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Aunque pueda contener afirmaciones, datos o apuntes procedentes de instituciones o profesionales sanitarios, la información contenida en el blog EMS Solutions International está editada y elaborada por profesionales de la salud. Recomendamos al lector que cualquier duda relacionada con la salud sea consultada con un profesional del ámbito sanitario. by Dr. Ramon REYES, MD

miércoles, 30 de agosto de 2017

TOURNIQUET TRAINING FOR ALL

TOURNIQUET TRAINING FOR ALL 



Oct. 22, 2013 7:47 p.m. ET
The school shooting in Newtown, Conn., and the Boston Marathon bombing are prompting medical experts to change their thinking about the long-disdained technique of using tourniquets to save lives.
Drawing on lessons from those attacks and battlefields in Afghanistan and Iraq, emergency-medicine doctors are recommending that rescue personnel carry tourniquets and be prepared to use them in mass-casualty events.
A tourniquet is a bandage or other device applied tightly to restrict blood flow and prevent a victim with an arm or leg wound from bleeding to death. For decades, many first-aid classes and doctors have taught that tourniquets were too dangerous to use, because prolonged loss of blood circulation can lead to loss of a limb.
Now, a group of surgeons is challenging that view, advocating tourniquet training not just for police officers but for teachers and others who work in public places.
"It's kind of a radical change in thinking, because for years we have been teaching that tourniquets should be the absolute last resort," said Peter Pons, associate medical director for the National Association of Emergency Medical Technicians. In recent months, he has begun teaching tourniquet use to police officers in Denver, where he lives.
Studies have shown that tourniquets distributed to soldiers in the Iraq and Afghanistan wars helped save lives, Dr. Pons said. And researchers haven't found instances in which improper tourniquet use cost a soldier's limb, he added.
The risk of limb loss may have been overstated because it can take two hours or more for a tourniquet to damage a limb beyond repair, and it is unusual in the U.S. for someone suffering a life-threatening injury to take more than two hours to reach professional medical help, according to Dr. Pons and others.
The tourniquet's benefit, by contrast, comes in the initial minutes before medical personnel arrive. Shooting or bombing victims can bleed to death in five minutes.
Several doctors noted that the response at the Boston Marathon—where bystanders immediately used T-shirts and whatever else they had to make improvised tourniquets—shows that, in some ways, common sense among the public is ahead of current medical practice.
Lenworth Jacobs, a Connecticut doctor, said tourniquets wouldn't have prevented the deaths of children in last December's shootings in Newtown, because so many of the wounds were to vital organs. But tourniquets, he argued, would save lives in other cases, including the recent terror attack at a mall in Nairobi, Kenya.
After the Newtown shooting, Dr. Jacobs was among the medical experts asked by the American College of Surgeons and the Federal Bureau of Investigation to draft recommendations for the best way to respond to such events. Those recommendations, called the Hartford Consensus, included a call for wider use of tourniquets.
Some experts remain cautious about tourniquets. Jeffrey Pellegrino, a member of the American Red Cross Scientific Advisory Council, said in a statement that "the majority of bleeding incidents can be stopped by applying direct pressure to the wound. Because of the risk to the limb, lay responders who have been trained should only use a tourniquet as a last resort in cases where help is delayed, when bleeding cannot be controlled by direct pressure, or if applying direct pressure is not possible."
Alexander Eastman, a trauma surgeon who is a member of the Dallas Police Department's SWAT team, said tourniquets should be carried on first responders' uniforms. In his own job on a SWAT team, he often carries a pack with military-style tourniquets he can distribute to officers or victims.
At a recent police conference in Philadelphia, Dr. Eastman asked a crowd of major-city police chiefs whether they had been trained that tourniquets were too dangerous to use. Most raised their hands, he said.
"It's a myth that these tourniquets can hurt somebody, and we are fighting to end that myth," he said.

