Tag Archives: trauma

Fluid resuscitation in bleeding trauma patient: are you aware of wich is the right fluid and the right strategy?

23 Apr

DCR copy

The fluids of choice in prehospital field are, in most cases, cristalloids (Norma Saline or Lactate Ringer).

But what is the physiological impact of saline solutions when administered in large amounts (as the latest ATLS guidelines indicates) to hypotensive trauma patients?

Is aggressive Fluid resuscitation the right strategy to be pursued?

The triad of post-trauma lethal evolution is:

  • Hypotermia
  • Acidosis
  • Coagulopathy

Aggressive fluid resuscitation with cristalloids, and saline solutions in particular, can be detrimental in many ways:

  1. Cristalloids tend to displace the already formed clots and improves bleeding
  2. Normal Saline produce hypercloremic acidosis worsening coagulation and precipitating renal and immune dysfunction
  3. Cristalloids diluts the coagulation factors and precipitate the coagulation system (dilution coagulopathy)
  4. Cristalloids rapidilly shift in intercellular space worsening SIRS process and interstitial edema (brain edema, bowel wall edema) with consequent compartment hypertension

So wich is the perfect fluid to infuse in trauma?

The perfect fluid doesn’t exists.

Balanced saline and Hypertonic saline are promisng prospective but there are still no good quality evidences about their benefit on clinical outcomes.

Colloids has no place in fluid resuscitation of trauma patients.

The fluid of choice, regarding the actual evidences and indications, is Lactate Ringer.

More than on the type of fluid the attention of researchers and clinicians is oriented on the strategy to pusue in those cases.

Hypotensive resuscitation, part of damage control resuscitation, is at the moment the strategy of choice in trauma bleeding patients.

Restrictive fluids administration is the way to achieve this goal.

The target systolic BP has to be diferentiated depending on the type of trauma

  • 60–70 mmHg for penetrating trauma
  • 80–90 mmHg for blunt trauma without TBI
  • 100–110 mmHg for blunt trauma with TBI.

More important do not delay definitive treatment.

ASAP give blood products (PRBC, FFP etc…) to contrast post-trauma coagulopathy and send the patients in OR to fix treatable causes of bleeding

The following are a collection of  un essentials resources on haemostatic resuscitation after trauma

 Logo MEDEST2

 

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

Logo MEDEST2

 

NICE released Major Trauma Guidelines Draft.

8 Ago
NICE-1024x131
The National Institute for Health and Care Excellence (NICE) published a Guidelines Draft on Major Trauma. The great thing about is that everyone can consult the draft and send suggestion (but only if you work for a stackholder organization) about the recommendations and scientific evidences contained.
Consult the documents at the links below:

Here are some highlights with a particular regard to pre-hospital environment recommendations:

Airway management

RSI and orotracheal intubation is the preferred method to manage airways (when compromised) in a trauma patient.
In prehospital setting RSI and OTI has to be performed on scene in less than 30 min from the initial call. Backup plan is SGA (in patients with reduced level of consciousness and no glottic reflexes) or basic airways maneuver plus adjuncts (patients with GAG reflexes still present), and transfer to Trauma Center (within 60 min) to manage airways. If Trauma Center is more than 60 minutes away, reach local hospital to perform RSI and than transfer the patient.

“The GDG had a strong belief that RSI of anaesthesia and intubation delivered by a competent person is the gold standard of care when maintaining the airway of both adults and children and made a recommendation for RSI of anaesthesia and
intubation accordingly.”

“The GDG suggested that the second best device for airway management was the supraglottic device. This device provides less protection than RSI of anaesthesia and intubation against aspiration; however this device provides greater protection than
basic airway adjuncts, and can be administered safely by in the pre-hospital environment by paramedics or physicians staff.”

“Supraglottic devices can only be used in patients without airway reflexes to avoid stimulating vomiting or laryngospasm,, and
are therefore only appropriate for use in patients with a reduced level of consciousness.”

“For patients with airway reflexes, where a supraglottic device cannot be used, the GDG recommended the use of basic airway manoeuvres and adjuncts until such time as RSI of anaesthesia and intubation is available.”

