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Don’t live me Breathless

28 Gen

Case presentation

You arrive on the scene of a motorbike accident. The driver, a 50 years old male, at your arrival is in “Pain” state with eyes closed and you can hear just a “snoring” sound coming from his mouth. His vitals are: NIMBP 80 over 50, HR 110, A quick primary survey reveal a low level of consciousness (eyes closed no finalised arms movement) with restored airway patency that after basic airway manoeuvres and O2 therapy (SaO2 goes to 95%) no signs of tension pneumo. A quick look to the pelvis and legs reveal a suspected “open book” lesion and a bilateral femoral fracture. No PMH is available at the moment.

Physiological response to shock

From the primary survey and vitals you can understand the patient is compensating a state of profound (hypovolemic) shock and consequent organ low perfusion with a sympathetic activation. Endogenous adrenergic mediators are trying to restore organ perfusion by vasoconstriction and increase in cardiac output.

First do not harm

Can we kill a patient destroying the physiologic response to shock?

The answer is YES! The need to protect airway performing a rapid pharmacological assisted airway management (RSI), can lead to bad consequences, destroying the physiological response to a state of profound shock.

All sedative, analgesic and anaesthetic drugs in fact antagonise and depress the sympathetic adrenergic response physiologically targeted to restore perfusion to vital organs.

First do not harm and choose minimal emodynamic impact type and dose of drugs to perform sedation. As we know (till now) the better choice are Ketamine and Etomidate with no clear evidences on which one is preferable. We for sure know that Ketamine can be dangerous in cathecolamine depleted patients and that this effect is dose dependent. So consider using a lower dose to reach dissociative threshold being conscious that can lead to a non ideal intubation condition.

Reanimate first intubate later (aka DSI)

After a dissociative dose of Ketamine, our next clinical target is to reanimate the patient form an oxygenation and/or an organ perfusion point of view.

So we shift from a concept of Rapid Sequence Intubation to a more comprehensive plan of Delayed Sequence Airway Management. Delayed (Ketamine/Etomidate induced) to get time and reanimate, Airway Management intended as any plan (tracheal intubation, supraglottic airway) we can apply in that specific patient in the middle of the road or in other prehospital scenarios.

A properly performed pre-oxygenation with the adjunct of apneic oxygenation can restore O2 levels giving us also a good reserve for following apnea times.

Cautelative fluid administration (avoid fluids in trauma, use BLOOD) and, push dose (Epinephrine, Phenilephrine) or continuous infusion (Norepinephrine) vasopressors, can restore perfusion to abdominal and extra abdominal organs by increasing circulating volume and cardiac performance (Alfa and Beta agonist ).

Delayed paralytic administration give us the time to perform a proper reanimation reanimation and to check the effects of our interventions.

If everything goes well and the patient’s oxygenation and emodynamic state is compensated, we can administer paralytic, and go straight to perform tracheal intubation.

But if the patient remains uncompensated despite all our efforts to correct the potentially lethal cause, our last weapon can be to preserve spontaneous breathing.

Don’t live me breathless

WHY? During inspiratory phase of respiratory cycle the negative intrathoracic pressure favourites venous return and increase the telediastolic volume of the left ventricle. The augmented left ventricle end diastolic pressure (LVEDP) according to Frank-Starling law improves myocardial performance increasing stroke volume and consequently cardiac output.

The refractory shocked patient is heavily preload dependent and suppressing the inspiratory drive risk to worsen the already dramatic emodynamic state taking him on the irreversible part of the shock curve.

We’ve got a plan

We need to have a plan for high difficult physiological airways. This is just a small residual percentage of the airways we manage in our clinical practice, but can be dramatically catastrophic when we deal with those patients without a precise plan.

We’ve got a backup plan

But when intubation fails we need to have a backup plan!

Case conclusion

You understand the need to protect patient’s airways but also the extreme physiologic difficulty of this airway.