Combat Tourniquet One of Army’s Top 10 Inventions for ’05

            Combat Application Tourniquet (C-A-T)


Combat Tourniquet One of Army’s Top 10 Inventions for ’05

by  on  • 12:56 pm
Combat Application Tourniquet (C-A-T)

Combat Application Tourniquet (C-A-T)

A new design for a tourniquet for use in combat has brought the devices back into favor with Army surgeons.
The Combat Application Tourniquet was tested along with eight other tourniquets in 2004 at the U.S. Army Institute of Surgical Research in San Antonio, Texas. The evaluation was prompted because many deploying Soldiers and units were purchasing tourniquets off the Internet, but the tourniquets’ effectiveness had not been determined. Once testing was complete, the institute’s researchers recommended the Combat Application Tourniquet be pushed to deployed troops to stop otherwise lethal blood loss.
“If USAISR (U.S. Army Institute of Surgical Research) hadn’t done the work, there still wouldn’t have been an effective tourniquet out there,” said Dr. Tom Walters of the institute that studies how to save the lives of Soldiers who are wounded in combat.
Up until that point, he added, the tourniquets that were available through the military’s supply system included a cravat-and-stick tourniquet that Soldiers were taught how to use in basic training and the strap-and-buckle tourniquet that dated back to the American Civil War. The latter “had always been known to be ineffective,” Walters said.
In the “tourniquet-off” held at the institute during the summer of 2004, 18 volunteers helped evaluate the nine tourniquets’ ability to cut off blood flow. When the results were in, the CAT, as well as two other tourniquets, came out on top. The CAT had a smaller learning curve than the others, so researchers recommended it for the Army. The Marine Corps has adopted it as well.


“Tourniquets are being used on almost every extremity injury, and they are saving lives,” said Holcomb, who was recently deployed as a surgeon at the 10th Combat Support Hospital in Iraq. “Tourniquets were rarely seen early in the war, and now it’s abnormal to see a severe extremity injury without a functional tourniquet in place. There is no pre-hospital device deployed in this war that has saved more lives than tourniquets.”
While it’s certainly come at a tremendous human cost, the Iraq war has shown us entire fields of technology where we’ve been lacking. Say what you will about technology that improves offensive potential, but innovations to keep soldiers and civilians alive are always good ideas.
More from ARNews
FlashbacksThe Special Operations Forces Tactical TourniquetArmy Develops Improved Tourniquet

lunes, 28 de agosto de 2017

iResus 2015 - now on iOS and Android RESUCITATION COUNCIL (UK). ILCOR

iResus 2015 - now on iOS and Android RESUCITATION COUNCIL (UK). ILCOR 
Dr. Ramon Reyes, MD  

The Resuscitation Council (UK) have developed a new version of the iResus app. 
This free tool allows healthcare professionals to access the latest algorithms from the 2015 guidelines quickly and easily using any tablet or mobile device. 
The app is lightweight and does not require an internet connection to function. 
It can be downloaded via the Apple App Store or Google play. 

Download the app in the link https://www.resus.org.uk/apps/iresus/
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EMS España / Emergency Medical Services en España
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International Liason Committee on Resuscitation ILCOR 2015-2020 / The “Highlights of the 2015-2020 American Heart Association Guidelines for CPR and ECC “ / Summary of the main changes in the Resuscitation "Guidelines ERC GUIDELINES 2015" / Recomendaciones para la Resucitación 2015 del Consejo Europeo de Resucitación (ERC) 2015 / Principales novedades para las nuevas guías de RCP



domingo, 27 de agosto de 2017

Capnography to Maximize Patient Care by .JEMS Journal of Emergency Medicine

Capnography EtCO2 Picture by American Heart Association


Capnography Provides Bigger Physiological Picture to Maximize Patient Care

 
Caring for patients in the prehospital setting lends itself to a finite number of resources, necessitating that the devices available on EMS units offer the most utility while occupying the smallest space.
Capnography, or in-line end-tidal carbon dioxide (EtCO2) monitoring, offers more physiological information than any other noninvasive device carried in the field. In different clinical scenarios, EtCOmeasurement can provide valuable information about total body cellular metabolism, the body’s basal metabolic rate, central venous return, pulmonary blood flow, cardiac output, minute ventilation and myriad pulmonary diseases.
EtCO2 is also used to successfully guide resuscitations and ensure that lifesaving maneuvers are done correctly. This article will review the use of EtCO2 monitoring and interpretation by EMS providers. It will also illustrate how, along with vital signs, EtCO2 monitoring can complete the physiologic profile of patients in the field.
THE BASICS OF CO2
CO2 is the byproduct of aerobic metabolism that diffuses from body tissues to the lungs via erythrocytes carried in venous blood, where it can then be released by exhalation, dependent on ventilation patterns.1

