terapeutici ed in cui l’assistenza e la cura non sono oramai un’emergenza.

Riassumiamo

L’accertamento della morte non è una procedura d’emergenza-urgenza e può essere effettuata da un medico (in genere il necroscopo) mediante il rilievo per 20 minuti in continuo delle’ECG.

Nel complesso delle norme non viene mai nominata la “constatazione del decesso” essa è spesso utilizzata come sinonimo fuorviante di accertamento di morte o dichiarazione di arresto cardiaco/morte.

L’arresto cardiaco è un riscontro clinico e può essere fatta da chiunque se addestrato o sotto guida dell’infermiere di centrale.

C’è una categoria di pazienti per i quali esistono clinicamente (assenza di prospettive di buon outcome per la presenza di patologie croniche in fase terminale o neoplasie senza margine ulteriore di trattamento) ed eticamente (fine vita, dichiarate o manifeste disposizioni anticipate di trattamento) delle chiare controindicazioni alla pratica di manovre rianimatorie.

Sistema 118, diagnosi ed accertamento di morte

Il sottile limite concettuale e temporale tra le urgenti manovre di rianimazione cardiopolmonare e l’accertamento della morte ha portato in questi anni a confondere il ruolo del medico del 118 con quello del certificatore della morte.

Ma viste le premesse ed in un’ottica di ottimizzazione e razionalizzazione dell’utilizzo delle risorse dell’emergenza preospedaliera non ha senso né clinico né organizzativo inviare il medico a fare diagnosi di morte ed accertare e certificare il decesso in paziente in cui è chiaramente controindicata la RCP.

In un’ottica attuale e limitatamente ai casi in cui non sono indicate le manovre rianimatorie, il compito della certificazione della morte dovrebbe essere affidato ad altre figure professionali come il MMG, il medico di continuità assistenziale o il medico necroscopo.

In pratica in caso di chiamata per arresto cardiaco in cui appaia chiara la futilità delle manovre rianimatorie si dovrebbero attivare, da parte della CO 118, risorse mediche alternative e non urgenti per procedere alla certificazione della morte. 

Open Chest Wounds. The Prehospital Management

3 Ago

Is the flutter valve beneficial? Is the chest seal itself beneficial? Or, does it convert a sucking chest wound into a life-threatening tension pneumothorax? “Why do we treat a non-lethal condition (open pneumothorax) with an intervention that may result in a lethal condition (tension pneumothorax)?” If the size of the chest seal defect is larger than the diameter of the trachea, then air will preferentially move through the chest defect which can be fatal. Many of the chest seals are being placed on small defects which could lead to a tension pneumothorax.

It is unknown whether modifying the current practice of treating an open pneumothorax with an occlusive chest dressing might cause some of these injuries to then result in fatalities.

Saving Lives on the Battlefield
A Joint Trauma System Review of Pre-Hospital Trauma Care in Combined Joint Operating Area – Afghanistan (CJOA-A)
FINAL REPORT
30 January 2013
U.S. Central Command Pre-Hospital Trauma Care Assessment Team

The current guidelines indicates commercial chest seals both vent or non vent as a valid option to treat open chest wounds. In any case if a commercial chest seal is not available the 3 sided closed dressing is no longer recommended and a total occlusive medication is the current indication.

Commercial chest seal VS improvised 3 sided chest dressing

A chest dressing closed on 3 sides was the traditional option of treatment. They are often difficult to adhere, ineffective and difficult to improvise in time-critical scenarios. New and recent guidelines recommended an occlusive medication with strict surveillance and in case of signs of tension pneumothorax the dressing must be removed. If the patients does not improve after removing the seal open thoracostomy is indicated.

There is no clear evidence to suggest that the use of one-way chest seals would reduce the incidence of respiratory complications in patients with penetrating chest wounds. However, these seals may be easier to use and should be considered as part of the medical kit for out-of-hospital settings.

BET 3: In a penetrating chest wound is a three-sided dressing or a one-way chest seal better at preventing respiratory complications?

BET 3: In a penetrating chest wound is a three-sided dressing or a one-way chest seal better at preventing respiratory complications?

