“Best Practice” preospedaliera: Arresto cardiaco in età pediatrica

16 Lug Arresto cardiaco pediatrico

Continua la pubblicazione di una serie di monografie dedicate alle Best Practices per l’emergenza preospedaliera.

La terza della serie riguarda l’arresto cardiaco in età pediatrica.

Potete scaricare il documento cliccando sull’icona sottostante.Arresto cardiaco pediatrico

 

 

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“Best Practice” preospedaliera: Arresto cardiaco in gravidanza

1 Lug Arresto cardiaco gravidanza_Page_1

Continua la pubblicazione di una serie di monografie dedicate alle Best Practices per l’emergenza preospedaliera.

La seconda della serie riguarda l’arresto cardiaco in gravidanza.

Potete scaricare il documento cliccando sull’icona sottostante.

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“Best Practice” preospedaliera

25 Giu Arresto cardiaco adulto non traumatico_Page_1

Da oggi inizia la pubblicazione di una serie di monografie dedicate alle Best Practices per l’emergenza preospedaliera.

La prima riguarda l’arresto cardiaco nel paziente adulto da causa non traumatica.

Potete scaricare il documento cliccando sull’icona sottostante.

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Emorragia post-traumatica

2 Giu DCR copy

References link:

https://drive.google.com/file/d/0B4F2UNmFsOSxUi16d3d0WDRGbkE/view?usp=sharing

Drug-to-drug interaction. New evidences on Morphine and delayed onset of action of antiplatelet agents.

8 Mag Logo MEDEST2

A recently published article entitled  “Chest pain relief in patients with acute myocardial infarction” (European Heart Journal: Acute Cardiovascular Care April 22, 2015) address in a very well documentrd way the topic about drug-to-drug interactiono between morfine and antiplatelets agents in STEMI patients.

Guido Parodi, a lead interventional cardiologist in Cardiovascular and Thoracic Department of Careggi Hospital in Florence, (Italy) author of the article, highlights the fact that “despite the complete absence of rigorous studies designed to assess the impact of morphine administration in patients with AMI, clinical practice guidelines for the management of patients with STEMI strongly recommend the use of morphine for analgesia.”

As indicated in the article recent literature indicates an increased risk of mortality in STEMI patients treated with Morphine.

The analysis of CRUSADE registry in 2005 has shown how patients treated with morphine had a higher adjusted risk of death than patients not treated with morphine even after using a propensity score matching method. This is a non randomized trial and so influenced from potential bias, and the hypothesis that morphine was administered to higher-risk patients is also to be considered. But an additional potential explanation of morphine’s negative impact on AMI outcome may be related to drug-to-drug interactions.

Biologically a cause effect relation can be explained, because morphine inhibits gastric emptying, delaying absorption and so decreasing peak plasma levels of orally administered drugs in general and antiplatelet agents in this particular case.
This was very well demonstrated in a 2015 study from the same author “Morphine is associated with a delayed activity of oral antiplatelet agents in patients with ST elevation acute myocardial infarction undergoing primary PCI” (Parodi G, Bellandi B, Xanthopoulou I, et al. Circ Cardiovasc Interv Epub ahead of print January 2015) in whom the negative impact of morphine on platelet inhibition was not only limited to patients who vomited (patients with vomiting were excluded), but morphine-treated patients clearly showed higher residual platelet reactivity compared with patients who did not receive morphine.

In ATLANTIC Trial (Montalescot G, van ‘t Hof AW, Lapostolle F, et al.; ATLANTIC Investigators. Prehospital ticagrelor in ST-elevation myocardial infarction. New Engl J Med 2014; 371: 1016–1027), STEMI patients who did not receive morphine had a significant improvement in the ECG-based primary end point (ST-segment resolution), reflecting better myocardial reperfusion,with a significant “p” value for interaction between morphine use and time of ticagrelor administration. Professor Montalescot one of the lead authors of this Trial noted:“Co-administration of morphine in the ambulance may have delayed ticagrelor’s onset of action. To what extent this interaction may have affected our results remains unknown at this stage.”

So what to do with analgesia strategy in STEMI patients?

Given the key importance of platelet inhibition in patients treated by PPCI for STEMI and the absence of data that may support a potential clinical benefit of morphine in patients with acute myocardial infarction, more caution should be used regarding morphine administration in STEMI patients, and a restricted morphine use seems to be reasonably recommended.

Morphine administration has to be reserved, as suggested in the article, just for level of pain ≥ 7 on the base of a numerical rating scale (NRS) related value.

Courtesely from Dott. Guido Parodi

Courtesely from Dott. Guido Parodi

For lower chest pain intensity (NRS ≤ 7) alternative strategies has to be persecuted.
The author indicates paracetamol (1 g) or aspirin (≥300 mg) as alternative of choice to reduce chest pain as well demonstrated in letterature.
It has also to be considered how first line agents, currently indicated from STEMI guidelines, as Beta- blocker and Nitrates are able to reduce AMI-related chest pain until the definitive pain relief effect obtained with myocardial mechanical reperfusion.

