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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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Only Evidenced Based Medicine? Evidently……not!

4 Feb
man-jumping_logoThe modern emergency medicine based most of his clinical practice on evidence-based trials. 
But really all that is not coming from randomized controlled trials does not exist?

The paradox of the demonstration of the effectiveness of the parachute with randomized controlled trials, in accordance with the method EBM (The Parachute trial), provocatively poses a fundamental question:

If the scientific basis of any therapeutic intervention are already strong, and the benefit for the population is large, is ethically correct to wait large-scale trial to implement it, delaying its potential benefits?

A 2006 article published in the BMJ Controversy Parachute approach to evidence based medicine brilliantly responded to this question.

It contains some examples of very common diseases in developing countries (HIV, dehydration in children, postpartum hemorrhage) whose remedies, implemented previously than results of relative trials where available, have saved thousands of lives.

The authors conclude that:

1. Randomised controlled trials are usually required before new interventions are implemented

2. If other evidence of effectiveness is good, and potential benefits large, the resultant delays may be unethical

3. Examples from poor countries show the price of delaying interventions

The triad of decision-making at the base of the construction of Evidenced Based Medicine provides an integrated approach between explicit data (scientific evidence derived from trials of good quality) and tacit data(clinical expertise and the patient’s needs).

MedInfo_EBMtriadImage

The clinical decision is derived from the combination of these three factors:
• Scientific evidence
• Clinical Experience

• Needs of the patient

But when defining the level of quality of evidence those derived from clinical practice and experience are relegated to the base (lower level) of the pyramid whose apex (higher degree) are the evidence derived from studies on large patient populations.

ebp_pyramid

Randomisation and de-personalization of scientific research, while eliminates everything that is “non-evident” in medical research, and is well suited to a concept of public health, on the other hand maintains an unbridgeable gap with daily clinical practice that is focused on the care of the individuals.

But in practice what we can do:

  • Integration of explicit data, result of the evidence, with the “tacit knowing” that is generated only from the direct doctor-patient relationship is desirable.
  • The “tacit knowing” is the basis of our medical education, such as learning the language is to pre-school children: it does not need structured teaching but it is learned from direct experience.
  • The “tacit-knowing”, often reduced to subjective data and therefore of lesser dignity, is in fact, just because “innate”, less prone to the common bias of explicit data;
  • We must recognize equal dignity to both those data “explicits” and “tacits.”
  • We must take into account both explicit and tacit elements in the formulation of the hypothesis and the resulting diagnostic therapeutic strategy.

We can and we must go beyond the exclusive use of EBM in medical research and clinical practice.

The adoption of an integrated approach between the explicit scientific evidence derived from clinical trials (EBM) and a “patient- centered approach” derived from the clinical experience, should be a stimulus and an intent to the future development of our approach to the critically ill patient.

It must always be clear in the mind of the emergency medicine professionals which treatment is scientifically more correct for a given disease, but he must contextualise, and implement it for the particular patient who is dealing with at that time

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Italian transcript

References:

Parachute use to prevent death and major trauma in gravitional accidentes: the first randomized controlled double blind trial!

3 Feb

© Copyright 2012 CorbisCorporationBusinessman falling in city center

Following the recent article published the on B.M.J. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials and its conclusions “We were unable to identify any randomized controlled trials of parachute intervention” so “the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials”,
MEDEST proposes the first ever randomized controlled double blind  trial on:

Parachute use to prevent death and major trauma in gravitational accidents.

  • Study design: Double blinded, randomized controlled trial
  • Randomization: the enrolled participants (also called “precipitants”) will all precipitated from a 800 meters height. They will be blindly randomized in two groups:
  1. Precipitants with parachute
  2. Precipitants without parachute (control group)
The precipitants and the investigators will be both blinded for humanitarian reasons.
  • Major end-points: surviving rate at 5, 10, 30 minutes from the impact.
Enrolled starts as soon as resolved some minor ethical issues.
Scarica la traduzione in italiano del post.

It could be me!

24 Gen
A  Rescue Helicopter suffered a fatal crash in L’Aquila, Abruzzo, Italy. Six person died in the crash. Doctor, Nurse, Pilot, HHO, Mountain rescue expert, patient. linea_a_lutto_by_gigicave
The helicopter crashed during a routine HEMS mission.
The five people of the crew and the patient all died.

When something like that happens the first thought for an HEMS professional is:

IT COULD BE ME!

Then you start to rationalise the situation, mostly in a technical and non emotional way, and arrive at the conclusion:

NEVER WOULD HAPPEN TO ME. 

There are many reason, in my opinion, why we arrive at that. 

We all have family and friends to care about and who take care of us. And we can’t even imagine them devastated by grief.

Our major concern is about patients health and not about our safety. 

And finally, we are humans and human being self-protect their inner fragility, avoiding to hurt themselves thinking about death, especially their own .

But I know, and always will. that IT COULD HAVE BE ME despite any protection and self-lie.

Cause even the 6 persons  who died in the crash had family and friends that now live in a devastating grief.

Even them were taking care of patients over they own safety.

And also them were humans, like me. 

So WAS ME! 

Today a part of me ideally died in that crash.

Tomorrow a new day will begin, but from now on things will look different.

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Sepsis: Sepsis 3, Surviving Sepsis Campaign what now?

23 Gen

From a practical clinical point of view, after the 2016 update of the SSC (Surviving Sepsis Campaign) guidelines we have two references when comes to deal with a potential septic patient. Question Marks Sphere Ball Many Questions Asked

2016 Sepsis 3 definition and early management.

2016 Surviving Sepsis Campaign

Let’s see how to treat, based on top evidences, a real patient in the the pre-hospital and emergency department time window. 

