Tecnologia e nuove competenze a supporto del cambiamento

Dott Enrico MirantePronto Soccorso e Medicina drsquoUrgenzaOspedale SantrsquoEugenio Roma

ldquoIl medico drsquoEmergenza-Urgenza deve possedere conoscenze teoriche

scientifiche e professionali nei campi della metodologia clinica del primo

inquadramento diagnostico e del primo trattamento delle urgenze mediche

chirurgiche e traumatologiche [hellip]rdquo

Valutare rianimare e stabilizzare il paziente in fase intra ed extra-

ospedaliera

Inquadrare dal punto di vista diagnostico e attuare il trattamento di tutti i

pazienti inclusi i pazienti pediatrici geriatrici ed in gravidanza che

arrivano in Pronto Soccorso con diversi sintomi e bisogni in base a criteri di

prioritagrave

Arresto cardiaco

Ritmo Defibrillabile (FV)

Copyright copy2005 Canadian Medical Association or its licensors

Rivers E P et al CMAJ 20051731054-1065

Fig 5 Treatment options in sepsis

La causa piugrave frequente di shock nel trauma egrave

lrsquoemorragia

IL PNEUMOTORACE IPERTESO CONDUCE RAPIDAMENTE A MORTE

ATLSPRIMARY SURVEY

ABCDE

1

AGIRE PER PRIORITArsquo

A B C D E

ROSSOGIALLOVERDEBIANCO

PROCEDURE SALVAVITA

Lrsquointubazione deve essere preceduta da pre-ossigenazione

Anche se lrsquointubazione presenta vantaggilrsquoobiettivo non egrave lrsquointubazione ma

bull il mantenimento della pervietagrave delle vie aeree

bull la ossigenazione

Non ostinarsi in ripetuti tentativi di intubazione

Ventilazione con pallone autoespansibile e maschera

Saper essere invasivihellip

bull PVC e ScvO2

Cosa serve per lrsquoinserzione di un CVC

LA STERILITArsquo

Ecografia

Tamponamento cardiaco

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

ldquoIl medico drsquoEmergenza-Urgenza deve possedere conoscenze teoriche

scientifiche e professionali nei campi della metodologia clinica del primo

inquadramento diagnostico e del primo trattamento delle urgenze mediche

chirurgiche e traumatologiche [hellip]rdquo

Valutare rianimare e stabilizzare il paziente in fase intra ed extra-

ospedaliera

Inquadrare dal punto di vista diagnostico e attuare il trattamento di tutti i

pazienti inclusi i pazienti pediatrici geriatrici ed in gravidanza che

arrivano in Pronto Soccorso con diversi sintomi e bisogni in base a criteri di

prioritagrave

Arresto cardiaco

Ritmo Defibrillabile (FV)

Copyright copy2005 Canadian Medical Association or its licensors

Rivers E P et al CMAJ 20051731054-1065

Fig 5 Treatment options in sepsis

La causa piugrave frequente di shock nel trauma egrave

lrsquoemorragia

IL PNEUMOTORACE IPERTESO CONDUCE RAPIDAMENTE A MORTE

ATLSPRIMARY SURVEY

ABCDE

1

AGIRE PER PRIORITArsquo

A B C D E

ROSSOGIALLOVERDEBIANCO

PROCEDURE SALVAVITA

Lrsquointubazione deve essere preceduta da pre-ossigenazione

Anche se lrsquointubazione presenta vantaggilrsquoobiettivo non egrave lrsquointubazione ma

bull il mantenimento della pervietagrave delle vie aeree

bull la ossigenazione

Non ostinarsi in ripetuti tentativi di intubazione

Ventilazione con pallone autoespansibile e maschera

Saper essere invasivihellip

bull PVC e ScvO2

Cosa serve per lrsquoinserzione di un CVC

LA STERILITArsquo

Ecografia

Tamponamento cardiaco

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

Arresto cardiaco

Ritmo Defibrillabile (FV)

