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Prehospital Emergency Procedures: Scalpel, Finger, Bougie. That’s all you need!

13 Lug

In Emergency Medicine “Simplicity” is synonymous of efficiency, efficacy and reproducibility.

More the time frame is stressful more we need procedures that are efficient, efficacious and standardised, in one word SIMPLE.

Critcothyrodotomy and chest drain are procedures usually performed in high stressing scenarios and more simply they are more chance of success they have.

I don’t like complicate kits. They need training of course but even a calm and protected environment, and the middle of a street or a busy ER room aren’t nothing like that. 

I don’t like blindly performed procedures but prefer trusting my own senses and sensibility when performing high invasive procedures that, mostly of the times, are a lifesaving last chance.

So this is the best way I know to perform a surgical access to the airway and to drain a highly unstable tense pneumo: using simple instruments, always present in every emergency pack, and trusting my own tactile sensitivity.

surgical-airway-sfb

In those following videos you can see live records of the procedures. They were captured during a recent cadaver lab where I had the honour to join Jim DuCanto, Yen Chow, Carmine Della Vella and Fabrizio Tarchi in teaching airway management and clinical emergency procedures.

Hope you enjoy.

 

 

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

21 Feb

NICE released the 2016 Major trauma Guidelines.

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

  • Airway management

  • Chest trauma

  • Haemorrage control

  • Circulatory access

  • Volume resuscitation

  • Fluid replacement

  • Pain management

  • Documentation

  • Training

Here is the Excerpt regarding the pre-hospital settings

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

Download the full Guidelines at:

Major trauma: assessment and initial management

NICE guidelines [NG39] Published date: February 2016

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The pregnant patient

30 Gen

The management of a pregnant women has been always a challenge for physicians.

The different physiology of pregnancy, makes clinical choices and treatment different than in usual adult patient, and needs attentions and practice that override standard care.

In emergency medicine, where standards and protocols are a way to think and to act, a change in routine care, together with the time dependency of the decision making process, makes the pregnant patient an effective challenge.

So here is the need of specific guidelines focused on pregnant patient for specific clinical emergency situations.

In this post we discuss two guidelines about the management of a pregnant trauma patient and cardiac arrest in a pregnant women, with an eye of regard on the aspects of the recommendations for prehospital care.

Guidelines for the Management of a Pregnant Trauma Patient (Open Access)

Approved by Executive and Board of the Society of Obstetricians and Gynaecologists of Canada

J Obstet Gynaecol Can June 2015;37(6):553–571

Airway
  • Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C)
  • A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content.(III-C)
Breathing
  • Oxygen supplementation should be given to maintain maternal oxygen saturation >95% to ensure adequate fetal oxygenation. (II-1B)
  • If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C)
Circulation
  • Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B)
  • After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement (Lateral Uterus Displacement L.U.D.) of the uterus or left lateral tilt (obsolete n.d.r). Care should be taken to secure the spinal cord (if indicated n.d.r.) when using left lateral tilt. (II-1B)
Transfer to health care facility
  • Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life nor limb threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks’ gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B)
Perimortem Caesarean section
  • A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B)

Take home points on modifications of assessment of trauma patients in presence (or suspect) of pregnancy

  1. When indicated a thoracostomy tube should be inserted 1 or 2 intercostal spaces upper than usual.

  2. Vasopressors has to be avoided in pregnancy.

  3. Perform L.U.D (Lateral Uterus Displacement) to relieve Inferior Vena Cava compression.

  4. Transport the severely injuried pregnant patient to an hospital with maternal facility if fetus is viable (≥ 23 weeks).

Cardiac Arrest in Pregnancy. A Scientific Statement From the American Heart Association (Open Access)

