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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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The 3-3-2 rule. A pratical tool for predicting the difficult airway on the field

31 Mag

3_3_2_ruleThe 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.

View in Prezi.com

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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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MEDEST Review 30. One year in Review.

25 Dic

MEDEST-review

 

 

 

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.

This is MEDEST way to wish you all Merry Xmas.

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Enjoy the reading:

Cardiac Arrest

Chest compression

Mechanical Devices

Vasoactive drugs

ECLS

Outcome and prognostication

Therapeutic Hypothermia

Other

Trauma

Spine immobilization

Fluids and blood products

Other

Airway management

Sepsis

ACS

Stroke

Guidelines

Emergency Pharmacology

Mechanical Ventilation

Other clinical conditions

Non Clinical

 

 

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Progressi nel soccorso extraospedaliero: utilizzo del VAR in emergenza urgenza extraospedaliera

24 Ott

On line le slide della mia presentazione al congresso nazionale SIS 118 2014 in svolgimento a Santa Margherita Ligure

 

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Settaggio iniziale del ventilatore polmonare.

27 Ago

Uno degli skill importanti per la gestione del paziente critico in emergenza è il settaggio e la gestione del ventilatore polmonare.

La scelta della modalità di ventilazione ed il settaggio consapevole dei parametri ventilatori spesso scoraggia l’uso di uno strumento fondamentale, per chi fin dalla fase preospedaliera deve gestire il malato critico che necessita di assistenza ventilatoria.

La familiarità con concetti base, ma non per questo scontati, di fisiopatologia polmonare, ma anche un piano operativo predefinito da applicare ed adattare volta per volta alle varie situazioni cliniche, sono di basilare importanza per il settaggio in emergenza del ventilatore.

Recenti concetti come la Lung Protective Ventialtion, hanno inoltre reso necessaria una rivoluzione critica di quelli che erano i vecchi cardini della ventialzione meccanica.

Sono liberamente disponibili in rete risorse preziose che illustrano in modo chiaro ed autorevole questi nuovi concetti.

Mechanical Ventilation Protocol Summary

Sono inoltre disponibili alcuni simulatori e tutorial molto utili per poter interagire e settare in modo virtuale, ma anche realistico, il ventilatore polmonare e comprendere la ventilazione polmonare.

Questo modulo che presentiamo di seguito fa parte del corso Prehospital Airway Management (PHAM) e spero sia utile per la comprensione dei settaggi di base per tutti coloro che non hanno una pratica quotidiana con il ventilatore ma che necessitano di usarlo in emergenza sia fuori che dentro l’ospedale.

Settaggio di base del ventilatore polmonare

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MEDEST Review : Speciale Trauma

13 Ago

MEDEST-review

 

 

Ancora letteratura ancora articoli ancora novità in medicina d’urgenza.

 

Attenzione! MEDEST incoraggia la lettura completa e responsabile degli articoli proposti. Evitate sgradevoli effetti collaterali!
Scaricate il full text ed approfondite gli argomenti d’interesse con altre fonti per un’informazione consapevole e quanto più possibile completa dei temi trattati.

In questa edizione straordinaria 5 articoli fondamentali che trattano aspetti attualissimi della gestione del trauma in emergenza.

Da leggere attentamente per cogliere i molteplici aspetti d’interesse per tutti i professionisti dell’emergenza sanitaria intra ed extraospedaliera

 

 

Puoi trovare la raccolta di tutti gli articoli citati nelle review di MEDEST a questo link

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