Tag Archives: medicina d’urgenza

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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My favourite VL view to increase first pass intubation

8 Feb

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.

3axys

The 3 axys theory for airway management

“Sniffing position” align the pharyngeal axis with the laryngeal one

Sniffing position

Sniffing position

Perfoming Direct Laryngoscopy with the laryngoscope we align the mouth axis to have a direct view of the cords.

DL view

DL VIEW

 

 

 

 

 

 

 

 

 

 

This view coincide with the route for passing the tube, making this step intuitive and easy.

 

When using a Video Laryngoscope we 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.

Visione in videolaringoscopia

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.

tubo stylet

Golf stick shape of the tube+stylet

But the first goal is to reach this view on the screen of the videolaryngoscope.

IMG_1278

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.

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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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Acute Pulmonary Edema: Myths and Facts

16 Nov
A Storify report by: Anand Swaminathan @EMSwami  from

 

  • Preamble:

Minimal change in therapeutic approach to APE over 40 years despite modern evidences.

In APE (Acute Pulmonary Edema), the first ten minutes of management dictate the course of the patient. This is where we can save a life.


 

  • Pathophysiology

Cardiorenal model basis for use of furosemide is mechanistically flawed and outdated.

Cardiocirculatory model: peripheral vasoconstriction leads to decrease in  cardiac function.

Neurohormonal model: build on increased norepinephrine levels and renin-angiotensin-aldosterone system activation


 

Urban Legend #1 – Loop diuretics are 1st line therapy in treatment of APE

The Truth #1 – Loop diuretics are not recommended as 1st line treatment in APE

References:

Urban Legend #2 – Patients presenting with APE are volume overloaded

The Truth #2 – Most patients with APE are not fluid overloaded and thus, do not require diuresis. Vascular Congestions DOES NOT equal fluid overload

References:
  • bit.ly/1gC5DMr  most pt w/ APE have incr cardiac filling pressure but minimal change in baseline/dry weight
  • 1.usa.gov/1gC5HvQ  > 50% pt w/ APE had weight gain < 2 lbs on presentation
  • bit.ly/1bO3DeU  Pulm edema results from fluid shifts not fluid gain

 

Urban Legend #3 – Loop diuretics are harmless in APE treatment so just give them

The Truth #3 – Loop diuretics are harmful early in the management of APE and should be withheld

References:

 

Urban Legend #4– Morphine should be part of the initial APE algorithm

The Truth #4– Morphine is harmful in APE and should be completely dropped from treatment algorithm

References:

 

Bottom line:

Myths

  • Loop diuretics are 1st line therapy in treatment of APE

  • Patients presenting with APE are volume overloaded

  • Loop diuretics are harmless in APE treatment so just give them

  • Morphine should be part of the initial APE algorithm

Facts

  • Loop diuretics are not recommended as 1st line treatment in APE

  • Most patients with APE are not fluid overloaded and thus, do not require diuresis

  • Loop diuretics are harmful in early phases of the management of APE and should be withheld

  • There is no role for furosemide in the management of APE

  • Morphine is harmful in APE and should be completely dropped from treatment algorithm

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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2014 NICE Guidelines. Acute heart failure: diagnosing and managing acute heart failure in adults

18 Ott

L’uscita di nuove linee guida è sempre un’occasione importante per chi ogni giorno si prende cura di pazienti critici in regime di emergenza-urgenza.

Quando poi l’argomento di cui trattano è importante, e per alcuni aspetti anche controverso, fa ancora più piacere l’uscita di un documento di consenso che permette di avere un riferimento affidabile per la pratica clinica giornaliera.

D’altra parte per i professionisti sanitari le linee guida non devono essere una gabbia professionale, bensì il valore aggiunto che guida le scelte cliniche ma la cui interpretazione critica prelude anche a scelte diverse, ma conseapevoli, da quele indicate.

Le nuove linee guida NICE (National Institute for Healthcare and Ecellence) sulla diagnosi e cura dello scompenso cardiaco acuto (2014 Acute heart failure NICE Full text Guidelines) pongono da questo punto di vista alcuni spunti interessanti quando si tratta di indicazioni per il trattamento iniziale.

Avevamo già trattato in un precedente post il trattamento dell’edema polmonare acuto affrontando le evidenze attuali ed i retaggi culturali che ancora persistono nel suo trattamento.

Vediamo se queste linee guida accolgono o meno i cambiamenti culturali che le nuove evidenze ci propongono.

1.3 Initial pharmacological treatment
1.3.2 Do not routinely offer opiates to people with acute heart failure.
 
Assolutamente d’accordo che il trattamento con oppiacei (se non per aumentare la compliance nel paziente in NIV) è inutile ed a volte dannoso. La somministrazione sistematica di Morfina quindi dovrebbe essere eliminata dall’algoritmo sulla gestione dello scompenso acuto di cuore.
References:
 
1.3.3 Offer intravenous diuretic therapy to people with acute heart failure. Starttreatment using either a bolus or infusion strategy.
 