After administering a dissociative dose of Ketamine, due to the failure of any try to restore perfusion, you decide to perform a DISSOCIATIVE INTUBATION using a videolaryngoscope with a hyperangulated blade and a bougie, AVOIDING PARALYSIS.

Then you put the patient on ACV mechanical ventilation targeting a TV of 6 ml/kg and considering a “zero PEEP” strategy.

Special Thanks to Scott Weingart and Jim DuCanto for the kindness and fundamental mentorship on inspiring and peer reviewing the algorithm


Brian E. Driver, Matthew E. Prekker, Robert F. Reardon, Benjamin J. Sandefur, Michael D. April, Ron M. Walls, Calvin A. Brown,
Success and Complications of the Ketamine-Only Intubation Method in the Emergency Department,
The Journal of Emergency Medicine

Weingart SD, Trueger NS, Wong N, Scofi J, Singh N, Rudolph SS. Delayed sequence intubation: a prospective observational study. Ann Emerg Med. 2015 Apr;65(4):349-55. doi: 10.1016/j.annemergmed.2014.09.025. Epub 2014 Oct 23. PMID: 25447559.

Merelman AH, Perlmutter MC, Strayer RJ. Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine. West J Emerg Med. 2019 May;20(3):466-471. doi: 10.5811/westjem.2019.4.42753. Epub 2019 Apr 26. PMID: 31123547; PMCID: PMC6526883.

Ko BS, Ahn R, Ryoo SM, et al. Prevalence and outcomes of endotracheal intubation–related cardiac arrest in the ED. Am J Emerg Med. 2015;33(11):1642-5.

Mort TC. Complications of emergency tracheal intubation: hemodynamic alterations – part I. J Intensive Care Med. 2007;22(3):157-65.

Jarvis JL, Gonzales J, Johns D, et al. Implementation of a clinical bundle to reduce out-of-pospital peri-intubation hypoxia. Ann Emerg Med.2018;72(3):272-279.e1.

Roantree RAG, Goldstein S. (2018). EMS, Facilitated Intubation Without 36.Paralytics. Treasure Island, Florida: StatPearls Publishing.

Braude D, Palomo O, Beamsley A. Sedation only intubation. EM:RAP. 39.2013.

Miller M, Kruit N, Heldreich C, et al. Hemodynamic response afterrapid sequence induction with ketamine in out-of-hospital patients 50. at risk of shock as defined by the shock index. Ann Emerg Med. 2016;68(2):181-8.e2.

Beyond Guidelines: what’s new in OCHA management

6 Set

Chest compressions alternate to abdominal compression–decompression technique


The abdominal compression–decompression technique is based on an “abdominal pump” model, which induces pressure changes within the abdominal cavity and promotes the return of blood from the abdominal cavity to fill the heart and be eventually pumped to the brain. A combination of abdominal compression–decompression and chest compression was previously shown to increase the venous refilling of the heart, which could generate increased coronary perfusion pressure and increase blood flow to vital organs . With this combination method, chest release during abdominal compression leads to increased venous return to the thorax by negative intrathoracic pressure. Moreover, abdominal decompression during chest compression may lead to increased blood flow via decreased afterload. In myocardial blood flow, a better 48-h outcome was documented with the combination method compared with STD-CPR

The study

Evaluation of abdominal compression– decompression combined with chest compression CP9R performed by a new device: Is the prognosis improved after this combination CPR technique?

This study was performed in China. It’s a single center, randomised, not blinded study.

The study aimed to compare the outcomes of standard cardiopulmonary resuscitation (STD- CPR) and combined chest compression and abdominal compression–decompression cardiopulmonary resuscitation (CO-CPR) following out-of-hospital cardiac arrest (OHCA).

Primary outcome ROSC. Secondary outcome hospital admission, hospital discharge and neurological outcome at hospital discharge.


ROSC and survival to hospital admission: no statistical benefit

Survival at hospital discharge and neurological outcome: CO-CPR had statistical significant better outcome respect STD-CPR


Single center, small sample size, no evaluation of possible abdominal injuries.

