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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

  • 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)
  • 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)
  • 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.






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
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



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


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


Highlights from 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation

24 Apr

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation

Sono state pubblicate le linee guida 2014 sul trattamento dei pazienti con Fibrillazione Atriale.

Ecco i punti  d’interesse per la medicina d’urgenza.

Per approfondire scaricate il full text nella sezione Linee Guida


  • “Paroxysmal AF”    “AF that terminates spontaneously or with intervention within 7 d of onset. Episodes may recur with variable frequency.”
  • “Persistent AF”    “Continuous AF that is sustained >7 d.”
  • “Longstanding persistent AF”    “Continuous AF of >12 mo duration.”
  • “Permanent AF”    “Permanent AF is used when there has been a joint decision by the patient and clinician to cease further attempts to restore and/or maintain sinus rhythm.
  • “Nonvalvular AF”    “AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair.”
  • “Lone AF” is a historical descriptor that has been variably applied to younger individuals without clinical or echocardiographic evidence of cardiopulmonary disease, hypertension, or diabetes mellitus (4-7).
    Because definitions are variable, the term “lone AF’” is potentially confusing and should not be used to guide
    therapeutic decisions.
Types of AF

AF Types

Clinical Evaluation: Recommendation

Class I
  • Electrocardiographic documentation is recommended to establish the diagnosis of AF. (Level of Evidence: C)

Rate control in AF

Class I
  • Control of the ventricular rate using a beta blocker or nondihydropyridine calcium channel antagonist is recommended for patients with paroxysmal, persistent, or permanent AF (260-262). (Level of Evidence: B)
  • Intravenous administration of a beta blocker or nondihydropyridine calcium channel blocker is  recommended to slow the ventricular heart rate in the acute setting in patients without pre-excitation. In hemodynamically unstable patients, electrical cardioversion is indicated. (Level of Evidence: B)
  • In patients who experience AF-related symptoms during activity, the adequacy of heart rate control should be assessed during exertion, adjusting pharmacological treatment as necessary to keep the ventricular rate within the physiological range. (Level of Evidence: C)
Class IIa
  • A heart rate control (resting heart rate <80 bpm) strategy is reasonable for symptomatic management of AF. (Level of Evidence: B)
  • Intravenous amiodarone can be useful for rate control in critically ill patients without preexcitation. (Level of Evidence: B)
Class IIb
  • A lenient rate-control strategy (resting heart rate <110 bpm) may be reasonable as long as patients remain asymptomatic and LV systolic function is preserved. (Level of Evidence: B)
  • Oral amiodarone may be useful for ventricular rate control when other measures are unsuccessful or contraindicated. (Level of Evidence: C)
Class III: Harm
  • Nondihydropyridine calcium channel antagonists should not be used in patients with decompensated HF as these may lead to further hemodynamic compromise. (Level of Evidence: C)
  • In patients with pre-excitation and AF, digoxin, nondihydropyridine calcium channel antagonists, or intravenous amiodarone should not be administered as they may increase the ventricular response and may result in ventricular fibrillation (274). (Level of Evidence: B)


Beta blockers
  • Metoprolol tartrate 2.5–5.0 mg IV bolus over 2 min; up to 3 doses 25–100 mg BID
  • Atenolol  25–100 mg QD
  • Esmolol 500 mcg/kg IV bolus over 1 min, then 50–300 mcg/kg/min IV
  • Propranolol 1 mg IV over 1 min, up to 3 doses at 2 min intervals 10–40 mg TID or QID
  • Nadolol 10–240 mg QD
  • Carvedilol 3.125–25 mg BID
  • Bisoprolol 2.5–10 mg QD
Nondihydropyridine calcium channel antagonists
  • Verapamil (0.075-0.15 mg/kg) IV bolus over 2 min, may give an additional 10.0 mg after 30 min if no response, then 0.005 mg/kg/min infusion 180–480 mg QD (ER)
  • Diltiazem 0.25 mg/kg IV bolus over 2 min, then 5-15 mg/h 120–360 mg QD (ER)
Digitalis glycosides
  • Digoxin 0.25 mg IV with repeat dosing to a maximum of 1.5 mg over 24 h 0.125–0.25 mg QD
  • Amiodarone 300 mg IV over 1 h, then 10–50 mg/h over 24 h 100–200 mg QD

