World Health Organization relesead the 2014 guidelines for Community management of opioid overdose.
Here are some highlights from the guidelines of particular relevance for emergency medicine
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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.
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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.
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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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MEDEST 
The pregnant patient
30 GenThe 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)
J Obstet Gynaecol Can June 2015;37(6):553–571
Airway
Breathing
Circulation
Transfer to health care facility
Perimortem Caesarean section
Take home points on modifications of assessment of trauma patients in presence (or suspect) of pregnancy
When indicated a thoracostomy tube should be inserted 1 or 2 intercostal spaces upper than usual.
Vasopressors has to be avoided in pregnancy.
Perform L.U.D (Lateral Uterus Displacement) to relieve Inferior Vena Cava compression.
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)
Chest Compressions in Pregnancy
Transporting Pregnant Women During Chest Compressions
Defibrillation Issues During Pregnancy
Advanced Cardiovascular Life Support
Breathing and Airway Management in Pregnancy
Management of Hypoxia
Arrhythmia-Specific Therapy During Cardiac Arrest
Epinephrine and vasopressine
Fetal Assessment During Cardiac Arrest
Delivery durin cardiac arrest
Take home points for resuscitation in trauma patient:
The utilization of mechanical chest compressors is not recommended.
Continuous LUD should be performed during resuscitation.
No modification in energy level when electrical therapy is needed.
No modification in timing and doses of ACLS drugs.
Fetal assessment is not indicated during resuscitation.
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:Guidelines for the Management of a Pregnant Trauma PatientCardiac Arrest in Pregnancy.A Scientific Statement From the American Heart Association (Open Access)Condividi:
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