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HEMS vs GEMS: by ground or by air, which is the best way to take care of traumatized patients

25 Apr

HEMS

Take home points:

Speed

Mission Time

  • –In case of simultaneous activation HEMS is competitive for distance >10 miles from Trauma Center
  • In case of non simultaneous activation HEMS is faster  for distances >45 miles from Trauma Center

 

On scene time

 

  • –HEMS > GEMS

Severity

  • –HEMS patients are generally more severely injured than GEMS patients

Trauma Center Access

  • –HEMS transported patients have more chances to be referred to a level I Trauma Center

Crew

  • –More time on scene (beyond the golden hour)
  • –More procedures performed
  • –The accuracy of prehospital documented diagnoses was not increased in HEMS compared to GEMS rescue

Survival 

  • –No definitive evidences on HEMS benefits on survival rate
  • –Recent literature points on a trend toward an increased chances of survival in some categories of trauma patients transported by HEMS

 

 

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Fluid resuscitation in bleeding trauma patient: are you aware of wich is the right fluid and the right strategy?

23 Apr

DCR copy

The fluids of choice in prehospital field are, in most cases, cristalloids (Norma Saline or Lactate Ringer).

But what is the physiological impact of saline solutions when administered in large amounts (as the latest ATLS guidelines indicates) to hypotensive trauma patients?

Is aggressive Fluid resuscitation the right strategy to be pursued?

The triad of post-trauma lethal evolution is:

  • Hypotermia
  • Acidosis
  • Coagulopathy

Aggressive fluid resuscitation with cristalloids, and saline solutions in particular, can be detrimental in many ways:

  1. Cristalloids tend to displace the already formed clots and improves bleeding
  2. Normal Saline produce hypercloremic acidosis worsening coagulation and precipitating renal and immune dysfunction
  3. Cristalloids diluts the coagulation factors and precipitate the coagulation system (dilution coagulopathy)
  4. Cristalloids rapidilly shift in intercellular space worsening SIRS process and interstitial edema (brain edema, bowel wall edema) with consequent compartment hypertension

So wich is the perfect fluid to infuse in trauma?

The perfect fluid doesn’t exists.

Balanced saline and Hypertonic saline are promisng prospective but there are still no good quality evidences about their benefit on clinical outcomes.

Colloids has no place in fluid resuscitation of trauma patients.

The fluid of choice, regarding the actual evidences and indications, is Lactate Ringer.

More than on the type of fluid the attention of researchers and clinicians is oriented on the strategy to pusue in those cases.

Hypotensive resuscitation, part of damage control resuscitation, is at the moment the strategy of choice in trauma bleeding patients.

Restrictive fluids administration is the way to achieve this goal.

The target systolic BP has to be diferentiated depending on the type of trauma

  • 60–70 mmHg for penetrating trauma
  • 80–90 mmHg for blunt trauma without TBI
  • 100–110 mmHg for blunt trauma with TBI.

More important do not delay definitive treatment.

ASAP give blood products (PRBC, FFP etc…) to contrast post-trauma coagulopathy and send the patients in OR to fix treatable causes of bleeding

The following are a collection of  un essentials resources on haemostatic resuscitation after trauma

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ACEP policy: Out-of-Hospital Use of Analgesia and Sedation

22 Gen

ACEP states that ” The relief of suffering is among the most common reasons for requesting EMS assistance. Pain and agitation are common causes of this suffering and are commonly encountered by EMS. There is a gap between the need for patient analgesia and the willingness of EMS personnel to provide it. There is a variety of medications available for the relief of pain and agitation.”

So let’s make the point on prehospital analgesia and sedation according with this policy.