Ci aspettavamo una scelta più coraggiosa e moderna a questo proposito da parte degli autori. La netta distinzione in termini fisiopatologici ha oramai evidenziato come molti delle presentazioni acute più drammatiche dello scompenso cardiaco non sono assolutamente determinate dal meccanismo del “volume overload” ma piuttosto sul “fluid shift”. Al contrario le presentazioni dovute ad un sovraccarico di volume sono di genesi più refratta nel tempo e quindi con sintomi meno drammatici, e molto spesso si giovano di un trattamento a lungo termine (anche con diuretici) e non sicuramente d’urgenza.
L’utilizzo di diuretici in emergenza per il paziente con scompenso cardiaco ha una utilità molto limitata, è potenzialmente  dannoso e dovrebbe essere riservato solo ad un selezionato selezionato gruppo di pazienti in una fase successiva della del trattamento.
References:
1.3.7 Do not routinely offer nitrates to people with acute heart failure.
1.3.8 If intravenous nitrates are used in specific circumstances, such as for people with concomitant myocardial ischaemia, severe hypertension or regurgitant aortic or mitral valve disease, monitor blood pressure closely in a setting where at least level
2 care can be provided.
 
La pratica clinica quotidiana, specie dopo l’avvento della NIV, ci conferma che l’utilizzo dei nitrati (specie in infusione continua) ha assunto un ruolo ed una priorità secondaria rispetto al trattamento non farmacologico, ma relegare il loro uso solo ad alcune situazioni particolari sembra inutilmente riduttivo per una terapia che presenta molti benefici in questa condizione patologica (elencati nella tabella seguente)
 
Benefits of Nitrate Therapy in Heart Failure

S-nitrosylation of effector proteins (8,13)
 Activates ryanodine receptors to improve myocardial contractility
 Regulates endothelial function
 Inhibits smooth muscle hyperplasia
 Regulates blood flow with changes in tissue oxygen tension matching flow to demand
 Protects myocytes by preventing oxidative damage
 Scavenges superoxide anions
 Regulates energy metabolism
 Protects cells from apoptosis
Guanylyl cyclase activation (8,17)
 Promotes venous and arterial smooth muscle relaxation decreasing preload and afterload
 Inhibits platelet aggregation by inhibiting platelet adhesion to vascular endothelium
 Has anti-inflammatory effects by preventing leukocyte adhesion to vascular endothelium
 Has antiapoptotic effects
 Has antiremodeling effects
Hemodynamic conditions (12,18,19)
 Decreased pulmonary capillary wedge pressure
 Decreased left ventricular end diastolic pressure
 Decreased pulmonary vascular resistance and right ventricular afterload
 Decreased systemic vascular resistance and left ventricular afterload
 Increased venous capacitance
 Decreased right atrial pressure
 Decreases myocardial oxygen demand
Divya Gupta, MD; Vasiliki V. Georgiopoulou, MD; Andreas P. Kalogeropoulos, MD Nitrate Therapy for Heart FailureBenefits and Strategies to Overcome Tolerance JCHF. 2013;1(3):183-191. doi:10.1016/j.jchf.2013.03.003
La somministrazione di Nitrati rimane quindi  (considerando anche i contesti in cui la NIV no è disponibile) un’utile opzione nel trattamento farmacologico dello scompenos cardiaco
1.4 Initial non-pharmacological treatment
1.4.1Do not routinely use non-invasive ventilation (continuous positive airways pressure [CPAP] or non-invasive positive pressure ventilation [NIPPV]) in people with acute heart failure and cardiogenic pulmonary oedema.
1.4.2 If a person has cardiogenic pulmonary oedema with severe dyspnoea and acidaemia consider starting non-invasive ventilation without delay at acute presentation or as an adjunct to medical therapy if the person’s condition has failed to respond
1.4.3 Consider invasive ventilation in people with acute heart failure that, despite treatment, is leading to or is complicated by:
respiratory failure or reduced consciousness or physical exhaustion
 
L’emergenza preospedaliera ha oramai adottato in modo stabile l’utilizzo della ventilazione non invasiva per il trattamento dello scompenso cardiaco. Le linee guida NICE raccomandano il suo utilizzo solo per pazienti che presentano “cardiogenic pulmonary oedema with severe dyspnoea and acidaemia“.
Mentre il criterio clinico sembra molto generico (manca infatti un riferimento ai parametri clinici per definire la dispnea grave, e mancano tutti i criteri di esclusione) risulta per la maggior parte delle nostre realtà territoriali non utilizzabile il parametro strumentale dell’acidemia.
La NIV è attualemnte uno dei cardini fondamentali della terapia non farmacologica dello scompenso cardiaco e il suo utilizzo dovrebbe essere implementato fin dalle prime fasi del soccorso.
References:
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Queste sono solo alcune alcune considerazioni.  Per approfondire l’argomento, potete comunque leggere
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