“The GDG therefore concluded that where possible, RSI should be delivered at scene and within a timeframe than minimised
pre-hospital time. Pre-hospitals systems should develop to make this widely available. Where pre-hospital RSI is not possible within a 30-minute window, the GDG recommended transporting the patient with supraglottic or basic airway adjuncts to a MTC within 60 minutes, otherwise to a TU”

Pre-hospital Tension Pneumothorax

  • Closed pneumo
Perform chest decompression of a suspected tension pneumothorax only in haemodynamically unstable patients or in pts who have respiratory compromise.
Perform open thorachostomy to drain tension pneumothorax in haemodynamically unstable patients (preferred on simple needle decompression).
Simple open thorachostomy can be performed only in intubated (and positive pressure ventilated) patients. In all other cases insert a chest drain to prevent a sucking chest open wounds
  • Open pneumo
No more vented or 3-sided occlusive dressing in open (sucking) pneumothorax: use a simple occlusive dressing to treat an open pneumothorax in the pre-hospital setting

“The GDG limited the recommendation to intervene to people who are haemodynamically unstable or have severe respiratory compromise. The GDG agreed that people who have signs of a tension pneumothorax but are haemodynamically normal can wait until hospital for a more definitive diagnosis and possible decompression.”

“Needle decompression is a simpler technique to perform than insertion of a chest drain but is associated with a number of complications. These include the cannula blocking, the catheter not being long enough and therefore, not penetrating the
thoracic parietal pleura, or incorrect placement of the needle, all of which result in the decompression not being successful. The GDG agreed by consensus that open thoracostomy is more effective and stable than needle decompression.”

“An open thoracostomy can only be used on intubated patients. A surgical incision is made, blunt dissection is performed, and the pleura penetrated. The wound is then left open. This is a rapid way of decompressing a tension pneumothorax in a critically injured trauma patient who is intubated. The positive pressure ventilation prevents the thoracostomy wound from acting as an open, ‘sucking’, chest wound”

“The GDG agreed that given the lack of evidence, no recommendation could be made around whether an occlusive dressing for an open pneumothorax should be vented or three-sided. Additionally, the GDG accepted there was no evidence to make a
recommendation around supplementing the dressing with a chest drain in the prehospital setting.The GDG decided through expert consensus to recommend using a simple occlusive dressing to treat an open pneumothorax in the pre-hospital setting. The GDG emphasised the importance of a ‘simple’ dressing that provides an airtight seal that is fast and straightforward to apply. The priority should be transporting the patient to a hospital where a chest drain can be inserted.”

Haemorrhage control

First line intervention is direct pressure with simple dressing.
If direct pressure failed use tourniquets (no difference between mechanical or penumatic ones) as backup method. Is controversial when tourniquets has to be used (as first line) over direct pressure
Use Tranexamic acid in suspected haemorrahagic patients as soon as possible but never beyond 3 hrs from trauma

“In the absence of any evidence in favour of haemostatic dressings, the GDG did not believe that they offered any improvement over and above standard dressings with direct pressure.”

“Whereas, immediate haemorrhage control can be achieved by direct pressure, the decision of when direct pressure should be
used over tourniquets was considered controversial as the GDG tried to weigh up the risk and cost of placing a tourniquet on a person who did not require it compared with those that do.”

Vascular access

In adults use IV access as first line and IO as rescue technique if IV failed
In children, when difficult vascular access is suspected, use IO access as first line technique

Fluid resuscitation

In pre-hospital environment the target for volume titration has to be maintaining a palpable central pulse (femoral or carotid)
In pre-hospital, if blood products are not available, small boluses of crystalloids are the preferred fluid volume replacement.

“The GDG discussed the situation when a pre-hospital practitioner is treating a patient in profound haemorrhagic shock but does not have access to blood products. In this case small boluses of crystalloids would be appropriate.”

Pain control

IV Morphine is the first line recommended agent. Ketamine (at pain relief doses) the second option.
Caution is recommended when Morphine is administered in a haemodinamically unstable patient.
Intranasal administration is the recommended route of administration when IV is not available.

“Two studies compared IV morphine with IV fentanyl and found no difference between the interventions for pain relief and adverse side effects.”

