Tag Archives: Emergency Medicine guidelines

“Best Practice” preospedaliera: Arresto cardiaco da trauma

4 Ago

Tra tutte le “Best Practices”, quella che rappresenta più di tutte un cambio radicale di mentalità nell’approccio clinico e terapeutico, è la gestione dell’arresto cardiaco da causa traumatica. Vi prego quindi di leggere attentamente le raccomandzioni raccolte nel documento sottostante e di non esitare a esprimere le vostre riflessioni nei commenti.

Arresto cardiaco adulto traumatico

Chi è interessato ad approfondire il razionale che sta alla base  delle raccomandazioni può scaricare e leggere il documento completo: Arresto cardiaco nell’adulto da causa traumatica full text

 

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“Best Practice” preospedaliera: Arresto cardiaco nel neonato

29 Lug

Continua la pubblicazione di una serie di monografie dedicate alle Best Practices per l’emergenza preospedaliera.

La quarta della serie riguarda l’arresto cardiaco nel neonato.

Potete scaricare il documento cliccando sull’icona sottostante.

Arresto cardiaco neonato

 

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“Best Practice” preospedaliera: Arresto cardiaco in età pediatrica

16 Lug

Continua la pubblicazione di una serie di monografie dedicate alle Best Practices per l’emergenza preospedaliera.

La terza della serie riguarda l’arresto cardiaco in età pediatrica.

Potete scaricare il documento cliccando sull’icona sottostante.Arresto cardiaco pediatrico

 

 

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“Best Practice” preospedaliera: Arresto cardiaco in gravidanza

1 Lug

Continua la pubblicazione di una serie di monografie dedicate alle Best Practices per l’emergenza preospedaliera.

La seconda della serie riguarda l’arresto cardiaco in gravidanza.

Potete scaricare il documento cliccando sull’icona sottostante.

Arresto cardiaco gravidanza_Page_1

 

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“Best Practice” preospedaliera

25 Giu

Da oggi inizia la pubblicazione di una serie di monografie dedicate alle Best Practices per l’emergenza preospedaliera.

La prima riguarda l’arresto cardiaco nel paziente adulto da causa non traumatica.

Potete scaricare il documento cliccando sull’icona sottostante.

Arresto cardiaco adulto non traumatico_Page_1

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Forget ACLS guidelines if you are dealing with Pulseless Electric Activity. Part 1.

5 Set
ACLS Guidelines are misleading about diagnosis and treatment of pulseless electric activity (PEA)
This takes to conceptual and clinical errors when treating patients in cardiac arrest.
Let’s see why and if there is a better way to follow when dealing with this kind of patients.
First part is about diagnosis and diagnostic tools.

Live your comment below and see you soon for Part 2. The treatment options.

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How a perfect ALS can kill: Pulseles Electric Activity a novel approach in medical cardiac arrest.

27 Ott

HOW PERFECT ALS CAN KILLHEMS arrives on a patients where ground medical service is conducting a perfect ALS.

The 50 years old pt is in PEA cardiac arrest (CA) (sinus bradycardia narrow QRS) airway secured with an 8 ET. The pt was still pulseless (double checked) after almost 20 min of CA, 6 mg of epi already administered and good quality chest compression was ongoing. EtCO2 was 35 (!!!!) even when chest compression were stopped for the pulse check(!!!).

Still no palpable pulse. At this point a 12 lead EKG was performed (against alla the ALS dogmas) with the patient still pulseless and the chest compressions were conseguently suspended (other ALS eresia) while placing the precordial leads and acquiring the EKG.

EKG result: Sinus Rithm 50 bpm. Inf+dx STEMI with reciprocal changes in lateral leads.

S…t she is alive!!! This is not PEA but profound cardiogenic shock.

 

Pulseles Electric Activity a novel approach in medical cardiac arrest

When classical ALS algorithm comes to non defib rithm says that asystole and PEA are the same and have to be equally treated.

There is not such a clinical and therapeutic mistake.

Cardiac stand still and contractile cardiac activity without a palpable central pulse are totally different issues.Pulseless electric activity in the majority of cases is more like a profound state of shock than an asystole, and like this has to be treated.

But let’s make just a step backword.

First cosideration is on the identification of pulseless patients.

At the moment official guidelines consider a pulseless patient based on the palpation of carotid pulse. ERC BLS 2010 official guidelines about carotid pulse palpation says: “Checking the carotid pulse (or any other pulse) is an inaccurate method of confirming the presence or absence of circulation, both for lay rescuers and for professionals” so is no long recommended.

So why if is no recommended for BLS is used in ALS guidelines to recognize pulseless patients and to treat them as an asystolic one? Is our finger a reliable instrument to decide beetwen life and death? Even the BLS guidelines give us the answer: NO.

Second consideration is the research of the underlyng causes of PEA.

The H’s and T’s classification is an etiologic definition and not a clinical one and is often impossible to use in emergency settings cause of the lack of clinicla informations.

Norman and Desbiensin their 2008 article Simplifying the diagnosis and management of pulseless electrical activity in adults: A qualitative review proposed a new classification based on a more clinical concept that is somehow useful for the emergency clinicians.

3 and 3 rule, even if still not validate, seems more helpful for clinicians working on the field or at least for quick use in emergency situation. On plus give us a guide for tretment according on patophisiologic origin of PEA.