Bottom line

For prehospital use of combined chest compression and abdominal compression–decompression cardiopulmonary resuscitation we have first of all to account the need of an additional rescuer to perform abdominal compression-decompression. By the way the alternate chest/abdominal compression-decompression method is promising even if we need larger multicenter randomised trial for a more consistent evaluation of its efficacy.

Head and thorax elevation during cardiopulmonary resuscitation


Gradual elevation of the head and thorax enhances venous return from the head and neck to the thorax and further lowers intracranial pressure. This automated controlled elevation (ACE) CPR strategy consists of: (1) manual active compression decompression (ACD)-CPR and/or suction cup-based automated (LUCAS 3) CPR; (2) an impedance threshold device (ITD); and (3) an automated controlled head and thorax patient positioning device (APPD).

The study

Head and thorax elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival

Observational, prospective study. The Objectives of the study was to assess the probability of OHCA survival to hospital discharge after ACE-CPR versus C-CPR. ACE-CPR data were collected from a dedicated registry implemented by 10 EMS Agencies. Conventional (C) CPR data were collected from 3 large historical randomized controlled OHCA resuscitation trials.

NB: for ACE-CPR only 6/10 agencies data were evaluated.

The primary outcome was survival to hospital discharge. Secondary outcomes included ROSC at any time, and survival to hospital dis- charge with favorable neurological function.


Cumulative results on primary and secondary outcome before taking into consideration the time from 911 call to ACE-CPR were not statistically significative differences. The statistical significance of ACE-CPR was reached only when time from 911 call to ACE-CPR initiation was considered.


Observational study. Participating personnel form EMS agencies were highly motivated about ACE-CPR. 165 patients excluded with no clear explanation (generally didn’t meet inclusion criteria) from 4 EMS participating agencies. Statistical significance on primary and secondary outcome was reached after surrogate secondary analysis that considered time form 911 call to ACE-CPR start.

Bottom line

There are still insufficient historical data to understand the benefit of automated controlled elevation (ACE) CPR and this study doesn’t clear any doubt about it’s efficacies on clinical oriented outcomes.

Aortic occlusion during cardiac arrest. Mechanical adrenaline?


Thoracic aortic occlusion during chest compressions limits the vascular bed for the generated cardiac output. This may increase the aortic pressure and subsequently the coronary perfusion pressure (CPP).

The coronary perfusion pressure (CPP), the pressure gradient between the aorta and right atrium, is a major determinant of the myocardial blood flow. Consequently, generating a high CPP by providing high-quality chest compression during CPR is one of the most critical factors for achieving ROSC in cardiac arrest patients.

It is uncontroversial to state that the desired effect of adrenaline in CPR is the potential increase in CPP. The potential detrimental effects of adrenaline, such as decreased cerebral blood flow, increased myocardial oxygen consumption or recurrent ventricular tachycardias after ROSC, is yet to be found with REBOA. However, adverse effects of REBOA are not reported in the limited human data published, nor has this been an endpoint in the studies conducted so far.

The study

Resuscitative endovascular occlusion of the aorta (REBOA) as a mechanical method for increasing the coronary perfusion pressure in non-traumatic out-of-hospital cardiac arrest patients

This is a pilot study. The aim of the study was to calculate the CPP before and after REBOA balloon inflation. EtCO2 and median aortic pressure before and after balloon inflating were also measured.


CPP, MAP and EtCO2 significative increased after REBOA placement in Zone 1 and balloon inflation


Single center, small numbers, need of a large number of operators to insert the REBOA and to obtain the measurements.

Bottom line

REBOA in Cardiac Arrest is potentially useful to increase CPP and less dangerous than epinephrine administration.

It’s feasibility in emergency (in-hospital and out of hospital) settings in a timely manner and with a small number of medical personnel needs to be demonstrated.

By Mario Rugna

In case of oesophageal intubation

19 Ago

Just published Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies

Thanks to a prestigious panel of international authors. Great job and definitely solid indication about how to prevent and recognise accidental oesophageal intubation.

