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1 Year in Review. 2018 Guidelines you must know.

13 Dic

So 2018 is at the end and we give, as every year, a look back to literature and articles of this finishing year.

This is the first step of 1 YEAR IN REVIEW the classical MEDEST appointment with all that matter in emergency medicine literature.

So let’s start with Guidelines but first I want to cite an important point of view about Clinical practice Guidelines and they future development:

Clinical practice guidelines will remain an important part of medicine. Trustworthy guidelines not only contain an important review and assessment of the medical literature but establish norms of practice. Ensuring that guidelines are up-to-date and that the development process minimizes the risk of bias are critical to their validity. Reconciling the differences in major guidelines is an important unresolved challenge.”

Paul G. Shekelle, MD, PhD. Clinical Practice Guidelines What’s Next?

And now here it is, divided by topics, the most important new 2018 Guidelines. Click on the link to read more.
  • Airway management

Guidelines for the management of tracheal intubation in critically ill adults
Guidelines for the management of tracheal intubation in critically ill adults PP presentation

  • Trauma

Management of severe traumatic brain injury (first 24 hours)
Spinal Motion Restriction in the Trauma Patient –A Joint Position Statement
Guidelines for Prehospital Fluid Resuscitation in the Injured Patient
Re-thinking resuscitation: leaving blood pressure cosmetics behind and moving forward to permissive hypotension and a tissue perfusion-based approach
  • Cardiac

2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay

  •  Stroke

2018 Guidelines for the Early Management of Patients with acute ischemic stroke.A Guideline for Healthcare Professionals From the American HeartAssociation/American Stroke Association

  • Others

Health Professions Council of South Africa. Clinical Practice Guidelines

 

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Sepsis: Sepsis 3, Surviving Sepsis Campaign what now?

23 Gen

From a practical clinical point of view, after the 2016 update of the SSC (Surviving Sepsis Campaign) guidelines we have two references when comes to deal with a potential septic patient. Question Marks Sphere Ball Many Questions Asked

2016 Sepsis 3 definition and early management.

2016 Surviving Sepsis Campaign

Let’s see how to treat, based on top evidences, a real patient in the the pre-hospital and emergency department time window. 

But, first of all,  the definitions:

  • Definitions

Both the guidelines now agree that:

Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection

Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) despite adequate volume resuscitation”

  • Early identification

    1. SIRS criteria. The new 2016 SSC guidelines do not indicate any criteria for early identification of sepsis, so SIRS criteria no longer exists.
    2. qSOFA score (G.C.S. of 13 or less, SBP of 100 mm Hg or less, and RR 22/min or greater): Good negative and positive prediction value(similar to that sepsiscouchof the full SOFA score outside the ICU). Non specific for sepsis. It’s the actual early identification tool for sepsis to use out-of-hospital end in emergency department. It performs quite good to identify patients at risk of negative evolution. A qSOFA score ≥2 indicates a high mortality risk comparing to a qSOFA ≤1.
      sofa-score-1024x743
    3. SOFA score: indicates organ disfunction (when the score is >2 points) consequent to the infection and defines sepsis. Is a validated ICU tool to asses risk and mortality chance. Is not a tool to use out-of-hospital or in ED.
    4. The Pre-hospital Sepsis Score (PSS) or Miami Sepsis Score: As out-of-hospital professional I love pre-hospital early warning tools.I like to mention PSS cause is well validated to early recognise sepsis in the field. PSS includes Shock Index (HR/SBP) that is really sensible to identify critical evolution chance, RR that is included in qSOFA and other sepsis score plus body temperature (obligatory) that identifies an infection. Is for me the good compromise, in the field, between good positive and negative predictive value. A PSS of 1 point identifies a low risk patient, 2 points moderate risk, 3-4 points high risk patients.pss
  • Early management

    1. Early goal directed therapy: no longer recommended. CVP is no longer required and fluid response to initial volemic reanimation has to be clinically and dynamically assessed (passive leg raise, fluid challenges)
    2. Fluid resuscitation: 30 ml/Kg(in the first 3 hrs) to restore normal emodynamics values (MAP >65 mmHg). Lactate is a risk assessment tool (>2 mmol/L) and is no longer recommended to guide resuscitation efforts. Crystalloids are the fluids of choice. 
    3. Vasopressors: indicated if initial fluid resuscitation doesn’t reach the target. Norepinephrine is the pressor of choice. Epinephrine the second line agent in case Norepinephrine is not sufficiente to reach the target.Stop giving Dopamine.
    4. Bloodcultures: immediately and preferably before starting antibiotics but without delaying  antibacterial therapy. 
    5. Antibiotics: no double cover routinely but broad spectrum mono therapy is the recommended choice.
    6. Corticosteroids: consider just if patient is fully volume resuscitated and vasopressors are unsuccessful to maintain emodynamic stability.