Copyright copy2005 Canadian Medical Association or its licensors

Rivers E P et al CMAJ 20051731054-1065

Fig 5 Treatment options in sepsis

La causa piugrave frequente di shock nel trauma egrave

lrsquoemorragia

IL PNEUMOTORACE IPERTESO CONDUCE RAPIDAMENTE A MORTE

ATLSPRIMARY SURVEY

ABCDE

1

AGIRE PER PRIORITArsquo

A B C D E

ROSSOGIALLOVERDEBIANCO

PROCEDURE SALVAVITA

Lrsquointubazione deve essere preceduta da pre-ossigenazione

Anche se lrsquointubazione presenta vantaggilrsquoobiettivo non egrave lrsquointubazione ma

bull il mantenimento della pervietagrave delle vie aeree

bull la ossigenazione

Non ostinarsi in ripetuti tentativi di intubazione

Ventilazione con pallone autoespansibile e maschera

Saper essere invasivihellip

bull PVC e ScvO2

Cosa serve per lrsquoinserzione di un CVC

LA STERILITArsquo

Ecografia

Tamponamento cardiaco

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

Copyright copy2005 Canadian Medical Association or its licensors

Rivers E P et al CMAJ 20051731054-1065

Fig 5 Treatment options in sepsis

La causa piugrave frequente di shock nel trauma egrave

lrsquoemorragia

IL PNEUMOTORACE IPERTESO CONDUCE RAPIDAMENTE A MORTE

ATLSPRIMARY SURVEY

ABCDE

1

AGIRE PER PRIORITArsquo

A B C D E

ROSSOGIALLOVERDEBIANCO

PROCEDURE SALVAVITA

Lrsquointubazione deve essere preceduta da pre-ossigenazione

Anche se lrsquointubazione presenta vantaggilrsquoobiettivo non egrave lrsquointubazione ma

bull il mantenimento della pervietagrave delle vie aeree

bull la ossigenazione

Non ostinarsi in ripetuti tentativi di intubazione

Ventilazione con pallone autoespansibile e maschera

Saper essere invasivihellip

bull PVC e ScvO2

Cosa serve per lrsquoinserzione di un CVC

LA STERILITArsquo

Ecografia

Tamponamento cardiaco

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

La causa piugrave frequente di shock nel trauma egrave

lrsquoemorragia

IL PNEUMOTORACE IPERTESO CONDUCE RAPIDAMENTE A MORTE

ATLSPRIMARY SURVEY

ABCDE

1

AGIRE PER PRIORITArsquo

A B C D E

ROSSOGIALLOVERDEBIANCO

PROCEDURE SALVAVITA

Lrsquointubazione deve essere preceduta da pre-ossigenazione

Anche se lrsquointubazione presenta vantaggilrsquoobiettivo non egrave lrsquointubazione ma

bull il mantenimento della pervietagrave delle vie aeree

bull la ossigenazione

Non ostinarsi in ripetuti tentativi di intubazione

Ventilazione con pallone autoespansibile e maschera

Saper essere invasivihellip

bull PVC e ScvO2

Cosa serve per lrsquoinserzione di un CVC

LA STERILITArsquo

Ecografia

Tamponamento cardiaco

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

1

AGIRE PER PRIORITArsquo

A B C D E

ROSSOGIALLOVERDEBIANCO

PROCEDURE SALVAVITA

Lrsquointubazione deve essere preceduta da pre-ossigenazione

Anche se lrsquointubazione presenta vantaggilrsquoobiettivo non egrave lrsquointubazione ma

bull il mantenimento della pervietagrave delle vie aeree

bull la ossigenazione

Non ostinarsi in ripetuti tentativi di intubazione

Ventilazione con pallone autoespansibile e maschera

Saper essere invasivihellip

bull PVC e ScvO2

Cosa serve per lrsquoinserzione di un CVC

LA STERILITArsquo

Ecografia

Tamponamento cardiaco

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

A B C D E

ROSSOGIALLOVERDEBIANCO

PROCEDURE SALVAVITA

Lrsquointubazione deve essere preceduta da pre-ossigenazione

Anche se lrsquointubazione presenta vantaggilrsquoobiettivo non egrave lrsquointubazione ma

bull il mantenimento della pervietagrave delle vie aeree

bull la ossigenazione

Non ostinarsi in ripetuti tentativi di intubazione

Ventilazione con pallone autoespansibile e maschera

Saper essere invasivihellip

bull PVC e ScvO2

Cosa serve per lrsquoinserzione di un CVC

LA STERILITArsquo

Ecografia

Tamponamento cardiaco

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

PROCEDURE SALVAVITA

Lrsquointubazione deve essere preceduta da pre-ossigenazione

Anche se lrsquointubazione presenta vantaggilrsquoobiettivo non egrave lrsquointubazione ma