Out of hospital analgesia

  1. Fentanyl for his short duration and rapid onset, multiple administration route (IV, IM, IN, and IO),   haemodynamic stability is the ideal narcotic agent for out of hospital use.
  2. Do not withhold narcotics in patients with abdominal pain for the myth of confounding the surgical assessment and so clouding the final diagnosis.
  3. Ketamine (at low doses) for analgesia (alone or in combination with narcotics) is safe, effective and haemodynamically stable without provoking respiratory drive and gag reflex suppression
  4. Concern about Ketamine effect on (increasing) intracranial pressure is misplaced

Out of hospital sedation and chemical restraint 

  1. Midazolam due to his rapid onset, short duration and multiple administration route (IV, IM, IN, and IO) is the ideal benzodiazepine for out of hospital sedation.
  2. Benzodiazepines, especially when administered in multiple doses can cause respiratory drive depression: use full monitoring of the patient when using benzodiazepines (MEDEST suggest waveform capnography). Consider other agents as butyrophenones (MEDEST suggest Aloperidol, Droperidol)
  3. Ketamine (in dissociative dose) is the ideal agent for patients with excited delirium (still not recognised as medical disorder in Italy!!!!!) cause of his rapid onset, safe haemodynamic profile and leave intact respiratory drive and gag reflex.

For full free open access text of this policy go to:

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Endovascular Treatment of Ischemic Stroke

14 Feb

merci01

Thrombolysis is nowadays the preferred therapy for ischemic stroke management.
Many controversies on his safety and discussion on evidences that support benefits on long term outcomes, aroused from most of the studies supporting the use of alteplase in stroke patients.
New technologies has been recently developed for endovascular therapy and this made possible a steady step forwar for its use in targeted treatment of obstructed cerebral vessels.
Imaging detection of the lesion, targeted vessels treatment has been applied to a selected group of patients avoiding blind systemic thrombolytic administration.
New studies and good evidences support this technique. Selecting patients with advanced imaging techniques, using the latest stent retriever devices, and performing the intervention earlier is the key of a revolving way to investigate endovascular theraphy in ischemic stroke.

The addition of this tecnique when one of the major cerebral artery is obstructed almost double, according some investigators, the chance of good neurological outcome comparing to tPa alone.

Here is a short review of the 4 most recent studies on this topic:

500 patients where enrolled at 16 medical centers in Netherlands were assigned to intra-arterial treatment or to usual care alone. The primary outcome was the odds ratio of achieving a lower score on the modified Rankin scale at 90 days with endovascular therapy. There was an absolute difference of 13.5 percentage points in the rate of functional independence in favor of the intervention (32.6% vs. 19.1%). There were no significant differences in mortality or the occurrence of symptomatic intracerebral hemorrhage.

Patients with a proximal intracranial occlusion in the anterior circulation were included up to 12 hours after symptom onset. Participants where randomly assigned to receive standard care (control group) or standard care plus endovascular treatment with the use of available thrombectomy devices (intervention group). Patients with a proximal intracranial occlusion in the anterior circulation were included up to 12 hours after symptom onset. Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded.

The trial was stopped early because of efficacy. The primary outcome favored the intervention, and the intervention was associated with reduced mortality (10.4%, vs. 19.0% in the control group). Symptomatic intracerebral hemorrhage occurred in 3.6% of participants in intervention group and 2.7% of participants in control group (P=0.75).

Patients with ischemic stroke who were receiving alteplase less than 4.5 hours after the onset of ischemic stroke where randomly assigned either to undergo endovascular thrombectomy with the Solitaire FR (Flow Restoration) stent retriever or to continue receiving alteplase alone. All the patients had occlusion of the internal carotid or middle cerebral artery and evidence of salvageable brain tissue and ischemic core of less than 70 ml on computed tomographic (CT) perfusion imaging.

The trial was stopped early because of efficacy after 70 patients had undergone randomization. The percentage of ischemic territory that had undergone reperfusion at 24 hours was greater in the endovascular-therapy group than in the alteplase-only group.

The study is to determine if patients experiencing an Acute Ischemic Stroke due to large vessel occlusion, treated with combined IV t-PA and Solitaire FR within 6 hours of symptom onset have less stroke-related disability than those patients treated with IV t-PA alone.

The Primary endpoint is 90-day global disability assessed via the blinded evaluation of modified Rankin score (mRS).

The primary endpoint showed a substantial shift to lower disability levels on the modified Rankin scale. The proportion of patients alive and free of major disability at 3 months also significantly improved, along with mean improvement of National Institutes of Health Stroke Scale (NIHSS) score at 27 hours.

