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Prehospital Emergency Procedures: Scalpel, Finger, Bougie. That’s all you need!

13 Lug

In Emergency Medicine “Simplicity” is synonymous of efficiency, efficacy and reproducibility.

More the time frame is stressful more we need procedures that are efficient, efficacious and standardised, in one word SIMPLE.

Critcothyrodotomy and chest drain are procedures usually performed in high stressing scenarios and more simply they are more chance of success they have.

I don’t like complicate kits. They need training of course but even a calm and protected environment, and the middle of a street or a busy ER room aren’t nothing like that. 

I don’t like blindly performed procedures but prefer trusting my own senses and sensibility when performing high invasive procedures that, mostly of the times, are a lifesaving last chance.

So this is the best way I know to perform a surgical access to the airway and to drain a highly unstable tense pneumo: using simple instruments, always present in every emergency pack, and trusting my own tactile sensitivity.

surgical-airway-sfb

In those following videos you can see live records of the procedures. They were captured during a recent cadaver lab where I had the honour to join Jim DuCanto, Yen Chow, Carmine Della Vella and Fabrizio Tarchi in teaching airway management and clinical emergency procedures.

Hope you enjoy.

 

 

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Prehospital POCUS: Why I love it! Real Clinical Scenario.

10 Lug

73 yrs old male found unconscious by his wife. CPR started by a neighbour with pre arrival CPR instructions provided by dispatcher. We found him in asystolic cardiac arrest. Established mechanical chest compressions (MCC), ventilated through an 8.0 ET tube, placed an intraosseus access, 10 min of ALS and 2 mg of epinephrine later, on the monitor appears an organised rhythm at 40 bpm (narrow junctional shape), NO CENTRAL PULSE. After 2 min (CPR still going) same rhythm stil NO CENTRAL PULSE but this time, during the MCC pause, a subcostal view of the heart was obtained (sorry for the quality of the images but were recorded during the code and I’m not an expert but just an ultrasound user) 

As you can see the heart is moving and the right ventricle is almost the double of the left one. Due also to the clinical history of a recent surgical knee replacement the most probable origine of the cardiac arrest is PE. We decided to continue chest compressions, but to stop epinephrine at 1 mg dose, starting push doses of 0,1 mg till the return of a central pulse. After 5 min a strong carotid pulse appeared and this is the ultrasound view of the heart at that moment

  

The patient arrived to the hospital sedated and paralysed in assisted pressure control ventilation. You can see on the monitor the rest of vital signs.

No follow up yet.

You can read more about PEA and Pseudo-PEA on MEDEST

Forget ACLS guidelines if you are dealing with Pulseless Electric Activity. Part 1.

Forget ALS Guidelines when dealing with PEA. Part 2.

“Best Practice” preospedaliera: Arresto cardiaco da trauma

4 Ago

Tra 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.

Arresto cardiaco adulto traumatico

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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“Best Practice” preospedaliera: Arresto cardiaco nel neonato

29 Lug

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.

Arresto cardiaco neonato

 

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“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.Arresto cardiaco pediatrico

 

 

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“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.

Arresto cardiaco gravidanza_Page_1

 

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“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.

Arresto cardiaco adulto non traumatico_Page_1

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The pregnant patient

30 Gen

The management of a pregnant women has been always a challenge for physicians.

The different physiology of pregnancy, makes clinical choices and treatment different than in usual adult patient, and needs attentions and practice that override standard care.

In emergency medicine, where standards and protocols are a way to think and to act, a change in routine care, together with the time dependency of the decision making process, makes the pregnant patient an effective challenge.

So here is the need of specific guidelines focused on pregnant patient for specific clinical emergency situations.

In this post we discuss two guidelines about the management of a pregnant trauma patient and cardiac arrest in a pregnant women, with an eye of regard on the aspects of the recommendations for prehospital care.

Guidelines for the Management of a Pregnant Trauma Patient (Open Access)

Approved by Executive and Board of the Society of Obstetricians and Gynaecologists of Canada

J Obstet Gynaecol Can June 2015;37(6):553–571

Airway
  • Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C)
  • A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content.(III-C)
Breathing
  • Oxygen supplementation should be given to maintain maternal oxygen saturation >95% to ensure adequate fetal oxygenation. (II-1B)
  • If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C)
Circulation
  • Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B)
  • After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement (Lateral Uterus Displacement L.U.D.) of the uterus or left lateral tilt (obsolete n.d.r). Care should be taken to secure the spinal cord (if indicated n.d.r.) when using left lateral tilt. (II-1B)
Transfer to health care facility
  • Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life nor limb threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks’ gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B)
Perimortem Caesarean section
  • A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B)

Take home points on modifications of assessment of trauma patients in presence (or suspect) of pregnancy

  1. When indicated a thoracostomy tube should be inserted 1 or 2 intercostal spaces upper than usual.

  2. Vasopressors has to be avoided in pregnancy.

  3. Perform L.U.D (Lateral Uterus Displacement) to relieve Inferior Vena Cava compression.

  4. Transport the severely injuried pregnant patient to an hospital with maternal facility if fetus is viable (≥ 23 weeks).

Cardiac Arrest in Pregnancy. A Scientific Statement From the American Heart Association (Open Access)

Circulation. 2015;132:00-00. DOI: 10.1161/CIR.0000000000000300
Cardiac Arrest in Pregnancy1
Chest Compressions in Pregnancy
  • There is no literature examining the use of mechanical chest compressions in pregnancy, and this is not advised at this time
  • Continuous manual LUD (left uterus dispalcement) should be performed on all pregnant women who are in cardiac arrest in which the uterus is palpated at or above the umbilicus to relieve aortocaval compression during resuscitation (Class I; Level of Evidence C).
  • If the uterus is difficult to assess (eg, in the morbidly obese), attempts should be made to perform manual LUD if technically feasible (Class IIb; Level ofEvidence C)
  • Cardiac Arrest in Pregnancy
Transporting Pregnant Women During Chest Compressions
  • Because an immediate cesarean delivery may be the best way to optimize the condition of the mother and fetus, this operation should optimally occur at the site of the arrest. A pregnant
    patient with in-hospital cardiac arrest should not be transported for cesarean delivery. Management should occur at the site of the arrest (Class I; Level of Evidence C). Transport to a facility that can perform a cesarean delivery may be required when indicated (eg, for out-of-hospital cardiac arrest or cardiac arrest that occurs in a hospital not capable of cesarean delivery)
Defibrillation Issues During Pregnancy
  • The same currently recommended defibrillation protocol should be used in the pregnant patient as in the nonpregnant patient. There is no modification of the recommended application of electric shock during pregnancy (Class I; Level of Evidence C).
Advanced Cardiovascular Life Support
Cardiac Arrest in Pregnancy 3
Breathing and Airway Management in Pregnancy
Management of Hypoxia
  • Hypoxemia should always be considered as a cause of cardiac arrest. Oxygen reserves are lower and the metabolic demands are higher in the pregnant patient compared with the nonpregnant patient; thus, early ventilatory support may be necessary (Class I; Level of Evidence C).
  • Endotracheal intubation should be performed by an experienced laryngoscopist (Class I; Level of Evidence C).
  • Cricoid pressure is not routinely recommended (Class III; Level of Evidence C).
  • Continuous waveform capnography, in addition to clinical assessment, is recommended as the most reliable method of confirming and monitoring correct placement of the ETT (Class I; Level of Evidence C) and is reasonable to consider in intubated patients to monitor CPR quality, to optimize chest compressions, and to detect ROSC (Class IIb; Level of Evidence C). Findings consistent with adequate chest compressions or ROSC include a rising Petco2 level or levels >10 mm Hg (Class IIa; Level of Evidence C).
  • Interruptions in chest compressions should be minimized during advanced airway placement (Class I; Level of Evidence C).
Arrhythmia-Specific Therapy During Cardiac Arrest
  • No medication should be withheld because of concerns about fetal teratogenicity (Class IIb; Level of Evidence C).
  • Physiological changes in pregnancy may affect the pharmacology of medications, but there is no scientific evidence to guide a change in current recommendations. Therefore, the usual drugs and doses are recommended during ACLS (Class IIb; Level of Evidence C).
Epinephrine and vasopressine
  • Administering 1 mg epinephrine IV/IO every 3 to 5 minutes during adult cardiac arrest should be considered. In view of the effects of vasopressin on the uterus and because both agents are considered equivalent, epinephrine should be the preferred agent (Class IIb; Level of Evidence C).
Fetal Assessment During Cardiac Arrest
  • Fetal assessment should not be performed during resuscitation (Class I; Level of Evidence C).
Delivery durin cardiac arrest
  • During cardiac arrest, if the pregnant woman (with a fundus height at or above the umbilicus) has not achieved ROSC with usual resuscitation measures with manual uterine displacement, it is advisable to prepare to evacuate the uterus while resuscitation continues (Class I; Level of Evidence C)
  • PMCD (Peri Mortem Cesarean Delivery) should be strongly considered for every mother in whom ROSC has not been achieved after ≈4 minutes of resuscitative efforts (Class IIa; Level of Evidence C).
  • If maternal viability is not possible (through eitherfatal injury or prolonged pulselessness), the procedure should be started immediately; the team does
    not have to wait to begin the PMCD (Class I; Level of Evidence C).
  • Assisted vaginal delivery should be considered when the cervix is dilated and the fetal head is at an appropriately low station (Class IIb; Level ofEvidence C)