Major trauma: assessment and initial management. 1.3 Management of chest trauma in pre‑hospital settings

Vent vs Non Vent Chest Seal

A vent commercial chest seal is the first line option in prehospital setting.

Both vented and unvented CSs provided immediate improvements in breathing and blood oxygenation in our model of penetrating thoracic trauma. However, in the presence of ongoing intrapleural air accumulation, the unvented CS led to tension PTx, hypoxemia, and possible respiratory arrest, while the vented CS prevented these outcomes.

Vented versus unvented chest seals for treatment of pneumothorax and prevention of tension pneumothorax in a swine model

Vented versus unvented chest seals for treatment of pneumothorax and prevention of tension pneumothorax in a swine model

Treatment of Thoracic Trauma: Lessons From the Battlefield Adapted to All Austere Environments

In case vent chest seal is not available use non vent chest seal and if the patients develops hypotension, hypoxia, respiratory distress, remove the seal or performa an open thoracostomy.

So what to do?

First get an airway and put the lung on positive pressure ventilation (Volume or Pressure Targeted Ventilation) :

Positive pressure in the chest during the entire respiratory cycle and avoiding negative pressure during inspiration decreases the risk of tension pneumothorax

If you have the patient on a spinal board with a cervical collar the larynx is narrowed and when the patient is in spontaneous breathing the air preferentially enters from the chest wound. Placing an OT and positive pressure ventilation avoids this mechanism and prevents tension in the thorax.

Positive pressure ventilation re-inflates the collapsed lung and improve oxygenation (PEEP) and ventilation (Minute Ventilation).

Second close the wound with

Vent chest seal as first option

Non vent chest seal if vent is not available

Non commercial chest dressing closed on 3 sides is your last resort

E’ andato tutto bene?

19 Mag

La tempesta COVID 19 ci ha travolto come società civile e come professionisti sanitari. La reazione delle istituzione è stata globalmente inadeguata. Tale inadeguatezza è apparsa subito palese dai numerosi messaggi, ambigui e spesso contraddittori che provenivano da coloro i quali dovevano essere i nostri punti di riferimento istituzionale ed invece apparivano incapaci di tracciare un percorso condiviso credibile

Abbiamo avuto la sensazione che proclami e direttive più o meno ufficiali fossero reattivi a stati di momentanea isteria collettiva e non una tappa sul percorso di una lucida gestione dell’emergenza.

Dopo il primo momento di sbandamento tutti noi abbiamo dovuto elaborare un nostro piano di “sopravvivenza” di fronte all’evidente incapacità dei nostri apparati direttivi. Questo è avvenuto nella nostra vita privata ma sopratutto nella nostra vita professionale

Il 118 è un sistema particolare; è paragonabile ad un organismo composto da cellule e tessuti che costituiscono organi ed apparati autonomi (centrale operativa, ambulanze medicalizzate automediche, ambulanze infermieristiche, elisoccorso) governati da una “testa” che spesso non comunica e non percepisce le sensazioni che provengono dalla periferia.

Alla stregua di un organismo paradossalmente deafferentato senza meccanismi di feedback efficaci, mentre nei periodi di “pace” va avanti per sostanziale inerzia, nei momenti di tempesta è paragonabile ad una nave senza nocchiero destinata a schiantarsi contro gli scogli o nella più fortunata delle ipotesi essere trascinata alla deriva.

Ma nell’emergenza COVID gli organi di questa chimera organizzativa, la ciurma di questa nave senza nocchiero hanno trovato un’emostasi, un governo spontaneo del vuoto immenso che li ha circondati. Ora, a differenza di ordinarie carenze di leadership a cui siamo abituati in modo atavico, sono state minacciate la nostra salute personale, quella dei nostri familiari e la qualità delle cure che potevamo fornire ai nostri pazienti.

Chiamatelo egoismo, chiamatelo spirito di sopravvivenza chiamatela etica professionale. Insomma chiamatelo come volete ma noi alla fine ci siamo organizzati, proteggendoci e continuando a curare i nostri pazienti con dedizione ed efficienza.

