Tag Archives: emergenza sanitaria territoriale

La “constatazione” di decesso. Storia presunta e non-fondamento legislativo di una leggenda metropolitana.

27 Ago

La “constatazione del decesso” è stata in questi anni frequente motivo d’invio di mezzi medicalizzati (automedica o ambulanza medicalizzata) da parte della CO 118. 

La più o meno fondata convinzione che la diagnosi ed il successivo accertamento della morte è  prerogativa della sola professione medica ha spesso giustificato l’utilizzo in emergenza territoriale di tale figura professionale per “constatare” la morte anche di quei pazienti in cui, per vari motivi clinici ed etici, non esisteva alcuna indicazione alla  rianimazione cardiopolmonare

Facciamo chiarezza esaminando i riferimenti di legge disponibili.

L’accertamento di morte e’ prerogativa della professione medica

Il fondamento legislativo dell’accertamento di morte risale al Testo Unico delle Leggi Sanitarie (TULS) approvato con Regio Decreto nel 1934 che all’articolo 103 tra le prerogative delle professioni sanitari recita che “Gli esercenti la professione di medico-chirurgo, oltre a quanto e’ prescritto da altre disposizioni di legge, sono obbligati a denunziare al podestà le cause di morte entro ventiquattro ore dall’accertamento del decesso.”

In esso sia pur indirettamente la figura medica veniva individuata come unica responsabile dell’accertamento e della comunicazione della morte alle autorità.

In epoca più recente la legge n. 578 del 29 dicembre 1993 “Norme per l’accertamento e la certificazione di morte”all’articolo 1 comma 1 stabilisce che “La morte si identifica con la cessazione irreversibile di  tutte le funzioni dell’encefalo.

La morte dell’ encefalo a tutti i suoi livelli infatti determina l’irreversibile disgregazione funzionale del classico “tripode vitale di Bichat”, che consiste nella contemporanea presenza della funzionalità respiratoria, cardiocircolatoria e del sistema nervoso centrale.

La medesima legge infatti all’articolo 2 comma 1 chiarisce cheLa  morte  per  arresto  cardiaco si intende avvenuta quando la respirazione e la circolazione sono  cessate  per  un  intervallo  di tempo  tale  da  comportare  la  perdita  irreversibile  di  tutte le funzioni dell’encefalo e puo’ essere accertata con le modalita’ definite con decreto emanato dal Ministro della sanita’.

Per le modalità di accertamento si rimanda quindi al decreto n. 582 del 22 agosto 1994, “Regolamento recante le modalita’ per l’accertamento e la certificazione di morte.”  che all’articolo 1 comma 1 stabilisce:  “In conformita’ all’art. 2, comma  1,  della  legge  29  dicembre 1993,  n.  578,  l’accertamento della morte per arresto cardiaco puo’ essere effettuato da  un  medico  con  il  rilievo  grafico  continuo dell’elettrocardiogramma protratto per non meno di 20 minuti primi.

Ma allora cos’e’ la “constatazione di decesso”? 

In effetti tale termine non ha alcun riferimento nel complesso legislativo che regola l’accertamento e la certificazione della morte e  non compare in nessuna parte dei regolamenti di polizia mortuaria. E’ quindi un termine derivato dalla consuetudine operativa, si confonde con la diagnosi e l’accertamento di morte ed è stato alimentato dalla trasmissione aneddotica/orale con sporadico riscontro nei  regolamenti locali. 

Ma per capire che un paziente e’ in arresto cardiaco serve un medico?

Sulla “diagnosi” di arresto cardiaco il BLS e la comune pratica ci hanno da anni insegnato che essa è clinica e non strumentale e può essere effettuata anche da personale laico addestrato e non addestrato sia pure se guidato anche in modo remoto da un professionista sanitario. Questo estendere una “diagnosi” a personale non sanitario ha contribuito in modo fondamentale ai progressi in termini di sopravvivenza nei pazienti colpiti da morte improvvisa  diffondendo la cultura e delle rcp di base e della defibrillazione precoce.