Just some of the key recommendations

  • Exhaled carbon dioxide monitoring and pulse oximetry should be available and used for all episodes of airway management.
  • Routine use of a videolaryngoscope is recommended whenever feasible.
  • Inability to detect sustained exhaled carbon dioxide requires oesophageal intubation to be actively excluded.
  • Tube removal should be undertaken if any of the following are true:
    • Oesophageal placement cannot be excluded
    • Sustained exhaled carbon dioxide cannot be restored
    • Oxygen saturation deteriorates at any point before restoring sustained exhaled carbon dioxide

Refer to the full text guidelines for more.
Here is the link to Safe Airway Society livestream event.
Must read, must follow. Free open access.

Let’s go outside

The following are personal considerations on peculiar aspects about management of accidental oesophageal intubation in prehospital environment and come from my personal clinical experience.

Beware they are just personal considerations and practical tricks and tips and are not intended to substitute the above guidelines. 

They are intended to suggest an alternative mental and technical approach when dealing with oesophageal intubation on uncontrolled patients in difficult environment.

Some general considerations

  1. Prehospital uncontrolled patients are not on empty stomach so are at high risk of regurgitation/inhalation
  2. Even few ventilation efforts in case of oesophageal intubation pone the patient at high risk of regurgitation/inhalation 
  3. Suctioning in prehospital setting is not always ready avalliate (mind your environment) or maximally performant (mind your equipment) 
  4. First attempt in prehospital setting must be always the best one. Think before trying a second attempt in case of failure. Implement your plan or change plan.
  5. Apply the Indication, Suitability, Feasibility approach while supporting oxygenation, ventilation and protection.


The way I like it. The way I do it.

  1. Live the “oesophageal” OT tube in (overcuffed) and if it’s possible apply a continuous suctioning to exclude the oesophagus and protect the airways 
  2. Place a SGA to restore oxygenation and ventilation (trough BMV or NIV)
  3. After restoring oxygenation (SaO2 >94%) and ventilation (EtCO2 40 mmHg) if suitable and feasible (see below) proceed to a second attempt of tracheal intubation (must be videolaryngoscope+bougie)
  4. If the second attempt succeeds remove the “oesophageal” OT
  5. If the second attempt is not suitable or feasible transport to nearest hospital (patient is well oxygenated and ventilated via SGA and protected via oesophageal exclusion) for further stabilisation (you can replace the oesophageal OT tube with a large bore oro-gastric tube or insert the orogastric tube trough the SGA dedicated channel)
  6. If you can’t restore oxygenation and ventilation via SGA or you can’t place a SGA remove the oesophageal OT tube and try to oxygenate and ventilate (remember patient is not protected) via BVM and NC (double oxygenation) 
  7. If even BVM fails declare CICO 
  • Do I have a plan to implement regarding the  first attempt
  • Can I improve my environment (Setting) moving the patient to a more comfortable place/position 
  • Is the time to nearest hospital short/long 
  • Am I in the right mental mood after 1st attempt (me) to try a better second one
  • Is my team ready for a second attempt (team) 
  • Do I have the right equipment to implement my second attempt (Equipment)

The visual algorithm

The Video

By Mario Rugna

2 Minutes Advanced Airways

14 Feb

There is a crazy guy on the street!

10 Gen

An original post by Mario Rugna

With the peer review and determinant inspiration of Minh Le Cong

Prehospital professionals dealing with acute agitated patients are always challenging all their clinical and non clinical skills at maximum levels. You need to deal with the patient, the bystanders and the law enforcement people trying to manage in the best way possible a social and clinical emergency.

Understanding if the patient is acutely intoxicated, psychiatrically decompensated (or both) is the first quick challenge we face. Clinical history, physical examination are not always possible so mostly of the times we have to guess based on our gestalt, clinical and non clinical experience.

What kind of patient I expect to find? Basically there is the sociopath agitated but collaborative, the agitated non collaborative but not dangerous (for himself and the others) the agitated non collaborative and highly dangerous. This is not a schematic and alway applicable definition but can help to understand how to gradually approach those kind of emergencies.