Abbiamo risposto alla valanga di chiamate non urgenti con la stessa pazienza e professionalità di sempre, ci siamo vestiti da teltubbies con maschere da snorkeling “cornute”, abbiamo coperto la testa dei pazienti con teli di nylon, ci siamo messi i sacchetti del supermercato come soprascarpe.

Lo abbiamo fatto da soli con il vento contro. Lo abbiamo fatto a favore dei nostri pazienti attaccati con i denti alla nostra competenza. Lo abbiamo fatto nonostante coloro che dovevano non ci abbiano mai supportato ed anzi hanno preteso di dirci come dovevamo fare il nostro “sporco” lavoro (senza averlo mai fatto) a colpi di direttive inapplicabili firmate con guanti candidi calate dal chiuso di uffici lontani e mai accessibili.

Ora tutto cambierà perché noi non dimenticheremo. Ci ricorderemo nomi, cognomi e facce. Ci ricorderemo quello che avete fatto ma sopratutto quello che non avete fatto.

Perché il ricordo non porta rancore o spirito di vendetta ma ci insegnerà a ripartire ed a non essere come voi.

Perché i nostri pazienti meritano una stagione di cure diversa in cui la sanità territoriale sia un’alternativa vera e non solo un proclama elettorale.

Noi del 118 ci saremo. Ci saranno i medici, gli infermieri e gli operatori sanitari.

Perché noi ce l’abbiamo fatta mentre voi no.

Beyond Advanced Cardiac Life Support. Do we have to change our practice in COVID Era?

3 Mag

Main changes in recommendations

Personal Protective Equipment for Advanced Life Support interventions need to be at maximum level of protection of full body, eyes and airways.

CAT 3 level of protection 4 (at least) for the full body

FPP2/N95 airway filter for team members who are NOT directly involved in airway management, ventilation or manual chest compressions

FPP3/N99 airway filter for providers who are directly involved in airway management, ventilation and manual chest compressions.

Face shield and protective googles are strongly suggested

Mechanical Chest compressors devices are the gold standard to perform cardiac massage. They reduce contacts and contamination risk and team member exposure to contaminants.

Adhesive disposable pads are the only option to check rhythm and deliver shock. Dispose non-disposable, manual pads.

Passive O2 administration (via simple face mack at a rate of 15l/m) during chest compressions is the first option over bag mask ventilation when performing Basic Life Support waiting for advanced airway management.When using a Bag Valve Mask always put a HEPA/HME filter between Bag and mask to avoid contamination

Hold chest compressions when performing airway managment

Cover patient head with a transparent plastic foil to minimise virus spreading and contamination when performing airway management and bag mask ventilation

Tracheal intubation using a video laryngoscope is the first line option for advanced airway management to minimise contamination.

If video laryngoscope is not available Extraglottic devices are an acceptable first line option

Use all the implementation to improve intubation first passage success:

Video laringoscopy

Bougie

RAMP positioning

Suctioning (SALAD technique)

Use all the implementation to improve Extraglottic device placement

Laryngoscope for tongue displacement and mouth opening (DO NOT USE hands)

Deflate cuff

Lubrificate the device

Whatever plan you apply use an HEPA/HME filter immediately after the ventilation device

Use disposable cover and disposable gel to perform Ultrasound during chest compressions

Airway management in COVID-19 era

9 Apr
Video

Supporto respiratorio non invasivo e gestione delle vie aeree in epoca COVID

2 Apr

Respiratory support in suspected COVID-19 patients. When conventional O2 therapy is not enough!

20 Mar

We talk about evidences on respiratory support in the dyspneic and moderately/severe hypoxic suspect COVID-19 patient on the field. Clinical evidences and contamination risks in the potentially infected COV 19 patients to guide our efforts toward a good outcome when the conventional O2 therapy is not enough.