(Many) Things that I Like about these guidelines

  1. The airway management approach! Totally agree on RSI and OTI as gold standard in trauma, and if performed, better be fast. The 30 min target is a quite fair indication but, as any other straight timing, depends on  the circumstances. The thing I appreciate is the idea of DO IT IN THE SHORTEST TIME POSSIBLE. Great. And if plan A (Ventilation+Oxygenation) fails? Plan B (Oxygenate) SGA and rush to TC, if close, or to any other trauma unit. And if for any reason placing a SGA is not possible? Use BVM and adjuncts and rush again. Love it!
  2. Thoracostomy better than needle decompression, both in prehospital and in hospital, for tension pneumothorax drainage. We are all aware of the bunch of studies indicating as needle decompression is inadequate in most cases, and all the FOAMED drums are rumbling on these frequencies. But till now none (first of all the Archaic Trauma Life Support)  officially stated this in a guideline (that I’m aware to, at least). So WELCOME expert consensus of NICE GDG!
  3. Simple occlusive dressing in open pneumo. Straight and simple.
  4. The choice for prehospital fluid replacement goes on crystalloids only cause blood products are not available, but in the text is highlighted as both crystalloids and colloids are detrimental on coagulation process (so they are banned in hospital setting). The future is blood products even in prehospital environment!

(Few) Things that I don’t like about these guidelines

  1. The choice of open simple thoracostomy just in intubated pts has to be more clearly highlighted. I suggest as an adjunct to main (yellow background) recommendation. And so as to be for thoracostomy plus chest drainage in non intubated pts.
  2. Why they just mention Morphine (as opioid) for pain control and don’t include fentanyl in the main recommendation, if in the text is clearly indicated as all the available evidences show no differences between the two drugs in terms of clinical effects and adverse events? I think Fentanyl due to its wide diffusion (with great satisfaction) worths a mention!

Draft closes for comments on 21 of September.

Logo MEDEST2

Trauma induced coagulopathy. Fixed Ratio or Goal Directed Therapy?

3 Mar

Trauma induced coagulopathy (TIC) is now recognized as one of the major contributors to mortality in bad injured patients.
Its pathophysiological pathways is debated and still not well known, but seem to be clear, and widely accepted, that the profibrinolytic state, triggered from many and different factors involved in trauma, leads to an acute Fibrinogen consumption.
Thrombin and Coagulation Factors in fact seems to be preserved and well functioning even in bad traumatized patients.
This lack of Fibrinogen, at least in the early phase of trauma, is the real cause of coagulopathy and has to be early recognized and treated to revert the altered coagulation asset existing in a great part of traumatic patients.

Coagulopathy pat

The substitution of massively deteriorated Fibrinogen is the therapy of choice in patients with acute TIC.
Two ways of achieving this goal are recently shown to be feasible, and from different point of view, effective.
The first is the Fibrinogen replacement with PRBC, FFP and PLT with a fixed ratio (1:1:1 or 1:1:2).
The second is a Goal Directed Therapy (GDT) with Fibrinogen concentrate administered on the base of thromboelastography profile of the clot, targeted to guide the Fibrinogen administration and monitoring the profile of clot formation.
The clinical challenge for physicians facing traumatic emergencies, both in prehospital and in-hospital field, is to early recognize the TIC in patients with low injurity score and well preserved physiologic parameters. The early recognition of coagulative system alteration leads to an early support of coagulation and hopefully to a better outcome.

There is no clear evidence and consensus on which hematologic or clinical indicators to use as acute coagulopathy risk stratification in trauma patients.

On Feb 20 and 21 in Bologna, some of major italian experts in trauma gave life to a consensus conference on this topic. The result of the conference leads to an initial, but not least important, consensus on the major implant of the theory at the base of recognition and treatment of TIC.

First step of this implant is the decision on when to treat the patients and when the treatment is futile. If the treatment is not futile the second step is to recognize, based on hematologic values and clinical parameters, the patients at risk of coagulopathy. Some values were identified as suitable for the stratification of the risk, but among the participants were not consensus on which is the most important and wich cut-off level to use.

BE, HB. SBP, Lactate levels were the most wanted indicators for recognizing of TIC. Next step, after recognizing the risk of coagulopathy is the choice of sustaining coagulation. The experts achieved the consensus on this statement but not on which was the best way to do it: Goal Directed Therapy (thromboelastography and targeted Fibrinogen replacement) or Fix Ratio supplement with PRBC FFP an PLT.

Till here the consensus.