Read also Medscape commentary at:

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F.A.R. in E.M. (Focus Assessed Review in Emergency Medicine ) #4: Stroke. Bonus feature, 2015 ACEP Clinical Policy on Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department

27 Gen
MEDEST F.A.RAnd here we are with the 4th episode of the F.A.R. series. If you accidentally lost the first two episodes you can find them here:
#1 Cardiac Arrest
#2 Airway Management
In this episode we’ll explore the best articles of 2014 about:

Stroke

Before starting we have to declare (if you are not aware of) that MEDEST is quite skeptical about the previous studies that are at the basis of thrombolytic therapy (Lo strano caso del trombolitico nell’ictus cerebrale ischemico, Pubblicate le nuove linee guida AHA/ASA sul trattamento precoce dello Stroke: nessuna nuova ed ancora qulache dubbio!, L’uso del trombolitico nello stroke. Stiamo giocando con la salute dei nostri pazienti?, rt-PA e Stroke: IST-3 l’analisi dei risultati). This can represent a potential bias on the choice of the articles. We also think that the actual evidences, and the consequent guidelines, are strongly influenced by commercial interests and not well supported from evidences that demonstrates how benefits outweight harms. We hope that 2015 will be the first year of a new era for stroke management, an era of well done studies producing strong evidences to achieve good neurological targets in all stroke patients.

In the first part we mention the litterature about thrombolytic therapy

And then the articles about endovascular therapy:

And now as anticipated in the title the 2015 ACEP Clinical Policy on Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department. Those freshly published guidelines give answer at two of most recurrent questions on stroke treatment:

  1. Is IV tPA safe and effective for acute ischemic stroke patients if given within 3 hours of symptom onset?
  2. Is IV tPA safe and effective for acute ischemic stroke patients treated between 3 to 4.5 hours after symptom onset?
Download and read the full policy to discover the recommendations made and based on the strength of the available data.
DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.
Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).
So download the full text and read it carefully to have a clear and complete opinion of the related topics.


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F.A.R. in E.M. (Focus Assessed Review in Emergency Medicine ) #3: Trauma

10 Gen
MEDEST F.A.RAnd here we are with the 3th episode of the F.A.R. series. If you accidentally lost the first two episodes you can find them here:
#1 Cardiac Arrest
#2 Airway Management
In this episode we’ll explore the best articles of 2014 about:

Trauma

Before approaching specific arguments about trauma here are some fundamental articles to read about new emerging concepts in trauma care. Those are the clinical and physiological bases to understand what is happening in the actual trauma management scene.

And now let’s go to specific area of interest:

  • Spine immobilization

Spine immobilization in trauma is changing.

After years of dogmatic approach to strict spine immobilization for all trauma patients regardless any other factor, is now pretty clear that not all the trauma patients benefits from this all or nothing way of thinking. MEDEST already faced the argument in previous posts (The Death of the Cervical Collar?) as also did some prehospital consensus guidelines (Faculty of Pre-Hospital Care Consensus Statements).

In 2014 many articles treated this topic in a critical and modern way of re-thinking spinal immobilization, in particular the widespread use of cervical collar. The lessons we learned is that:

  1. Widespread use of cervical collar in neck trauma has to be carefully evaluated (and even avoided) due to the low incidence of unstable spinal lesions.
  2. Routine use of cervical collar is of unclear benefit and supported by weak evidences. A new selective approach has to be implemented based on prehospital clearance protocols.

What is “revolution” in clinical practice? We don’t have the answer to this dilemma, but what is happening in fluid resuscitation for trauma patients seems likely to be revolutionary. Restrictive strategies and new blood products are the future for the treatment of trauma patients (read also Fluid resuscitation in bleeding trauma patient: are you aware of wich is the right fluid and the right strategy?).

But much more happened in 2014 about trauma….

Resuscitative throacotomy is now a reality not only “in” but even “out” of hospital, so read all about it

An evergreen topic is TBI but new concepts are arousing so read here the latest updates

New drugs and new protocols for airway and pain management: a rationale guide to choose the right drug for the right patient.

DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.
Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).
So download the full text and read it carefully to have a clear and complete opinion of the related topics.