A step backward

The COVID-19 pneumonia. More than a “baby lung”

Clinical features and Imaging in early phases

  • Mild dyspnea
  • Severe hypoxia
  • Low P/F ratio
  • Respiratory failure
  • Lung failure
  • ARDS pattern
  • Ground glass
  • Crazy paving

Clinical characteristics and imaging manifestations of the 2019 novel coronavirus disease (COVID-19):A multi-center study in Wenzhou city, Zhejiang, China

The imaging pattern of multifocal peripheral ground glass or mixed opacity with predominance in the lower lung is highly suspicious of COVID-19 in the first week of disease onset. 

Lung mechanics

  • High compliance
  • Low driving pressure
  • Reclutability
  • PEEP responsive

Evidences of clinical features of OneLevel (CPAP) and BiLevel (BiPAP) respiratory support in massive epidemic crisis.

Not much of that. NIV in SARS and MERS epidemic demonstrated a poor outcome over invasive mechanical ventilation and possible delay effect on tracheal intubation and mechanical ventilation.

Noninvasive ventilation in critically ill patients with the Middle East respiratory syndrome. Basem M. Alraddadi et al. Influenza Other Respi Viruses. 2019;13:382–390

The vast majority (92.4%) of patients who were managed initially with NIV re‐ quired intubation and invasive mechanical ventilation, and were more likely to require inhaled nitric oxide compared to those who were managed initially with invasive MV. ICU and hospital length of stay were similar between NIV patients and invasive MV patients. The use of NIV was not independently associated with 90‐day mortality (propensity score‐adjusted odds ratio 0.61, 95% CI [0.23, 1.60] P = 0.27).

Clinical features OneLevel respiratory support

  • It’s not a ventilation but a spontaneous breathing on a fixed one expiratory level pressure. No inspiratory support.
  • Give a tritrable PEEP in the highly reclutable and “PEEP responsive” COVID-19 lung

Clinical features BiLevel respiratory support

  • It’s a proper ventilation on two level pressure
  • Give expiratory and inspiratory support with a tritrable driving pressure

Risk benefits assessment

More risk patient level
  • Patient may become agitated or combative due to hypoxia
  • Patient PPE must be removed
  • Clinicians are in close proximity to the patient’s airway
  • Aerosol generating events are more likely
More risk device level
  • High flow oxygen
  • Aerosol generation procedure
  • Poor mask sealing
  • Continuous manipulation at the mask/strap level to optimise sealing and patients compliance
Droplet spreading. OneLevel VS BiLevel respiratory support

DSC Hui, MTV Chan, B Chow. Aerosol dispersion during various respiratory therapies: a risk assessment model of nosocomial infection to health care workers. Hong Kong Med J 2014;20(Suppl 4):S9-13

When inspiratory positive airway pressure (IPAP) increased from 10 to 18 cmH2O, the exhaled air of a low normalised concentration through the ComfortFull 2 mask increased from 0.65 to 0.85 m at a direction perpendicular to the head of the HPS along the median sagittal plane. In contrast, when an IPAP of 10 cmH2O was applied via the Image 3 mask connected to the whisper swivel exhalation port, the exhaled air dispersed to 0.95 m towards the end of the bed along the median sagittal plane, whereas a higher IPAP resulted in wider spread of a higher concentration of smoke (….) It is also important to avoid the use of higher IPAP, which could lead to wider distribution of exhaled air and substantial room contamination.

Prehospital strategy and practical tips

When high flow conventional O2 therapy is not enough to reach clinical goals in the highly risk patient, non otherwise transportable and at risk of rapidly loosing airway patency One level PEEP respiratory support (CPAP) is the best compromise between clinical efficacy and contamination risk.

Ventilatory inspiratory support (BiPAP) doesn’t add much from a clinical point of view and increase the risk of contamination so has to be avoided.

Practical tips when using CPAP on the field

  • Use a non ventilated elbow to prevent risk of dissemination
  • Use a filter between the mask and the patient to prevent risk of contamination
References
  1. Wenjie Yang et al. Clinical characteristics and imaging manifestations of the 2019 novel coronavirus disease (COVID-19):A multi-center study in Wenzhou city, Zhejiang, China. Journal of Infection. 2020
  2. Hui DS, Chow BK, NG SS, et al. Exhaled air dispersion distances during noninvasive ventilation via different Respironics face masks. Chest 2009;136:998-1005.
  3. Randy S. Wax, MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients, Can J Anesth/J Can Anesth. https://doi.org/10.1007/s12630-020-01591-x
  4. WHO. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected. Interim guidance 13 March 2020
  5. Xiaobo Yang, Yuan Yu. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. http://www.thelancet.com/respiratory
  6. David J Brewster , Nicholas C Chrimes. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group.