Giuseppe Nardi, an intensivist working in Rome at Shock and Trauma Center of Azienda Ospedaliera S. Camillo Forlanini and widely recognized as one of the major experts in trauma, tried to go beyond this statement, designing a clear path for future investigations and hopefully new consensus.
Steady underlining the subjective value of the data, he identified a potential cut-off value for each of the most important indicators of early coagulopathy in trauma.
He indicated:

  • BE -6 
  • SBP ↓100 mmHg
  • HB  ↓10 mg/dl 
  • Lactate ↑ 5 mmol/L

Said that just one of this values is predictive of fibrinogen depletion (normal plasma fibrinogen levels range from 200 to 450 mg/dl, and current guidelines recommend maintaining the plasma fibrinogen level above 150 m g/dl) and on the base of those values he hypothesized that, with a good approximation, clinicians can identify the risk of trauma induced coagulopathy.

Nardi based his assumption on some good articles present in letterature, but he mentioned one in particular:

Estimation of plasma fibrinogen levels based on hemoglobin, base excess and Injury Severity Score upon emergency room admission.

This is a retrospective study of major trauma patients (ISS ≥16) with documented plasma fibrinogen analysis upon ER admission. Plasma fibrinogen was correlated with Hb, BE and ISS, alone and in combination.

The study, being retrospective, is at risk of confounding bias even if regression analysis was conducted.

The authors concluded:”Upon ER admission, FIB of major trauma patients shows strong correlation with rapidly obtainable, routine laboratory parameters such as Hb and BE. These two parameters might provide an insightful and rapid tool to identify major trauma patients at risk of acquired hypofibrinogenemia. Early calculation of ISS could further increase the ability to predict FIB in these patients. We propose that FIB can be estimated during the initial phase of trauma care based on bedside tests.”

Nardi, together with Osvaldo Chiara, Giovanni Gordini and other well known experts in trauma, is part of the Trauma Update Network (TUN) and elaborated the Early Coagulopathy Support (ECS) protocol:

“The protocol aims to avoid the use of plasma in the patients who will need a limited number of PRBCs, reduce the plasma related complications, and improve coagulation support in patients requiring massive transfusion through the early restoration of fibrinogen blood concentration. The ECS protocol has been developed assuming to have a point of care monitoring of coagulation, but can also be applied if a viscoelastic monitoring is not available. The ECS will be adopted by the TUN trauma centers with strict monitoring of economic impact and clinical results” (from: Giuseppe Nardi, Vanessa Agostini, Beatrice Rondinelli Maria et al. Prevention and treatment of trauma induced coagulopathy (TIC). An intended protocol from the Italian trauma update research group)

The basic principles of ECS can be so summarized:

  • All hemorrhagic patients (or bleeding risk) should receive early antifibrinolytic therapy (within the first 3 hours of injury)
  • The severity of hypoperfusion and the risk of coagulopathy correlate with the levels of Lactate and BE and pH as well as with the values of PA and Hb.
  • In case of bleeding fibrinogen is the most critical factor in the coagulation process and should be early replaced
  • The remaining coagulation factors are significantly decreased only later, and only in response to massive hemorrhage
  • Platelets decreased significantly only after massive hemorrhage but their functionality may be significantly limited by hypothermia
  • The control and correction of hypothermia is essential
  • Fluid challenge can be granted using crystalloids in patients with bleeding who do not requires massive transfusion (≤6 PRBC within 24 hours)
  • Transfusions of plasma and PTL to patients who do not have a massive hemorrhage should be avoided
  • In case of massive bleeding, it is desirable to transfuse plasma early in relation Plasma / PRBC in 1: 2 or 1: 1 ratio.
  • It is not necessary to start the transfusion of platelets it immediately after the admission of the patient (except in cases of anti-aggregation therapy)
  • Coagulation monitoring should be guaranted by viscoelastic methods (ROTEM / TEG); in the absence of these tools coagulation parameters (INR, PTT) over a, fibrinogen and platelets, must be monitored at close intervals.
But how those assumption can be related to practical clinical world?
The identification of parameters and cut-off values to recognize TIC can be a great step forward on the choice of the right patients in whom starting an early hemostatic resuscitation, avoiding both the risk of exposure to unneeded side effects than the possibility of wasting precious clinical resources.
The achievement of target level of plasmatic fibrinogen (with Fresh Frozen Plasma in fix ratio or with the goal directed administration of concentrated Fibrinogen ) can be the next level for treating trauma patients.
In term of treatment, damage control resuscitation and early support of coagulation must guide our clinical gestalt when treating trauma patients.