But, first of all,  the definitions:

  • Definitions

Both the guidelines now agree that:

Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection

Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) despite adequate volume resuscitation”

  • Early identification

    1. SIRS criteria. The new 2016 SSC guidelines do not indicate any criteria for early identification of sepsis, so SIRS criteria no longer exists.
    2. qSOFA score (G.C.S. of 13 or less, SBP of 100 mm Hg or less, and RR 22/min or greater): Good negative and positive prediction value(similar to that sepsiscouchof the full SOFA score outside the ICU). Non specific for sepsis. It’s the actual early identification tool for sepsis to use out-of-hospital end in emergency department. It performs quite good to identify patients at risk of negative evolution. A qSOFA score ≥2 indicates a high mortality risk comparing to a qSOFA ≤1.
      sofa-score-1024x743
    3. SOFA score: indicates organ disfunction (when the score is >2 points) consequent to the infection and defines sepsis. Is a validated ICU tool to asses risk and mortality chance. Is not a tool to use out-of-hospital or in ED.
    4. The Pre-hospital Sepsis Score (PSS) or Miami Sepsis Score: As out-of-hospital professional I love pre-hospital early warning tools.I like to mention PSS cause is well validated to early recognise sepsis in the field. PSS includes Shock Index (HR/SBP) that is really sensible to identify critical evolution chance, RR that is included in qSOFA and other sepsis score plus body temperature (obligatory) that identifies an infection. Is for me the good compromise, in the field, between good positive and negative predictive value. A PSS of 1 point identifies a low risk patient, 2 points moderate risk, 3-4 points high risk patients.pss
  • Early management

    1. Early goal directed therapy: no longer recommended. CVP is no longer required and fluid response to initial volemic reanimation has to be clinically and dynamically assessed (passive leg raise, fluid challenges)
    2. Fluid resuscitation: 30 ml/Kg(in the first 3 hrs) to restore normal emodynamics values (MAP >65 mmHg). Lactate is a risk assessment tool (>2 mmol/L) and is no longer recommended to guide resuscitation efforts. Crystalloids are the fluids of choice. 
    3. Vasopressors: indicated if initial fluid resuscitation doesn’t reach the target. Norepinephrine is the pressor of choice. Epinephrine the second line agent in case Norepinephrine is not sufficiente to reach the target.Stop giving Dopamine.
    4. Bloodcultures: immediately and preferably before starting antibiotics but without delaying  antibacterial therapy. 
    5. Antibiotics: no double cover routinely but broad spectrum mono therapy is the recommended choice.
    6. Corticosteroids: consider just if patient is fully volume resuscitated and vasopressors are unsuccessful to maintain emodynamic stability.

Take home points for early phase management

Early Identification
Use either:
  • qSOFA (preferred in ED) cut off ≥2 points
  • PSS (preferred in the field) cut off ≥2 points.
Initial Management (target to a MAP >65)
  • Emodynamic stabilisation
    • 1st Fluid 30 ml/Kg of crystalloids.
    • 2nd Norepinephrine up to 35-90 μg/min (if 1st step failed).
    • Add Epinephrine up to 20-50 μg/min to achieve MAP target (if first 2 step failed).
  • Take blood cultures (if feasible before antibiotics but without delaying antibiotics).
  • Do not delay early broad spectrum antibiotic mono therapy.

 

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References 

 

 

 

My favourite EM articles of 2016. Part 1.

19 Gen

Here are some articles that influenced my clinical practice and my clinical thinking during the last year.

They are not probably the best of all but are my choice, and are all free full text.

So read carefully the full article and judge yourself if worth  or not the mention.

Good reading to everyone. 

The state of the art: Moderate to high quality evidence suggests that compared with medical care alone in a selected group of patients endovascular thrombectomy as add-on to intravenous thrombolysis performed within six to eight hours after large vessel ischaemic stroke in the anterior circulation provides beneficial functional outcomes, without increased detrimental effects.

A radical change in definition and concepts of Sepsis and sepsis management . From SSC to Sepsis 3. Not a worldwide accepted change in clinical practice. If you are interested in more about go to Sepsis folder

A complete guide to approach at children with decreased level of consciounes is for me a constant friend in my clinical practice.

Less is better when comes to Oxygen therapy. This very well done Italian study despite his early unplanned termination (cause of a earthquake that hitted the centre of Italy) confirm the trend toward reduced mortality in conservative targeted oxygen administration versus conventional liberal therapy.

Hypoxic lactic production is a mantra in both patho-physiology and clinical practice. In this article the author gives different interpretation of the phenomena. One of my favourite. 

This systematic review and meta-analysis clearly demonstrate how in both cases CA and CS, ECMO support improve mortality compared with standard techniques. Every emergency system has to consider this option.

Rare but dramatic condition among all the epileptics status need the best of EB treatment. Here is the latest reference guidelines released by one of the most important international scientific society. Must read.

Traditional performance measures and a proposal for a new more complete model for Clinical Performance Benchmarking. An efficiency and quality assessment method that prehospital systems need to acquire. 

Debating about with model of EMS is the more efficient in performing out of hospital CPR? This systematic review and meta-analysis  affirm that physician based models have better performances than non physician based ones.

HEMS vs GEMS. Ground or air transport in traumatized patients? This article is not the end of the story, but pose a good base on how HEMS can be a better alternative to rescue and transport trauma patients.

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2016 in Review

12 Gen

MEDEST-review

2016 has been a great year for Emergency Medicine.
MEDEST on a daily base, via Twitter or Facebook, shared the best (for us) Emergency Medicine articles coming from the net.
At the beginning of a new year we would like to share a collection of those articles (all free full text) organised by topics.
You can browse freely for research or educational proposal
I hope you’ll enjoy.

2016 Review by topic

You can also find articles from previous years on this page

MEDEST Review’s

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