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Articles at the Top. Take home messages from 2017 (part 2).

19 Gen

Welcome to our annual review of the best articles from the finishing year.

This will be a weekly (or so..) appointment with the top (or so…) articles of 2017 divided by topic and chosen by me.

Here is the best (for me) about:

 Advanced Life Support

Here are the best 2017 articles:

My take home messages:

Pathophysiological bases in experimental swine models

  • In a swine model following primary cardiac arrest the respiration continues at least for 1 minute. and after that Gasping starts lasting for another minute.
  • In a swine model following primary cardiac arrest the blood shifts from high pressure compartment (arteries) to low pressure compartment (veins). 
  • In a swine model the PaO2 following primary cardiac untreated VF arrests PaO2 results 70 mmHg after 9 min with a saturation of 93% and decrease at 44 mmHg with a saturation of 61% after 14 min of CPR. In this period airway management with possible interruption of chest compressions and starting positive pressure ventilation (with decreased return to the thorax end depression of cardiac output) is not mandatory due to the low cost/beneficial ratio and the potential detrimental effect. 

Chest compressions

  • Chest compressione only CPR is associated with worst outcome in children under 8 yers. Always perform chest compression/ventilation (ratio 15:2) in children <8 years of age (only exception if the cardiac arrest is due to primitive cardiac causes). 
  • Chest compressione only CPR can be a valuable option in adult witnessed VF/pulseless VT primary cardiac arrest (delayed airway management and passive O2 administration is reasonable).
  • Mechanical chest compression (MCC) is the future of CPR. They still do not demonstrated evident superiority in terms of outcome respect to manual chest compressions, but are evidently not inferior with a similar rate of life treating lesions. For sure MCC avoid variability in quality and allows good quality CC during transport. 

Ventilation

  • Lower Tidal volumes following OHCA is independently associated with favourable neurocognitive outcome
  • Weak evidences demonstrate that the ideal rate for ventilation of intubated patients  during CPR is 10/min

Airway management

  • There is not beneficial effect on outcome with early intubation in Cardiac Arrest (CA)
  • Privilege High Quality CPR and Defibrillation (if needed).
  • Use Supraglottic Airway Devices (SAD) in first part (15 min) of resuscitation 
  • If Mechanical Chest Compressions is used, to optimise ventilation with SAD, use 30:2 ratio (because the intrathoracic pressure generated during MCC overrules that generated from SAD and impaires ventilation).
  • In prolonged Cardiac Arrest management converting SAD to Endotracheal Tube can be considered.
  • Experience provider only can perform endotracheal intubation in CA. They have a better chance of first passage rate, without interruption in chest compressions. First pass success rate is positively associated to survival and good neurological outcome.

Defibrillation

  • Escalating bilevel energy (150-200-360 Joule) is associated with more efficacy in termination of shock resistant VF/pulselessVT cardiac arrest
  • Dual Sequential Defibrillation is feasible and safe. Although the evidences on its beneficial effect on outcome are still lacking it has to be considered in case of CA with refractory shockable rhythm. 

Antiarrhythmics drugs

  • There has been no conclusive evidence that any antiarrhythmic agents improve rates of ROSC, survival to admission, survival to discharge or neurological outcomes.

Ultrasound

  • Ultrasound in PEA is a key tool to detect CA causes improving survivival.

Post Resuscitation Care

  • In post resuscitation phase avoid any arterial oxygen and carbon dioxide abnormality because are associated to increased mortality.
  • Centralisation of resuscitated patients toward an acute PCI/CABG capable Center  is associated to better outcome.

Targeted Temperature Management

  • Prehospital cooling does not improve faster in-hospital target temperature achieving and due to its costs is not recommended.
If you are interested on a daily update about the best emergency medicine literature follow me on Facebook, Twitter or give your like to MEDEST Facebook page.

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Articles at the Top. Take home messages from 2017 (part 1).

25 Dic

Welcome to our annual review of the best articles from the past year.

This will be a weekly (or so..) appointment with the top (or so…) articles of 2017 divided by topic and chosen by me.

At the end of the post I will also mention some take home points as summary of the evidences emerged from the articles. 