Bottom Line

The first impact to reduce chest pain has to be reserved to Nitrates or B-blockers (where all contraindications are excluded).

After this NRS has to be evaluated and the use of Morphine is indicated only for values above 7. For lower values Paracetamol or Aspirin are the agents of choice.

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References

  • Parodi G. Chest pain relief in patients with acute myocardial infarction. Eur Heart J Acute Cardiovasc Care. 2015 Apr 22. pii: 2048872615584078. [Epub ahead of print] Review.PMID:25904757

  • Meine TJ, Roe MT, Chen AY, et al. Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative. Am Heart J 2005; 149: 1043–1049.

  • Parodi G,Valenti R, Bellandi B, et al. Comparison of prasugrel and ticagrelor loading doses in ST-segment elevation
    myocardial infarction patients: RAPID (Rapid Activity of Platelet Inhibitor Drugs) primary PCI study. J Am Coll Cardiol 2013; 61: 1601–1606
  • Parodi G, Bellandi B, Valenti R, et al. Comparison of double (360 mg) ticagrelor loading dose with standard (60 mg) prasugrel loading dose in STEMI patients: The Rapid Activity of Platelet Inhibitor Drugs (RAPID) primary PCI 2 study.
    Am Heart J 2014; 167: 909–914.
  • Nimmo WS, Heading RC, Wilson J, et al. Inhibition of gastric emptying and drug absorption by narcotic analgesics. Br J Clin Pharmacol 1975; 2: 509–513.
  • Parodi G, Xanthopoulou I, Bellandi B, et al. Ticagrelor crushed tablets administration in STEMI patients: The MOJITO study. J Am Coll Cardiol 2015; 65: 511–512.
  • Montalescot G, van ‘t Hof AW, Lapostolle F, et al.; ATLANTIC Investigators. Prehospital ticagrelor in ST-elevation myocardial infarction. New Engl J Med 2014; 371: 1016–1027
  • Duggan ST and Scott LJ. Intravenous paracetamol (acetaminophen). Drugs 2009; 69: 101–113.
  • Zijlstra F, Ernst N, de Boer MJ, et al. Influence of prehospital administration of aspirin and heparin on initial patency of
    the infarct-related artery in patients with acute ST elevation myocardial infarction. J Am Coll Cardiol 2002; 39: 1733–1737
  • Yusuf S, Sleigh P, Rossi P, et al. Reduction in infarct size and chest pain by early intravenous beta blockade in suspected
    acute myocardial infarction. Circulation 1983; 67: 132–141.
  • Kim YI and Williams JF Jr. Large dose sublingual nitroglycerin in acute myocardial infarction: Relief of chest pain and reduction of Q wave evolution. Am J Cardiol 1982; 49: 842–848.

Fluid resuscitation in bleeding trauma patient: are you aware of wich is the right fluid and the right strategy?

23 Apr

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The fluids of choice in prehospital field are, in most cases, cristalloids (Norma Saline or Lactate Ringer).

But what is the physiological impact of saline solutions when administered in large amounts (as the latest ATLS guidelines indicates) to hypotensive trauma patients?

Is aggressive Fluid resuscitation the right strategy to be pursued?

The triad of post-trauma lethal evolution is:

  • Hypotermia
  • Acidosis
  • Coagulopathy

Aggressive fluid resuscitation with cristalloids, and saline solutions in particular, can be detrimental in many ways:

  1. Cristalloids tend to displace the already formed clots and improves bleeding
  2. Normal Saline produce hypercloremic acidosis worsening coagulation and precipitating renal and immune dysfunction
  3. Cristalloids diluts the coagulation factors and precipitate the coagulation system (dilution coagulopathy)
  4. Cristalloids rapidilly shift in intercellular space worsening SIRS process and interstitial edema (brain edema, bowel wall edema) with consequent compartment hypertension

So wich is the perfect fluid to infuse in trauma?

The perfect fluid doesn’t exists.

Balanced saline and Hypertonic saline are promisng prospective but there are still no good quality evidences about their benefit on clinical outcomes.

Colloids has no place in fluid resuscitation of trauma patients.

The fluid of choice, regarding the actual evidences and indications, is Lactate Ringer.

More than on the type of fluid the attention of researchers and clinicians is oriented on the strategy to pusue in those cases.

Hypotensive resuscitation, part of damage control resuscitation, is at the moment the strategy of choice in trauma bleeding patients.

Restrictive fluids administration is the way to achieve this goal.