References:

Logo MEDEST2

 

Mind of Resuscitation in Traumatic Cardiac Arrest

19 Apr
TCA blunt

BLUNT TRAUMATIC CARDIAC ARREST

MEDEST
TCA pen

PENETRATING TRAUMATIC CARDIAC ARREST

MEDEST

Aggiornamento Linee Guida NICE sul trauma cranico

2 Feb

Il National Institute for Helath and care Excellence (NICE) ha aggiornato le Linee Guida per il triage ed il trattamento del trauma cranico dall’età pediatrica a quella adulta.

Dal trattamento preospedaliero agli algoritmi decisionali e diagnostici intraospedalieri, in forma chiara e concisa.

MEDEST you tube

ACEP Clinical Policies e Trauma Ultrasound eBook

9 Gen

Scaricate le Clinical Policies dell’American College of Emergency Physicians nella sezione delle Linee Guida a loro dedicata.

ACEP Clinical Policies

Sempre da ACEP nuova applicazione e libro multimediale sull’eFAST nel trauma. Una risorsa completa ed interattiva per che usa l’ecografia sia in DEA che sul territorio.

Trauma Ultrasound eBook

Faculty of Pre-Hospital Care Consensus Statements

20 Dic
Nuove Consensus Statements da parte della Faculty of Pre-Hospital Care che riguardano l’immobilizzazione spinale preospedaliera, l’inserzione farmacologicamente assistita della maschera laringea, la movimentazione minima preospedaliera del paziente traumatizzato e l’utilizzo dei device per la contenzione del bacino.
Sono tutte scaricabili liberamente sul nuovo sito della Faculty of Pre-Hospital Care e sulla pagina di MEDEST dedidcata alle linee guida.

Faculty of Pre-Hospital Care new Consensus Statements.

Sedare un paziente di cui si vuole gestire le vie aeree ed inserire un presidio sovraglottico? Un’eresia o una pratica che comunque esiste e come tale deve essere “goveranta”? La lettura di questo Statements apre nuove prospettive ad una pratica non ortodossa ma che, seppure in casi limitati, ha un suo razionale clinico.

L’immobilizazione spinale deve essere selettiva, e non deve riguardare tutti i pazienti traumatizzati a prescindere da criteri clinico prognostici. Già in passato MEDEST si è occupata di immobilizzazione spinale auspicando l’adozione di criteri clinici selettivi per l’utilizzo dei presidi d’immobilizzazione nel trauma preospedaliero. Questa Consensus Statements va finalmente in questa direzione.

Riassumiamo le principali racomandazioni:

  1. L’asse spinale è un presidio da utilizzare solo per l’estricazione del paziente vittima di trauma.
  2. Per il trasporto e le manovre diagnostiche intraospedaliere la barella scoop è il presidio più adatto. Minimizza i movimenti e diminuisce il rischio di lesioni da pressioni in regione dorsale.
  3. L’immobilizzazione in linea del capo è la tecnica raccomandata per l’immobilizzazione del rachide cervicale, in particolare in pazienti: con vie aeree compromesse che necessitano di essere gestite,  sospetto di aumentata pressione intracranica, combattivi ed agitati, bambini.
  4. Il collare cervicale se utilizzato deve essere ben dimensionato e correttamente applicato. Deve essere comunque allentato per evitare discomfort del paziente, facilitare la gestione delle vie aeree ed evitare il possibili innalzamento della pressione intracranica.
  5. I pazienti vittima di trauma penetrante senza segni neurologici non devono essere immobilizzati.
  6. I pazienti coscienti senza segni di intossicazione da sostanze o lesioni distraenti, se non intrappolati, devono essere invitati a posizionarsi autonomamente sulla barella.
  7. Viene scoraggiato l’utilizzo della manovra “standing take down” (paziente in piedi che viene posizionato sull’asse spinale facendolo appoggiare su di essa e poi accompagnato in posizione supina).

Un presidio per l’immobilizzazione pelvica deve essere sempre usato quando è presente un meccanismo di lesione compatibile con lesione del bacino e contemporanea instabilità emodinamica. Secondo gli autori non esistono evidenze che fanno preferire un presidio rispetto ad un altro. L’immobilizzatore del bacino non è controindicato anche in presenza di frattura alta del femore che  coinvolga l’acetabulo.

