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Defibrillation Strategies: Why AHA’s position on VC and DSED is Controversial

New 2025 Guidelines on Cardiopulmonary Resuscitation stated that alternative strategy for defibrillation of persistent VF/pVT are not yet ready for prime line based on the actual available evidences.

Previously ILCOR stated about the same topic: We suggest that a double sequential defibrillation strategy (weak recommendation, low certainty of evidence) or a vector change defibrillation strategy (weak recommendation, very low certainty of evidence) may be considered for adults with cardiac arrest who remain in ventricular fibrillation or pulseless ventricular tachycardia after 3 or more consecutive shocks.

So AHA degraded the ILCOR “may be considered to a “non useful” despite the same level of grade and evidences. Let’s see why and why THIS IS WRONG

AHA: It found significant improvement in survival at hospital discharge with VC and DSED compared to standard defibrillation by intention-to-treat, but notably not when trial findings were analyzed by the treatment strategy patients actually received

In summary, AHA highlighted one point for not suggesting VC or DSED over standard defibrillation. The reason is that the DOSE VF trial did not show any statistically relevant advantage in “per protocol analysis”!

I’m not a methodologist but I think that any of them can suffer of an heart attack hearing this statement! Intention to treat analysis is the core of randomization!

To summarize this concept here is a head to head compare between Intention to treat analysis VS per protocol analysis

Approach	Statistically Strong?	Less Bias?	More Power?
Intention-to-treat	✅ Yes (most robust)	✅ Low bias	❌ Less power
Treatment / Per-protocol	❌ No (can be biased)	❌ Higher bias	✅ More power

In randomized control trials, analyzing patients “per protocol” removes the advantages of randomization. This choice degrades the study results to an observational level. So AHA statement is incorrect and the trial results are highly relevant

AHA: Furthermore, in a secondary exploratory analysis a significant survival benefit from DSD was only observed in the 17% of study patients in whom VF was incessant, and not in the vast majority (83%) of patients in whom VF recurred after a successful shock.

You can find the cited secondary analysis here: The impact of alternate defibrillation strategies on shock-refractory and recurrent ventricular fibrillation: A secondary analysis of the DOSE VF cluster randomized controlled trial. And the following are the results:

Shock-Refractory VF (n. 60)

Shock-Recurrent VF (n. 285)

In both cases, recurrent or persistent, even if not always statistically significant, DSD and VC performed much better than standard defibrillation WITH RESULTS ABSOLUTELY CLINICALLY RELEVANT ON ALL MAJOR OUTCOMES

AHA: The interval between each sequential “double” shock required for successfully terminating VF has also been shown experimentally (animal studies 10-100 Mses) and demonstrated in DOSE-VF itself (mean interval 650 Mses. ) to require a level of precision (separated by milliseconds) unlikely to be consistently achievable by manual activation of two defibrillators.

Th is totally wrong. The small ( 10- 100 Mses) cited from the guidelines refers to experimental animal study . DOSE-VF trial demonstrates statistically significant superiority to standard defibrillation. This superiority is observed with intervals >500 Msec that is absolutely replicable in clinical practice. The investigators also demonstrated the increase of advantages for shorter intervals. But, this increase is not seen at 10 Mses, which is only referred to in animal studies.

DSED and VC are superior to standard defibrillation on every clinical relevant clinical outcome
DSED and VC uphold clinical advantages on both persistent and recurrent VF/pVT
When you chose DSED the interval between the 2 shocks is easily reproducible in clinical practice

In case of VF/pVT. First approach:

If recurrent or refractory VF/pVT

Tags: ACLS, ACR, arresto cardiaco, dual sequential defibrillition, emergency medicine, emergenza sanitaria territoriale, Guidelines, litterature review, medicina d'urgenza, medicina d'urgenza preospedaliera, refractory ventricular fibrillation, vector change defibrillation

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Categories Commenti dell'autore

Confirming Tracheal Intubation: stop wasting your time!

2 Jul

Intro

The methods to confirm tracheal intubation (and exclude accidental oesophageal intubation) are classically divided in Techniques not requiring manual ventilation and Techniques requiring manual ventilation::

Techniques not requiring manual ventilation
- Inspection of the vocal cords: there should be visual confirm- ation that the tube lies surrounded by the glottic structures
- Palpation of the trachea: an assistant palpating the external trachea may feel vibrations, corresponding to the tube passing the tracheal rings
- Oesophageal detector device: Tracheal placement results in free aspiration of gas from the lungs; in oesophageal intubation, the walls of the oesophagus collapse around the tube lumen preventing gas flow
Techniques requiring manual ventilation:
- Sounds
- Compliance: A ‘normal’ compliance during manual ventilation
- Inspection of the chest: Good expansion of the chest on manual ventilation
- Auscultation of the epigastrium
- Auscultation of the chest
- CO2 detection
  - Capnography – a normal capnogram for at least six breaths suggests tracheal intubation
  - Capnometry – a change in indicator to denote CO2 suggests tracheal intubation

Despite nowadays is evident that CO2 detection is the gold standard in terms of sensibility and specificity, our daily practice in managing airways still and strongly rely on clinical methods to confirm when the tube is correctly posed in the trachea and not in the oesophagus.