bull il mantenimento della pervietagrave delle vie aeree

bull la ossigenazione

Non ostinarsi in ripetuti tentativi di intubazione

Ventilazione con pallone autoespansibile e maschera

Saper essere invasivihellip

bull PVC e ScvO2

Cosa serve per lrsquoinserzione di un CVC

LA STERILITArsquo

Ecografia

Tamponamento cardiaco

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

Lrsquointubazione deve essere preceduta da pre-ossigenazione

Anche se lrsquointubazione presenta vantaggilrsquoobiettivo non egrave lrsquointubazione ma

bull il mantenimento della pervietagrave delle vie aeree

bull la ossigenazione

Non ostinarsi in ripetuti tentativi di intubazione

Ventilazione con pallone autoespansibile e maschera

Saper essere invasivihellip

bull PVC e ScvO2

Cosa serve per lrsquoinserzione di un CVC

LA STERILITArsquo

Ecografia

Tamponamento cardiaco

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

Ventilazione con pallone autoespansibile e maschera

Saper essere invasivihellip

bull PVC e ScvO2

Cosa serve per lrsquoinserzione di un CVC

LA STERILITArsquo

Ecografia

Tamponamento cardiaco

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

Saper essere invasivihellip

bull PVC e ScvO2

Cosa serve per lrsquoinserzione di un CVC

LA STERILITArsquo

Ecografia

Tamponamento cardiaco

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

bull PVC e ScvO2

Cosa serve per lrsquoinserzione di un CVC

LA STERILITArsquo

Ecografia

Tamponamento cardiaco

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

Cosa serve per lrsquoinserzione di un CVC

LA STERILITArsquo

Ecografia

Tamponamento cardiaco

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

Ecografia

Tamponamento cardiaco

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

Emergency echocardiography

bull Subcostal or apical four chamber scan

bull The global ventricular function can be qualitatively assessed by visual ispectionalone (eye balling)

bull Evaluating whether cardiac function is normally moderately or severely impairedis sufficient in most cases

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

Rimozione di 5-10ml liquido pericardico

Aumento dello stroke volume 25-50

Tamponamento cardiaco

Rottura di atrio segni e sintomi di Tamponamento cardiaco si manifestano lentamenteECO FAST DI CONTROLLO

FAST DIAGNOSI + TRATTAMENTO (ECO + PERICARDIOCENTESI)

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

CARDIOGENICSHOCK

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

IC = 30

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

Valvola peep

boussignac

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

NON INVASIVE VENTILATION

Pinsp gt Pesp

Riduce il lavoro dei muscoli respiratori e puograve garantire un supporto respiratorio completo

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

Chest 2015 Jul148(1)253-61Spoletini G Alotaibi M Blasi F Hill NS

High Flow Nasal Cannula (HFNC) administer humidified and heated airoxygen mixtures at high flows (up to 60 Lmin)

Enhance patient confort and tolerance

Permit less entrainment of room air during patient inspiration

Combined with the flushing of expired air from the upper airway during expiration assuremore reliable delivery of high FiO2 levels improves ventilatory efficiency and reduces the work of breathing

HFNC also generates PEEP wich may counterbalance auto-PEEP further reducing ventilatorywork improve oxygenation and provide back pressure to enhance airway patency during

expiration

Very few high quality studies have been pubblished

EMERGENZE PEDIATRCHE

non consideratemi un adulto in miniatura

cambiano i parametri vitali normali

FCveglia FCsonno FR PA sistolica PA diastolica

Neonato 100-180 80-160 40-60 60-90 20-60

Lattante 100-160 75-160 30-60 87-105 53-66

1deg infanzia (2 anni)

80-110 60-90 24-40 95-105 53-66

2deg infanzia (5 anni)

70-100 60-90 22-34 96-110 55-69

Etagrave scolare (7 anni)

65-110 60-90 18-30 97-112 57-71

Adolescente (15 anni)

60-90 50-90 12-16 112-128 66-80

Robert M Kliegman et al editors Nelson Textbook of Pediatrics 18th edition (Philadelphia Saunders Elsevier 2007) 389 modificato