Figure 1: Normal capnography wave
Capnometry is a measurement of the partial pressure of EtCO2, which, under normal ventilation and perfusion states, approximates the alveolar partial pressure of CO2.2

Waveform capnography is a graphical representation of the concentration of CO2 exhaled, used as an indirect indicator of the actual concentration, or partial pressure, of CO2 in arterial blood.
Figure 1 illustrates a normal capnography waveform:3
  • A–B demonstrates the exhalation of the dead space;
  • B–C represents lower airway exhalation;
  • C–D represents alveolar exhalation, as measured from the lips or nares; and
  • D–E represents inhalation.3
CO2 rises rapidly from B to C in a normal ventilatory pattern, with the end of exhalation represented at point D. This point correlates with the EtCO2 reading. Normal EtCO2 values range from 35–45 mmHg. Values < 35 mmHg generally can be considered diagnostic of hyperventilation or hypocarbia. Values > 45 mmHg indicate hypoventilation or hypercarbia.

Figure 2: EtCO2 patterns
VENTILATION PATTERNS IN NON-INTUBATED PATIENTS
Hyperventilation is frequently observed in patients, often in response to a sudden stressor, mediated by a catecholamine release. Hyperventilation is also seen in asthmatics, patients with a pulmonary embolism, or drug ingestions, including stimulants like cocaine or amphetamines. It causes a decreased EtCO reading (< 40 mmHg). As the EtCO2 approaches 25 mmHg, patients may complain of numbness and tingling in the hands, and may become disoriented.
Hypoventilation causes an increase in the measured EtCO2. Common causes include depressed mental status due to head trauma, intoxication by sedatives, alcohol, narcotics or the postictal period.
Patients in bronchospasm, such as asthmatics or those with chronic obstructive pulmonary disease (COPD), may have a "shark fin" appearance on the EtCO2 waveform. With this pathology, patients have prolonged exhalation—hence the gradual sloping of the tracing. In chronically retaining COPD patients, elevated EtCO2 levels may be observed at baseline, sometimes over 60 mmHg. (See Figure 2.)
ENDOTRACHEAL INTUBATION & MECHANICAL VENTILATION
Waveform capnography is the gold standard for confirmation of prehospital intubation.
The most common use of prehospital capnography is to confirm endotracheal tube (ETT) placement. In an already critical patient, correct placement of the ETT is an essential step in management. In one study, 15% of intubations were unrecognized as being esophageal when auscultation was the only confirmation method.4
Color-changing capnometry devices are still in use in many systems and are applied immediately after placement of the ETT to confirm placement, along with auscultation. However, waveform capnography is 100% sensitive and specific in assuring correct ETT placement after the administration of seven breaths.5