AF indicates atrial fibrillation; BID, twice daily; ER, extended release; IV, intravenous; N/A, not applicable; QD, once
daily; QID, four times a day; and TID, three times a day


Approach to Selecting Drug Therapy for Ventricular Rate Control

Rhythm Control

Electrical and Pharmacological Cardioversion of AF and Atrial Flutter

Thromboembolism Prevention: Recommendations
Class I
  • For patients with AF or atrial flutter of 48-hour duration or longer, or when the duration of AF is unknown, anticoagulation with warfarin (INR 2.0 to 3.0) is recommended for at least 3 weeks prior to and 4 weeks after cardioversion, regardless of the CHA2DS2-VASc score and the method (electrical or pharmacological) used to restore sinus rhythm (313-316). (Level of Evidence: B)
  • For patients with AF or atrial flutter of more than 48 hours or unknown duration that requires immediate cardioversion for hemodynamic instability, anticoagulation should be initiated as soon as possible and continued for at least 4 weeks after cardioversion unless contraindicated. (Level of Evidence: C)
  • For patients with AF or atrial flutter of less than 48-hour duration and with high risk of stroke, intravenous heparin or LMWH, or administration of a factor Xa or direct thrombin inhibitor, is recommended as soon as possible before or immediately after cardioversion, followed by longterm anticoagulation therapy. (Level of Evidence: C)
  • Following cardioversion for AF of any duration, the decision regarding long-term anticoagulation therapy should be based on the thromboembolic risk profile (Section 4). (Level of Evidence: C)
Direct-Current Cardioversion:

A number of technical factors influence cardioversion efficacy, including energy, waveform, and electrode placement. A biphasic waveform is more effective than a monophasic waveform. Anteroposterior electrode placement is superior to anterolateral placement in some but not all studies. If an attempt at cardioversion using 1 electrode placement fails, another attempt using the alternative placement is recommended. The initial use of a higher-energy shock is more effective and may minimize the number of
shocks required as well as the duration of sedation. The risks associated with cardioversion include thromboembolism, sedation-related complications, ventricular tachycardia and fibrillation, bradyarrhythmias, skin burn or irritation from electrodes, muscle soreness, and reprogramming or altering implanted cardiac device function. Elective cardioversion should not be performed in patients with evidence of digoxin toxicity, severe hypokalemia, or other electrolyte imbalances until these factors are corrected.

Class I
  • In pursuing a rhythm-control strategy, cardioversion is recommended for patients with AF or atrial flutter as a method to restore sinus rhythm. If cardioversion is unsuccessful, repeated direct-current cardioversion attempts may be made after adjusting the location of the electrodes or applying pressure over the electrodes, or following administration of an antiarrhythmic medication (320). (Level of Evidence: B)
  • Cardioversion is recommended when a rapid ventricular response to AF or atrial flutter does not respond promptly to pharmacological therapies and contributes to ongoing myocardial ischemia, hypotension, or HF. (Level of Evidence: C)
  • Cardioversion is recommended for patients with AF or atrial flutter and pre-excitation when tachycardia is associated with hemodynamic instability. (Level of Evidence: C)
Pharmacological Cardioversion: Recommendations
Class I
  • Flecainide, dofetilide, propafenone, and intravenous ibutilide are useful for pharmacological cardioversion of AF or atrial flutter provided contraindications to the selected drug are absent. (Level of Evidence: A)
Class IIa


  • Administration of oral amiodarone is a reasonable option for pharmacological cardioversion of AF. (Level of Evidence: A)
  • Propafenone or flecainide (“pill-in-the-pocket”) in addition to a beta blocker or nondihydropyridine calcium channel antagonist is reasonable to terminate AF outside the hospital once this treatment has been observed to be safe in a monitored setting for selected patients.(Level of Evidence: B)
Class III: Harm
  • Dofetilide therapy should not be initiated out of hospital owing to the risk of excessive QT prolongation that can cause torsades de pointes. (Level of Evidence: B)
Strategies for Rhythm Control in Patients with Paroxysmal and Persistent AF
Strategies for Rhythm Control in Patients with Paroxysmal and Persistent AF

