A  Rescue Helicopter suffered a fatal crash in L’Aquila, Abruzzo, Italy. Six person died in the crash. Doctor, Nurse, Pilot, HHO, Mountain rescue expert, patient. 

The helicopter crashed during a routine HEMS mission.

The five people of the crew and the patient all died.

When something like that happens the first thought for an HEMS professional is:

IT COULD BE ME!

Then you start to rationalise the situation, mostly in a technical and non emotional way, and arrive at the conclusion:

NEVER WOULD HAPPEN TO ME. 

There are many reason, in my opinion, why we arrive at that. 

We all have family and friends to care about and who take care of us. And we can’t even imagine them devastated by grief.

Our major concern is about patients health and not about our safety. 

And finally, we are humans and human being self-protect their inner fragility, avoiding to hurt themselves thinking about death, especially their own .

But I know, and always will. that IT COULD HAVE BE ME despite any protection and self-lie.

Cause even the 6 persons  who died in the crash had family and friends that now live in a devastating grief.

Even them were taking care of patients over they own safety.

And also them were humans, like me. 

So WAS ME! 

Today a part of me ideally died in that crash.

Tomorrow a new day will begin, but from now on things will look different.

Here are some articles that influenced my clinical practice and my clinical thinking during the last year.

They are not probably the best of all but are my choice, and are all free full text.

So read carefully the full article and judge yourself if worth  or not the mention.

Good reading to everyone. 

• Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis.

The state of the art: Moderate to high quality evidence suggests that compared with medical care alone in a selected group of patients endovascular thrombectomy as add-on to intravenous thrombolysis performed within six to eight hours after large vessel ischaemic stroke in the anterior circulation provides beneficial functional outcomes, without increased detrimental effects.

• The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) and The new sepsis consensus definitions: the good, the bad and the ugly.

A radical change in definition and concepts of Sepsis and sepsis management . From SSC to Sepsis 3. Not a worldwide accepted change in clinical practice. If you are interested in more about go to Sepsis folder

• Decon guidelines.The management of children and young people with an acute decrease in conscious level.

A complete guide to approach at children with decreased level of consciounes is for me a constant friend in my clinical practice.

• Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit The Oxygen-ICU Randomized Clinical Trial.

Less is better when comes to Oxygen therapy. This very well done Italian study despite his early unplanned termination (cause of a earthquake that hitted the centre of Italy) confirm the trend toward reduced mortality in conservative targeted oxygen administration versus conventional liberal therapy.

• Humans Are Not Yeast.

Hypoxic lactic production is a mantra in both patho-physiology and clinical practice. In this article the author gives different interpretation of the phenomena. One of my favourite. 

• Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis.

This systematic review and meta-analysis clearly demonstrate how in both cases CA and CS, ECMO support improve mortality compared with standard techniques. Every emergency system has to consider this option.

• Evidenced-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society.

Rare but dramatic condition among all the epileptics status need the best of EB treatment. Here is the latest reference guidelines released by one of the most important international scientific society. Must read.

• Evidence-Based Performance Measures For Emergency Medical Services Systems: A Model For Expanded EMS Benchmarking.

Traditional performance measures and a proposal for a new more complete model for Clinical Performance Benchmarking. An efficiency and quality assessment method that prehospital systems need to acquire. 

• Influence of EMS-physician presence on survival after out-of-hospital cardiopulmonary resuscitation: systematic review and meta-analysis.

Debating about with model of EMS is the more efficient in performing out of hospital CPR? This systematic review and meta-analysis  affirm that physician based models have better performances than non physician based ones.

• Impact of Helicopter Emergency Medical Service in Traumatized Patients: Which Patient Benefits Most?

HEMS vs GEMS. Ground or air transport in traumatized patients? This article is not the end of the story, but pose a good base on how HEMS can be a better alternative to rescue and transport trauma patients.

2016 has been a great year for Emergency Medicine.

MEDEST on a daily base, via Twitter or Facebook, shared the best (for us) Emergency Medicine articles coming from the net.

At the beginning of a new year we would like to share a collection of those articles (all free full text) organised by topics.

You can browse freely for research or educational proposal

I hope you’ll enjoy.

2016 Review by topic

You can also find articles from previous years on this page

MEDEST Review’s

Was one of my first shift as pre-hospital emergency physician in an ambulance, when I was called on a basketball field where a young man collapsed during a match.