3+3+3 rule

 

 

More recently Littmann, Bustin and Haley in the 2013 article “A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity” use EKG findings to guide the diagnosys of cause of PEA and to treat it. On the base of QRS duration they identify a possible origin, mechanical or metabolic, and accordingly propose the specific treatment.

PEA evaluation algo

 

 

 

 

 

 

 

 

PEA evaluation algo1PEA evaluation algo2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The introduction of point of care echo and EtCO2 in ED and on the field put a new brick in definition, diagnosys and treatment of PEA.

Ultrasonography give us the chance to expolore, confirming or excluding, most of the mechanical causes of PEA and EtCO2 is a more reliable indicator of perfusion than the subjective pulse palpation.

Regarding the tretment options, there are still no evidences in favour or against epinephrine administation and chest compression utility in patients pulseless with electric activity and no cardiac standstill.

The end of clinical case

After performing 12 leads EKG the patients was loaded on the helicopter and directed to the cat lab where the patients arrived still pulseless but with EtCO2 38. The angio, performed after an echo showing weak heart contractility with inferior wall ipokinesia, confirmed critical occlusion of the dx coronary artery. A medicated STENT was placed with good TIMI flow result.

The patient regained consciouness a couple of hours later, and was dismissed from the hospital afer 15 days with CPC 1 and 45% EF.

In this case the strict observance of ALS protocol would have conducted the medical team to continue CPR, despite the presence of a organized rythm, due to the absence of a palpable central pulse. Epinephrine would have been regularry administered (at CA doses) and chest compressions performed.

The decision to load and go to the PCI center gave the patient the chance to treat the underlyng cause of CA.

Not the same thing can be said about the ALS protocol.

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References:

Linee Guida 2014 sulla gestione del paziente con Fibrillazione Atriale

11 Giu

Rinnovata attenzione al rischio cardioembolico anche nei pazienti con insorgenza databile entro le 48 ore, attenta anamnesi cardiologica per la scelta del farmaco giusto, e molto altro ancora.

Una veloce (e spero completa) guida per il medico d’emergenza al trattamento della FA dal territorio al DEA.

o visualizza la presentazione cliccando qui

References:

2014 AHA_ACC_HRS Guideline for the Management of Patients With Atrial Fibrillation

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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

To cool or not to cool. Possiamo fare finta di non vedere?

23 Nov

Audit ACR

I dati di questo trial appena pubblicato, hanno acceso il dibattito sull’utilità dell’ipotermia nell’arresto cardiaco, già dalla fase preospedaliera.

Vediamo il disegno dello studio. I pazienti (1359) venivano randomizzati fin dal ROSC preospedaliero in due gruppi; uno riceveva il trattamento standard mentre il secondo veniva sottoposto ad l’ipotermia (liquidi freddi per via parenterale). I pazienti di entrambi i gruppi venivano poi comunque “raffreddati” all’arrivo in DEA.

I risultati. Nessun beneficio viene dimostrato nei pazienti sottoposti ad ipotermia sia in termini di mortalità che di outcome neurologico. Veine anzi evidenziato un aumento delle recidive di ACR e di scompenso cardico congestizio nei pazienti sottoposti ad ipotermia.

La critica mossa agli auotri riguarda il non stretto controllo della temperatura ed il metodo di raffreddamento. Due litri di salina a 4° infatti somministrati per via endovenosa possono avere un impatto emodinamico significativo.

Allora tutta colpa dello studio condotto male?

Audit ACR

Ecco quindi questo studio  anch’esso dello stesso periodo, condotto in Europa ed in Australia su 950 pazienti.

Lo studio questa volta è molto rigoroso sul controllo della temperatura  e sulla selezione dei pazienti. Indaga quale target di temepratura  dimostri maggior beneficio nei pazienti vittima di ACR, se i classici 33° o 36°, indicati come ipotermia moderata.

I risultati. Anche questo studio non dimostra nessun beneficio derivato dall’applicazione di una ipotermia spinta su quella moderata. Un sensibile peggioramento veniva dimostrato solo nei pazienti ipertermici. Quindi indicazioni sicuramente sul controllo della temperatura per evitare l’ipertermia nei pazienti sopravvissuti da ACR ma ancora nessuna evidenza sul beneficio dell’ipotermia.

Possiamo ancora far finta di non vedere?

Possiamo ignorare che le indicazioni che riguardano l’uso dell’ipotermia, e su cui si basano le attuali linee guida, sono sostenute da studi datati e poco potenti?

Bottom line

Quello che questi studi devono stimolare è l’attenione massima sul “post-resuscitative care” del paziente rianimato da ACR.

Non finisce tutto dopo il ROSC, anzi! Il buon outcome comincia proprio dalla ripresa del circolo!

Massima attenzione va quindi posta sulla globalità trattamento post-rianimatorio:

  • Controllo della ventilazione assistita
    • Controllo delle pressioni
    • Controllo dei volumi
    • Paralisi
  • Evitare l’iperossia
    • Target di saturazione di O2 94-98%
  • Mantenere l’eucapnia
    • Target di EtCO2 35-40
  • Evitare l’ipertermia
    • TTM (Targeted Temperature Management)
  • Trattamento della causa sottostante
    • PTCA
  • Considerare la circolazione extracorporea
    • Pazienti con shock cardiogeno persistente post ROSC

Come e quanto raffreddare il paziente rianimato? Seguiamo con interesse il dibattito internazionale in attesa di nuovi, sicuramente necessari, trial che facciano più chiarezza sull’argomento.

MEDEST you tube



References:
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EM Lyceum

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