AF Complicating ACS: Recommendations

Class I
  • Urgent direct-current cardioversion of new-onset AF in the setting of ACS is recommended for patients with hemodynamic compromise, ongoing ischemia, or inadequate rate control. (Level of Evidence: C)
  • Intravenous beta blockers are recommended to slow a rapid ventricular response to AF in patients with ACS who do not display HF, hemodynamic instability, or bronchospasm. (Level of Evidence: C)
Class IIb
  • Administration of amiodarone or digoxin may be considered to slow a rapid ventricular response in patients with ACS and AF associated with severe LV dysfunction and HF or hemodynamic instability. (Level of Evidence: C)
  • Administration of nondihydropyridine calcium antagonists might be considered to slow a rapid ventricular response in patients with ACS and AF only in the absence of significant HF or hemodynamic instability. (Level of Evidence: C)

Hyperthyroidism: Recommendations

Class I
  • Beta blockers are recommended to control ventricular rate in patients with AF complicating thyrotoxicosis unless contraindicated. (Level of Evidence: C)
  • In circumstances in which a beta blocker cannot be used, a nondihydropyridine calcium channel antagonist is recommended to control the ventricular rate. (Level of Evidence: C)

Pulmonary Disease: Recommendations

Class I
  • A nondihydropyridine calcium channel antagonist is recommended to control the ventricular rate in patients with AF and chronic obstructive pulmonary disease. (Level of Evidence: C)
  • Direct-current cardioversion should be attempted in patients with pulmonary disease who become hemodynamically unstable as a consequence of new onset AF. (Level of Evidence: C)

Pulmonary Disease: Recommendations

Class I
  • A nondihydropyridine calcium channel antagonist is recommended to control the ventricular rate in patients with AF and chronic obstructive pulmonary disease. (Level of Evidence: C)
  • Direct-current cardioversion should be attempted in patients with pulmonary disease who become hemodynamically unstable as a consequence of new onset AF. (Level of Evidence: C)

WPW and Pre-Excitation Syndromes: Recommendations

Class I
  • Prompt direct-current cardioversion is recommended for patients with AF, WPW, and rapid ventricular response who are hemodynamically compromised (64). (Level of Evidence: C)2. Intravenous procainamide or ibutilide to restore sinus rhythm or slow the ventricular rate is recommended for patients with pre-excited AF and rapid ventricular response who are not hemodynamically compromised (64). (Level of Evidence: C)
  • Catheter ablation of the accessory pathway is recommended in symptomatic patients with preexcited AF, especially if the accessory pathway has a short refractory period that allows rapid antegrade conduction (64). (Level of Evidence: C)
Class III: Harm
  • Administration of intravenous amiodarone, adenosine, digoxin (oral or intravenous), or nondihydropyridine calcium channel antagonists (oral or intravenous) in patients with WPW syndrome who have pre-excited AF is potentially harmful as they accelerate the ventricular rate. (Level of Evidence: B)