He was in cardiac arrest and I was panicking.  At that time there were small evidences on almost everything, but I grabbed the paddles and defibrillated him. BOOM he had a ROSC. I did it!.

When we arrived at the hospital and old nurse came to me, and tapping on my shoulder said “well done ‘dottorino’ (cute young doctor) but next time don’t forget to put gel on the pads!” Looking at the guy I noticed two circled rush on the chest right in the place where I defibrillated him. At that exact time I realized that even if you fell like a god you have always something to learn, even from the last person you can imagine.

That ‘dottorino’ grown up and experienced a bit now but never stopped studying and learning from everyone, and this is my wish for 2017, to every professional who works in emergency medicine:

Never stop studying  even if you feel to be “the best”.
Never stop listening to everyone, they can have something useful to say.
Open your mind to innovation and be ready to change everyday.
Be ready to start again even in the worst moments of your career; every start is the beginning of a better life.
You can look at the future just if you have a steady past.

Good 2017 to all MEDEST friends and followers.

Mario

The glorious past.

In 1901 Jokichi Takamine (1854-1922) isolated the pure form of adrenaline, also known as epinephrine.

In 1893, George Oliver (1841– 1915), using his own instruments, studied the impact of glycerol extracts on arteries.

Routine use of adrenaline for cardiac arrest was first proposed in the 1960’s. Its inclusion within cardiac arrest management was based upon an understanding of the physiological role of adrenaline, and experimental data from animal research which showed that ROSC was more likely when the drug was used. It was not included on the basis of evidence of benefit in humans, but has remained, since today, a significant component of advanced life support despite minimal human data indicating beneficial effect .

The (in)famous present

Let’s review some physiology about aortic pressure and coronary perfusion.

• Coronary vessels are contained in epicardium and their flow is possible in the diastole when they are not compressed by myocardium during systolic contraction.

• 

  Coronary flow depends from the gradient between aortic diastolic (Ao) pressure and diastolic left ventricular (LV) pressure.

• Higher is the coronary pressure perfusion (CPP), greater is the chance of ROSC.

• The cut off value for ROSC is 15 mmHg of CPP, but more is better.
• Epinephrine is a key determinant factor in maintaining diastolic aortic pressure in cardiac arrest; thanks to its interaction with alpha receptors, located on the endothelium of the arteries, produce generalized peripheral arterial vasoconstriction maintaining aortic diastolic pressure to a high level even during chest compressions.

So why epinephrine doesn’t work and can be detrimental on long term outcome

I think there are two key factors, in the actual way to use Epinephrine,cwho determine its failure:

The wrong administration route

When epinephrine is administered intravenously in a low flow state patient (as is a patient during cardiac arrest, even if proper chest compressions are performed), the amount of drug that arrives to perform the “local” alpha effect on arteries is just a minimal quantity of the (high!!!) dose. The major part rely in the venous circulation and is mobilized in great quantity only when ROSC happens determining a widespread vasoconstriction and a consequent “overdose” effect (think just at the “stunned” myocardium that has to overwhelm such ha great post-load).

The wrong dose to the wrong patient

From the coronary perfusion pressure (CPP) point of view, every cardiac arrest patient is different: some patients have a (relative) good aortic pressure and a (relative) good  coronary perfusione comparing to others.

When we administer the same amount of epinephrine to each of them this takes to an underdose in some patients (with low flow state) and an overdose in others (with good or high flow state).

The possible future

The right administration route

Probably the best route to administer epinephrine is not the vein but the artery.

It allows, even in a low flow state patient, a better chance to reach the vasoconstrictor effect maintaining a good aortic diastolic pressure and a consequent good coronary flow.

Nowdays (the era of REBOA, open thoracotomy and more) the chance to use ultrasound make this skill easier than before and definitively possible even in prehospital settings.

The right dose to the right patient

Giving epinephrine (standard dose) to a patient who has a low flow state (patients who need it more) make epinephrine usefulness (underdose) because just a little part of it circulate.

Giving  epinephrine to patients in a good or high flow state (patients that need it less or don’t need epi at all) is detrimental and can cause overdose effect.

We need to know wich is the circulatory state of the patients to administer the right dose avoiding the “overdose” effect.

The only way to do this is monitoring aortic diastolic pressure through an arterial catheter. We can target Epinephrine dosage to reach a good aortic pressure maintaining a good CPP (achieving ROSC) and avoiding overdose.

Take home points for future improvement.