38

PRESIDI GRIGIOOK

radicROSAROSSO

OK

radicVIOLA

OK

radicGIALLO

OK

radicBIANCO

OK

radicBLU

OK

radicARANCIO

OK

radicVERDE

OK

radic

Maschera per

ventilazione0 1 2 3 3 3 3 3 3 4

Canala di

Guedel

35

mm

45 mm

45 mm 55 mm 55 mm 55 mm 70 mm 70 mm 70 90 mm

Catetere

Aspirazione8 fr 8 fr 10 fr 10 fr 10 fr 10 fr 10 fr 10 fr

Lama

laringoscopio

0 1

dritta

(curva)

1 dritta

(curva)

1 dritta

(curva)

2 dritta

(curva)

2 dritta

(curva)2 drittacurva

2

drittacurva

3

drittacurva

Tubo

endotracheal

e

25 ndash 3

35 no

cuffia

35 no cuffia

4

no

cuffia(cuffiato)

45 no

cuffia(cuffiato)

5 no

cuffia(cuffiato)

55 no

cuffia(cuffiato)6 cuffiato 65 cuffiato

Mandrino 6 fr 6 fr 6 fr 6 fr 6 fr 14 fr 14 fr 14 fr

Canula naso

faringea

12 - 14

fr14 fr 18 fr 20 fr 22 fr 24 fr 26 fr 30 fr

Maschera

Laringea LMA1 15 2 2 2 2 - 25 25 3

Sondino naso

gastrico5 - 8 fr 5 - 8 fr 8 - 10 fr 10 fr 10 fr 12 - 14 fr 14 - 18 fr 16 fr

Catetere

vescicale5 fr 8 fr 8 - 10 fr 10 fr 10 - 12 fr 10 - 12 fr 12 fr 12 fr

Tubo toracico

(trocar

Argyle)

10-12

fr10 - 12 fr 16 - 20 fr 20 - 24 fr 20 - 24 fr 24 - 32 fr 28 - 32 fr 32 - 38 fr

Ago canula22 - 24

ga22 - 24 ga 20 - 24 ga 18 - 22 ga 18 - 22 ga 18 - 20 ga 18 - 20 ga 18 - 20 ga

Butterfly22 - 24

ga23 - 25 ga 23 - 25 ga 21 - 23 ga 21 - 23 ga 21 - 23 ga 21 - 22 ga 18 - 21 ga

CHECK LIST CASSETTI BIMBI A COLORI DATAhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip FIRMAhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

neonato tra 4 e 7 kg tra 8 ed 11 kg tra 11 e 14 kg tra 14 e 17 kg tra 18 e 22 kg tra 24 e 30 kg oltre 34 kg

sono diversi i presidi da utilizzarehellip

PALS Bradycardia Algorithm

Kleinman M E et al Circulation 2010122S876-S908

Copyright copy American Heart Association

The Broselow-Luten SystemEmergency System

YELLOW

DRUGS and EQUIPMENT

GREEN

ORANGE

WHITE

YELLOW

PURPLE

RED

PINK

33mL

27 mL

17 mL

13 mL

1 mL

085 mL

065 mL

BLUE 2 mL

EPINEPHRINEConcentration

01 mgmL 110000

ED overcrowding has been found tocorrelate with

1) increased patient mortality2) decreased patient satisfaction

Sepsis and septic shock are medical emergencies and we recommend that treatment and resuscitation begin immediatelyBest Practice Statement

Summary

bull Start resuscitation early with source control intravenous fluids and antibiotics

bull Frequent assessment of the patientsrsquo volume status is crucial throughout the resuscitation period

bull We suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion

2Diagnostica - EGA

Egrave la saturazione del sangue della vena cava o dellrsquoatrio destro

Rappresenta lrsquoossigenazione residua del sangue proveniente dai tessuti dopo lrsquoestrazione di ossigeno

Ersquo un indice della relazione tra apporto di O2 (DO2) ed estrazione di O2 (VO2)

Vn gt 70

ScvO2Saturazione venosa centrale

darr DO2

Ipossia tissutale globale

ScvO2 lt 70

uarr Lattati

bull Tonometria gastrica

bull Capnografia sublinguale

bull ∆ (vc ndash a) CO2 gt 5 mmHg

uarr CO2 tissutale

World Society of Abdominal

Compartment Syndrome (WSSCS)

valori normali 5-7 mmHg

pazienti obesi 7-14 mmHg

pz in posizione semiseduta (30ndash45deg) 4ndash9 mmHg

Ipertensione intra-addominale (IAH)

persistente elevazione della IAP ge 12 mmHg

I grado 12-15mmHg II grado 16-20mmHg

III grado 21-25mmHg IV grado gt25mmHg

Sindrome compartimentale addominale (ACS)

incremento della IAP gt 20 mmHg associata ad una disfunzione o insufficienza drsquoorgano di nuova insorgenza