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F.A.R. in E.M. (Focus Assessed Review in Emergency Medicine ) #2

5 Gen
MEDEST F.A.RThe second episode of this focus reviews will deeply assess a topic that is very “hot” for every emergency professional.
Before reading this episode give a look at the first of the series about the best of 2014 literature on  Cardiac Arrest
And now enjoy the very best of 2014 articles on:

Airway Management

Not all is CRASH! Especially when it comes to airway management. RSI is the gold standard when we talk about intubating a spontaneously breathin patient but DSI is becoming a classic. And is recommended by Scott Weingart and Seth Trueger, not properly two “new kids on the block”….
Caution! You are about to perform an invasive maneuver on a previously spontaneously breathing patient. So remember to carefully avoid desaturation and hyper-inflation!
This disclaimer should be written on the handle of every laryngoscope to remember two of the most frequent fault to avoid when managing the airways.
Always rewarded as a nightmare for the emergency professional, surgical airway is most of the time a real no through road for the patient. So here is a complete guide on how to approach in the best way such a difficult skill.
Does the aggressive management of the airways gets benefits on critically ill patients or a more conservative approach gives best results on clinical outcomes? Facts (few) and doubts (many) in this year literature.

 

DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.
Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).
So download the full text and read it carefully to have a clear and complete opinion of the related topics.


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F.A.R. in E.M. (Focus Assessed Review in Emergency Medicine ) #1

2 Gen
MEDEST F.A.RThis is the first (of a series) of literature reviews dedicated to a particular topic of Emergency Medicine clinical life.
We tried to give a deep look to all the articles that had a relevance for a particular argument in this year, and made some considerations regarding the emerged evidences . All the articles are full text end ready to be downloaded.
The first edition is focused on the “king argument” for an emergency medicine and critical care professional:

Cardiac Arrest

Chest compressions

This year the importance of chest compressions in CA was confirmed and even emphasized as one of the few (along with defibrillation) really wothy intervention to perform during CPR.

Mechanical Devices

The “black year” for mechanical devices saw 3 major trials finding no difference in outcome between mechanical and (good quality) manual chest compressions. Still remains the subjective (personal) impression that mechanical devices are of some utility for the human resources management and  transport during CPR.

Vasoactive (and other) drugs

Like (and perhaps more) than for mechanical devices, 2014 signed a really bad year for epinephrine.

Lack of evidence on his utility and emerging ones on detrimental effects, accompanied this “historical” drug through the year that preludes to new 2015 CA Guidelines. Will epinephrine still be there at the end of this 2015? Or new emerging trends on use of steroids and vasopressin will prevale at the end?

ECLS

And after interventions that are loosing evidence in the years, new future prospectives for the management of CA patients, comes from Extra-Corporeal Membrane Oxygenation that gives renewed hopes of better survival and good neurological outcome, despite initial difficulties and skepticism.

Outcome and prognostication

Therapeutic Hypothermia

New era for the post-resuscitative care! Less oxygen, lower tidal volume and last, but not least, less cooling. And, while this year will give us some answers about intra-arrest cooling, now we know that 33°C is equally effective as 36°C and is no longer recommended in post ROSC patients! Maybe….

Other

Hypotermia (accidental not therapeutic), highlights from ERC 2014 Congress and decision on non starting CPR: what changes and what remains in our daily practice.

DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.
Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).
So download the full text and read it carefully to have a clear and complete opinion of the related topics.

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MEDEST Review 30. One year in Review.

25 Dic

MEDEST-review

 

 

 

DISCLOSURE: MEDEST strongly encourage AWARNESS reading the propoused articles.
Abstracts are often misleading and articles potentially biased. Even this selection is not immune from potential bias (just human factors not commercial interests).
So download the full text and read it carefully to have a clear and complete opinion of the related topics.

The latest Review of the year is dedicated to a collection of the most important (for us) articles of this 2014.

This is MEDEST way to wish you all Merry Xmas.

Logo MEDEST xmas

Enjoy the reading:

Cardiac Arrest

Chest compression

Mechanical Devices

Vasoactive drugs

ECLS

Outcome and prognostication

Therapeutic Hypothermia

Other

Trauma

Spine immobilization

Fluids and blood products

Other

Airway management

Sepsis

ACS

Stroke

Guidelines

Emergency Pharmacology

Mechanical Ventilation

Other clinical conditions

Non Clinical

 

 

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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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