Tag Archives: Emergency Medicine guidelines

Beyond Advanced Cardiac Life Support. Do we have to change our practice in COVID Era?

3 Mag

Main changes in recommendations

Personal Protective Equipment for Advanced Life Support interventions need to be at maximum level of protection of full body, eyes and airways.

CAT 3 level of protection 4 (at least) for the full body

FPP2/N95 airway filter for team members who are NOT directly involved in airway management, ventilation or manual chest compressions

FPP3/N99 airway filter for providers who are directly involved in airway management, ventilation and manual chest compressions.

Face shield and protective googles are strongly suggested

Mechanical Chest compressors devices are the gold standard to perform cardiac massage. They reduce contacts and contamination risk and team member exposure to contaminants.

Adhesive disposable pads are the only option to check rhythm and deliver shock. Dispose non-disposable, manual pads.

Passive O2 administration (via simple face mack at a rate of 15l/m) during chest compressions is the first option over bag mask ventilation when performing Basic Life Support waiting for advanced airway management.When using a Bag Valve Mask always put a HEPA/HME filter between Bag and mask to avoid contamination

Hold chest compressions when performing airway managment

Cover patient head with a transparent plastic foil to minimise virus spreading and contamination when performing airway management and bag mask ventilation

Tracheal intubation using a video laryngoscope is the first line option for advanced airway management to minimise contamination.

If video laryngoscope is not available Extraglottic devices are an acceptable first line option

Use all the implementation to improve intubation first passage success:

Video laringoscopy

Bougie

RAMP positioning

Suctioning (SALAD technique)

Use all the implementation to improve Extraglottic device placement

Laryngoscope for tongue displacement and mouth opening (DO NOT USE hands)

Deflate cuff

Lubrificate the device

Whatever plan you apply use an HEPA/HME filter immediately after the ventilation device

Use disposable cover and disposable gel to perform Ultrasound during chest compressions

“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

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