Figure 3: EtCO2 waveform assessment
A study examining the ability of paramedics and paramedic students to recognize and address ETT dislodgment in simulation found the detection of dislodgement by providers using capnography was two minutes, compared to four minutes by providers without access to capnography.6
During patient transport, the ETT is at risk for dislodgement for a number of reasons including road conditions, lack of adequate tube securement or patient movement, making continuous waveform capnography an invaluable resource in ensuring the safety and ventilatory status monitoring of the patient.7
SHOCK, SEPSIS & LOW-FLOW STATES
Capnography is now considered a key diagnostic tool to detect shock and poor perfusion states. In shock, the relative hypoperfusion of oxygen causes cells and tissues to rely on anaerobic respiration, leading to an increase in lactate and metabolic acidosis. To compensate, the respiratory rate increases, causing more CO2 to be exhaled, or "blown off." Therefore, it’s expected that patients in shock would have abnormally low EtCO2 readings.
When examining the association between increased lactate levels, organ dysfunction and damage, and EtCO2 measurements, EtCO2readings are inversely correlated with lactate levels and organ failure criteria.8 (For more on the use of capnography to reliably detect septic shock, see "Utilizing Capnography in Sepsis: End-tidal CO2 may be used in place of lactate to screen for severe sepsis," by Christopher Hunter, MD, PhD, in the March 2014 issue.)
Another study examining EtCO2 levels and serum lactate in trauma patients showed a similar strong inverse correlation between low EtCO2 levels and elevated lactate levels that prompted acute surgical intervention.9 EtCO2 measurements < 25 mmHg in the setting of two or more systemic inflammatory response syndrome criteria correlated with lactate levels > 4 mmol/L and increased mortality.10 Another study of 103 patients presenting with hypotension found the mean EtCO2 value for all patients, regardless of etiology, was 29.07 mmHg.11
USE IN CARDIAC ARREST
Cardiac arrest leads to a drastic fall in EtCO2 levels due to lack of cardiac output and perfusion providing a means for CO2 to reach the lungs for expiration. (See Figure 3.) Literature demonstrates that not only can a provider gauge the quality of CPR, as demonstrated by rising EtCO2 values, and determine return of spontaneous circulation (ROSC) by a significant increase in EtCO2 levels, but they can also predict cases where ROSC is unlikely to be achieved.12
EtCO2 differences in asphyxia-related cardiac arrests versus cardiac-related cardiac arrests (v fib or pulseless v tach) showed a difference in value of EtCO2 between the groups both initially and after one minute.
Arrests due to asphyxia, whether due to foreign body obstruction, aspiration, hanging, drowning, acute asthma attack or airway tumor, initially had higher EtCO2 than patients who suffered an arrest due to cardiac causes, therefore not producing an initial prognostic value for ROSC. However, EtCO2 readings after one minute were more prognostic of outcome.13
During CPR, EtCO2 tracings have been shown to decrease with rescuer fatigue and increase when a new rescuer begins compressions, demonstrating the necessity for providers to watch the capnography and evaluate quality of CPR in real time. Although an initial EtCO2 reading of < 10 mmHg is poor prognostically, some patients have developed ROSC.14 However, no patient survived with an EtCO2 of < 10 mmHg after 20 minutes of CPR, making this a valuable practice guideline.15 Regaining ROSC was associated with an average 13.5 mmHG increase in EtCO2 readings.16
PUTTING IT ALL TOGETHER
EtCO2 monitoring is an extremely valuable tool for EMS providers that’s rapidly becoming a standard piece of equipment on all EMS response vehicles. Patterns of activity or trends can lead to findings such as:
  • A drastic decrease in EtCO2 may demonstrate sudden hyperventilation, ETT occlusion or dislodgement, or a massive pulmonary embolism.