1. Train to reach an US guided arterial line in cardiac arrest

2. Check aortic pressure via peripheral or central (femoral) arterial line

3. Give Adrenaline intrarterially

4. Target Adrenaline doses to maintain a good aortic pressure

Tanks to Jim Manning who inspired this post with his talk Rethinking Adrenaline in Cardiac Arrest

References

• 1900: The discovery of epinephrine (adrenaline)

• Adrenaline and cardiac arrest. Ambulancetoday

• Hagihara A, Hasegawa M, et al. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA, March 21, 2012—Vol 307, No. 11
• Clifton W. Callaway, MD, PhD. Questioning the Use of Epinephrine to Treat Cardiac Arrest. JAMA, March 21, 2012—Vol 307, No. 11
• Lin S, et al. Adrenaline for out-of-hospital cardiac arrest resuscitation: A systematic review and meta-analysis of randomized controlled trials. Resuscitation (2014).

• Rethinking Adrenaline in Cardiac Arrest- Jim Manning on Vimeo from SMACC Dub

• Manning JE,  Murphy CA Jr. Aortic arch versus central venous epinephrine during CPR. Ann Emerg Med. 1993 Apr;22(4):703-8.
  

Save

Si è appena concluso il decimo congresso nazionale SIMEU che è già tempo di bilanci e conclusioni.

Io non sono in grado di farlo, conosco pochissimo il mondo SIMEU, come purtroppo la maggior parte dei medici d’emergenza che lavorano in ambito preospedaliero. Ma anche SIMEU conosce pochissimo il mio mondo.

Quest’anno però è successo qualcosa di nuovo.

Mi sono avvicinato, timidamente con le mie certezze e qualche pregiudizio, al mondo SIMEU ed ho tenuto due relazioni, una nella (unica a parte qualche altro spot sparso) sessione dedicata al setting preospedaliero, l’altra nella sessione dedicata all’arresto cardiaco.

Ma SIMEU cosa ha fatto per me.

Secondo me moltissimo.

Mi ha fatto capire che nel suo mondo, tra i suoi uomini e le sue donne c’è già il seme del nuovo medico di medicina d’urgenza.

Un medico che ha competenza e capacità per accompagnare il paziente da casa o dalla strada al ricovero in reparto passando per la stabilizzazione preospedaliera a quella in DEU. Un medico che ha capacità per affrontare scelte cliniche e terapeutiche complesse ed attuare le tecniche che permettono di raggiungerle in tutti i setting dell’emergenza.

Ma sopratuttto un medico che ha un’umanità sconfinata, un professionista che si realizza nell’assistenza delle persone prima che dei pazienti, nella cura dell’anima prima che del corpo.

Tutto questo ho visto nelle persone con cui ho parlato e con cui ho sognato un futuro entusiasmante per tutti noi.

Federica, Matteo, Giacomo, Efrem (e non cito altri perchè non ricordo i nomi ma solo le bellissime facce) sono già così: competenti, umani e pieni d’entusiasmo.

Sono stati Alessandro, Mario, Fabio, Carlo e tanti altri ad ispirarli, e loro sono già pronti.

Saranno Mario, Alessandro, Fabio, Carlo a guidarli, ma loro sono il futuro.

Buongiorno Medicina d’Emergenza Urgenza!

Beyond theories and protocols, here we are three (real) clinical prehospital scenarios  in which without ultrasound my own practice would have been different with (probably!!!) some (bad!!) consequence on patients final outcome.

Case #1

Apparently 45 yrs old female found unconscious in a secondary street by people accidentally passing by. No witness of the event. No other information on the patient.

When the first medical team arrived, the patient was unconscious with some non coordinated vocal response (if stimulated) and no finalized movements of the extremities; she was spontaneously breathing with an apparent good respiratory drive a RR of 24 and O2 sat of 98% on room air.  Good breath sounds were (apparently) bilaterally transmitted (not easy to appreciate when you perform auscultation of the chest on the roadside).

She had a good palpable radial pulse (bilaterally), the HR was 72 and her BP 110 over 70. To a quick external exam multiple minor signs of trauma where present on her face, forehead and left anterior chest wall. No sign of major external bleeding was present.

When we arrived the above clinical scenario was confirmed. The cops, on the scene, were investigating about what happened, but at the moment no other new information was available.

As first thing I was concerned, cause of the low level of consciousness, about patient’s competence to maintain airway patency , so I decided to protect the airways with tracheal intubation. 