The article

Hansel, J., Law, J.A., Chrimes, N., Higgs, A. and Cook, T.M. (2023),

Clinical tests for confirming tracheal intubation or excluding oesophageal intubation: a diagnostic test accuracy systematic review and meta-analysis. Anaesthesia. https://doi.org/10.1111/anae.16059

In this meta-analysis the authors investigated the literature about the reliability of different methods to confirm tracheal intubation and exclude oesophageal intubation.

This is a clinically relevant point cause the unrecognised oesophageal intubation leads to catastrophic consequences on patients health.

Which Clinical test they evaluated:

How they presented the data

The false positive rate (FPR)

The FPR indicates how often any sign that is considered suggestive of successful tracheal intubation (for example chest rising or hearing breath sounds),might occur despite the tube is not in the trachea but in the oesophageal. Usually an acceptable number of FPR can be 0,1 (or the 10% (10 out of 100) of the total positive results) but you can understand how in this case, considered the high clinical relevance of the topic we have to reach for lower FPR the 1 out of 10.

The Likelihood Ratio (LR): positive (LR+) or negative (LR-)

The positive LR (LR+) indicates how many times is more probable that the tube is the trachea than in the oesophagus the investigated sign is present

A test with a LR+=10 (cut off value for reliability) means that there is 10 times more probability that the tube is really in the trachea than in the oesophagus

The negative LR (LR-) indicates how many times is more probable that the tube is the oesophagus han in the trachea if the investigated sign is present

A test with a LR- of 0.1 (cut off value for reliability) means that there is 1/10 times more probability that the tube is in the oesophagus than in the trachea.

What they found

Conclusion

The available data strongly suggest that clinical signs lack the discriminatory power to exclude oesophageal intubation to a sufficient degree to ensure patient safety when capnography is not available or doubted. The oesophageal detector device performs better than clinical examination, and in resource-limited environments with no access to capnography, may be sufficiently sensitive and specific to help guide decision-making.

Clinical Practice Take Home Message

Based on the result of this study when available use waveform capnography to confirm tracheal intubation and exclude oesophageal intubation. Clinical tests can be dangerously misleading and potentially a waste of precious time in difficult environments as emergency prehospital setting.

In poor resources systems if any form of ETCO2 is not available, the most reliable test to confirm tracheal intubation is the Oesophageal detector device.

Tags: advanced airway management, Airway management, gestione avanzata delle vie aeree, litterature review, medicina d'urgenza, medicina d'urgenza preospedaliera

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Categories advanced airway management, Airway management, Review di letteratura

God save the King!

27 Jun

Matthew E. Prekker, M.D., M.P.H., Brian E. Driver, Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults

The DirEct versus VIdeo LaryngosCopE (DEVICE) trial is a prospective, multicentre, non-blinded, randomised trial being conducted in 7 EDs and 10 ICUs in the USA

Critically ill adults undergoing tracheal intubation randomly assigned to the video-laryngoscope group or the direct-laryngoscope group

The primary outcome was successful intubation on the first attempt.

The secondary outcome was the occurrence of severe complications during intubation: severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest, or death.

The trial was stopped for efficacy at the time of the single preplanned interim analysis.

Conclusions: Among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a videolaryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope.

Comment: This a long journey hopefully coming to an end. From 2022 we have clear evidences on the superiority of Video versus Direct laryngoscopy Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database Syst Rev. 2022 Apr 4;4(4):CD011136. doi: 10.1002/14651858.CD011136.pub3. PMID: 35373840; PMCID: PMC8978307.. Main airway management societies (Difficult Airway Society; Society for Airway Management; European Airway Management Society; All India Difficult Airway Society; Canadian Airway Focus Group; Safe Airway Society; and International Airway Management Society) recently updated their statements on preventing the accidental oesophageal intubation in that sense. Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies. The DEVICE trial is another brick in the wall of consciousness about superiority of VL vs DL despite some findings are not replicable ( ex. DL FPS 70,8%) in systems where airway management and expertise in DL is a longstanding tradition. But as said we didn’t need this trial to arrive at the conclusion of the journey.

Use the videolaryngoscope (VL) as first choice in emergent tracheal intubation to improve first passage success and prevent accidental oesophageal intubation.