  • A gradual decrease in EtCO2 can be caused by hyperventilation or decreased CO2 production.
  • Patients who are tachypnic with a gradually rising EtCO2 tracing or a rising baseline, indicating CO2 rebreathing, may be tiring out and progressing to respiratory failure, requiring ventilatory support and/or intubation.
  • If the EtCO2 is gradually dropping during CPR, a rescuer may be tired and providing less adequate compressions, and therefore needs to change roles.
  • A sudden increase in EtCO2 is seen when ROSC is achieved or when sodium bicarbonate is administered.
  • A gradual increase in EtCO2 may be caused by hypoventilation, perhaps caused by sedatives or analgesics administered, or an increase in CO2 production.
  • In patients with acute pulmonary edema or congestive heart failure (CHF) receiving continuous positive airway pressure, EtCO2 can be an indicator of the success of treatment, as a previously tachypnic patient has an EtCO2 tracing slowly returning to normal.
  • A gradual increase in EtCO2 in a patient with a suspected intracranial hemorrhage may help the provider recognize a worsening clinical picture and the need for intubation.
CONCLUSION
Vital signs, clinical impression and EtCO2 monitoring can work together to give a more complete picture of the patient. Routine use of EtCO2 monitoring in the prehospital setting will allow providers to give better, more timely and more effective care.
REFERENCES
1. Kupnik D, Skok P. Capnometry in the prehospital setting: Are we using its potential? Emerg Med J. 2007;24(9):614–617.
2. Sanders AB. Capnometry in emergency medicine. Ann Emerg Med. 1989;18(12):1287–1290.
3. Farish SE, Garcia PS. Capnography primer for oral and maxillofacial surgery: Review and technical considerations. J Anesthe Clinic Res. 2013;4(3):295.
4. Anderson KH, Hald A. Assessing the position of tracheal tube. The reliability of different methods. Anaesthesia. 1989;44(12):984–985.
5. Grmec S, Mally S. Prehospital determination of tracheal tube placement in severe head injury. Emerg Med J. 2004;21(4):518–520.
6. Langhan ML, Ching K, Northrup V, et al. A randomized controlled trial of capnography in the correction of simulated endotracheal tube dislodgement. Acad Emerg Med. 2011;18(6):590–596.
7. Bhende MS, LaCovey DC. End-tidal carbon dioxide in the prehospital setting. Prehosp Emerg Care. 2001;5(2):208–213.
8. McGillicuddy D, Tang A, Cataldo L, et al. Evaluation of end-tidal carbon dioxide role in predicting elevated SOFA scores and lactic acidosis. Intern Emerg Med. 2009;4(1):41–44.
9. Caputo N, Fraser R, Paliga A, et al. Nasal cannula end-tidal CO2 correlates with serum lactate levels and odds of operative intervention in penetrating trauma patients; A prospective cohort study. J Trauma Acute Care Surg. 2012;73(5):1202–1207.
10. Hunter CL, Silvestri S, Dean M, et al. End-tidal carbon dioxide is associated with lactate levels and mortality in emergency department patients with suspected sepsis. Am J Emerg Med. 2013;31(1):64–71.
11. Kheng CP, Rahman NH. The use of end-tidal carbon dioxide monitoring in patients with hypotension in the emergency department. Int J Emerg Med. 2012;5(1):31.
12. Falk JL, Rackow EC, Weil MH. End-tidal carbon dioxide concentration during cardiopulmonary resuscitation. N Engl J Med. 1988;318(10):607–611.
13. Grmec S, Lah K, Tusek-Bunc K. Difference in end-tidal CO2 between asphyxia cardiac arrest and ventricular fibrillation/pulseless ventricular tachycardia cardiac arrest in the prehospital setting. Crit Care. 2003;7(6):R139–R144.
14. Callaham M, Barton C. Prediction of outcome of cardiopulmonary resuscitation from end-tidal carbon dioxide concentration. Crit Care Med. 1990;18(4):358–362.
15. Levine RL, Wayne MA, Miller CC. End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest. N Engl J Med. 1997;337(5):301–306.
16. Grmec S, Krizmaric M, Mally S, et al. Utstein style analysis of out-of-hospital cardiac arrest—Bystander CPR and end expired carbon dioxide. Resuscitation. 2007;72(3):404–414.