Alternative diagnosis

Consider alternative diagnosis:


  • Lung 
  • Urinary
  • Brain
  • Sepsi


  • Ipoglicemia
  • Alcol
  • Drugs psychoactive substances
  • Electrolytes


  • Stroke or Tia
  • Seizure or post critical state
  • SAH
  • Intracranial
  • Brain tumor
  • Subdural emorrhage


  • Cardiac
  • Ischemia
  • PE

Drug abuse

  • Anticholinergic
  • Sedatives
  • Opioids

Risk Score and patient assessment.

Grade and scale the level of agitation

Patient Category Risk Score

Consider the risk to administer a sedative to a morbid agitated patient

Mental Risk Assessment and Patient Risk Score

Consider the level of agitation and the sedative/anaesthetic administration risk

Surviving Sedation Guidelines 2017
Authorship : Dr Minh Le Cong, Dr Andy Buck, Dr George Douros, Dr Casey Parker, Dr Tim Leeuwenberg,

Agitated and collaborative

Use your non clinical skills, use humanity. Mostly of the times talking and trying to understand what is the problem is already a solution. Cigarettes and coffe helps more than police and drugs.

Agitated non collaborative non dangerous

You have time to de-escalate, it’s not an emergency. Try to enter behind the patients psychological self-defences. Here some tips on de-escalation techniques:


Is not an emergency but you are an emergency medical service! Your time is precious and is non endless. When words and non clinical skills are not enough you need to use your pharmacological weapons.

IM (intramuscular) is the favourite route to administer drugs cause is fast, effective easily and widely accessible .

IN (intranasal) is fast effective but most of the times is not reliable and widely accessible.

Last chance is IV (intravenous) that need more time to be placed and put at great danger the rescuers and the patient himself.

My receipt is a combination of Benzodiazepines and Antipsychotics to reach all the possible receptors in assuefatte patients and to minimise the doses of each one to reduce possible side effects.



5 MG IV, 10 MG IM


Agitated non collaborative and dangerous

Is a social and medical emergency! You need to act fast to protect patient and others and most of the time law enforcement need to apply a strong contention.

Highly agitated patients are physically and psychologically stressed and mostly of the times present a strong metabolic acidosis. When restraining them applying hypoxic measures (supine position, chest ore neck pressure, airway closure) we add respiratory acidosis and highly elevates the risk of mortality.

10-36% mortality

Learn how to restrain safely!

  • Avoid prone position
  • Avoid pressure on the chest
  • Avoid covering the agitated patient’s mouth and/or nose with a gloved hand
  • Lay the patient down in supine position
  • Immobilise one arm above the head and the other below the waist.
  • Use an oxygen mask to prevent the patient from spitting on staff

Favourite drug for this kind of patient is the one that doesn’t impact hemodinamyc and respiratory drive


Associating Ketamine with low dose Midazolam (0,03 mg/Kg) is a viable option.

Special conditions

Elderly agitated patients

  • Avoid Benzo for increased risk of respiratory depression and delirium
  • Best choice is Haloperidol (0,5 mg IM stating dose)
  • Start without low doses, tritrate (slowly) to desired effect

Alcohol intoxication

  • Alcohol intoxication is a high risk sedation.
  • Avoid Midazolam
  • Haloperidol or Droperidol are safest options but work slow for emergency situations.
  • In emergency give half dose IM ketamine ( 2mg/kg) then Haloperidol or Droperidol if needed.

RSI in agitated patients

  • Avoid succinylcholine because of potential side effects such as hyperkalemia, hyperthermia and acidemia.