Sei interssato alle ultime linee guida in Emergenza Sanitaria

Visita la pagina di MEDEST dedicata alle ultime novità dal mondo dell’Emergenza

Logo MEDEST2

2013 Management of bleeding and coagulopathy following major trauma: an updated European guideline

3 Dic
Aggiornate le raccomandazioni Europee sulla diagnosi ed il controllo delle emorragie nei traumi maggiori.
Consultatele e scaricatele in pdf
Alla pagina dedicata alle linee guida trovate tutte le linee guida appena pubblicate su molti argomenti di attualità clinica in medicina d’urgenza.
Linee Guida

MEDEST you tube

Arresto cardiaco da trauma. Da figlio di un Dio minore a gemello diverso.

8 Ott

Death trauma

L’arresto cardiaco di un paziente vittima di trauma viene visto, a differenza di quello non traumatico, come una strada senza ritorno e con una sola uscita: l’exitus.

Il fatalismo che aleggia in questi casi ci porta a sottodosare il nostro impegno terapeutico ed a personalizzarne in modo estremo la gestione.

Questo atteggiamento diffuso è in qualche modo avallato, per chi come il medico di medicina d’urgenza fonda la pratica clinica quotidiana sulla formazione e sul’adozione di algoritmi specifici, dall’attuale status della didattica.

Mentre infatti il corso ALS fa della gestione dell’ACR il cardine del messaggio didattico, nei corsi sulla gestione del trauma, sia in ambito intra che extraospedaliera, la gestione dell’ACR è relegato al massimo un breve accenno nel corso delle presentazioni o ad un paragrafo sui relativi manuali.

L’assenza di algoritmi specifici per la gestione dell’arresto cardiaco nel trauma sicuramente non facilita la standardizzazione degli interventi attuati a tutti i livelli di cura.

Non è intenzione di questo post entrare nel merito della decisione su se e quando intraprendere un RCP in un paziente in ACR traumatico.

L’obiettivo è capire se, una volta presa la decisione di intraprendere le manovre di ALS, abbia senso condurle in modo standard o se il paziente traumatizzato meriti una gestione diversa delle priorità d’intervento e delle procedure praticate.

Il massaggio cardiaco, che è il pernio della rianimazione in un paziente “medico”, è concettualemnte inutile nella maggior parte dei casi di arresto cardiaco traumatico perchè inefficace in pazienti la cui incapacita a generare un’attività meccanica apprezzabiel è a genesi prevelentemente ipovolemica od ostruttiva.

La terapia elettrica ed i farmaci, vasopressori ed antiaritmici, occupano uno spazio marginale nella farmacologia dell’arresto da trauma, dominato da ritmi non defibrillabili di origine diversa rispetto ai pazienti “medici”.

Di qui la necessità di rivedere la priotrità mentale del nostro approccio sul paziente in ACR da trauma.

La compressione del torace ha un senso solo se associata ad un’attenta ricerca delle cause reversibili dell’ACR. Non deve mai comunque ritardare o impedire l’esecuzioni delle manovre atte a prevenire o curare tali cause.

La tempestiva gestione delle vie aeree, che nel paziente in ACR da causa “medica” diventa secondaria rispetto alla RCP di base, sale di priorità perchè  risolve l’ipossia, causa frequente dell’ACR traumatico.

L’attenta interpretazione del tracciato capnografico, deve guidare tutto il percorso rianimatorio; l’individuazione della pseuo-PEA come stimolo alla maggiora aggressività nella ricerca e nella risoluzione delle cause reversibili; il basso valore di capnometria, nonostante l’esecuzione di tuttle le manovre indicate ed in presenza di una RCP di buona qualità, come indice predittivo altamente infausto.

L’aggressiva rianimazione volemica deve essere una priorità, ed il sottofondo di tutte le procedure applicate durante lo svolgimento delle manovre avanzate.

La toracostomia bilaterale è una manovra indispensabile nai pazienti altamenti instabili o in ACR, dopo un evidente o sospetto trauma del torace, in quanto risolve in modo efficace  sia il pneumo che l’emotorace. La tecnica percutanea con ago è solo accettabile in caso di difficoltà di accesso ai reperi toracostomici, ed è comunque una tecnica ponte in attesa della procedura definitiva.

L’adozione da parte della Royal London Air Ambulance di un protocollo per l’arresto cardiaco da trauma, che prevede tra l’altro l’esecuzione della toracotomia d’urgenza già in fase preospedaliera nei pazienti vittima di trauma penetrante in assenza di segni vitali, ha portato ad un significativo miglioramento della sopravvivenza. Altri studi hanno evidenziato risultati contrastanti sull’incidenza di questa procedura nei vari setting in cui viene praticata.