COVID-19 and O2 therapy. Initial prehospital approach in mild symptomatic patients.

16 Mar

General considerations (dyspneic non infective patients)

Self Protection 

The generic dyspneic patients do not pose any particular self protection issues above the general precautions

Clinical needs

Non infected dyspneic patient need moderately high FiO2 but considerately high oxygen flow rates. 

The available systems we have in this moment (at least on my operative setting) to deliver normally pressured O2 are:

  1. Nasal cannula
    • Maximum gas flow 15 l/m
    • FiO2 variable between 25-45% 
  2. Simple face mask
    • Maximum gas flow 15 l/m 
    • FiO2 variable between 40-60% at the mask level
  3. Nonrebreather face mask (reservoir)
    • Maximum gas flow 15 l/m
    • FiO2 more 80-100%
  4. Venturi mask 
    • Gas flow between 40 to over 80 l/m
    • FiO2 titratable between 24% and 60%management-devices-fio2-oxygen-delivery-original

To satisfy the increased minute ventilation of the highly dyspneic patient Venturi mask is the best device (high flow rate) and permits at the same time to tritrate the FiO2 based on the patients need avoiding indiscriminate hyperoxygenation. 


Particular considerations in dyspneic potentially infective COVID-19 patients

Disclaimer

The following considerations derived from our initial experience on the field in suspect or confirmed COVID-19 with respiratory symptoms at their presentation or in the initial phases. Those are the majority of the patients we observed till the day this post was written. 

The following considerations are not intended for all the severe hypoxic patients who definitively need early intubation and positive pressure ventilation.

Clinical needs

Those are dyspneic hypoxic patients who needs moderately high FiO2 and request more gas flow rates to satisfy increased minute ventilation.

So from an exclusively clinical point of view the best way to deliver oxygen it would be a Venturi mask. 

Self Protection 

In the actual situation in Italy the epidemiological geographical criteria is no more reliable to identify COVID-19 patients so any prehospital healthcare professional providing direct care to a dyspneic patient needs to be protected al least with:

    • Eye protection or Facial shield
    • Medical mask 
    • Disposable gown
    • Disposable gloves

At the same time good practice is to reduce at minimum the number of direct caring providers, to maintain, if possible, a security distance > 1 mt,  to invite any patient to wear, if tolerated, a surgical mask,  and a pair of disposable gloves to minimise the risk of infection. 

When providing direct care of dyspneic patients who needs O2 therapy the level of risk for droplet diffusion is generally increased cause of the presence of the gas flow. 

All the available systems for oxygen delivery we mentioned above are open and allow a free exaltation of the patient in the surrounding area and potentially exposes all the healthcare caregivers to an increased risk of contamination cause of the augmented droplet dispersion and to a lack of protection.


Considerations 

So when dealing with O2 therapy in the potentially infected patients we need to consider the relationship between risk of contamination and clinical efficacy of any device.

Nasal Cannula

  • Oxygenation –—+
  • Protection ++++

Nasal Cannula is the only device that permits the patient to wear a surgical mask on nose and mouth,  decreasing droplet diffusion and protecting the healthcare team and at the same time maintains a certain clinical efficacy..

So my first approach is Nasal Cannula underneath a medical mask. 

Utilising a different device than nasal cannula plus medical mask on the patient mouth and nose (simple, non rebreather or Venturi face mask) to deliver oxygen therapy all healthcare professionals need to be aware that the risk infection increases and the patient has no barriers and so they have to consider improving his own self protection level (N95, FPP2 mask at least)

Simple/Non rebreather Facial Mask 

  • Oxygenation —++
  • Protection ++–

When you can’t reach a clinical acceptable SpO2 with nasal cannula we need to downgrade on our first goal (protection) to achieve a better clinical outcome. 