And now here is the best (for me) about:

 Airway management

Here are the best articles of the past year about Airway Management:

My take home messages about airway management:

  1. Risk factors for intubation related cardiac arrest are: overweight or obesity, age more than 75 years old, low SBP prior to intubation, hypoxemia prior to intubation, and absence of preoxygenation before intubation procedure.
  2. Preoxygenation is crucial (at least 2 minutes), before paralysing, to extend safe apnea time.
  3. Use apneic oxygenation during intubation attempts.
  4. Tracheal intubation is good in the hands of very well skilled professionals. Otherwise can improve mortality rate.
  5. Supraglottic devices perform well in cardiac arrest and are a valuable option for airway management. 
  6. Videolaryngoscopy improve glottic view but need training to improve first pass success.
  7. Always use paralytics when intubating a non cardiac arrest patient. It improves the chances fo first pass success.
  8. Rocuronium and Succynocholine are both valuable options for paralysis in airway management. 
  9. Dose Succynocholine, and other depolarising neuromuscular blockade drugs, based on actual body weight. Dose Rocuronium or Vecuronium based on ideal body weight.
  10. Use cuffed tracheal tubes even in paediatric patients. They perform well and  complications rate is the same. 
  11. The difficult airway is a myth. It’s not  a matter of technique but of decision making.
If you are interested on a daily update about the best emergency medicine literature follow me on Facebook, Twitter or give your like to MEDEST Facebook page.

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The “3 SIMPLE Rules”: an easy and accurate tool for recognizing VT

17 Dic
Following the discussion on ectopy and aberrancy (view Ectopy or aberrancy? Google Ecg+ community comments on a clinical case.)  Ken Grauer, EKG master and author of many EKG books, gave us the permission to share his “3 SIMPLE Rules” to recognize VT in a simple ad accurate way.
 
  • Rule #1 Is there extreme axis deviation during WCT

Extreme axis deviation is easy to recognize. The QRS complex will be entirely negative in either lead I or lead aVF. The presence of extreme axis deviation during a WCT rhythm is virtually diagnostic of VT.
  • Rule #2 Is lead V6 all (or almost all) negative?

IF ever the QRS in lead V6 is either all negative (or almost all negative)  then VT is highly likely.
  • Rule #3 Is the QRS during WCT “ugly”?

The “uglier” the QRS the more likely the rhythm is. VT originates from a ventricular focus outside of the conduction system. As a result VT is more likely to be wider and far less organized (therefore “uglier”) in its conduction pattern
 
The “3 simple rules” is an extract from ACLS 2013 Arrhythmias  where you can find the complete explanation and much more on arrhythmias.
Visit Ken Grauer Amazon page to find out more and discover all the amzing EKG books he wrote. They are accurate and reliable for use in many emergency situation.
I’ll include Ken’s reply in the main script of the post cause it contains some very important adjuncts and expalnations. At the end of the replay you’ll find the link to download the full text of the section regarding the WCT topic. You’ll also appreciate the perfect Ken’s italian. I’m amazed….
Molto grazie Mario per la pubblicazione del mio consiglio su le tre semplici regole per diagnosticare VT! I’ll make a few brief additions to what Mario wrote. RULE #1 – Remember that slight or even moderate axis deviation is of no help. The QRS complex must be ALL negative in either lead I or in lead aVF. If it is – then the rhythm is almost always VT. RULE #2 – Again, moderate negativity in lead V6 is common and means nothing. But if the QRS complex in lead V6 is either all negative or shows no more than a tiny r wave – then VT is likely. This is because such marked negativity in lead V6 implies that the impulse is moving away from the apex – and that almost always means VT. RULE #3 – Supraventricular rhythms with either preexisting bundle branch block or aberrant conduction typically resemble some form of conduction defect (ie, either RBBB, LBBB or RBBB with LAHB and/or LPHB). However, if the QRS complex is amorphous (ie, very “ugly” and formless) – then it is much more likely to be originating from the ventricles. Occasionally, patients may have unusual forms of IVCD – so this rule is not 100% accurate – but it is a helpful supportive point in the differential diagnosis. For those wanting more complete description of the 3 Rules (and other pointers in assessing wide tachycardias) – feel free to download these Sections from my ACLS-2013-ePub – GO TO – https://www.dropbox.com/s/8bc9h5cumo7e4vy/8.0%2C9.0%2C10.0-%20ACLS-2013-e-PUB-WCT-Criteria-%2810-13.11-2014%29-LOCK.pdf?dl=0 – Detailed description of the 3 Simple Rules begins in Section 08.17. Spero che questo vi aiuta.”
Ken Grauer
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Do you needle cric?