L’ultrasonografia è sicuramente la diagnostica d’elezione nel trauma, anche preospedaliero, per facilità d’esecuzione ed attendibilità.

Bottom line:

  • L’ACR traumatico merita un’approccio diverso rispetto a quello non traumatico.
  • L’adozione di un protocollo specifico per il paziente traumatizzato in ACR deve guidare le priorità d’intervento e le procedure da applicare.
  • La gestione precoce delle vie aeree diventa un passaggio imprescindibile nell’arresto cardiaco post-trauma.
  • Il massaggio cardiaco esterno ha un’utilità limitata
  • Differenziare mediante la capnografia i ritmi perfondenti, anche in assenza di attività meccanica apprezzabile al polso centrale (pseudo PEA), deve guidare gli sforzi rianimatori e l’aggressività delle procedure praticate.
  • Deve sempre essere sempre e tempestivamente praticata una massiccia rianimazione volemica.
  • Non ci sono evidenze che i vasopressori migliorino l’outcome.
  • In caso di evidente o anche sospetto trauma toracico la toracostomia bilaterale è il gold standard. La tecnica percutanea con ago può essere una manovra ponte per motivi di non accessibilità del paziente.
  • In caso di traumi penetranti ed in assenza di segni vitali l’esecuzione della toracotomia d’urgenza aumenta la sopravvivenza
  • Il ruolo dell’ecografia rimane cruciale nella diagnostica differenziale della causa di ACR
Le vie di mezzo non pagano. Se si decide di intraprendere una RCP in un paziente in ACR da trauma l’esecuzione delle manovre che tendono a curare le sue cause reversibili devono essere necessariamente effettuate.

Clicca sul logo e scopri di più su MEDEST MEDEST you tube

 

 

 

References:

ALL Ohio EM

Supporting ALL Ohio EM Residencies in the #FOAMed World

Triggerlab

Let's try to make it simple

thinking critical care

a blog for thinking docs: blending good evidence, physiology, common sense, and applying it at the bedside!

urgentcareultrasound

More definitive diagnosis, better patient care

Critical Care Northampton

Reviewing Critical Care, Journals and FOAMed

OHCA research

Prehospital critical care for out-of-hospital cardiac arrest

SonoStuff

Education and entertainment for the ultrasound enthusiast

phemcast

A UK PREHOSPITAL PODCAST

First10EM

Emergency medicine resuscitation - When minutes matter...

Songs or Stories

Sharing the Science and Art of Paediatric Anaesthesia

airwayNautics

"Live as if you will die tomorrow; Learn as if you will live forever"

resusNautics

Navigating resuscitation

Life in the Fast Lane • LITFL • Medical Blog

Emergency medicine and critical care medical education blog

emDOCs.net - Emergency Medicine Education

Our goal is to inform the global EM community with timely and high yield content about what providers like YOU are seeing and doing everyday in your local ED.

The Collective

A Hive Mind for Prehospital and Retrieval Med

Dave on Airways

Thoughts and opinions on airways and resuscitation science

FOAMcast

A Free Open Access Medical Education Emergency Medicine Core Content Mash Up

Broome Docs

Rural Generalist Doctors Education

St.Emlyn's

Emergency Medicine #FOAMed

"CardioOnline"Basic and Advanced Cardiovascular medicine" Cariology" concepts and Review -Dr.Nabil Paktin,MD.FACC.دکتـور نبــــیل "پاکطــــین

این سایت را به آن دکتوران و محصلین طب که شب و روز برای رفاه نوع انسان فداکاری می کنند ، جوانی و لذایذ زندگی را بدون چشمداشت به امتیاز و نفرین و آفرین قربان خدمت به بشر می کنند و بار سنگین خدمت و اصلاح را بدوش می کشند ، اهداء می کنم This site is dedicated to all Doctors and students that aver the great responsibility of People’s well-being upon their shoulders and carry on their onerous task with utmost dedication and Devotionاولین سایت و ژورنال انتــرنتی علـــمی ،تخـصصی ، پــژوهشــی و آمــوزشــی طبـــی در افغــانســـتان

EmergencyPedia

Free Open Access Medical Education

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 Travel Blog

Local Travel Agent, sommelier, food & wine expert in Florence, Italy

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

%d blogger hanno fatto clic su Mi Piace per questo: