Next year SMACC, the Conference of the Conferences, will come in Europe.
Dublin 13-16 Jun 2016.
Italian Emergency Medicine and Critical Care bloggers rise up! There is the chance to submit your topics, idea, talks and whatever you have in mind for evaluation by organising committee.
Fill the form at smaccDUB Speaker Suggestions and get the chance to participate as speaker to one of the most exciting event of the year.
Here is the original message from the SMACC Organising Committee:
The SMACC Organising Committee are currently crafting plans for the next SMACC event. It will be in Dublin from Monday June 13th to Thursday 16th June 2016. We get plenty of suggestions about who should join the SMACC faculty as speakers and workshop instructors and have created this form to make the process easier. We can’t make every wish a reality, but we will do our damnedest to make smaccDUB the event of 2016 for anyone in critical care who wants to learn, to meet and be inspired.
The 3-3-2 rule is part of the evaluation in a patient for a predicted difficult airway. This evaluation can be done on an unconscious patient in supine position and is reliable tool for the anticipation of a difficult BVM ventilation and intubation out of the hospital.
In the video you can see the 3-3-2- rule application on a patient with a predicted difficult airway. .
This patient was difficult to BVM ventilate (cause of the “sloopy” chin) and was intubated in VL with the aid of a bougie. In this case the predicted difficulty of the airway, determined the choice of VL bougie aided intubation as first choice for the airway management, avoiding so multiple attempts. This choice was of more importance view the difficulty of BVM ventilation that would have conducted to a critical desaturation during the intubation attempts.
The invasive airway management is a critical skill in out of hospital emergency medicine and, when indicated, not avoidable. Predicting in advance the difficulty is important to choose the right plan and avoiding multiple attempts.
A debate is ongoing among #FOAMED social media about increasing first passage rate in tracheal intubation and some difficulties when using VL.
At the beginning of my experience with VL I experienced some difficulties, but with a radical change in technical approach I reached a good security on first pass success.
Here are my consideration and I hope will be useful for anyone is starting using VL
There are some fundamental differences in VL technique respect to DL, that makes the DL more easy and intuitive to pass the tube trough the cords.
The 3 axys theory for airway management
“Sniffing position” align the pharyngeal axis with the laryngeal one
Sniffing position
Perfoming Direct Laryngoscopy with the laryngoscope we align the mouth axis to have a direct view of the cords.
DL VIEW
This view coincide with the route for passing the tube, making this step intuitive and easy.
When using a Video Laryngoscopewe take our eyes right in front of the larynx, having a perfect “video” view of the vocal cords, but also minimally modifying the axis of the mouth.
VL VIEW
This difference makes the act of passing the tube not so easy and not so intuitive, cause of the contrast between the perfect video laryngeal view and the not easy passage of the tube trough the cords.
In those cases the stylet, the Bougie/Froban or the external glottic maneuvers, are useful to facilitate the video-intubation.
Golf stick shape of the tube+stylet
But the first goal is to reach this view on the screen of the videolaryngoscope.
I want to have the epiglottis right at the center of the screen and this comes prior of a good view of the larynx.
Epiglottoscopy is the key point of my management of the airways in general and when prforming VL in particular.
Having the epiglottis in central position on the screen allow to:
lower the glottic plane facilitating intubation
decrease the force to apply on the airways minimizing traumatism and neck movement in case of trauma.
fits all the difficult airway situations because a poor view of the cords is what you are looking for!
If you agree, memorize my favorite view and reach for it when using a video device to mange the airways.
All comments are welcome so please let me know your thoughts.
Is IV tPA safe and effective for acute ischemic stroke patients if given within 3 hours of symptom onset?
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.
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.
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:
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.
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.
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 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.
This 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.
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.
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?
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.
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….
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.
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.
HEMS 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.
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.
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.
این سایت را به آن دکتوران و محصلین طب که شب و روز برای رفاه نوع انسان فداکاری می کنند ، جوانی و لذایذ زندگی را بدون چشمداشت به امتیاز و نفرین و آفرین قربان خدمت به بشر می کنند و بار سنگین خدمت و اصلاح را بدوش می کشند ، اهداء می کنم This site is dedicated to all Doctors and students that aver the great responsibility of People’s well-being upon their shoulders and carry on their onerous task with utmost dedication and Devotionاولین سایت و ژورنال انتــرنتی علـــمی ،تخـصصی ، پــژوهشــی و آمــوزشــی طبـــی در افغــانســـتان
Learning everything I can from everywhere I can. This is my little blog to keep track of new things medical, paramedical and pre-hospital from a student's perspective.
The 3-3-2 rule is part of the evaluation in a patient for a predicted difficult airway. This evaluation can be done on an unconscious patient in supine position and is reliable tool for the anticipation of a difficult BVM ventilation and intubation out of the hospital. 
Le tue opinioni sono il nostro valore aggiunto!
MEDEST 
FOAMed Italy: time to rise up!
15 JulDublin 13-16 Jun 2016.
Italian Emergency Medicine and Critical Care bloggers rise up! There is the chance to submit your topics, idea, talks and whatever you have in mind for evaluation by organising committee.
Fill the form at smaccDUB Speaker Suggestions and get the chance to participate as speaker to one of the most exciting event of the year.
Here is the original message from the SMACC Organising Committee:
The SMACC Organising Committee are currently crafting plans for the next SMACC event. It will be in Dublin from Monday June 13th to Thursday 16th June 2016. We get plenty of suggestions about who should join the SMACC faculty as speakers and workshop instructors and have created this form to make the process easier. We can’t make every wish a reality, but we will do our damnedest to make smaccDUB the event of 2016 for anyone in critical care who wants to learn, to meet and be inspired.
All the best,
Chris Nickson, Oli Flower, Roger Harris and the SMACC Organising Committee
http://smacc.net.au
http://twitter.com/smaccteam
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Tags: critical care, emergency medicine, SMACC