Take home points for resuscitation in trauma patient:

  1. The utilization of mechanical chest compressors is not recommended.

  2. Continuous LUD should be performed during resuscitation.

  3. No modification in energy level when electrical therapy is needed.

  4. No modification in timing and doses of ACLS drugs.

  5. Fetal assessment is not indicated during resuscitation.

  6. Peri Mortem Cesarean Delivery (PMCD) has to be performed without delay and at the site of cardiac arrest (no transport is indicated), after 4 minutes of ineffective resuscitation attempts.

 

References: 

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ACEP policy: Out-of-Hospital Use of Analgesia and Sedation

22 Gen

ACEP states that ” The relief of suffering is among the most common reasons for requesting EMS assistance. Pain and agitation are common causes of this suffering and are commonly encountered by EMS. There is a gap between the need for patient analgesia and the willingness of EMS personnel to provide it. There is a variety of medications available for the relief of pain and agitation.”

So let’s make the point on prehospital analgesia and sedation according with this policy.

Out of hospital analgesia

  1. Fentanyl for his short duration and rapid onset, multiple administration route (IV, IM, IN, and IO),   haemodynamic stability is the ideal narcotic agent for out of hospital use.
  2. Do not withhold narcotics in patients with abdominal pain for the myth of confounding the surgical assessment and so clouding the final diagnosis.
  3. Ketamine (at low doses) for analgesia (alone or in combination with narcotics) is safe, effective and haemodynamically stable without provoking respiratory drive and gag reflex suppression
  4. Concern about Ketamine effect on (increasing) intracranial pressure is misplaced

Out of hospital sedation and chemical restraint 

  1. Midazolam due to his rapid onset, short duration and multiple administration route (IV, IM, IN, and IO) is the ideal benzodiazepine for out of hospital sedation.
  2. Benzodiazepines, especially when administered in multiple doses can cause respiratory drive depression: use full monitoring of the patient when using benzodiazepines (MEDEST suggest waveform capnography). Consider other agents as butyrophenones (MEDEST suggest Aloperidol, Droperidol)
  3. Ketamine (in dissociative dose) is the ideal agent for patients with excited delirium (still not recognised as medical disorder in Italy!!!!!) cause of his rapid onset, safe haemodynamic profile and leave intact respiratory drive and gag reflex.

For full free open access text of this policy go to:

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Clinical Tips in Prehospital Emergency Medicine 

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Quick tutorial video on simple clinical questions in prehospital emergency medicine


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