26 Apr

Great demonstration from Minh Le Cong on how to needle cric in emergency prehospital situation. Visit PHARM Blog for more great FOAMED stories.

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Mind of Resuscitation in Traumatic Cardiac Arrest

19 Apr
TCA blunt

BLUNT TRAUMATIC CARDIAC ARREST

MEDEST
TCA pen

PENETRATING TRAUMATIC CARDIAC ARREST

MEDEST

Brian Burns: Always carry your scalpel!

26 Ott
From SMACC 2013 Dr. Brian Burns (Greater Sydney Area HEMS) presents why a scalpel is an imprtant item in your emergency bag. Never miss it!
A don’t miss talk/slides for every prehospital emergency physician. The last part of the talk regards the trauma arrest algorithm: how to treat arrested trauma patient in the field.
I think every prehospital professional as to be aware about new prospective on trauma treatment. Enanching survival in trauma is one of the missions of prehospital emergency service.
So enjoy Dr Burns slides and audio on “Always carry your scalpel”

Un bisturi può essere un importante aiuto in molte situazioni difficili. Non ci credete?  Ascoltate Brian Burns (Greater Sydney Area HEMS) che illustra molti utili “usi” del bisturi in medicina d’emergenza preospedaliera.

Click HERE for the audio

The fastest ambulance…..

10 Ott

Great ideas usually come from apparent insanity…..

Cardiac arrest complicating emergency airway management

24 Ago

References:

Incidence and factors associated with cardiac arrest complicating emergency airway management

RAPID: Ticagrelor e Copidogrel a confronto nel paziente con STEMI.

8 Ago

Comparison of Prasugrel and Ticagrelor Loading Doses in ST-Segment Elevation Myocardial Infarction Patients

RAPID (Rapid Activity of Platelet Inhibitor Drugs) Primary PCI Study

Guido Parodi, MD, PHD, Renato Valenti, MD, Benedetta Bellandi, MD, Angela Migliorini, MD, Rossella Marcucci, MD, Vincenzo Comito, MD, Nazario Carrabba, MD, Alberto Santini, MD, Gian Franco Gensini, MD, Rosanna Abbate, MD, David Antoniucci, MD Florence, Italy

OBJECTIVES: This study sought to compare the action of prasugrel and ticagrelor in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI). BACKGROUND: It has been documented that prasugrel and ticagrelor are able to provide effective platelet inhibition 2 h after a loading dose (LD). However, the pharmacodynamic measurements after prasugrel and ticagrelor LD have been provided by assessing only healthy volunteers or subjects with stable coronary artery disease. METHODS: Fifty patients with STEMI undergoing PPCI with bivalirudin monotherapy were randomized to receive 60 mg prasugrel LD (n = 25) or 180 mg ticagrelor LD (n = 25). Residual platelet reactivity was assessed by VerifyNow at baseline and 2, 4, 8, and 12 h after LD. RESULTS: Platelet reactivity units (PRU) 2 h after the LD (study primary endpoint) were 217 (12 to 279) and 275 (88 to 305) in the prasugrel and ticagrelor groups, respectively (p = NS), satisfying pre-specified noninferiority criteria. High residual platelet reactivity (HRPR) (PRU ≥240) was found in 44%and 60% of patients (p = 0.258) at 2 h. The mean time to achieve a PRU <240 was 3 ± 2 h and 5 ± 4 h in the prasugrel and ticagrelor groups, respectively. The independent predictors of HRPR at 2 h were morphine use (odds ratio: 5.29; 95% confidence interval: 1.44 to 19.49; p = 0.012) and baseline PRU value (odds ratio: 1.014; 95% confidence interval: 1.00 to 1.03; p = 0.046). CONCLUSIONS: In patients with STEMI, prasugrel showed to be noninferior as compared with ticagrelor in terms of residual platelet reactivity 2 h after the LD. The 2 drugs provide an effective platelet inhibition 2 h after the LD in only a half of patients, and at least 4 h are required to achieve an effective platelet inhibition in the majority of patients. Morphine use is associated with a delayed activity of these agents. (Rapid Activity of Platelet Inhibitor Drugs Study, NCT01510171).

