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Beyond Guidelines: what’s new in OCHA management

6 Set

Chest compressions alternate to abdominal compression–decompression technique

Background

The abdominal compression–decompression technique is based on an “abdominal pump” model, which induces pressure changes within the abdominal cavity and promotes the return of blood from the abdominal cavity to fill the heart and be eventually pumped to the brain. A combination of abdominal compression–decompression and chest compression was previously shown to increase the venous refilling of the heart, which could generate increased coronary perfusion pressure and increase blood flow to vital organs . With this combination method, chest release during abdominal compression leads to increased venous return to the thorax by negative intrathoracic pressure. Moreover, abdominal decompression during chest compression may lead to increased blood flow via decreased afterload. In myocardial blood flow, a better 48-h outcome was documented with the combination method compared with STD-CPR

The study

Evaluation of abdominal compression– decompression combined with chest compression CP9R performed by a new device: Is the prognosis improved after this combination CPR technique?

This study was performed in China. It’s a single center, randomised, not blinded study.

The study aimed to compare the outcomes of standard cardiopulmonary resuscitation (STD- CPR) and combined chest compression and abdominal compression–decompression cardiopulmonary resuscitation (CO-CPR) following out-of-hospital cardiac arrest (OHCA).

Primary outcome ROSC. Secondary outcome hospital admission, hospital discharge and neurological outcome at hospital discharge.

Results

ROSC and survival to hospital admission: no statistical benefit

Survival at hospital discharge and neurological outcome: CO-CPR had statistical significant better outcome respect STD-CPR

Limitations

Single center, small sample size, no evaluation of possible abdominal injuries.

Bottom line

For prehospital use of combined chest compression and abdominal compression–decompression cardiopulmonary resuscitation we have first of all to account the need of an additional rescuer to perform abdominal compression-decompression. By the way the alternate chest/abdominal compression-decompression method is promising even if we need larger multicenter randomised trial for a more consistent evaluation of its efficacy.

Head and thorax elevation during cardiopulmonary resuscitation

Background

Gradual elevation of the head and thorax enhances venous return from the head and neck to the thorax and further lowers intracranial pressure. This automated controlled elevation (ACE) CPR strategy consists of: (1) manual active compression decompression (ACD)-CPR and/or suction cup-based automated (LUCAS 3) CPR; (2) an impedance threshold device (ITD); and (3) an automated controlled head and thorax patient positioning device (APPD).

The study

Head and thorax elevation during cardiopulmonary resuscitation using circulatory adjuncts is associated with improved survival

Observational, prospective study. The Objectives of the study was to assess the probability of OHCA survival to hospital discharge after ACE-CPR versus C-CPR. ACE-CPR data were collected from a dedicated registry implemented by 10 EMS Agencies. Conventional (C) CPR data were collected from 3 large historical randomized controlled OHCA resuscitation trials.

NB: for ACE-CPR only 6/10 agencies data were evaluated.

The primary outcome was survival to hospital discharge. Secondary outcomes included ROSC at any time, and survival to hospital dis- charge with favorable neurological function.

Results

Cumulative results on primary and secondary outcome before taking into consideration the time from 911 call to ACE-CPR were not statistically significative differences. The statistical significance of ACE-CPR was reached only when time from 911 call to ACE-CPR initiation was considered.

Limitations

Observational study. Participating personnel form EMS agencies were highly motivated about ACE-CPR. 165 patients excluded with no clear explanation (generally didn’t meet inclusion criteria) from 4 EMS participating agencies. Statistical significance on primary and secondary outcome was reached after surrogate secondary analysis that considered time form 911 call to ACE-CPR start.

Bottom line

There are still insufficient historical data to understand the benefit of automated controlled elevation (ACE) CPR and this study doesn’t clear any doubt about it’s efficacies on clinical oriented outcomes.

Aortic occlusion during cardiac arrest. Mechanical adrenaline?

Background

Thoracic aortic occlusion during chest compressions limits the vascular bed for the generated cardiac output. This may increase the aortic pressure and subsequently the coronary perfusion pressure (CPP).

The coronary perfusion pressure (CPP), the pressure gradient between the aorta and right atrium, is a major determinant of the myocardial blood flow. Consequently, generating a high CPP by providing high-quality chest compression during CPR is one of the most critical factors for achieving ROSC in cardiac arrest patients.

It is uncontroversial to state that the desired effect of adrenaline in CPR is the potential increase in CPP. The potential detrimental effects of adrenaline, such as decreased cerebral blood flow, increased myocardial oxygen consumption or recurrent ventricular tachycardias after ROSC, is yet to be found with REBOA. However, adverse effects of REBOA are not reported in the limited human data published, nor has this been an endpoint in the studies conducted so far.

The study

Resuscitative endovascular occlusion of the aorta (REBOA) as a mechanical method for increasing the coronary perfusion pressure in non-traumatic out-of-hospital cardiac arrest patients

This is a pilot study. The aim of the study was to calculate the CPP before and after REBOA balloon inflation. EtCO2 and median aortic pressure before and after balloon inflating were also measured.

Results

CPP, MAP and EtCO2 significative increased after REBOA placement in Zone 1 and balloon inflation

Limitations

Single center, small numbers, need of a large number of operators to insert the REBOA and to obtain the measurements.

Bottom line

REBOA in Cardiac Arrest is potentially useful to increase CPP and less dangerous than epinephrine administration.

It’s feasibility in emergency (in-hospital and out of hospital) settings in a timely manner and with a small number of medical personnel needs to be demonstrated.