I

A

P

APP=MAP-IAPVn gt60mmHg

Shock 2017 Jul 19 doi 101097SHK0000000000000949 [Epub ahead of print]

Evaluation of Non-Invasive Hemoglobin Monitoring in

Trauma Patients with Low Hemoglobin LevelsGamal M1 Abdelhamid B Zakaria D Dayem OAE Rady A Fawzy M Hasanin A

CONCLUSIONS Sp-Hb showed accurate precision in both absolute values and trend values compared to

Lab-Hb measurement in trauma patients with low hemoglobin levels

cambiano i parametri vitali normali

FCveglia FCsonno FR PA sistolica PA diastolica

Neonato 100-180 80-160 40-60 60-90 20-60

Lattante 100-160 75-160 30-60 87-105 53-66

1deg infanzia (2 anni)

80-110 60-90 24-40 95-105 53-66

2deg infanzia (5 anni)

70-100 60-90 22-34 96-110 55-69

Etagrave scolare (7 anni)

65-110 60-90 18-30 97-112 57-71

Adolescente (15 anni)

60-90 50-90 12-16 112-128 66-80

Robert M Kliegman et al editors Nelson Textbook of Pediatrics 18th edition (Philadelphia Saunders Elsevier 2007) 389 modificato

38

PRESIDI GRIGIOOK

radicROSAROSSO

OK

radicVIOLA

OK

radicGIALLO

OK

radicBIANCO

OK

radicBLU

OK

radicARANCIO

OK

radicVERDE

OK

radic

Maschera per

ventilazione0 1 2 3 3 3 3 3 3 4

Canala di

Guedel

35

mm

45 mm

45 mm 55 mm 55 mm 55 mm 70 mm 70 mm 70 90 mm

Catetere

Aspirazione8 fr 8 fr 10 fr 10 fr 10 fr 10 fr 10 fr 10 fr

Lama

laringoscopio

0 1

dritta

(curva)

1 dritta

(curva)

1 dritta

(curva)

2 dritta

(curva)

2 dritta

(curva)2 drittacurva

2

drittacurva

3

drittacurva

Tubo

endotracheal

e

25 ndash 3

35 no

cuffia

35 no cuffia

4

no

cuffia(cuffiato)

45 no

cuffia(cuffiato)

5 no

cuffia(cuffiato)

55 no

cuffia(cuffiato)6 cuffiato 65 cuffiato

Mandrino 6 fr 6 fr 6 fr 6 fr 6 fr 14 fr 14 fr 14 fr

Canula naso

faringea

12 - 14

fr14 fr 18 fr 20 fr 22 fr 24 fr 26 fr 30 fr

Maschera

Laringea LMA1 15 2 2 2 2 - 25 25 3

Sondino naso

gastrico5 - 8 fr 5 - 8 fr 8 - 10 fr 10 fr 10 fr 12 - 14 fr 14 - 18 fr 16 fr

Catetere

vescicale5 fr 8 fr 8 - 10 fr 10 fr 10 - 12 fr 10 - 12 fr 12 fr 12 fr

Tubo toracico

(trocar

Argyle)

10-12

fr10 - 12 fr 16 - 20 fr 20 - 24 fr 20 - 24 fr 24 - 32 fr 28 - 32 fr 32 - 38 fr

Ago canula22 - 24

ga22 - 24 ga 20 - 24 ga 18 - 22 ga 18 - 22 ga 18 - 20 ga 18 - 20 ga 18 - 20 ga

Butterfly22 - 24

ga23 - 25 ga 23 - 25 ga 21 - 23 ga 21 - 23 ga 21 - 23 ga 21 - 22 ga 18 - 21 ga

CHECK LIST CASSETTI BIMBI A COLORI DATAhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip FIRMAhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

neonato tra 4 e 7 kg tra 8 ed 11 kg tra 11 e 14 kg tra 14 e 17 kg tra 18 e 22 kg tra 24 e 30 kg oltre 34 kg