Heart Failure: Recommendations

Class I
  • Control of resting heart rate using either a beta blocker or a nondihydropyridine calcium channel antagonist is recommended for patients with persistent or permanent AF and compensated HF with preserved EF (HFpEF) (262). (Level of Evidence: B)
  • In the absence of pre-excitation, intravenous beta blocker administration (or a nondihydropyridine calcium channel antagonist in patients with HFpEF) is recommended to slow the ventricular response to AF in the acute setting, with caution needed in patients with overt congestion, hypotension, or HF with reduced LVEF (496-499). (Level of Evidence: B)
  • In the absence of pre-excitation, intravenous digoxin or amiodarone is recommended to control heart rate acutely in patients with HF (270, 497, 500, 501). (Level of Evidence: B)
  • Assessment of heart rate control during exercise and adjustment of pharmacological treatment to keep the rate in the physiological range is useful in symptomatic patients during activity. (Level of Evidence: C)
  • Digoxin is effective to control resting heart rate in patients with HF with reduced EF. (Level of Evidence: C)
Class IIa
  • A combination of digoxin and a beta blocker (or a nondihydropyridine calcium channel antagonist for patients with HFpEF), is reasonable to control resting and exercise heart rate in patients with AF (260, 497). (Level of Evidence: B)
  • It is reasonable to perform AV node ablation with ventricular pacing to control heart rate when pharmacological therapy is insufficient or not tolerated (262, 502, 503). (Level of Evidence: B)
  • Intravenous amiodarone can be useful to control the heart rate in patients with AF when other measures are unsuccessful or contraindicated. (Level of Evidence: C)
  • For patients with AF and rapid ventricular response causing or suspected of causing tachycardiainduced cardiomyopathy, it is reasonable to achieve rate control by either AV nodal blockade or a rhythm-control strategy (52, 300, 504). (Level of Evidence: B)
  • For patients with chronic HF who remain symptomatic from AF despite a rate-control strategy, it is reasonable to use a rhythm-control strategy. (Level of Evidence: C)
Class IIb
  • Oral amiodarone may be considered when resting and exercise heart rate cannot be adequately controlled using a beta blocker (or a nondihydropyridine calcium channel antagonist in patients with HFpEF) or digoxin, alone or in combination. (Level of Evidence: C)
  • AV node ablation may be considered when the rate cannot be controlled and tachycardiamediated cardiomyopathy is suspected. (Level of Evidence: C)
Class III: Harm
  • For rate control, intravenous nondihydropyridine calcium channel antagonists, intravenous beta blockers, and dronedarone should not be administered to patients with decompensated HF. (Level of Evidence: C)


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ST↑ in aVR: un’alterazione di tutto rispetto

16 Apr


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:


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





  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


L’arresto cardiaco intraospedaliero: strategie per migliorare la sopravvivenza.

2 Feb

Molto abbiamo scritto sull’ACR extraospedaliero, ma quale è la situazione dentro l’ospedale?

La sensazione è che molto ci sia ancora da fare, sia dal punto di vista culturale che organizzativo, per uniformare in tema di gestione dell’ACR le molte realtà presenti.

Epidemiologia, best practices e un deciso incoraggiamento ad un cambio di passo  nella gestione dell’arresto cardiaco intraospedaliero, tutto questo è contenuto nel recentissimo documento di consenso dell’American Heart Association che indica in modo chiaro gli standard attuali al di là delle differenze logistico culturali.

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Tutte le ultimissime Linee Guida in Medicina d’Urgenza?

Le trovi su MEDEST! Tutte full text e scaricabili in pdf nella sezione a loro dedicata.

Clicca qui e vai alla pagina dedicata

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Aggiornamento Linee Guida NICE sul trauma cranico

2 Feb

Il National Institute for Helath and care Excellence (NICE) ha aggiornato le Linee Guida per il triage ed il trattamento del trauma cranico dall’età pediatrica a quella adulta.

Dal trattamento preospedaliero agli algoritmi decisionali e diagnostici intraospedalieri, in forma chiara e concisa.

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ACEP Clinical Policies e Trauma Ultrasound eBook

9 Gen

Scaricate le Clinical Policies dell’American College of Emergency Physicians nella sezione delle Linee Guida a loro dedicata.

ACEP Clinical Policies

Sempre da ACEP nuova applicazione e libro multimediale sull’eFAST nel trauma. Una risorsa completa ed interattiva per che usa l’ecografia sia in DEA che sul territorio.

Trauma Ultrasound eBook

Intossicazione da CO sul territorio

27 Dic


La diagnosi di intossicazione da CO (monossido di carbonio) è clinica. La definizione classica prevede la presenza della triade:

  • Storia di esposizione a CO
  • Sintomi compatibili con intossicazione da CO
  • Elevati livelli di CO nel sangue

Non esiste alcun sintomo patognomonico per intossicazione da CO nonostante la diagnosi clinica ne preveda la presenza.

