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Spinal Motion Restriction: Why?

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Year in Review. 2019 Advanced Life Support Literature of note.

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Year in Review. 2019 Guidelines you must read. Free Open Access.

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Year in Review. 2019 Trauma Literature of note.

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Year in Review. 2019 Airway Management Literature of note.

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TXA in Trauma Patients. The CRASH 3 Trial.

21 Ott

Pulseless electrical activity following traumatic cardiac arrest: Sign of life or death?

11 Giu

On May 2019 was published an article we review today, cause the authors conclusions are pretty astonishing and worth a deeper look.

Israr, S & Cook, AD & Chapple, KM & Jacobs, JV & McGeever, KP & Tiffany, BR & Schultz, SP & Petersen, SR & Weinberg, JA. (2019). Pulseless electrical activity following traumatic cardiac arrest: Sign of life or death?. Injury. 10.1016/j.injury.2019.05.025.

Authors Conclusions: Following pre-hospital traumatic cardiac arrest, PEA on arrival portends death. Although Cardiac Wall Motion (CWM) is associated with survival to admission, it is not associated with meaningful survival. Heroic resuscitative measures may be unwarranted for PEA following pre-hospital traumatic arrest, regardless of CWM.Trauma death 2.jpg

What kind of study is this?

retrospective, cohort study consisting of adult trauma patients (n. 277 patients ≥18 years of age) admitted to one of two American College of Surgeons verified level 1 trauma centers in Maricopa County, Arizona within the same hospital system between February 2013 to September 2017 and January 2015 to December 2017.

Pre-hospital management by emergency medical transport services was guided by advanced life support protocols. 

Both hospitals for management of Traumatic Cardiac Arrest (TCA) followed the Western Trauma Association Guidelines

The following variables were collected from each patient:

  • Age
  • Gender
  • Duration of pre-hospital CPR
  • Survival to admission vs. pronouncement of death in ED
  • Disposition at hospital discharge


  • 277 trauma patients that underwent pre-hospital CPR for TCA
  • Mean patient age was 43.1
  • Mechanism of injury was penetrating in 99 patients (35.7%), the most common of which was due to ballistic injuries, the rest where blunt trauma.
  • 52.0% of the patients were intubated prior to hospital arrival
  • 235 patients received epinephrine in route (84.8%)
  • Pre-hospital resuscitation duration, 20.0 (15.0 – 25.0) minutes


20 patients were identified on arrival to have had ROSC. 18 of these patients survived to hospital admission and 4 of them were discharged alive from hospital

147 patients were identified on arrival in asystole. Among these patients none were discharged alive from hospital.

The remaining 110 patients presented with PEA. 10 patients survived to admission, 9.1%, but only one, 0.9% was discharged from alive from hospital.

P-FAST was performed in 79 of the 110 patients with PEA (71.8%)

Presence of CWM was significantly associated with survival to hospital admission (2 but not to hospital discharge (zero with or without CWM).

Authors conclusions

  • Resuscitative efforts are unlikely to reverse the course of this pathophysiology, warranting sound clinical judgement from the treating physician concerning the decision to continue or desist, relative to mechanism of injury and clinical presentation.
  • CWM (signifying a beating heart and thereby pseudo PEA) was not associated with meaningful survival.
  • Nonetheless, we conclude that P-FAST is a useful tool for distinguishing PEA with cardiac standstill, which is in all likelihood terminal (and continued resuscitation would become an attempt at reanimation), versus pseudo PEA, whereby the heart is actually still beating, representative of a veritable sign of life, and ongoing resuscitative attempts may be considered appropriate despite the unfavorable prognosis.

My considerations on methodology and results

  1. Conventional ACLS protocol, as performed in the study, IS NOT the standard of care in TCA.
  2. No clinical intervention to address reversible causes where performed (or mentioned) in the field.
  3. The only clinically oriented manoeuvre performed in the field was tracheal intubation in just half of the patients (52.0% of the patients were intubated).
  4. Prehospital resuscitation time (20 minutes mean time) was spent performing non useful and potentially  dangerous interventions (closed chest compressions, epinephrine administration) for TCA.
  5. Patients with PEA and documented CWM (but not only them) at their arrival in ED has been hypo perfused during the entire pre-hospital resuscitation time and lost most of their chances for good clinical outcome.

So in my opinion this study and it’s conclusions are biased by a wrong approach to Traumatica Cardiac Arrest in the prehospital phase.