Circulation. 2015;132:00-00. DOI: 10.1161/CIR.0000000000000300
Cardiac Arrest in Pregnancy1
Chest Compressions in Pregnancy
  • There is no literature examining the use of mechanical chest compressions in pregnancy, and this is not advised at this time
  • Continuous manual LUD (left uterus dispalcement) should be performed on all pregnant women who are in cardiac arrest in which the uterus is palpated at or above the umbilicus to relieve aortocaval compression during resuscitation (Class I; Level of Evidence C).
  • If the uterus is difficult to assess (eg, in the morbidly obese), attempts should be made to perform manual LUD if technically feasible (Class IIb; Level ofEvidence C)
  • Cardiac Arrest in Pregnancy
Transporting Pregnant Women During Chest Compressions
  • Because an immediate cesarean delivery may be the best way to optimize the condition of the mother and fetus, this operation should optimally occur at the site of the arrest. A pregnant
    patient with in-hospital cardiac arrest should not be transported for cesarean delivery. Management should occur at the site of the arrest (Class I; Level of Evidence C). Transport to a facility that can perform a cesarean delivery may be required when indicated (eg, for out-of-hospital cardiac arrest or cardiac arrest that occurs in a hospital not capable of cesarean delivery)
Defibrillation Issues During Pregnancy
  • The same currently recommended defibrillation protocol should be used in the pregnant patient as in the nonpregnant patient. There is no modification of the recommended application of electric shock during pregnancy (Class I; Level of Evidence C).
Advanced Cardiovascular Life Support
Cardiac Arrest in Pregnancy 3
Breathing and Airway Management in Pregnancy
Management of Hypoxia
  • Hypoxemia should always be considered as a cause of cardiac arrest. Oxygen reserves are lower and the metabolic demands are higher in the pregnant patient compared with the nonpregnant patient; thus, early ventilatory support may be necessary (Class I; Level of Evidence C).
  • Endotracheal intubation should be performed by an experienced laryngoscopist (Class I; Level of Evidence C).
  • Cricoid pressure is not routinely recommended (Class III; Level of Evidence C).
  • Continuous waveform capnography, in addition to clinical assessment, is recommended as the most reliable method of confirming and monitoring correct placement of the ETT (Class I; Level of Evidence C) and is reasonable to consider in intubated patients to monitor CPR quality, to optimize chest compressions, and to detect ROSC (Class IIb; Level of Evidence C). Findings consistent with adequate chest compressions or ROSC include a rising Petco2 level or levels >10 mm Hg (Class IIa; Level of Evidence C).
  • Interruptions in chest compressions should be minimized during advanced airway placement (Class I; Level of Evidence C).
Arrhythmia-Specific Therapy During Cardiac Arrest
  • No medication should be withheld because of concerns about fetal teratogenicity (Class IIb; Level of Evidence C).
  • Physiological changes in pregnancy may affect the pharmacology of medications, but there is no scientific evidence to guide a change in current recommendations. Therefore, the usual drugs and doses are recommended during ACLS (Class IIb; Level of Evidence C).
Epinephrine and vasopressine
  • Administering 1 mg epinephrine IV/IO every 3 to 5 minutes during adult cardiac arrest should be considered. In view of the effects of vasopressin on the uterus and because both agents are considered equivalent, epinephrine should be the preferred agent (Class IIb; Level of Evidence C).
Fetal Assessment During Cardiac Arrest
  • Fetal assessment should not be performed during resuscitation (Class I; Level of Evidence C).
Delivery durin cardiac arrest
  • During cardiac arrest, if the pregnant woman (with a fundus height at or above the umbilicus) has not achieved ROSC with usual resuscitation measures with manual uterine displacement, it is advisable to prepare to evacuate the uterus while resuscitation continues (Class I; Level of Evidence C)
  • PMCD (Peri Mortem Cesarean Delivery) should be strongly considered for every mother in whom ROSC has not been achieved after ≈4 minutes of resuscitative efforts (Class IIa; Level of Evidence C).
  • If maternal viability is not possible (through eitherfatal injury or prolonged pulselessness), the procedure should be started immediately; the team does
    not have to wait to begin the PMCD (Class I; Level of Evidence C).
  • Assisted vaginal delivery should be considered when the cervix is dilated and the fetal head is at an appropriately low station (Class IIb; Level ofEvidence C)

Take home points for resuscitation in trauma patient:

  1. The utilization of mechanical chest compressors is not recommended.

  2. Continuous LUD should be performed during resuscitation.

  3. No modification in energy level when electrical therapy is needed.

  4. No modification in timing and doses of ACLS drugs.

  5. Fetal assessment is not indicated during resuscitation.

  6. Peri Mortem Cesarean Delivery (PMCD) has to be performed without delay and at the site of cardiac arrest (no transport is indicated), after 4 minutes of ineffective resuscitation attempts.

 

References: 

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2014年第一届潇湘急诊重症与呼吸治疗国际论坛. 2014 Xiao Xiang International Forum on Emergency and Critical Care Medicine.

1 Ott

From 23 to 25 of September at Hunan Provincial People’s Hospital in Changsha (People’s Republic of China) was held the Xiao Xiang International Forum on Emergency and Critical Care Medicine and Reapiratory Therapy.

Many speakers from differents part of Asia and US talked about different and interesting topics. I was honored to be part of this group.

I want to thank my friend and colleague Zhang Yi Xiong for the great opportunity he gave me. I also thank him for the wonderful human experience I had meeting all the chinese colleagues who work in Emergency Depatment of  Provincial People’s Hospital.

Here is my presentation

You can also watch the presentation on line at the link below

http://prezi.com/x41ftjbiv17b/?utm_campaign=share&utm_medium=copy&rc=ex0share

Clik the links below to download the pdf and ppt version of the presentation

Emerging Trends in Prehospital Emergency Medicine.pdf

Emerging Trends in Prehospital Emergency Medicine.ppt

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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.

MEDEST you tube

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

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.

Sei interssato alle ultime linee guida in Emergenza Sanitaria

Visita la pagina di MEDEST dedicata alle ultime novità dal mondo dell’Emergenza

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Brian Burns: Always carry your scalpel!

26 Ott
From SMACC 2013 Dr. Brian Burns (Greater Sydney Area HEMS) presents why a scalpel is an imprtant item in your emergency bag. Never miss it!
A don’t miss talk/slides for every prehospital emergency physician. The last part of the talk regards the trauma arrest algorithm: how to treat arrested trauma patient in the field.
I think every prehospital professional as to be aware about new prospective on trauma treatment. Enanching survival in trauma is one of the missions of prehospital emergency service.
So enjoy Dr Burns slides and audio on “Always carry your scalpel”

Un bisturi può essere un importante aiuto in molte situazioni difficili. Non ci credete?  Ascoltate Brian Burns (Greater Sydney Area HEMS) che illustra molti utili “usi” del bisturi in medicina d’emergenza preospedaliera.

Click HERE for the audio

Ketamine use in Traumatic Brain Injury: Pool result are here!

18 Ott

Some weeks ago we pubblished this post:

I’m deeply convinced that Ketamine use in TBI is safe, and that the evidences against his use in patients with TBI are based on old and small case studies affected by major limitations.
The recent evidences that shown as Ketamine doesn’t race ICP, despite increasing MAP (thank god!), are based on small but well done trials and are as good (or even more) than the previous ones.
I’m also convinced that the utlity of Ketamine in sedation of severe injuried patients so much outweight the so lightly evidenced controindication in TBI, that his use is still mandatory in trauma patients who need emergency sedation.

 We launched the following pool

and here are the results

Pool result Ketamine in TBI

Click to enlarge

 

References:

 

MEDEST you tube

 

 

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