I sintomi più comunemente associati all’esposizione acuta sono cefalea, nausea/vomito, ipostenia, dolore toracico, dispnea e sincope. Quello forse più comune è la cefalea, anche se non ha una clinica tipica. Non esistono inoltre combinazioni sintomatologiche tali da poter confermare o escludere la diagnosi d’intossicazione da CO. Storicamente è stato indicato il colore “rosso ciliegia” della cute come indicatore vagamente patognomonico della patologia. In realtà, tale segno è sia raro che tardivo, e quando presente indica uno stato molto avanzato caratterizzato da livelli ematici pressoché letali di CO.

La diagnosi clinica necessita comunque di conferma strumentale che dimostri la presenza di livelli elevati di CO ematica.

Valori superiori al 3-4% nei non fumatori e superiori al 10% nei fumatori devono essere considerati valori eccedenti la fisiologica quantità di carbossiemoglobina.

Si parla di:

  • Intossicazione lieve:con valoro di CO >10% senza segni clinici
  • Intossicazione moderata: con valoro di CO >10% con segni e sintomi minori (cefalea, letargia, astenia)
  • Intossicazione severa: con valoro di CO >20-25% con perdita di conoscenza, confusione mentale, segni d’ischemia miocardica

La misurazione non invasiva della Carbossiemoglobina attraverso apparecchi che sfruttano l’assorbimento della lunghezza d’onda pulsata è controversa in termini di affidabilità e va comunque sempre confermata attraverso la misurazione mediante prelievo ematico (venoso o arterioso).

La rilevazione della SaO2 nei pazienti con sospetta intossicazione da CO non è indicativa dell’effettivo stato d’ossigenazione del sangue periferico. Lo spettro di assorbimento della carbossiemoglobina infatti è molto vicino a quello dell’emoglobina ridotta ed i normali saturimetri per tale motivo non sono in grado di discriminare tra quella effettivamente legata all’O2 e quella legata al CO.

La rilevazione di bassi livelli ambientali di CO in presenza di storia di esposizione acuta al tossico non esclude la possibile intossicazione delle persone coinvolte. Al momento della misurazione infatti i valori rilevati potrebbero essere falsati dalla precedente apertura di porte o finestre.

La rilevazione di alti livelli ambientali di CO di contro rende mandatoria la valutazione  clinico strumentale dei pazienti convolti ed il loro trattamento d’emergenza in caso di sospetto clinico.

L’O2 normobarico ad alti flussi somministrato via maschera facciale o tubo orotracheale è il trattamento di prima linea per l’intossicazione da CO (nonostante non esistano trial adeguati che ne dimostrino la reale efficacia).

Non esistono evidenze di livello A che indichino l’utilizzo mandatorio dell’ossigeno iperbarico nei pazienti intossicati da CO.

Non esistono segni o sintomi che indichino l’utilizzo dell’ossigeno iperbarico.

La terapia con O2 iperbarico  può essere considerata (secondo il parere di alcuni esperti Livello C) nei seguenti casi:

  • Coma
  • Transitoria perdita di conoscenza
  • Alterazione del comportamento
  • Cefalea
  • Nausea o vomito
  • Vertigini
  • Dolore toracico o segni ECG di ischemia
  • Aritmie
  • Gravidanza
  • Bambini inferiori a 6 mesi d’età (per la presenza di Hb fetale)
  • Esposizione a CO accertata ≥24 hours

La terapia con O2 iperbarico è controindicata nei seguenti casi:

  • Pnx non drenato,
  • Crisi comiziali,
  • Claustrofobia accertata

Tutti i mezzi di soccorso dovrebbero essere dotati di rilevatore di CO. L’unità di misura in cui tale dispositivo visualizza i livelli misurati è il ppm (parti per milione).