The target systolic BP has to be diferentiated depending on the type of trauma

  • 60–70 mmHg for penetrating trauma
  • 80–90 mmHg for blunt trauma without TBI
  • 100–110 mmHg for blunt trauma with TBI.

More important do not delay definitive treatment.

ASAP give blood products (PRBC, FFP etc…) to contrast post-trauma coagulopathy and send the patients in OR to fix treatable causes of bleeding

The following are a collection of  un essentials resources on haemostatic resuscitation after trauma

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Bougie Intubation with the Kiwi-DuCanto Grip

14 Apr

Love this tecnique. Consider Kiwi grip tecnique for every direct or video intubation and in alternative to stylet use. You will be surprised on how easy and effective this tecnique is.

Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds

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Measuring performances in prehospital emergency medicine

5 Apr opperational_efficiency_process

Clinical pathways are the essence of clinical practice. They start from diagnose and therapy (usually provided from a physician) and then continue in assistance (usually provide from a nurse).

career-path-300x225

Medical systems are ensembles of medical professionals, doctors and nurses, and to standardize the diagnose, the therapy and the assistance on every identified clinical pathway a common trace is needed.

Clinical guidelines and evidenced based literature are the bases on whom clinical pathways and best practices are designed. The interventions and the therapies mentioned in clinical guidelines have positive influence on different outcomes so every medical professional can refer to those established common practice to standardize his clinical behavior.

Emergency Medical Systems aim to be considered an excellence in order of clinical, technical and non technical skills. To reach such results financial and human resources are needed. How can we demonstrate that such resources are well invested. In other words which is the impact of emergency medical systems on public health and how can we measure it?

opperational_efficiency_process

Measuring performances in medicine is an exciting challenge. Pre-hospital emergency medicine and pre-hospital emergency services make no exception. We are the frontline of medical care and beyond organizational duties we have a moral assignment to plan, measure, analyze and improve our performances, both individually and as public system.

First step is to establish a series of Best Practices about a series of representative clinical pathways derived from an epidemiological analysis of our local clinical experience. International guidelines, evidenced based medicine and other forms of medical literature are the field where to find the best interventions and therapies, in term of positive influence on various clinical outcomes, to incorporate in every pathway.

Education, planning and other form of diffusion has to be integral part of the process, to allow the professionals involved to be active part of the story.

The way to define the impact of a medical system on public health is to measure how many of those intended interventions (alone or bundled) will be performed in real practice.

This impact can be expressed in N.N.T. in the contest of every single clinical pathway.

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Historically the pre-hospital services where judged on the basis of response times and survival from cardiac arrest, but this new way to measure performance on the base of clinical outcomes is more patient centered and will change the way to analyze the emergency medical systems.

A 5 year experience from Pre-Hospital Outcomes for Evidence-Based Evaluation (PHOEBE) project (the Lincoln Institute for Health), in its impact evaluation says:

“This project will change the way in which the quality of ambulance services is measured.  As such, it goes beyond just measuring performance in terms of response times.  This may impact on the operation of ambulance services from organisations that concentrate on meeting response time targets towards those that are geared to improving the quality of patient care.”

Let’s make practical examples of combined or single interventions that have decisive impact on public health?

In an article entitled “EVIDENCE-BASED PERFORMANCE MEASURES FOR EMERGENCY MEDICAL SERVICES SYSTEMS:A MODEL FOR EXPANDED EMS BENCHMARKING” published in PREHOSPITAL EMERGENCY CARE 2008;12:141–151 are indicated some clinical pathways to measure in order of NNT

In STEMI patients, according to AHA Guidelines, those three elements make the difference:

  1. Aspirin (if not allergic)
  2. 12-Lead electrocardiograph and pre-arrival activation of interventional cardiology team as indicated
  3. Direct transport to percutaneous coronary intervention (PCI) capable facility for ECG to PCI time <90 minutes

When present together (Care Bundle) the NNT is 15 on stroke, 2nd myocardial infarction, or a death. In other terms, every 60 patients that receive the treatment 4 of them avoid the mentioned complications.

Noninvasive positive pressure ventilation (NIPPV) in Pulmonary Edema has a NNT of 6 for need of endotracheal intubation (ETI). In other terms every 6 NIPPV applied in pulmonary edema patients 1 ETI is avoided.

And so on for other pathways…..

Recently Care Flight a Medical retrieval service based in Australia posted on its blogsite The Collective a post on this topic entitled PHARM quality – how do you know when you’re doing it well?

In this post Dr. Alan Garner talks about Carebundle approach (here the definition from  Institute for Healthcare Improvement (IHI) website)  to track performances in EM.

He also mentioned how German based company ADAC use this method (defined as “tracer diagnosis” by Erwin Stolpe chair of the ADAC medical committee) to report performances on defined clinical pathways. 