Use direct laryngoscope (DL) just as rescue device in case of technical failure of the videolrayngoscope

All medical systems involved in airway management need to be aware of this. A videolaryngoscope is no longer an option but a standard equipment. The best choice is to have both, standard and hyperangulated geometry blades, in adult and paediatric sizes.

The first approach with a standard geometry blade permits to shift from VL to DL without changing device. The hyparangulated blade can be useful in selected cases even as first option..

We also consequently need to shift paradigm from classical way of teaching airway management, to a VL first approach as default method and simulating any tech failure during the practical training forcing the trainee to use the DL as rescue plan.

To let me know what is your opinion fill the survey at the link below:

VL first approach

2 Minutes Advanced Airways

14 Feb

Tags: advanced airway management, Airway management, emergency medicine, Emergency Medicine guidelines, medicina d'urgenza, medicina d'urgenza preospedaliera

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Categories Commenti dell'autore

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

27 Aug

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 che “La 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.

Tags: emergenza sanitaria territoriale, medicina d'urgenza, medicina d'urgenza preospedaliera

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Categories Commenti dell'autore

Open Chest Wounds. The Prehospital Management

3 Aug

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

Tags: emergency medicine, emergenza sanitaria territoriale, major trauma, medicina d'urgenza, medicina d'urgenza preospedaliera, pneumothorax, pneumotorace, prehospital emergency medicine, trauma, trauma toracico

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Categories Commenti dell'autore

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

3 May

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

References

Tags: ACLS, COVID-19, Emergency Medicine guidelines, emergenza, emergenza sanitaria territoriale, medicina d'urgenza, medicina d'urgenza preospedaliera

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Categories cardiac arrest, Commenti dell'autore, Emergency Medicine, Guidelines update, Linee guida update

Prehospital Emergency Procedures: Scalpel, Finger, Bougie. That’s all you need!

13 Jul

In Emergency Medicine “Simplicity” is synonymous of efficiency, efficacy and reproducibility.

More the time frame is stressful more we need procedures that are efficient, efficacious and standardised, in one word SIMPLE.

Critcothyrodotomy and chest drain are procedures usually performed in high stressing scenarios and more simply they are more chance of success they have.

I don’t like complicate kits. They need training of course but even a calm and protected environment, and the middle of a street or a busy ER room aren’t nothing like that.

I don’t like blindly performed procedures but prefer trusting my own senses and sensibility when performing high invasive procedures that, mostly of the times, are a lifesaving last chance.

So this is the best way I know to perform a surgical access to the airway and to drain a highly unstable tense pneumo: using simple instruments, always present in every emergency pack, and trusting my own tactile sensitivity.

In those following videos you can see live records of the procedures. They were captured during a recent cadaver lab where I had the honour to join Jim DuCanto, Yen Chow, Carmine Della Vella and Fabrizio Tarchi in teaching airway management and clinical emergency procedures.

Hope you enjoy.

Tags: bougie aided cricothyroidotomy, chest drain, cricothyroidotomy, cricotiroidotomia, emergency cricothyroidotomy, emergency medicine, emergency procedures, emergency thoracostomy, medicina d'urgenza, medicina d'urgenza preospedaliera, prehospital emergency medicine, scalpel finger bougie, toracostomia

Comments 3 Comments
Categories Commenti dell'autore, Emergency Medicine, Trauma

Prehospital POCUS: Why I love it! Real Clinical Scenario.

10 Jul

73 yrs old male found unconscious by his wife. CPR started by a neighbour with pre arrival CPR instructions provided by dispatcher. We found him in asystolic cardiac arrest. Established mechanical chest compressions (MCC), ventilated through an 8.0 ET tube, placed an intraosseus access, 10 min of ALS and 2 mg of epinephrine later, on the monitor appears an organised rhythm at 40 bpm (narrow junctional shape), NO CENTRAL PULSE. After 2 min (CPR still going) same rhythm stil NO CENTRAL PULSE but this time, during the MCC pause, a subcostal view of the heart was obtained (sorry for the quality of the images but were recorded during the code and I’m not an expert but just an ultrasound user)

As you can see the heart is moving and the right ventricle is almost the double of the left one. Due also to the clinical history of a recent surgical knee replacement the most probable origine of the cardiac arrest is PE. We decided to continue chest compressions, but to stop epinephrine at 1 mg dose, starting push doses of 0,1 mg till the return of a central pulse. After 5 min a strong carotid pulse appeared and this is the ultrasound view of the heart at that moment

The patient arrived to the hospital sedated and paralysed in assisted pressure control ventilation. You can see on the monitor the rest of vital signs.

No follow up yet.

You can read more about PEA and Pseudo-PEA on MEDEST

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

Forget ALS Guidelines when dealing with PEA. Part 2.