Il professionista sul territorio in caso di sospetto clinico di intossicazione da CO

  • Allontana il paziente dalla fonte di CO
  • Inizia il trattamento con O2 ad alti flussis
  • Sostiene i parametri vitali
  • Centralizza il paziente al DEA dell’ospedale dove è presente il servizio d’urgenza per il trattamento con O2 iperbarico


  1. Kao LW, Nanagas KA, Carbon monoxide poisonin. Emerg Clin N Am. 2004 Nov;22(4):985-1018.
  2. Buckley NA, Juurlink DN, Isbister G, Bennett MH, Lavonas EJ, Hyperbaric oxygen for carbon monoxide poisoning. Cochrane Database Syst Rev. 2011 Apr 13;(4):CD002041.
  3. Wolf SJ, Lavonas EJ, Sloan EP, Jagoda AS; American College of Emergency Physicians. Clinical Policy- Critical Issues in the Management of Adult Patients Presenting to the Emergency Department with Acute Carbon Monoxide Poisoning. Ann Emerg Med. 2008 Feb;51(2):138-52.
  4. Weaver LK. Clinical practice. Carbon monoxide poisoning. N Engl J Med. 2009 Mar 19;360(12):1217-25.

MEDEST you tube

Faculty of Pre-Hospital Care Consensus Statements

20 Dic
Nuove Consensus Statements da parte della Faculty of Pre-Hospital Care che riguardano l’immobilizzazione spinale preospedaliera, l’inserzione farmacologicamente assistita della maschera laringea, la movimentazione minima preospedaliera del paziente traumatizzato e l’utilizzo dei device per la contenzione del bacino.
Sono tutte scaricabili liberamente sul nuovo sito della Faculty of Pre-Hospital Care e sulla pagina di MEDEST dedidcata alle linee guida.

Faculty of Pre-Hospital Care new Consensus Statements.

Sedare un paziente di cui si vuole gestire le vie aeree ed inserire un presidio sovraglottico? Un’eresia o una pratica che comunque esiste e come tale deve essere “goveranta”? La lettura di questo Statements apre nuove prospettive ad una pratica non ortodossa ma che, seppure in casi limitati, ha un suo razionale clinico.

L’immobilizazione spinale deve essere selettiva, e non deve riguardare tutti i pazienti traumatizzati a prescindere da criteri clinico prognostici. Già in passato MEDEST si è occupata di immobilizzazione spinale auspicando l’adozione di criteri clinici selettivi per l’utilizzo dei presidi d’immobilizzazione nel trauma preospedaliero. Questa Consensus Statements va finalmente in questa direzione.

Riassumiamo le principali racomandazioni:

  1. L’asse spinale è un presidio da utilizzare solo per l’estricazione del paziente vittima di trauma.
  2. Per il trasporto e le manovre diagnostiche intraospedaliere la barella scoop è il presidio più adatto. Minimizza i movimenti e diminuisce il rischio di lesioni da pressioni in regione dorsale.
  3. L’immobilizzazione in linea del capo è la tecnica raccomandata per l’immobilizzazione del rachide cervicale, in particolare in pazienti: con vie aeree compromesse che necessitano di essere gestite,  sospetto di aumentata pressione intracranica, combattivi ed agitati, bambini.
  4. Il collare cervicale se utilizzato deve essere ben dimensionato e correttamente applicato. Deve essere comunque allentato per evitare discomfort del paziente, facilitare la gestione delle vie aeree ed evitare il possibili innalzamento della pressione intracranica.
  5. I pazienti vittima di trauma penetrante senza segni neurologici non devono essere immobilizzati.
  6. I pazienti coscienti senza segni di intossicazione da sostanze o lesioni distraenti, se non intrappolati, devono essere invitati a posizionarsi autonomamente sulla barella.
  7. Viene scoraggiato l’utilizzo della manovra “standing take down” (paziente in piedi che viene posizionato sull’asse spinale facendolo appoggiare su di essa e poi accompagnato in posizione supina).

Un presidio per l’immobilizzazione pelvica deve essere sempre usato quando è presente un meccanismo di lesione compatibile con lesione del bacino e contemporanea instabilità emodinamica. Secondo gli autori non esistono evidenze che fanno preferire un presidio rispetto ad un altro. L’immobilizzatore del bacino non è controindicato anche in presenza di frattura alta del femore che  coinvolga l’acetabulo.

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