And here some resources from Erwin Stolpe

I think that, as in hospital, prehospital emergency environment has to report and track performance quality to improve and justify the investment of financial and human resources.

Every medical system has to target the right method to his particular logistic and cultural situation, but has to find a way to measure how good it is and how good its professionals works.

This gonna take us out from sterile discussion about which is the best model in prehospital emergency medicine and let’s us to make a step forward to demonstrate which organizational model really works in term of public health and patients centered clinical outcomes.

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2016 NICE Major Trauma Guidelines. The pre-hospital recommendations.

21 Feb IMG_1655

NICE released the 2016 Major trauma Guidelines.

Many interesting recommendations where made for pre-hospital and in hospital providers about several topics

  • Airway management

  • Chest trauma

  • Haemorrage control

  • Circulatory access

  • Volume resuscitation

  • Fluid replacement

  • Pain management

  • Documentation

  • Training

Here is the Excerpt regarding the pre-hospital settings

Download the full guidelines for in-hospital recommendations and full description of Guidelines process and rationale behind every single recommendation

Download the full Guidelines at:

Major trauma: assessment and initial management

NICE guidelines [NG39] Published date: February 2016

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When chest compressions and early defibrillation are not the most important interventions in cardiac arrest

6 Feb CFR 2A

CFR 2A

The chain of survival is well known and most of us work everyday to spread it’s use at every level. Chest compressions is, along with early defibrillation, the most important and evidence based intervention to save a cardiac arrest patient’s life.

But there is a group of cardiac arrest patient in whom chest compressions and early defibrillation are not the first and most important intervention to perform. 

When a trauma is at the base of a cardiac arrest we know that this patient is either hypovolemic or there is an obstruction at the blood flow at the base of the cardiac arrest,  so chest compressions (and vasoactive drugs) are not effective.

We also know that the most common ekg presentation rhythms are Asystole and PEA and early defibrillation is not required.

That’s why when advanced care is performed in traumatic cardiac arrest all the interventions are directed to resolve reversible causes and chest compressions or defibrillation are not indicated.

In brain trauma the most critical phase are the 10 min following the impact. In this phase some critical, but mostly neglected, events occur and the survival of the patients depends on their entity.

Brain impact apnoea and catecholamine surge are the early pato-physiologic processes that determine the life or death of a severely brain injured patient in the first phase of the trauma. Both are proportional to the entity of the impact and can be cause of most of the cardiac arrest in which prehospital providers intervene. 

Apnoea is a reaction to the impact and concussion of brain stem in trauma. Apnoea occurs even for obstrution of first respiratory tract due to head position and muscles relaxation following head trauma.

Apnoea cause hypoxia and cell death, but even hypercarbia who leads to vasodilatation and increased blood volume in the brain. All this induce brain swelling and cerebral edema with permanent neurological damage or death.

Catecholamine surge is a reaction of the sympathetic system to head trauma, as to many other stressful conditions, that produces a massive releasing of vasoactive principles who leads to systemic hypertension. This condition determines increasing ICP that, associated with vasodilatation and relative loss of vascular regulatory function, increase brain oedema and neurological damage.

Massive cathecholamine excretion leads also to increasing pre-load and after-load responsible for the secondary heart failure function and acute cardiovascular insufficiency often discovered in massive trauma patients, who develop profound and refractory  hypotension in absence of evident, external or internal, blood loss. Other phenomena can also occur as consequence of direct cahecholamine insult as gastric ischemic ulceration, neurogenic pulmonary oedema and myocardial necrosis. 

Unfortunately those early phenomena are less likely to be testified by prehospital providers even if an efficient dispatch policy is in place. That’s why there is not much in literature about those topics and all the evidence derives from studies on animal models.

Most of the times this early phase of brain trauma is testified by community responders who has to be aware and instructed that when respiratory or cardiac arrest happens following head trauma, the most effective intervention is opening the airway and supporting ventilation and not performing chest compressions.

Prehospital professionals as also to be aware of the physiologic and clinical implications when comes to deliver Advanced Care. Supporting ventilation and promoting oxygenation and normocarbia are the key features for those patients and have to be prioritized in regard to other interventions.

We also have to remark, when teaching and lecturing in professional and community settings, the difference of priority in interventions between medical and traumatic cardiac arrest.

GoodSam app is a new instrument for EMS and community responders, commonly used for prioritize C interventions (chest compressions and defibrillation) in medical cardiac arrest, but was originally intended to diffuse awareness of brain impact apnoea and to encourage bystanders to perform A (airway opening) and B (ventilation) interventions. 

In the future when, thanks to culture and technologies devolopment, everyone at every level will be well conscious about the importance of opening the airway and ventilation in the early phases of trauma  the morbidity and mortality associated with head injury will be reduced to a level not yet achieved.

References and resources

 

By Mario Rugna

 

 

 

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