sono diversi i presidi da utilizzarehellip

PALS Bradycardia Algorithm

Kleinman M E et al Circulation 2010122S876-S908

Copyright copy American Heart Association

The Broselow-Luten SystemEmergency System

YELLOW

DRUGS and EQUIPMENT

GREEN

ORANGE

WHITE

YELLOW

PURPLE

RED

PINK

33mL

27 mL

17 mL

13 mL

1 mL

085 mL

065 mL

BLUE 2 mL

EPINEPHRINEConcentration

01 mgmL 110000

ED overcrowding has been found tocorrelate with

1) increased patient mortality2) decreased patient satisfaction

Sepsis and septic shock are medical emergencies and we recommend that treatment and resuscitation begin immediatelyBest Practice Statement

Summary

bull Start resuscitation early with source control intravenous fluids and antibiotics

bull Frequent assessment of the patientsrsquo volume status is crucial throughout the resuscitation period

bull We suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion

2Diagnostica - EGA

Egrave la saturazione del sangue della vena cava o dellrsquoatrio destro

Rappresenta lrsquoossigenazione residua del sangue proveniente dai tessuti dopo lrsquoestrazione di ossigeno

Ersquo un indice della relazione tra apporto di O2 (DO2) ed estrazione di O2 (VO2)

Vn gt 70

ScvO2Saturazione venosa centrale

darr DO2

Ipossia tissutale globale

ScvO2 lt 70

uarr Lattati

bull Tonometria gastrica

bull Capnografia sublinguale

bull ∆ (vc ndash a) CO2 gt 5 mmHg

uarr CO2 tissutale

World Society of Abdominal

Compartment Syndrome (WSSCS)

valori normali 5-7 mmHg

pazienti obesi 7-14 mmHg

pz in posizione semiseduta (30ndash45deg) 4ndash9 mmHg

Ipertensione intra-addominale (IAH)

persistente elevazione della IAP ge 12 mmHg

I grado 12-15mmHg II grado 16-20mmHg

III grado 21-25mmHg IV grado gt25mmHg

Sindrome compartimentale addominale (ACS)

incremento della IAP gt 20 mmHg associata ad una disfunzione o insufficienza drsquoorgano di nuova insorgenza

I

A

P

APP=MAP-IAPVn gt60mmHg

Shock 2017 Jul 19 doi 101097SHK0000000000000949 [Epub ahead of print]

Evaluation of Non-Invasive Hemoglobin Monitoring in

Trauma Patients with Low Hemoglobin LevelsGamal M1 Abdelhamid B Zakaria D Dayem OAE Rady A Fawzy M Hasanin A

CONCLUSIONS Sp-Hb showed accurate precision in both absolute values and trend values compared to

Lab-Hb measurement in trauma patients with low hemoglobin levels

38

PRESIDI GRIGIOOK

radicROSAROSSO

OK

radicVIOLA

OK

radicGIALLO

OK

radicBIANCO

OK

radicBLU

OK

radicARANCIO

OK

radicVERDE

OK

radic

Maschera per

ventilazione0 1 2 3 3 3 3 3 3 4

Canala di

Guedel

35

mm

45 mm

45 mm 55 mm 55 mm 55 mm 70 mm 70 mm 70 90 mm

Catetere

Aspirazione8 fr 8 fr 10 fr 10 fr 10 fr 10 fr 10 fr 10 fr

Lama

laringoscopio

0 1

dritta

(curva)

1 dritta

(curva)

1 dritta

(curva)

2 dritta

(curva)

2 dritta

(curva)2 drittacurva

2

drittacurva

3

drittacurva

Tubo

endotracheal

e

25 ndash 3

35 no

cuffia

35 no cuffia

4

no

cuffia(cuffiato)

45 no

cuffia(cuffiato)

5 no

cuffia(cuffiato)

55 no

cuffia(cuffiato)6 cuffiato 65 cuffiato

Mandrino 6 fr 6 fr 6 fr 6 fr 6 fr 14 fr 14 fr 14 fr

Canula naso

faringea

12 - 14

fr14 fr 18 fr 20 fr 22 fr 24 fr 26 fr 30 fr

Maschera

Laringea LMA1 15 2 2 2 2 - 25 25 3

Sondino naso

gastrico5 - 8 fr 5 - 8 fr 8 - 10 fr 10 fr 10 fr 12 - 14 fr 14 - 18 fr 16 fr

Catetere

vescicale5 fr 8 fr 8 - 10 fr 10 fr 10 - 12 fr 10 - 12 fr 12 fr 12 fr

Tubo toracico

(trocar

Argyle)