Simple facial masks maintain a moderate protection form droplet spreading with a more clinical efficacy respect th the nasal cannula.

Nonrebreather facial mask either moderately protects against droplet diffusion with an improvement in FiO2 above simple face mask but the nonrebreather bag is a potential expirate gas reservoir potentially  increasing the risk of spreading.

Venturi mask

  • Oxygenation -++++
  • Protection —-+

High flow titratable FiO2 in an open system mask can satisfy all minute ventilation needing guaranteeing Oxygenation at a cost of a great risk of spreading. My last choice in the scale of conventional Oxygen therapy.

 

References:

DSC Hui,  MTV Chan, B Chow. Aerosol dispersion during various respiratory therapies: a risk assessment model of nosocomial infection to health care workers. Hong Kong Med J 2014;20(Suppl 4):S9-13

M. P. Wan , C. Y. H. Chao , Y. D. Ng , G. N. Sze To & W. C. Yu (2007) Dispersion of Expiratory Droplets in a General Hospital Ward with Ceiling Mixing Type Mechanical Ventilation System, Aerosol Science and Technology, 41:3, 244-258, DOI: 10.1080/02786820601146985

Shu-An Lee, Dong-Chir Hwang, He-Yi Li, Chieh-Fu Tsai, Chun-Wan Chen,and Jen-Kun Chen. Particle Size-Selective Assessment of Protection of
European Standard FFP Respirators and Surgical Masks against Particles-Tested with Human Subjects
. Journal of Healthcare Engineering. Volume 2016, Article ID 8572493, 12 pages

Thanks for reviewing and suggesting to: Scott Weingart, Jim DuCanto, Velia Marta Antonini, Giacomo Magagnotti, Andrea Paoli and all the other colleagues and friends who supported this post

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Spinal Motion Restriction: Why?

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"CardioOnline"Basic and Advanced Cardiovascular medicine" Cariology" concepts and Review -Dr.Nabil Paktin,MD.FACC.دکتـور نبــــیل "پاکطــــین

این سایت را به آن دکتوران و محصلین طب که شب و روز برای رفاه نوع انسان فداکاری می کنند ، جوانی و لذایذ زندگی را بدون چشمداشت به امتیاز و نفرین و آفرین قربان خدمت به بشر می کنند و بار سنگین خدمت و اصلاح را بدوش می کشند ، اهداء می کنم This site is dedicated to all Doctors and students that aver the great responsibility of People’s well-being upon their shoulders and carry on their onerous task with utmost dedication and Devotionاولین سایت و ژورنال انتــرنتی علـــمی ،تخـصصی ، پــژوهشــی و آمــوزشــی طبـــی در افغــانســـتان

EmergencyPedia

Free Open Access Medical Education

Little Medic

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.

Prehospital Emergency Medicine Blog

All you want to know about prehospital emergency medicine

Italy Customized Tour Operator in Florence

Italy Food and Wine Vacations

GoogleFOAM

The FOAM Search Engine

EM Lyceum

where everything is up for debate . . .

AmboFOAM

Free Open Access Medical Education for Paramedics

FOAM4GP

Free Open Access Meducation 4 General Practice

Rural Doctors Net

useful resources for rural clinicians

Auckland HEMS

Unofficial site for prehospital care providers of the Auckland HEMS service

ECHOARTE

L'ECOGRAFIA: ENTROPIA DELL'IMMAGINE

MEDEST

Prehospital Emergency Medicine

ruralflyingdoc

Just another WordPress.com site

KI Doc

WE HAVE MOVED - VISIT WWW.KIDOCS.ORG FOR NEW CONTENT

Emergency Live

Prehospital Emergency Medicine

AMP EM

Academic Medicine Pearls in Emergency Medicine from THE Ohio State University Residency Program

Prehospital Emergency Medicine

 Academic Life in Emergency Medicine

Prehospital Emergency Medicine

Comments on: Homepage

Prehospital Emergency Medicine

Greater Sydney Area HEMS

The Pre-hospital & Retrieval Medicine Team of NSW Ambulance

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