Take home points for early phase management

Early Identification
Use either:
  • qSOFA (preferred in ED) cut off ≥2 points
  • PSS (preferred in the field) cut off ≥2 points.
Initial Management (target to a MAP >65)
  • Emodynamic stabilisation
    • 1st Fluid 30 ml/Kg of crystalloids.
    • 2nd Norepinephrine up to 35-90 μg/min (if 1st step failed).
    • Add Epinephrine up to 20-50 μg/min to achieve MAP target (if first 2 step failed).
  • Take blood cultures (if feasible before antibiotics but without delaying antibiotics).
  • Do not delay early broad spectrum antibiotic mono therapy.

 

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References 

 

 

 

“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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2016 NICE Major Trauma Guidelines. The pre-hospital recommendations.

21 Feb

NICE released the 2016 Major trauma Guidelines.

Many interesting recommendations where made for pre-hospital and in hospital providers about several topics

  • Airway management

  • Chest trauma

  • Haemorrage control

  • Circulatory access

  • Volume resuscitation

  • Fluid replacement

  • Pain management

  • Documentation

  • Training

Here is the Excerpt regarding the pre-hospital settings

Download the full guidelines for in-hospital recommendations and full description of Guidelines process and rationale behind every single recommendation

Download the full Guidelines at:

Major trauma: assessment and initial management

NICE guidelines [NG39] Published date: February 2016

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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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Community management of opioid overdose

6 Nov

World Health Organization relesead the 2014 guidelines for Community management of opioid overdose.

Reccomendation 1

Here are some highlights from the guidelines of particular relevance for emergency medicine

  • Formulation and dose of naloxone

Route of administration
The GDG recognizes that the IV route is appropriate and effective in medical settings
The capacity of the nasal mucosa to absorb liquids is limited, so if the intranasal route of administration is to be used, concentrated forms of naloxone should ideally be used.
The GDG has made this recommendation fully aware that the intranasal route is currently an off-label (non-licensed) route.
Affordability may dictate the preferred route in particular contexts
Dosage
The choice of initial dose will depend on the formulation of naloxone to be used and the context.
In medical settings dose selection is not generally an issue as dose titration is standard practice. In non-medical settings dose titration is not so easily accomplished and higher initial doses may be desirable.
The context also dictates the total amount of naloxone made available to non-medical responders.
The initial dose should be 0.4mg–2mg, targeting recovery of breathing. In most cases 0.4–0.8 mg is an effective dose. It is important to provide sufficient naloxone to supplement the initial dose, as necessary.

Intranasal delivery may require a higher dose. It should be noted that the commonly used method of intranasal administration is to spray 1 ml of the 1 mg/ml formulation of naloxone into each nostril with an atomizerconnected to a syringe.

Where possible, efforts should be made to tailor the dose to avoid marked opioid withdrawal symptoms. The GDG notes that higher initial doses above 0.8 mg IM/IV/SC are more likely to precipitate significant withdrawal symptoms.

A more complicated situation arises where there has been an overdose of a combination of drugs. In this situation naloxone is still beneficial for reversing the opioid intoxication component of the overdose.

 

  • Cardiopulmonary resuscitation

In suspected opioid overdose, first responders should focus on airway management, assisting ventilation and
administering naloxone.
Because the key feature of opioid overdose is respiratory arrest, ventilation is a priority. While recognizing there are different protocols in different parts of the world, the GDG suggests the following steps in resuscitating an individual with suspected opioid overdose.
Apply vigorous stimulation, check and clear airway, and check respiration – look for chest rising and falling.
In the presence of vomit, seizures or irregular breathing, turn the patient on their side, and, if necessary, clear the airway of vomit.
In the absence of regular breathing provide rescue ventilation and administer naloxone.
If there are no signs of life, commence chest compressions.
Re-administer naloxone after two to three minutes if necessary
In all cases call for professional assistance.
Monitor the person until professional help arrives.
  • Post resuscitative care

After successful resuscitation following the administration of naloxone, the affected person should have their level of consciousness and breathing closely observed until they have fully recovered.
The definition of ‘fully recovered’ is a return to pre-overdose levels of consciousness two hours after the last dose of naloxone.
Ideally, observation should be performed by properly-trained professionals.
The period of observation needed to ensure full recovery is at least two hours, following overdose from short-acting opioids such as heroin. It may be longer where a longer acting opioid has been consumed.
If a person relapses into opioid overdose, further naloxone administration may be required.
The definition of ‘fully recovered’ is a return to pre-overdose levels of consciousness two hours after the last dose of naloxone

Download the full guidelines at

http://apps.who.int/iris/bitstream/10665/137462/1/9789241548816_eng.pdf?ua=1

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2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes

8 Ott

2014 AHA:ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes were published on September 23.

The new terminology, from Non STE Miocardial Infarction to Non STE Acute coronary Syndromes, establishes a  pathophysiological continuum between unstable angina and Non STE Acute coronary Syndromes, and make those two identities indistinguishable and considered together in this 2014 Guideline.

The need of High Sensitive Troponin and the importance of risk stratification are just few of the many changes made in this 2014 update

You con find this and all the newst guidelines on MEDEST Guidelines section

Sono state pubblicate il 23 di Settembre le 2014 AHA:ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes

Trovate queste e tutte le nuove linee guida su MEDEST nella sezione dedicata

Linee Guida

References:

2014 AHA:ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes

New Non-ST-Elevation ACS Guidelines: New Title, New Approach

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