Emergency providers, when treating patients in traumatic cardiac arrest, need to perform interventions addressing the possible REVERSIBLE causes:

  1. Exanguination/Massive Hemorrage (Pelvic Binding, TXA administration, Tourniquet or direct compression)
  2. Hypoxia (Tracheal Intubation)
  3. Tension Pneumo (Double Thoracostomy)
  4. Hypovolemia (Blood or fluid resuscitation)

Emergency providers need to rely on direct (central pulse palpation, Ultrasuond) or indirect (EtCO2, Plethysmography) signs of perfusion to guide their clinical interventions.

Resuscitation of Traumatic Cardiac Arrest patients in not futile just need to be performed in the right way.




Israr, S & Cook, AD & Chapple, KM & Jacobs, JV & McGeever, KP & Tiffany, BR & Schultz, SP & Petersen, SR & Weinberg, JA. (2019). Pulseless electrical activity following traumatic cardiac arrest: Sign of life or death?. Injury. 10.1016/j.injury.2019.05.025.



Tips in Airway Management

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Do we really need Lights and Sirens when transporting a patient?

16 Apr

For who has a multiyear experience in prehospital emergency medicine and deals everyday with emergency transportation of critical patients the sensation is that the use of emergency warning systems are, mostly of times, useless and doesn’t really have any impact on clinical outcomes. 


But beyond any subjective thought, do we have any evidence on that?

My analysis starts from this article published in 2018 on Annals of Emergency Medicine

by Brooke L. Watanabe, MD et al. and entitled  “Is Use of Warning Lights and Sirens Associated With Increased Risk of Ambulance Crashes? A Contemporary Analysis Using National EMS Information System (NEMSIS) Data”. The authors conclusion says that Ambulance use of lights and sirens is associated with increased risk of ambulance crashes. The association is greatest during the transport phase. EMS providers should weigh these risks against any potential time savings associated with lights and sirens use.

Curbside to Beside blog published an interesting post about this topic and resumed the data in this incredibly intuitive infographic


Data extrapolated from
Wantabe et al. (2018)

While ambulances crash rate when using L&S (light and sirens) in the response phase is slightly increased  (7.0 vs 5.4) in the transportation phase the amount of crashes associated with L&S use is significatively higher (17.1 vs 7.0). 

So L&S transportation increases the odd of crash (and this is intuitive) but, on the other side, is there any evidence that use of L&S increases response time and improve clinical outcome?

Fast is Time????

Fabrice Dami et al in an article entitled Use of lights and siren: is there room for improvement?” found that the time saved with L&S transport was 1.75 min (105 s; P<0.001) in day time and 0.17 min (10.2 s; P=0.27) night-time.

So evidently fast is time, but is a gain of less than 2 min a clinical significative time?

Time is Life???

In 2010 in the article “Emergency Medical Services Intervals and Survival in Trauma:Assessment of the “Golden Hour” in a North AmericanProspective Cohort” concluded that there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field”.

Anderson et al in a 2014 article “Preventable deaths following emergency medical dispatch – an audit study” demonstrated how just 0,2% of the 94.488 “non L&S” dispatched emergencies died in the first 24 hours from the call.  Of those just 0.02% of total “non L&S” emergencies were considered “potentially preventable if the dispatcher had assessed the call as more urgent and this had led to an ambulance dispatch with a shorter response time and possible rendezvous with a physician-staffed mobile emergency care unit”

So mostly of the emergencies are not time sensitive and the clinical outcome does not differ if the transport time is shorter.

Take home messages for our system and for clinical practice

Maybe we need lights and sirens in response phase, cause slightly increase in accident risk corresponds to  some gain in arriving time on the scene.

Maybe we don’t need lights and sirens in transportation phase  cause a great increase in risk of crash do not correspond to a clinical sensitive time gain.


For sure when using L&S we need to be aware that the risk doesn’t worth the price, and even if we use L&S in the varies phases of emergencies pushing the threshold of                security too forward increases the risks and don’t improve clinical benefits for the transported patients.

Clinicians need to be more concerned about performing the right procedures to stabilise patients on pre-hospital phase more than hurrying  with unstable patients toward an unreal Eldorado and risking their own and patients lives




Syncope. We need a prehospital pathway.

18 Feb

Non traumatic Transitory Lost Of Consciousness (TLOC) is a common cause of medical emergency call. Among TLOC Syncope is the most common cause. So the first challenge for an emergency professional is discerning from Syncope and non syncope situations (seizures, psychogenic, other rare causes).