Take Home Points

  1. Consider alternative diagnosis
  2. Grade and scale the level of agitation
  3. Consider the risk to administer a sedative
  4. Cross match risk and level of agitation
  • What kind of patient you are dealing with?
    • Agitated collaborative
    • Agitated non collaborative non dangerous
    • Agitated non collaborative dangerous
  • Agitated collaborative
    • Understand patients needs
    • Be nice
  • Agitated non collaborative non dangerous
    • Take your time
    • De-escalate
    • If still agitated sedate
    • Choose the most reliable administration route
      1. IM
      2. IV
      3. IN route is most of the times unreliable in emergent agitated patient
    • Combine drugs for best result
      • Midazolam
      • Haloperidol/Droperidol
  • Agitated non collaborative dangerous
    • Act fast
    • Protect patient during physical restraining
    • Avoid asfittic stimuluses
    • Sedate
      • Ketamine IM
      • Midazolam IM

Treat and Think

Acute Agitated Patient Grade/Risk Assessment/Treatment Scheme


  1. American College of Emergency Physicians White Paper Report on Excited Delirium Syndrome September 2009
  2. Gill JR. The syndrome of excited delirium. Forensic Sci Med Pathol 2014; 10:223-228.
  3. Vilke GM, Bozeman WP, Dawes DM et al. Excited Delirium Syndrome (EXDS); Treatment Options and Considerations. Journal of Forensic and Legal Medicine 2012; 19:117-121.
  4. Vilke GM, Payne-James J, Karch SB. “Excited delirium (ExDS): Redefining an old diagnosis. Journal of Forensic and Legal Medicine 2012; 19:7-11
  5. Hick JL, Smith S, Lynch MT. Metabolic acidosis in restraint-associated cardiac arrest: a case series. Academic Emergency Medicine 1999; 6(3):239-243.
  6. Dimsdale JE, Hartley LH, Guiney T et al. Post exercise peril – plasma catecholamines and exercise. JAMA 1984; 251(5): 630-632.
  7. Green SM, Roback MG, Kennedy RM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Annals of Emergency Medicine 2011; 57(5): 449-461.
  8. Vilke GM, DEBard ML, Chan TC et al. Excited Delirium Syndrome (EXDS): Defining based on a review of the literature. Journal of Emergency Medicine 2012; 43(5): 897-905.
  9. Chan EW, Taylor DM, Knott JC et al. Intravenous droperidol or olanzapine as an adjunct to midazolam for the acutely agitated patient: a multicenter, randomised, double blind, placebo controlled clinical trial. Ann Emerg Med 2013; 61:72-81.
  10. Ibister GK, Calver LA, Page CB et al. Randomised controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: The DORM study. Ann Emerg Med 2010; 56:392 – 401.

Hot off the press. My favourite 2021 Articles

1 Gen

Even for 2021 we had to chose (in many fields) between science/evidences and non science/non evident way to perform our clinical activity. I chosen science and this is just a little extract of what I read in those 12 months. I hope you’ll enjoy it and fell free to send me more suggestions about interesting articles in 2021 emergency medicine literature.

A good 2022 to everyone.

Mario Rugna


Airway management

Cardiac Arrest

Pain management


Fuori binario. Consapevolezza della diversità ed elogio della soggettività in Medicina d’Urgenza “street level”

26 Giu


Sono sempre stato affascinato dalla rivista Fuori Binario una pubblicazione indipendente che si definisce“un giornale di strada, fatto, scritto e distribuito dalle persone che vivono il disagio sulla propria pelle o che ad esso sono molto vicino.” La distribuzione di Fuori Binario è fatta per strada ad offerta libera e devo dire che lo leggo sempre quando c’è occasione non solo per contribuire in piccolissima parte a finanziare chi lo scrive e la pubblica, ma sopratutto perchè gli argomenti trattati e lo stile con cui è scritto mi ricorda molto la mia Medicina d’Urgenza “di strada”. Si perché di questo si tratta quando parliamo di Medicina d’Urgenza preospedaliera di una specialità portata a livello della strada fatta anche per le persone che vivono per strada di giorno e di notte come gli autori e buona parte dei lettori di Fuori Binario

E le similitudini non finiscono qui. Perché la Medicina d’Urgenza preospedalera, come i lettori e gli autori di Fuori Binario, è la parte “povera” e diciamolo un pò dimenticata della Medicina d’Urgenza, tra scarsità di mezzi e carenze ataviche di personale. Ma è anche la parte più libera ed indipendente della nostra specialità così lontana dagli occhi dei Direttori e dei Coordinatori dispersa in postazioni territoriali remote e spesso disagiate.

E noi professionisti? Anche noi siamo diversi. Diversi tra noi, un misto tra convenzionati e dipendenti, diversi come provenienza culturale, tra giovani specialisti e “vecchi” autoformati.

Siamo diversi perchè esercitiamo la Medicina d’Urgenza in ambienti difficili con scarso controllo di tutto ciò che ci accade intorno senza nessun filtro o barriera architettonica a proteggere quello che facciamo. Il nostro lavoro è sempre sotto gli occhi di tutti.

I nostri pazienti sono diversi. Polipatologici, spessì agitati, difficilmente approcciabili per limiti ed incomprensioni linguistiche o culturali, quasi mai attendibili quando si tratta di ottenere un’anamnesi accurata. Spesso non sono critici e non hanno grosse esigenze cliniche ma hanno sempre bisogno di una parola o di una carezza.

Siamo un’armata Brancaleone! Eteroassortiti un team misto di professionisti medici ed infermieri affiancati da volontari e tecnici con differente livello culturale ed espressivo sempre pieni di buona volontà, ma con cui è impossibile fare una programmazione preventiva o anche una razionale divisione dei ruoli.


La formazione in Medicina d’Urgenza negli ultimi anni sta diffondendo la cultura della standardizzazione su protocolli internazionali validi a Firenze ma anche a Perth a Oslo o a Seattle. I protocolli internazionali sono oramai diventati il nostro strumento di lavoro ed il metro di valutazione della qualità sia dentro che fuori dall’ospedale. Ma avete mai riflettuto sull’etimologia del termine PROTOCOLLO, perchè è nella radice etimologica della parola che spesso si nasconde la vera natura del suo significato.

Protocollo: πρωτόκολλον, comp. di πρῶτος «primo» e κόλλα «colla», termine col quale s’indicava il primo foglio di un rotolo di papiro costituito dalla giustapposizione, per mezzo di colla, di più fogli.

Cit. Dizionario Treccani

In pratica il protocollo è solo la copertina di un libro ed utilizzarlo pedissequamente è come leggere solo la prima pagina dell’intero quadro clinico di un paziente. Significa rendere semplicisticamente standard quello che standard non può essere perchè ogni paziente è diverso per fisiologia e patologia ed ogni linea guida o protocollo non può non tenerne conto. La soggettività con cui noi professionisti sanitari esercitiamo la nostra pratica clinica non è caos e disorganizzazione ma rispetto per la diversità delle persone che soccorriamo, sia dal punto di vista clinico che umano. Personalmente lo considero un valore aggiunto e non un difetto di professionalità. Chi pretende di valutare la qualità dell’assistenza esclusivamente in base alla stretta aderenza ai protocolli o alle linee guida, senza tenere conto delle ragionevoli variabilità legate alla soggettività dei pazienti può essere solo chi questa professione non l’ha mai esercitata perchè amministrare è diverso da curare.

Il professionista esperto e culturalmente adeguato conosce il protocollo ma sa quando uscirne per salvaguardare la salute del paziente.

La formazione in Medicina d’Urgenza non deve mai perdere il contatto con la realtà clinica quotidiana in cui la diversità e la soggettività sono determinanti fondamentali, e deve porsi come obiettivo prioritario non semplificare e standardizzare, ma fornire ai professionisti strumenti culturali e tecnici per esaltare ed esercitare adeguatamente la propria discrezionalità clinica.

Per utilizzare i protocolli servono delle prototeste (teste primordiali) ma per andare oltre essi serve acume clinico esperienza e cultura.

All about Ketamine with Minh Le Cong, Fabio De Iaco e Mario Guarino

25 Gen

Watch the full video meeting

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.


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)
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


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