10-12

fr10 - 12 fr 16 - 20 fr 20 - 24 fr 20 - 24 fr 24 - 32 fr 28 - 32 fr 32 - 38 fr

Ago canula22 - 24

ga22 - 24 ga 20 - 24 ga 18 - 22 ga 18 - 22 ga 18 - 20 ga 18 - 20 ga 18 - 20 ga

Butterfly22 - 24

ga23 - 25 ga 23 - 25 ga 21 - 23 ga 21 - 23 ga 21 - 23 ga 21 - 22 ga 18 - 21 ga

CHECK LIST CASSETTI BIMBI A COLORI DATAhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip FIRMAhelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

neonato tra 4 e 7 kg tra 8 ed 11 kg tra 11 e 14 kg tra 14 e 17 kg tra 18 e 22 kg tra 24 e 30 kg oltre 34 kg

sono diversi i presidi da utilizzarehellip

PALS Bradycardia Algorithm

Kleinman M E et al Circulation 2010122S876-S908

Copyright copy American Heart Association

The Broselow-Luten SystemEmergency System

YELLOW

DRUGS and EQUIPMENT

GREEN

ORANGE

WHITE

YELLOW

PURPLE

RED

PINK

33mL

27 mL

17 mL

13 mL

1 mL

085 mL

065 mL

BLUE 2 mL

EPINEPHRINEConcentration

01 mgmL 110000

ED overcrowding has been found tocorrelate with

1) increased patient mortality2) decreased patient satisfaction

Sepsis and septic shock are medical emergencies and we recommend that treatment and resuscitation begin immediatelyBest Practice Statement

Summary

bull Start resuscitation early with source control intravenous fluids and antibiotics

bull Frequent assessment of the patientsrsquo volume status is crucial throughout the resuscitation period

bull We suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion

2Diagnostica - EGA

Egrave la saturazione del sangue della vena cava o dellrsquoatrio destro

Rappresenta lrsquoossigenazione residua del sangue proveniente dai tessuti dopo lrsquoestrazione di ossigeno

Ersquo un indice della relazione tra apporto di O2 (DO2) ed estrazione di O2 (VO2)

Vn gt 70

ScvO2Saturazione venosa centrale

darr DO2

Ipossia tissutale globale

ScvO2 lt 70

uarr Lattati

bull Tonometria gastrica

bull Capnografia sublinguale

bull ∆ (vc ndash a) CO2 gt 5 mmHg

uarr CO2 tissutale

World Society of Abdominal

Compartment Syndrome (WSSCS)

valori normali 5-7 mmHg

pazienti obesi 7-14 mmHg

pz in posizione semiseduta (30ndash45deg) 4ndash9 mmHg

Ipertensione intra-addominale (IAH)

persistente elevazione della IAP ge 12 mmHg

I grado 12-15mmHg II grado 16-20mmHg

III grado 21-25mmHg IV grado gt25mmHg

Sindrome compartimentale addominale (ACS)

incremento della IAP gt 20 mmHg associata ad una disfunzione o insufficienza drsquoorgano di nuova insorgenza

I

A

P

APP=MAP-IAPVn gt60mmHg

Shock 2017 Jul 19 doi 101097SHK0000000000000949 [Epub ahead of print]

Evaluation of Non-Invasive Hemoglobin Monitoring in

Trauma Patients with Low Hemoglobin LevelsGamal M1 Abdelhamid B Zakaria D Dayem OAE Rady A Fawzy M Hasanin A

CONCLUSIONS Sp-Hb showed accurate precision in both absolute values and trend values compared to

Lab-Hb measurement in trauma patients with low hemoglobin levels

PALS Bradycardia Algorithm

Kleinman M E et al Circulation 2010122S876-S908

Copyright copy American Heart Association

The Broselow-Luten SystemEmergency System

YELLOW

DRUGS and EQUIPMENT

GREEN

ORANGE

WHITE

YELLOW

PURPLE

RED

PINK

33mL

27 mL

17 mL

13 mL

1 mL

085 mL

065 mL

BLUE 2 mL

EPINEPHRINEConcentration

01 mgmL 110000

ED overcrowding has been found tocorrelate with

1) increased patient mortality2) decreased patient satisfaction

Sepsis and septic shock are medical emergencies and we recommend that treatment and resuscitation begin immediatelyBest Practice Statement