Abbiamo parlato con uno degli autori del lavoro: Guido Parodi, cardiologo interventista della Dipartimento del cuore e dei vasi al Policlinico Ospedaliero Universitario di Careggi a Firenze.

Logo MEDEST2Guido buongiorno e grazie di aver accettato il nostro invito

Buongiorno a tutti

Logo MEDEST2Quali sono le implicazioni  del vostro sudio per l’emergenza sanitaria preospedaliera.

Sicuramente la somministrazione dell’antiaggregante precocemente sul territorio ha un benefit sia in termini di flusso Timi all’arrivo in sala di emodinamica che di re-stenosi e di mortalità sul paziete con STEMI che viene sottoposto a PCI.

 Logo MEDEST2Quindi l’ASA somministrata dal medico d’emergenza a casa del paziente è ancora un cardine nella terapia dello STEMI

Direi di si, anzi i dati evidenziano una tendenziale preferenza per dosaggi alti e via di somministrazione rapida (Aceltisalicilato di Lisina ev ndr) come opzione migliore sull’inibizione della catena dell’acido arachidonico.

Logo MEDEST2Parliamo ora dei nuovi antiaggreganti piastrinici. Ha un vantaggio la loro somministrazione in fase preospedaliera, e la doppia antiaggregazione già a casa del paziente è un’opzione valida e priva di rischi

Siamo ancora in attesa dei risultati dei due grossi trial (ACCOAST ed ATLANTIS ndr) che indagano questo aspetto, anche se le prime indiscrezioni rivelano come un aumento dei sanguinamenti maggiori abbia costituito un elemento limitante perlomeno per uno di essi. Sicuramente i nostri dati indicano come l’attività antipiastirnica, sia del Prasugrel che del Ticagrelor  abbia bisogno di almeno 4 ore dalla LD (loading dose ndr) prima di raggiungere livelli efficaci

Logo MEDEST2Concordi quindi che in attesa di dati certi sull’efficacia e la sicurezza  dell’uso preospedaliero di questi nuovi antiaggreganti convenga concentrare le nostre energie sull’efficacia organizzativa e sulla riduzione dei tempi nel paziente con STEMI

Sicuramente la riduzione del tempo tra il FMC (first medical contact ndr) e l’arrivo del paziente alla porta dell’ospedale in questo momento garantisce un maggiore beneficio sull’outcome del paziente ed è quindi prioritario

Logo MEDEST2Ho notato che tu escludi a priori il Clopidogrel dall’uso in emergenza. Confermi quindi quelli che sono le indicazioni della review apparsa sul JAMA lo scorso anno: nessun beneficio, tempi d’azione lunghi, aumento dei rischio sanguinamento non giustificato.

Assolutamente si, riserverei l’utilizzo del Clopidogrel solo in pazienti selezionati e ne sconsiglio l’uso routinario in emergenza.

Logo MEDEST2Passiamo ora alle considerazioni sull’anticoagulante di scelta. Eparina non frazionata, a basso peso molecolare o cos’altro

L’eparina non frazionata (anche se di classe I B ndr) ha un suo ruolo visto il rapporto favorevolissimo tra impatto economico ed efficacia rispetto ad esempio alla Bivaluridina che ha costi estremamente elevati (attualmente non proponibili per la maggior parte dei sistemi d’emergenza ndr). Vorrei comunque puntualizzare come la via di somministrazione sottocutanea sia assolutamente da evitare; non ci permette infatti di misurare lo stato coagulativo del paziente che giunge in sala, e rende difficile un eventuale shift ad altri tipi di eparina che noi usiamo comunemente. Quindi eparina non frazionata, ma endovena ai dosaggi raccomandati dalle attuali linee guida.

Logo MEDEST2Leggendo i risultati del vostro trial, tra essi noto al punto 4 come la morfina rallenti l’attività antipiastrinica sia del Ticagrelor che del Prasugrel. Ci puoi dire di più a proposito

La morfina nell’analisi statistica retrospettiva è risultato un fattore di regressione negativo riguardo ad uno degli end-point secondari (HRPR high residual platelet reactivity ndr). Il rallentamento della motilità gastrica ed il vomito possono essere le spiegazioni di tale effetto; bisogna comunque anche evidenziare che i pazienti che ricevono morfina sono quelli tendenzialmente più sofferenti con un livello di vasocostrizione già elevato e precedente la somministrazione dell’oppiaceo.

Logo MEDEST2Quale atteggiamento consigli in funzione di tale osservazione riguardo all’analgesia del paziente STEMI, ed all’uso della morfina.

L’uso dei Nitrati (in aggiunta all’ASA ndr) come farmaco di primo impatto per l’analgesia potrebbe essere una scelta razionale che rimane nell’ambito delle evidenze attuali. Limiterei l’uso della Morfina ai casi di dolore refrattario a questo trattamento (obbligatorio l’uso di una scala di valutazione del dolore che ne permette il monitoraggio nel tempo ed il raggiungimento del target desiderato ndr) arginando così il numero di pazienti che ricevono oppiacei e rispettando allo stesso tempo il diritto all’analgesia

Logo MEDEST2Un oppiode di sintesi, fentanyl o remifentanyl ad esempio, potrebbe essere a tuo parere un’alternativa valida

Non sono a conoscenza di dati in merito. Potrebbe essere uno spunto di studio ulteriore.

Logo MEDEST2Infine una domanda che va oltre gli argomenti del trial ma che sta molto a cuore a tutti noi che lavoriamo sul territorio ed in emergenza in generale, e che riguarda anche voi cardiologi interventisti. I pazienti che recuperano un circolo sul territorio che tipo di priorità diagnostica dovrebbero avere una volta arrivati in DEA

A questo proposito non vi è dubbio, anche alla luce di dati oramai solidi e già recepiti della linee guida internazionali, che questi pazienti, a meno di una eziologia già chiaramente delineata in altro senso, penso al trauma all’evento neurologico ad esempio, dovrebbero di default effettuare uno studio coronarico per escludere cause ischemiche o predisponenti ad aritmie ipercinetiche ventricolari. In entrambi i casi la PCI rispettivamente  o il posizionamento di un ICD porterebbero alla cura ed alla dimissione precoce.

Logo MEDEST2Guido grazie e buon proseguimento del tuo lavoro

Grazie a voi tutti ed a presto.

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Riassumiamo quindi i punti principali:

  • In attesa di dati certi, e viste le deboli evidenze sull’utilità dei nuovi antiaggreganti piastrinici, il loro uso routinario in emergenza al di fuori dall’ospedale non è raccomandato.

  • La somministrazione di ASA dovrebbe essere, ove possibile, effettuata per via e.v. ed a dosi piene.

  • L’uso della Morfina come analgesico di primo impatto per il paziente con STEMI da sottoporre a PCI dovrebbe essere scoraggiato; l’uso della Morfina dovrebbe essere riservato ai pazienti con VAS che premane elevata nonostante la somministrazione di ASA e Nitrati ev.

  • Tutti i pazienti con ROSC e con eziologia di ACR non già chiaramente delineata, dovrebbero effettuare uno studio coronarografico per escludere l’eziologia primitivamente ischemica o aritmica dell’arresto.

References:

Comparison of prasugrel and ticagrelor loading doses in ST-segment elevation myocardial infarction patients: RAPID (Rapid Activity of Platelet Inhibitor Drugs) primary PCI study.

Department of Cardiology, Careggi Hospital, Florence, Italy. parodiguido@gmail.com

rt-PA e Stroke: IST-3 l’analisi dei risultati

10 Apr

Stroke 3

L’analisi detagliata dei dati dello studio più potente e promettente sull’uso del trombolitico nello stroke ischemico chiude definitivamente la discussione su uno studio nato per essere conclusivo, ma che ottiene il risultato, non solo di suscitare molti (e decisivi) dubbi, ma anche di scalfire alcune ragionevoli certezze.

Scarica la trascrizione del podcast

Scarica la Cronostoria dei trials sulla trombolisi nello stroke ischemico

Guarda la cronistoria dei trials sulla trombolisi nell’ictus ischemico

Leggi il post sul “pubblication bias”

Referencs:
  1. IST 3 Study The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen
  2. IST 3 analysys 2013
  3. Bekelman JE, Li Y, Gross CP. Scope and impact of financial conflicts of interest in biomedical research: a systematic review.
    JAMA. 2003;289:454-469.
  4. Lexchin J, Bero LA, Djulbegovic B, et al. Pharmaceutical industry sponsorship and research outcome and quality: systematic review.
    BMJ. 2003;326:1167-1170
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