Abbiamo quindi oramai universalmente stabilito che i laici possono  individuare la presenza di criteri clinici di arresto cardiaco tanto che essi sono autorizzati ad effettuare un massaggio cardiaco ed utilizzare un defibrillatore. 

L’arresto cardiaco nei pazienti in cui non e’ indicata la RCP

A maggior ragione tale “diagnosi” può essere effettuata da familiari o astanti in pazienti a fine vita, affetti da patologie in fase terminale  in cui sono esauriti i margini terapeutici ed in cui l’assistenza e la cura non sono oramai un’emergenza.

Riassumiamo

L’accertamento della morte non è una procedura d’emergenza-urgenza e può essere effettuata da un medico (in genere il necroscopo) mediante il rilievo per 20 minuti in continuo delle’ECG.

Nel complesso delle norme non viene mai nominata la “constatazione del decesso” essa è spesso utilizzata come sinonimo fuorviante di accertamento di morte o dichiarazione di arresto cardiaco/morte.

L’arresto cardiaco è un riscontro clinico e può essere fatta da chiunque se addestrato o sotto guida dell’infermiere di centrale.

C’è una categoria di pazienti per i quali esistono clinicamente (assenza di prospettive di buon outcome per la presenza di patologie croniche in fase terminale o neoplasie senza margine ulteriore di trattamento) ed eticamente (fine vita, dichiarate o manifeste disposizioni anticipate di trattamento) delle chiare controindicazioni alla pratica di manovre rianimatorie.

Sistema 118, diagnosi ed accertamento di morte

Il sottile limite concettuale e temporale tra le urgenti manovre di rianimazione cardiopolmonare e l’accertamento della morte ha portato in questi anni a confondere il ruolo del medico del 118 con quello del certificatore della morte.

Ma viste le premesse ed in un’ottica di ottimizzazione e razionalizzazione dell’utilizzo delle risorse dell’emergenza preospedaliera non ha senso né clinico né organizzativo inviare il medico a fare diagnosi di morte ed accertare e certificare il decesso in paziente in cui è chiaramente controindicata la RCP.

In un’ottica attuale e limitatamente ai casi in cui non sono indicate le manovre rianimatorie, il compito della certificazione della morte dovrebbe essere affidato ad altre figure professionali come il MMG, il medico di continuità assistenziale o il medico necroscopo.

In pratica in caso di chiamata per arresto cardiaco in cui appaia chiara la futilità delle manovre rianimatorie si dovrebbero attivare, da parte della CO 118, risorse mediche alternative e non urgenti per procedere alla certificazione della morte. 

Open Chest Wounds. The Prehospital Management

3 Ago

Is the flutter valve beneficial? Is the chest seal itself beneficial? Or, does it convert a sucking chest wound into a life-threatening tension pneumothorax? “Why do we treat a non-lethal condition (open pneumothorax) with an intervention that may result in a lethal condition (tension pneumothorax)?” If the size of the chest seal defect is larger than the diameter of the trachea, then air will preferentially move through the chest defect which can be fatal. Many of the chest seals are being placed on small defects which could lead to a tension pneumothorax.

It is unknown whether modifying the current practice of treating an open pneumothorax with an occlusive chest dressing might cause some of these injuries to then result in fatalities.

Saving Lives on the Battlefield
A Joint Trauma System Review of Pre-Hospital Trauma Care in Combined Joint Operating Area – Afghanistan (CJOA-A)
FINAL REPORT
30 January 2013
U.S. Central Command Pre-Hospital Trauma Care Assessment Team

The current guidelines indicates commercial chest seals both vent or non vent as a valid option to treat open chest wounds. In any case if a commercial chest seal is not available the 3 sided closed dressing is no longer recommended and a total occlusive medication is the current indication.