Tags: ACLS, Advanced Cardiac Life Support, arresto cardiaco, cardiac arrest, ecografia, emergency medicine, medicina d'urgenza, PEA, POCUS, point of care ultrasound, pulseless electric activity

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Categories Commenti dell'autore, Emergency Medicine

Only Evidenced Based Medicine? Evidently……not!

4 Feb

The modern emergency medicine based most of his clinical practice on evidence-based trials.

But really all that is not coming from randomized controlled trials does not exist?

The paradox of the demonstration of the effectiveness of the parachute with randomized controlled trials, in accordance with the method EBM (The Parachute trial), provocatively poses a fundamental question:

If the scientific basis of any therapeutic intervention are already strong, and the benefit for the population is large, is ethically correct to wait large-scale trial to implement it, delaying its potential benefits?

A 2006 article published in the BMJ Controversy Parachute approach to evidence based medicine brilliantly responded to this question.

It contains some examples of very common diseases in developing countries (HIV, dehydration in children, postpartum hemorrhage) whose remedies, implemented previously than results of relative trials where available, have saved thousands of lives.

The authors conclude that:

1. Randomised controlled trials are usually required before new interventions are implemented

2. If other evidence of effectiveness is good, and potential benefits large, the resultant delays may be unethical

3. Examples from poor countries show the price of delaying interventions

The triad of decision-making at the base of the construction of Evidenced Based Medicine provides an integrated approach between explicit data (scientific evidence derived from trials of good quality) and tacit data(clinical expertise and the patient’s needs).

The clinical decision is derived from the combination of these three factors:
• Scientific evidence
• Clinical Experience

• Needs of the patient

But when defining the level of quality of evidence those derived from clinical practice and experience are relegated to the base (lower level) of the pyramid whose apex (higher degree) are the evidence derived from studies on large patient populations.

Randomisation and de-personalization of scientific research, while eliminates everything that is “non-evident” in medical research, and is well suited to a concept of public health, on the other hand maintains an unbridgeable gap with daily clinical practice that is focused on the care of the individuals.

But in practice what we can do:

Integration of explicit data, result of the evidence, with the “tacit knowing” that is generated only from the direct doctor-patient relationship is desirable.
The “tacit knowing” is the basis of our medical education, such as learning the language is to pre-school children: it does not need structured teaching but it is learned from direct experience.
The “tacit-knowing”, often reduced to subjective data and therefore of lesser dignity, is in fact, just because “innate”, less prone to the common bias of explicit data;
We must recognize equal dignity to both those data “explicits” and “tacits.”
We must take into account both explicit and tacit elements in the formulation of the hypothesis and the resulting diagnostic therapeutic strategy.

We can and we must go beyond the exclusive use of EBM in medical research and clinical practice.

The adoption of an integrated approach between the explicit scientific evidence derived from clinical trials (EBM) and a “patient- centered approach” derived from the clinical experience, should be a stimulus and an intent to the future development of our approach to the critically ill patient.

It must always be clear in the mind of the emergency medicine professionals which treatment is scientifically more correct for a given disease, but he must contextualise, and implement it for the particular patient who is dealing with at that time

Italian transcript

References:

Kevin Mackway-Jones, uno dei maggiori esperti di E.B.M. ed autore del sito Best BET’s presents “How Evidenced Based Medicine Changes Through the Years”.
The philosophical limits of evidence based medicine
Viewpoint: Moving Beyond Evidence Based Medicine
Michael Polanyi’s philosophy of tacit knowing

Tags: basata sulle, based, d'urgenza, EBM, emergency, evidenced, evidenced based medicine, evidenze, medicina, medicina d'urgenza, medicina d'urgenza preospedaliera, medicine

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Shock-Refractory VF (n. 60)

Shock-Recurrent VF (n. 285)

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The false positive rate (FPR)

The Likelihood Ratio (LR): positive (LR+) or negative (LR-)

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Conclusions: Among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a videolaryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope.

Use the videolaryngoscope (VL) as first choice in emergent tracheal intubation to improve first passage success and prevent accidental oesophageal intubation.

Use direct laryngoscope (DL) just as rescue device in case of technical failure of the videolrayngoscope

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L’accertamento di morte e’ prerogativa della professione medica

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

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

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

Riassumiamo

Sistema 118, diagnosi ed accertamento di morte

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Commercial chest seal VS improvised 3 sided chest dressing

Vent vs Non Vent Chest Seal

So what to do?

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The modern emergency medicine based most of his clinical practice on evidence-based trials.

But really all that is not coming from randomized controlled trials does not exist?

If the scientific basis of any therapeutic intervention are already strong, and the benefit for the population is large, is ethically correct to wait large-scale trial to implement it, delaying its potential benefits?

References:

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