Screenshot 2019-02-09 at 11.33.01

2018 ESC Guidelines for the diagnosis and management of syncope

Syncope according to 2018 Guidelines definition is a “TLOC due to cerebral hypoperfusion, characterised by a rapid onset, short duration, and spontaneous complete recovery”. 

Among Syncope the causes can be found in vagal reflex (Reflex syncope), a drop in blood pressure due to a deficiency of compensation in a standing position (Orthostatic syncope) and a cardiac cause of syncope (Cardiac syncope)

Screenshot 2019-02-17 at 17.44.17

2018 ESC Guidelines for the diagnosis and management of syncope

But what is the role and what can and must be done on the prehospital field to understand treat and risk stratify a Syncope?


Is a fundamental step to understand and risk stratify a syncope episode. It has to be targeted to collect all the important informations and to don’t loose precious time.

We can divide the information we collect in two categories.

The first kind of information we area going to ask (to bystanders and patients) is about the syncope event.

  • How much the lost of consciousness lasted
  • How it happened (standing, sitting or laying)
  • What was the patient doing (resting or during exercise)
  • What the patient felt before the syncope (palpitations, chest pain, dyspnea, dizziness, other)
  • What happened during or immediately after the syncope (seizures, other)

Second step is collecting informations about the patient medical conditions. We have to focus on

  • What medical condition he actually suffers or suffered in the past
  • Which kind of drugs he is actually doing

After a focus anamnesis the second step is about the physical exam of the patient.

Diagnostic tests

During physical exam a rapid general neurologic and cardiac examination has to be completed, but two additional steps need to be done in a syncope patients

  • Orthostatic challenge in active standin position
  • Carotid sinus massage (CSM) in patients aged >40 years.

Orthostatic challenge:  Standing BP evaluation has to be done after 3 minutes of active standing position with the patient fully monitored, and “abnormal BP fall is defined as a progressive and sustained fall in systolic BP from baseline value >_20 mmHg or diastolic BP >_10 mmHg, or a decrease in systolic BP to <90 mmHg” (European Society of Cardiology 2018 ESC Guidelines for the diagnosis and management of syncope).

Carotid sinus massage: A ventricular pause lasting >3 s and/or a fall in systolic BP of >50mmHg is known as carotid sinus hypersensitivity. “Carotid sinus syndrome (CSS) There is strong consensus that the diagnosis of CSS requires both the reproduction of spontaneous symptoms during CSM and clinical features of spontaneous syncope compatible with a reflex mechanism.” (European Society of Cardiology 2018 ESC Guidelines for the diagnosis and management of syncope)

12 leads EKG

It’s a fundamental diagnostic tool and has to be performed in all syncope patients.

What are the risky features we have to consider when looking to ann EKG of a syncope patients:

At least 6:

  1. Ischemia
  2. Arrithmia
  3. Pre-excitation/WPW
  4. Brugada pattern
  5. Hypertrophic cardiomyopathy
  6. Arrhythmogenic Right Ventricular Cardiomyopathy


Is there a role for Point of Care Ultrasound in differential diagnosis and risk stratification of syncope.

Probably yes cause we can look at:

  • Aorta for dissection
  • VD/VS ratio for PE
  • Pericardium for effusion
  • EF for cardiac function evaluation
High risk VS non high risk syncope

At the end of those steps the prehospital professional has two chances.

  1. There is a likely cause of syncope
  2. The syncope is of unknown cause
Screenshot 2019-02-17 at 18.52.22

2018 ESC Guidelines for the diagnosis and management of syncope

If the cause is known or very likely we have to follow the specific pathway.

In the unknown syncope we have to stratify the risk.

In prehospital field is important to look for high risk features of syncope:

  • History of heart failure or other cardiac conditions
  • Syncvope in supine position
  • Syncope during excercise
  • Dyspnea before or immediately following syncope
  • Palpitations before syncope episode
  • EKG abnormalities
  • Persisting low blood pressure (SBP<90 mmHg) in supine positi
  • Orthostatic Hypotension

Each one of those is indicative of high risk prehospital features and the patient need further ED examination.

In all other cases the clinician can decide case by case if the patient can be treated out of the hospital or need admission to ED.


References :

Michele Brignole, Angel Moya et al. European Society of Cardiology 2018 ESC Guidelines for the diagnosis and management of syncope




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