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Clinical Tips in Prehospital Emergency Medicine 

12 Ott

Quick tutorial video on simple clinical questions in prehospital emergency medicine

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2014年第一届潇湘急诊重症与呼吸治疗国际论坛. 2014 Xiao Xiang International Forum on Emergency and Critical Care Medicine.

1 Ott

From 23 to 25 of September at Hunan Provincial People’s Hospital in Changsha (People’s Republic of China) was held the Xiao Xiang International Forum on Emergency and Critical Care Medicine and Reapiratory Therapy.

Many speakers from differents part of Asia and US talked about different and interesting topics. I was honored to be part of this group.

I want to thank my friend and colleague Zhang Yi Xiong for the great opportunity he gave me. I also thank him for the wonderful human experience I had meeting all the chinese colleagues who work in Emergency Depatment of  Provincial People’s Hospital.

Here is my presentation

You can also watch the presentation on line at the link below

http://prezi.com/x41ftjbiv17b/?utm_campaign=share&utm_medium=copy&rc=ex0share

Clik the links below to download the pdf and ppt version of the presentation

Emerging Trends in Prehospital Emergency Medicine.pdf

Emerging Trends in Prehospital Emergency Medicine.ppt

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ST↑ in aVR: un’alterazione di tutto rispetto

16 Apr

homer_the_scream

Qualche mese fa MEDEST ha pubblicato un post in merito ad un caso clinico in cui un ECG con alterazione del tratto ST in aVR era stato trascurato per un atteggiamento di diffusa sufficienza con cui molti clinici guardano alle alterazioni presenti in questa derivazione.

Approfittiamo di questo ECG, registrato ieri a domicilio in un paziente di con dolore toracico, per puntualizzare alcuni concetti fondamentali riguardo alle alterazioni del tratto ST in aVR:

STE aVR_c

Click to enlarge/Clicca per ingrandire

  • L’elevazione del tratto in ST↑ ≥1 mm in aVR, nel contesto di diffuse alterazioni ischemiche (ST↓), è un segno ischemico molto grave, patognomonico per occlusione del tronco comune (LMCA), della discendente anteriore (LAD) o di malattia dei tre vasi (3VD)
  • I pazienti con ST↑ ≥1 mm in aVR e clinica tipica devono essere sottoposti PTCA in urgenza
  • L’assenza di ST↑ in aVR esclude con molta accuratezza la probabilità di occlusione del tronco comune
  • I criteri sopra esposti non sono applicabili in caso di TPSV o in assenza di segni clinici di ischemia
  • ST ↑ in aVR+ST↑ in aVL indicano occlusione del tronco comune (LMCA)
  • ST ↑ in aVR+ST↑ in V1 indicano occlusione del tronco comune (LMCA) o della discendente anteriore (LAD)
    • ST ↑ in aVR >ST↑ in V1 fa sospettare l’occlusione del tronco comune (LMCA) piuttosto che quello della discendente anteriore (LAD)
  • ST↑ in aVR ≥ 1mm è associato con un aumento fino a 6 volte della mortalità
  • ST↑ in aVR ≥ 1.5mm è associato ad una mortalità che può andare dal 25% al 70%

In conclusione aVR merita più considerazione, perchè il rilievo di ST↑ in questa derivazione indica lesioni a carico di vasi motlo critici per la circolazione coronarica e la prognosi di questi pazienti è altamente sfavorevole.

MEDEST you tube

 

 

 

References:

  1. aVR the forgotten lead
  2. ST Elevation in aVR – LMCA occlusion?
  3. aVR The Neglected Lead
  4. Williamson K, Mattu A, Plautz CU, et al. Electrocardiographic applications of lead aVR. Am J Emerg Med. 2006 Nov;24(7):864-74
  5. Rokos IC, French WJ, Mattu A, et al. Appropriate cardiac cath lab activation: optimizing the electrocardiogram interpretation and clinical decision making for acute ST-elevation myocardial infarction. Am Heart J. 2010 Dec; 160(6):995-1003
  6. Nikus KC, Eskola MJ. Electrocardiogram patterns in acute left main coronary artery occlusion. J Electrocardiology. 2008 Nov-Dec;41(6):626-9
  7. Kosuge M, Ebina T, Hibi K, et at. An early and simple predictor of severe left main and/or three-vessel disease in patients with non-ST-segment elevation acute coronary syndrome. Am J Cardiol. 2011 Feb 15;107(4):495-500
  8. Nikus K, Pahlm O, Wagner G, et al. Electrocardiographic classification of acute coronary syndromes: a review by a committee of the International Society for Holter and Non-Invasive Electrocardiology. 2010 Mar-Apr;43(2):93, 97-98
 

 

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Time is brain?

13 Apr

On Stroke (an AHA journal) has recently been published a study entitled “Stroke Thrombolysis- Save a Minute, Save a Day” in wich the authors concluded that “time is brain”

This is an observational prospective study conducted between 1998 and 2011 on a cohrt of 2258 consecutive stroke patients treated with r-TPA.

The results shown how any minute delay on TPA administration is a day less in the patient’s life.

But I’m skeptical, and to support my skpepticism, here is a post of the king of skeptical blog in emergency medicine: The Skeptical guide to Emergency Medicine:  Thrombolysis for Acute Stroke in wich in wich are well summarized all the trials on TPA in stroke and many other great resources.

This is the wonderful presentation  by Ken MilneTPA-in-CVA-pdf on the argument.

MEDEST you tubeSo are you really sure that the actual evidences at the base of TPA administration for the stroke patients are so evident?

 

 

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