Commercial chest seal VS improvised 3 sided chest dressing

A chest dressing closed on 3 sides was the traditional option of treatment. They are often difficult to adhere, ineffective and difficult to improvise in time-critical scenarios. New and recent guidelines recommended an occlusive medication with strict surveillance and in case of signs of tension pneumothorax the dressing must be removed. If the patients does not improve after removing the seal open thoracostomy is indicated.

There is no clear evidence to suggest that the use of one-way chest seals would reduce the incidence of respiratory complications in patients with penetrating chest wounds. However, these seals may be easier to use and should be considered as part of the medical kit for out-of-hospital settings.

BET 3: In a penetrating chest wound is a three-sided dressing or a one-way chest seal better at preventing respiratory complications?

BET 3: In a penetrating chest wound is a three-sided dressing or a one-way chest seal better at preventing respiratory complications?

Major trauma: assessment and initial management. 1.3 Management of chest trauma in pre‑hospital settings

Vent vs Non Vent Chest Seal

A vent commercial chest seal is the first line option in prehospital setting.

Both vented and unvented CSs provided immediate improvements in breathing and blood oxygenation in our model of penetrating thoracic trauma. However, in the presence of ongoing intrapleural air accumulation, the unvented CS led to tension PTx, hypoxemia, and possible respiratory arrest, while the vented CS prevented these outcomes.

Vented versus unvented chest seals for treatment of pneumothorax and prevention of tension pneumothorax in a swine model

Vented versus unvented chest seals for treatment of pneumothorax and prevention of tension pneumothorax in a swine model

Treatment of Thoracic Trauma: Lessons From the Battlefield Adapted to All Austere Environments

In case vent chest seal is not available use non vent chest seal and if the patients develops hypotension, hypoxia, respiratory distress, remove the seal or performa an open thoracostomy.

So what to do?

First get an airway and put the lung on positive pressure ventilation (Volume or Pressure Targeted Ventilation) :

Positive pressure in the chest during the entire respiratory cycle and avoiding negative pressure during inspiration decreases the risk of tension pneumothorax

If you have the patient on a spinal board with a cervical collar the larynx is narrowed and when the patient is in spontaneous breathing the air preferentially enters from the chest wound. Placing an OT and positive pressure ventilation avoids this mechanism and prevents tension in the thorax.

Positive pressure ventilation re-inflates the collapsed lung and improve oxygenation (PEEP) and ventilation (Minute Ventilation).

Second close the wound with

Vent chest seal as first option

Non vent chest seal if vent is not available

Non commercial chest dressing closed on 3 sides is your last resort

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

“Humans Are Not Yeast”: (almost) everything we believe about lactate is a myth. 

5 Ott

4e193a6c-13de-44f2-aabe-2b095321f652_1-8a517f942153f96606ebbde8331f1dc8On September issue of Emergency Medicine News, Paul Marik wrote an article entitled “Humans are not yeast”

This is a game changer article about the current concepts on lactic acid and its clinical meaning in emergency medicine.

The author illustrate simple but well established concepts about lactic acid metabolism that revert most of the common conceptions about its significance in clincal medicine.  

I will resume below some of the most relevant concepts expressed in the article. The italic bullet point text is from the original article.

I really encourage all of you to read the full text of original article to completely understand the whole rationale behind those statements and to access the complete list of references.

It is free open access.

Let’s start with some biochemistry.  

Piruvate, the product of glycolysis, can enter in Krebs cicle to produce energy through aerobic (oxygen driven) process or can take a shorter and faster (x100 times) way to produce energy when is transformed to lactate (the basis of lactic acid) using NADH (so reduced to NAD+ and ready to take another H+) and H+.