By Mario Rugna

In case of oesophageal intubation

19 Ago

Just published Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies

Thanks to a prestigious panel of international authors. Great job and definitely solid indication about how to prevent and recognise accidental oesophageal intubation.

Just some of the key recommendations

  • Exhaled carbon dioxide monitoring and pulse oximetry should be available and used for all episodes of airway management.
  • Routine use of a videolaryngoscope is recommended whenever feasible.
  • Inability to detect sustained exhaled carbon dioxide requires oesophageal intubation to be actively excluded.
  • Tube removal should be undertaken if any of the following are true:
    • Oesophageal placement cannot be excluded
    • Sustained exhaled carbon dioxide cannot be restored
    • Oxygen saturation deteriorates at any point before restoring sustained exhaled carbon dioxide

Refer to the full text guidelines for more.
Here is the link to Safe Airway Society livestream event.
Must read, must follow. Free open access.

Let’s go outside

The following are personal considerations on peculiar aspects about management of accidental oesophageal intubation in prehospital environment and come from my personal clinical experience.

Beware they are just personal considerations and practical tricks and tips and are not intended to substitute the above guidelines. 

They are intended to suggest an alternative mental and technical approach when dealing with oesophageal intubation on uncontrolled patients in difficult environment.

Some general considerations

  1. Prehospital uncontrolled patients are not on empty stomach so are at high risk of regurgitation/inhalation
  2. Even few ventilation efforts in case of oesophageal intubation pone the patient at high risk of regurgitation/inhalation 
  3. Suctioning in prehospital setting is not always ready avalliate (mind your environment) or maximally performant (mind your equipment) 
  4. First attempt in prehospital setting must be always the best one. Think before trying a second attempt in case of failure. Implement your plan or change plan.
  5. Apply the Indication, Suitability, Feasibility approach while supporting oxygenation, ventilation and protection.

DO NOT REMOVE THE OT TUBE STRAIGHT FORWARD IN CASE OF ACCIDENTAL OESOPHAGEAL INTUBATION IN PREHOSPITAL ENVIRONMENT.

The way I like it. The way I do it.

  1. Live the “oesophageal” OT tube in (overcuffed) and if it’s possible apply a continuous suctioning to exclude the oesophagus and protect the airways 
  2. Place a SGA to restore oxygenation and ventilation (trough BMV or NIV)
  3. After restoring oxygenation (SaO2 >94%) and ventilation (EtCO2 40 mmHg) if suitable and feasible (see below) proceed to a second attempt of tracheal intubation (must be videolaryngoscope+bougie)
  4. If the second attempt succeeds remove the “oesophageal” OT
  5. If the second attempt is not suitable or feasible transport to nearest hospital (patient is well oxygenated and ventilated via SGA and protected via oesophageal exclusion) for further stabilisation (you can replace the oesophageal OT tube with a large bore oro-gastric tube or insert the orogastric tube trough the SGA dedicated channel)
  6. If you can’t restore oxygenation and ventilation via SGA or you can’t place a SGA remove the oesophageal OT tube and try to oxygenate and ventilate (remember patient is not protected) via BVM and NC (double oxygenation) 
  7. If even BVM fails declare CICO 
Suitability 
  • Do I have a plan to implement regarding the  first attempt
  • Can I improve my environment (Setting) moving the patient to a more comfortable place/position 
  • Is the time to nearest hospital short/long 
Feasibility 
  • Am I in the right mental mood after 1st attempt (me) to try a better second one
  • Is my team ready for a second attempt (team) 
  • Do I have the right equipment to implement my second attempt (Equipment)

The visual algorithm

The Video

By Mario Rugna

Beyond Advanced Cardiac Life Support. Do we have to change our practice in COVID Era?

3 Mag

Main changes in recommendations

Personal Protective Equipment for Advanced Life Support interventions need to be at maximum level of protection of full body, eyes and airways.

CAT 3 level of protection 4 (at least) for the full body

FPP2/N95 airway filter for team members who are NOT directly involved in airway management, ventilation or manual chest compressions

FPP3/N99 airway filter for providers who are directly involved in airway management, ventilation and manual chest compressions.

Face shield and protective googles are strongly suggested

Mechanical Chest compressors devices are the gold standard to perform cardiac massage. They reduce contacts and contamination risk and team member exposure to contaminants.

Adhesive disposable pads are the only option to check rhythm and deliver shock. Dispose non-disposable, manual pads.

Passive O2 administration (via simple face mack at a rate of 15l/m) during chest compressions is the first option over bag mask ventilation when performing Basic Life Support waiting for advanced airway management.When using a Bag Valve Mask always put a HEPA/HME filter between Bag and mask to avoid contamination

Hold chest compressions when performing airway managment

Cover patient head with a transparent plastic foil to minimise virus spreading and contamination when performing airway management and bag mask ventilation

Tracheal intubation using a video laryngoscope is the first line option for advanced airway management to minimise contamination.

If video laryngoscope is not available Extraglottic devices are an acceptable first line option

Use all the implementation to improve intubation first passage success:

Video laringoscopy

Bougie

RAMP positioning

Suctioning (SALAD technique)

Use all the implementation to improve Extraglottic device placement

Laryngoscope for tongue displacement and mouth opening (DO NOT USE hands)

Deflate cuff

Lubrificate the device

Whatever plan you apply use an HEPA/HME filter immediately after the ventilation device

Use disposable cover and disposable gel to perform Ultrasound during chest compressions

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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