But first to proceed to RSI, during the preox period and despite the apparent hemodynamic stability I decided to perform an extended FAST ultrasound exam; it takes 2 min, is safe and free.  The EFAST revealed a pneumothorax on the left, no abdominal bleeding, no pericardial fluid effusion. At this point we decide to open the chest (finger bougie tecnique, Ketamin pre-medication) before intubating the patient in prevision  of the mechanical positive pressure ventilation, and air transport.

The patient arrived well compensated (from both respiratory and hemodynamic point of view) at the trauma  center where was discharged 3 weeks later without major clinical consequences.

But what without ultrasound???

We don’t have a clinical guidance (and practice) to open the chest simply ‘cause of the presence of external sign of chest trauma when the patient is in a well compensated respiratory status and had a good hemodynamic balance.

In this case the chance to find clear US signs of penumothorax, prevented a possible worsening of respiratory and hemodynamic status  after intubation.  Intubation itself, PPV and high altiutde transport, are all factors that can precipitate a prior stable pneumothorax.

Case #2

28 yrs male victim in a car accident extricated after several minutes by the firefighters. At the arrival of the fire crew he was still breathing but when the first medical crew arrived found him in CA. Advanced life support started and was ongoing when we arrived.

The patient was intubated on the field, two thoracic tubes were bilaterally placed (emo-thorax on the right side no pneumo bilaterally)  and a bolus of 2 liters of fluids administered via two large bore venous accesses.

He had an organized cardiac electric activity and an EtCO2 value of 35 mmHg (without chest compressions in place). The US of the heart shown some weak wall motion (coordinated with electric activity), so we decided to rapidly transport the patient to the nearest trauma center where he was reanimated for more than 1 hour and then called  without any evidence of possible cause of death.

In this case the presence of wall motion at the US exam (well supported from EtCO2 values and and by an organized cardiac electric activity) strongly influenced the decision to transport the patient in TCA to the hospital for definitive care.

Ultrasound can be a further hint in the decision to carry on the resuscitative efforts in patients in CA with PEA and no evidence of reversible causes on the field. It can be also the decisive tool in deciding  to transport those patients to the hospital for second level diagnostic assessment and advanced care.

Case #3

24 yrs old pedestrian male hit by a motorbike while crossing the road. He was found unconscious by first responders. When we arrived the patient was lying down on the spinal board wearing a cervical collar with eyes closed but responsive when called and able to execute simple commands with no apparent deficit of the limbs. He suffered a severe facial trauma  with  avulsion of several frontal teeth and a profound total tickness wound to the superior lip with presence of a lot of blood in the mouth and  the first part of the airways; his breathing was laborious and noisy. Anyway  the patient was able to maintain an ox sat of 93% on room air (that easily improved to 98% with 2 liters of oxygen administered via simple O2 mask). 

The radial pulse was present at a rate of 90/min and the BP was 100 over 70. The rest of external exam highlighted a profound wound at the internal part of the calf with exposition of muscular plan and some hemorrhage well controlled with external manual compression.

We provided (with not much success due to the unstoppable bleeding) to clear the airways from blood and secretions, but still the respiration was difficult and noisy even if the ox sat was on a satisfying 98% on O2 non rebreather mask . In the meanwhile two large bore venous accesses were placed and some fluids keep going.

The EFAST exam revealed no signs of pneumo but presence of blood in the right and left upper quadrant of the abdomen.

We decided to do not insist further on airways control because at this point the control of abdominal bleeding became the first priority. After a rapid transport in ED the total body CT (he was still hemodynamically compensated)  confirmed the presence of internal bleeding and the patient proceeded straight to OR.

Often the suspect of internal bleeding is not clear just by considering clinical signs, especially when we have to deal with young patients who have a large compensation range. POCUS can give us the chance to see the presence of blood in the abdomen and to prioritize our clinical pathway pondering these findings.

Take home points

#1

Performing a chest US before intubating a even stable chest trauma patient, prevents possible  (pre, intra and post) intubation hemodynamic disasters.

#2

Prehospital arrested trauma patients with an organized electric activity and good EtCO2  might have some cardiac activity even in absence of palpable carotid or femoral pulse. They deserve a strong effort on addressing reversible causes and a rapid transport to a  trauma center for advanced in hospital care.

#3

The presence of internal bleeding (revealed by US) can revolve clinical priorities enabling a fast track toward the OR. This virtuous path can start from the prehospital environment.