viernes, 25 de agosto de 2017

Escoger asiento más seguro en 6 medios de transporte diferente by porquenosemeocurrio.net

Publicado en este blog Dr. Ramon Reyes, MD 
A la mayoría de las personas nos gusta viajar, conocer nuevos lugares, nuevas ciudades, nuevas culturas y personas, respirar otros aires, es por eso que siempre estamos esperando las vacaciones o el momento exacto para subirnos a un medio de transporte ya sea por aire, tierra o mar, eso no importa, el simple hecho de salir de tu vida cotidiana es un placer.
Pero no todo es diversión y placer al viajar, también tenemos que tener en consideración los riesgos o accidentes que se pueden presentar al momento de tomar un medio de trasporte, a pesar de que cada año se mejora la seguridad de estos para prevenir accidentes, reduciendo el índice de mortalidad para el beneficio del cliente, debemos de ser precavidos y tener en cuenta que la seguridad es primero.
La forma más fácil de evitar un accidente durante un viaje, es escoger correctamente el asiento  que ocuparás al desplazarte de un lugar a otro y es por eso que a continuación te mostraremos cuales son los asientos más seguros que puedes ocupar al tomar los 7 medios de trasporte más usados, después de haber revisado algunas estadísticas de muchos accidentes.
El moderno sistema de medio de transporte es uno de los mayores avances de la humanidad
El avance tecnológico ha revolucionado  al mundo como lo vemos hoy, desde el transporte aéreo teniendo la facilidad de cruzar océanos en horas, lo cual era imposible hace 100 años, hasta el tren bala que puede viajar  más de 300 km/h.
Por más modernos y seguros que sean los medios de transporte, a veces pueden ocasionar un accidente.
Desde luego siempre aparece el miedo de subirnos a un vehículo o transporte para viajar, pensando que podemos sufrir una tragedia, pero es necesario saber que las victimas mortales son pocas, debido a que cada año se mejora la seguridad en los medios de trasporte para prevenir accidentes, sin embargo, no está de más saber que asiento tomar en los distintos medios de transporte para viajar más seguro y sufrir el menor daño posible.
Barco
La forma más segura de transportarte en un barco es tomar los camarotes que se encuentran en cubierta o los más cerca de ella, debido a que la parte superior es la última en hundirse, todo lo contrario de los camarotes que se encuentran en la parte  inferior del barco debido a que se encuentra más cerca del agua y del casco.

Auto
Si optas por tener un viaje en automóvil debes de considerar que el asiento más inseguro es el del copiloto debido a que durante un choque de frente con otro automóvil  el conductor intenta por instinto esquivar el vehículo poniendo en riesgo al copiloto, por otra parte los asientos más seguros se encuentran detrás del conductor ya que durante un choque de frente son los que menos reciben daño.

Avión
Si nos ponemos a pensar no existe muchas posibilidades de sobrevivir durante un accidente aéreo, aunque se considera uno de los medios de transporte más seguros del mundo, aun así para tratar de salir ileso muchos expertos piensan que tomar los asientos de la parte posterior de un avión tienes más posibilidad de sobrevivir que tomar los de la parte frontal.
Minivan
La forma más segura de tratar de salir ileso durante un viaje en una minivan es sentarte en los asientos que se encuentran en dirección contraria al movimiento, ya que si se frena súbitamente existe menos posibilidad que te golpees la cabeza con el respaldo, sin embargo, los asientos más inseguros se encuentran cerca de las puertas y ventanas ya que durante un accidente se pueden cortar con los vidrios si estos revientan, de igual forma el asiento del copiloto es conveniente evitarlo.
Tren
Toma en cuenta que los vagones más afectados al viajar en tren son los que se encuentran en los extremo, ya sea por descarrilamiento o colisión, es por eso que te recomendamos tomar los vagones que se encuentran a la mitad de este, usualmente es entre el 5to y el 7mo vagón dependiendo el que tu elijas y así tomar los asientos que se encuentran a la dirección del movimiento del tren ya que los que están perpendiculares al eje largo del vagón son menos seguros.

Tranvía
Se tiene que considerar que no en todo el mundo se maneja por el mismo lado, ya sea izquierda o derecha, es por eso que te recomendamos buscar los asientos del medio en dirección al movimiento para tu seguridad, por otro lado los asientos que se encuentran cerca de las ventanas evita tomarlos pues es probable que salgas lastimado por algún vidrio roto en una colisión.
Autobús
Los asientos más seguros al viajar en un autobús tratando de salir ileso se encuentran  en la parte derecha y en medio del pasillo debido a que se ubican más lejos del tráfico que va en dirección contraria, sabiendo esto debes de tomar en cuenta que los asientos más peligrosos se encuentran en las dos primeras filas debido a que durante un choque de frente pueden salir heridos al romperse el parabrisas o por algún pedazo o astilla que se desprenda del otro coche, de la misma manera evita tomar los asientos de atrás debido a que son igual de peligrosos si ocurre un choque trasero, los asientos que se encuentran cerca de las ventanas y puertas, tienen más posibilidad de sufrir alguna herida por un vidrio quebrado durante el choque.

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 Cinematica de Trauma