  • No hydrogen ions are present in glycolysis. In fact, the conversion of pyruvate to lactate consumes hydrogen ions. It is actually a lactic alkalosis. (J Mol Cell Cardiol 1997;9[11]:867.)
  • Increased lactate may simply occur because of increased production of pyruvate due to in- creased glycolysis there is no oxygen debt. We spoke about the muscles exporting lactate; the same thing happens in shock: lactate is used as a fuel for oxidative metabolism. Lactate is transported into the mitochondrion through specific transport proteins, and then is converted to pyruvate in the mitochondrial intermembrane space. Pyruvate then moves into the mitochondrial matrix and undergoes oxidative metabolism.
    Lactate is, therefore, a fuel for oxidative metabolism. It’s consumed by the brain and heart, and that is absolutely vital to survival when someone is in shock
    .
So why is lactate produced and used for?
Lactate is aerobically producted by muscle and is a more efficient source of energy for the brain and the heart.
  • Lactate is a much more efficient bioenergetic fuel than glucose so as someone exercises, the muscles make lactate to fuel the heart. The heart works much more efficiently with lactate. What happens to the brain? The exact same thing. As someone exercises, brain lactate goes up, and the brain starts using lactate preferentially as a source of fuel. This is a brilliant design: Muscles make lactate aerobically as a source of energy for the brain and heart.
Lactic metabolic acidosis is a biochemical myth! It’s more a lactic alkalosis.
  • The lactic acidosis explanation of metabolic acidosis is not supported by fundamental biochemistry, and has no research basis. Acidosis is caused by reactions other than lactate production.  
  • No hydrogen ions are present in glycolysis. In fact, the conversion of pyruvate to lactate consumes hydrogen ions. It is actually a lactic alkalosis. (J Mol Cell Cardiol 1997;9[11]:867.)
Hypoxia does not induce lactate serum level elevation, and in sepsis oxygen cellular level is not decreased. 
  • There is this pervasive idea that people with sepsis have cellular hypoxia and bioenergetic failure, but this concept was debunked in 1992. Compared with limited infection, the muscle O2 goes up in patients with severe sepsis.
  • Increased lactate may simply occur because of increased production of pyruvate due to increased glycolysis there is no oxygen debt. We spoke about the muscles exporting lactate; the same thing happens in shock: lactate is used as a fuel for oxidative metabolism. Lactate is, therefore, a fuel for oxidative metabolism. It’s consumed by the brain and heart, and that is absolutely vital to survival when someone is in shock. The body makes lactate, which is then used as a metabolic fuel.
Iperlactic state is generated, by epinephrine and not by hypoxia, in case of extreme physiological stress as protective mechanism.
  • The clinical plausibility was that lactate increases during adrenergic states and in the absence of an oxygen debt. Lactate increases with epinephrine infusion; lactate increases with hyperdynamic sepsis. All of the states have a high cardiac output, high oxygen delivery, and not a single trace of hypoxia. It’s driven by epinephrine, not by hypoxia.
  • We do know that lactate is associated with increased mortality because the sicker a patient is, the higher his epinephrine levels. It’s a protective mechanism. The association is related to the fact that lactate is a biomarker of physiological stress. And clearly the greater the physiological stress, the greater the risk of death. But lactate itself is a survival advantage, and it’s not an evolutionary accident that we make lactate.

Credits:

Thanks to the author and to Aidan Baron who originally shared the article.

Reference:

  1. The Science of Emergency Medicine: Humans Are Not Yeast. Emergency Medicine News: September 2016 – Volume 38 – Issue 9 – pp 1,29–30 doi:10.1097/01.EEM.0000499522.28133.48

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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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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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F.A.R. in E.M. (Focus Assessed Review in Emergency Medicine ) #4: Stroke. Bonus feature, 2015 ACEP Clinical Policy on Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department

27 Gen
MEDEST F.A.RAnd here we are with the 4th episode of the F.A.R. series. If you accidentally lost the first two episodes you can find them here:
#1 Cardiac Arrest
#2 Airway Management
In this episode we’ll explore the best articles of 2014 about:

Stroke

Before starting we have to declare (if you are not aware of) that MEDEST is quite skeptical about the previous studies that are at the basis of thrombolytic therapy (Lo strano caso del trombolitico nell’ictus cerebrale ischemico, Pubblicate le nuove linee guida AHA/ASA sul trattamento precoce dello Stroke: nessuna nuova ed ancora qulache dubbio!, L’uso del trombolitico nello stroke. Stiamo giocando con la salute dei nostri pazienti?, rt-PA e Stroke: IST-3 l’analisi dei risultati). This can represent a potential bias on the choice of the articles. We also think that the actual evidences, and the consequent guidelines, are strongly influenced by commercial interests and not well supported from evidences that demonstrates how benefits outweight harms. We hope that 2015 will be the first year of a new era for stroke management, an era of well done studies producing strong evidences to achieve good neurological targets in all stroke patients.

In the first part we mention the litterature about thrombolytic therapy

And then the articles about endovascular therapy:

And now as anticipated in the title the 2015 ACEP Clinical Policy on Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department. Those freshly published guidelines give answer at two of most recurrent questions on stroke treatment:

  1. Is IV tPA safe and effective for acute ischemic stroke patients if given within 3 hours of symptom onset?
  2. 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.


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F.A.R. in E.M. (Focus Assessed Review in Emergency Medicine ) #3: Trauma

10 Gen
MEDEST F.A.RAnd here we are with the 3th episode of the F.A.R. series. If you accidentally lost the first two episodes you can find them here:
#1 Cardiac Arrest
#2 Airway Management
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.

And now let’s go to specific area of interest:

  • Spine immobilization

Spine immobilization in trauma is changing.

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:

  1. 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.
  2. 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.

What is “revolution” in clinical practice? We don’t have the answer to this dilemma, but what is happening in fluid resuscitation for trauma patients seems likely to be revolutionary. Restrictive strategies and new blood products are the future for the treatment of trauma patients (read also Fluid resuscitation in bleeding trauma patient: are you aware of wich is the right fluid and the right strategy?).

But much more happened in 2014 about trauma….

Resuscitative throacotomy is now a reality not only “in” but even “out” of hospital, so read all about it

An evergreen topic is TBI but new concepts are arousing so read here the latest updates

New drugs and new protocols for airway and pain management: a rationale guide to choose the right drug for the right patient.

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.


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F.A.R. in E.M. (Focus Assessed Review in Emergency Medicine ) #2

5 Gen
MEDEST F.A.RThe 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.


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F.A.R. in E.M. (Focus Assessed Review in Emergency Medicine ) #1

2 Gen
MEDEST F.A.RThis 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.

Mechanical Devices

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.

Vasoactive (and other) drugs

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?

ECLS

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.

Outcome and prognostication

Therapeutic Hypothermia

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….

Other

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.

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Little Medic

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.

Prehospital Emergency Medicine Blog

All you want to know about prehospital emergency medicine

Italy Customized Tour Operator in Florence

Italy Food and Wine Vacations

GoogleFOAM

The FOAM Search Engine

EM Lyceum

where everything is up for debate . . .

AmboFOAM

Free Open Access Medical Education for Paramedics

FOAM4GP

Free Open Access Meducation 4 General Practice

Rural Doctors Net

useful resources for rural clinicians

Auckland HEMS

Unofficial site for prehospital care providers of the Auckland HEMS service

ECHOARTE

L'ECOGRAFIA: ENTROPIA DELL'IMMAGINE

MEDEST

Prehospital Emergency Medicine

ruralflyingdoc

Just another WordPress.com site

KI Doc

WE HAVE MOVED - VISIT WWW.KIDOCS.ORG FOR NEW CONTENT

Emergency Live

Prehospital Emergency Medicine

AMP EM

Academic Medicine Pearls in Emergency Medicine from THE Ohio State University Residency Program

Prehospital Emergency Medicine

 Academic Life in Emergency Medicine

Prehospital Emergency Medicine

Comments on: Homepage

Prehospital Emergency Medicine

Greater Sydney Area HEMS

The Pre-hospital & Retrieval Medicine Team of NSW Ambulance

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