Continua la pubblicazione di una serie di monografie dedicate alle Best Practices per l’emergenza preospedaliera.
La quarta della serie riguarda l’arresto cardiaco nel neonato.
Potete scaricare il documento cliccando sull’icona sottostante.
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La terza della serie riguarda l’arresto cardiaco in età pediatrica.
Potete scaricare il documento cliccando sull’icona sottostante.
La seconda della serie riguarda l’arresto cardiaco in gravidanza.
“Best Practice” preospedaliera: Arresto cardiaco nel neonato
29 Lug
La quarta della serie riguarda l’arresto cardiaco nel neonato.
“Best Practice” preospedaliera: Arresto cardiaco in età pediatrica
16 Lug
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.
“Best Practice” preospedaliera: Arresto cardiaco in gravidanza
1 Lug
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.
“Best Practice” preospedaliera
25 Giu
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.
Drug-to-drug interaction. New evidences on Morphine and delayed onset of action of antiplatelet agents.
8 Mag
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
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.
References
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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
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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.
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Parodi G,Valenti R, Bellandi B, et al. Comparison of prasugrel and ticagrelor loading doses in ST-segment elevationmyocardial infarction patients: RAPID (Rapid Activity of Platelet Inhibitor Drugs) primary PCI study. J Am Coll Cardiol 2013; 61: 1601–1606
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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.
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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.
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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.
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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
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Duggan ST and Scott LJ. Intravenous paracetamol (acetaminophen). Drugs 2009; 69: 101–113.
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Zijlstra F, Ernst N, de Boer MJ, et al. Influence of prehospital administration of aspirin and heparin on initial patency ofthe infarct-related artery in patients with acute ST elevation myocardial infarction. J Am Coll Cardiol 2002; 39: 1733–1737
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Yusuf S, Sleigh P, Rossi P, et al. Reduction in infarct size and chest pain by early intravenous beta blockade in suspectedacute myocardial infarction. Circulation 1983; 67: 132–141.
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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
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:
- Cristalloids tend to displace the already formed clots and improves bleeding
- Normal Saline produce hypercloremic acidosis worsening coagulation and precipitating renal and immune dysfunction
- Cristalloids diluts the coagulation factors and precipitate the coagulation system (dilution coagulopathy)
- 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
- Current Issues in Fluid Resuscitation Following Trauma
- Fluid resuscitation in trauma patients- what should we know
- The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study
- Hypotensive Resuscitation
- Liberal Versus Restricted Fluid Resuscitation
- Trauma-Induced Coagulopathy
- Fluid Resuscitation for Trauma Patients: Crystalloids Versus Colloids
- Recent developments in the assessment of the multiply injured trauma patient
- Meta-analysis of high- versus low-chloride content in perioperative and critical care fluid resuscitation
Bougie Intubation with the Kiwi-DuCanto Grip
14 AprLove 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.
Measuring performances in prehospital emergency medicine
5 Apr
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).
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?
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.
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:
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Aspirin (if not allergic)
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12-Lead electrocardiograph and pre-arrival activation of interventional cardiology team as indicated
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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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“Best Practice” preospedaliera: Arresto cardiaco da trauma
4 AgoTra tutte le “Best Practices”, quella che rappresenta più di tutte un cambio radicale di mentalità nell’approccio clinico e terapeutico, è la gestione dell’arresto cardiaco da causa traumatica. Vi prego quindi di leggere attentamente le raccomandzioni raccolte nel documento sottostante e di non esitare a esprimere le vostre riflessioni nei commenti.
Chi è interessato ad approfondire il razionale che sta alla base delle raccomandazioni può scaricare e leggere il documento completo: Arresto cardiaco nell’adulto da causa traumatica full text
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Tag:ACR, arresto cardiaco, emergency medicine, Emergency Medicine guidelines, Linee guida, medicina d'urgenza, prehospital emergency medicine