Summary

bull Start resuscitation early with source control intravenous fluids and antibiotics

bull Frequent assessment of the patientsrsquo volume status is crucial throughout the resuscitation period

bull We suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion

2Diagnostica - EGA

Egrave la saturazione del sangue della vena cava o dellrsquoatrio destro

Rappresenta lrsquoossigenazione residua del sangue proveniente dai tessuti dopo lrsquoestrazione di ossigeno

Ersquo un indice della relazione tra apporto di O2 (DO2) ed estrazione di O2 (VO2)

Vn gt 70

ScvO2Saturazione venosa centrale

darr DO2

Ipossia tissutale globale

ScvO2 lt 70

uarr Lattati

bull Tonometria gastrica

bull Capnografia sublinguale

bull ∆ (vc ndash a) CO2 gt 5 mmHg

uarr CO2 tissutale

World Society of Abdominal

Compartment Syndrome (WSSCS)

valori normali 5-7 mmHg

pazienti obesi 7-14 mmHg

pz in posizione semiseduta (30ndash45deg) 4ndash9 mmHg

Ipertensione intra-addominale (IAH)

persistente elevazione della IAP ge 12 mmHg

I grado 12-15mmHg II grado 16-20mmHg

III grado 21-25mmHg IV grado gt25mmHg

Sindrome compartimentale addominale (ACS)

incremento della IAP gt 20 mmHg associata ad una disfunzione o insufficienza drsquoorgano di nuova insorgenza

I

A

P

APP=MAP-IAPVn gt60mmHg

Shock 2017 Jul 19 doi 101097SHK0000000000000949 [Epub ahead of print]

Evaluation of Non-Invasive Hemoglobin Monitoring in

Trauma Patients with Low Hemoglobin LevelsGamal M1 Abdelhamid B Zakaria D Dayem OAE Rady A Fawzy M Hasanin A

CONCLUSIONS Sp-Hb showed accurate precision in both absolute values and trend values compared to

Lab-Hb measurement in trauma patients with low hemoglobin levels

The Broselow-Luten SystemEmergency System

YELLOW

DRUGS and EQUIPMENT

GREEN

ORANGE

WHITE

YELLOW

PURPLE

RED

PINK

33mL

27 mL

17 mL

13 mL

1 mL

085 mL

065 mL

BLUE 2 mL

EPINEPHRINEConcentration

01 mgmL 110000

ED overcrowding has been found tocorrelate with

1) increased patient mortality2) decreased patient satisfaction

Sepsis and septic shock are medical emergencies and we recommend that treatment and resuscitation begin immediatelyBest Practice Statement

Summary

bull Start resuscitation early with source control intravenous fluids and antibiotics

bull Frequent assessment of the patientsrsquo volume status is crucial throughout the resuscitation period

bull We suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion

2Diagnostica - EGA

Egrave la saturazione del sangue della vena cava o dellrsquoatrio destro

Rappresenta lrsquoossigenazione residua del sangue proveniente dai tessuti dopo lrsquoestrazione di ossigeno

Ersquo un indice della relazione tra apporto di O2 (DO2) ed estrazione di O2 (VO2)

Vn gt 70

ScvO2Saturazione venosa centrale

darr DO2

Ipossia tissutale globale

ScvO2 lt 70

uarr Lattati

bull Tonometria gastrica

bull Capnografia sublinguale

bull ∆ (vc ndash a) CO2 gt 5 mmHg

uarr CO2 tissutale

World Society of Abdominal

Compartment Syndrome (WSSCS)

valori normali 5-7 mmHg

pazienti obesi 7-14 mmHg

pz in posizione semiseduta (30ndash45deg) 4ndash9 mmHg

Ipertensione intra-addominale (IAH)

persistente elevazione della IAP ge 12 mmHg

I grado 12-15mmHg II grado 16-20mmHg

III grado 21-25mmHg IV grado gt25mmHg

Sindrome compartimentale addominale (ACS)

incremento della IAP gt 20 mmHg associata ad una disfunzione o insufficienza drsquoorgano di nuova insorgenza

I

A

P

APP=MAP-IAPVn gt60mmHg

Shock 2017 Jul 19 doi 101097SHK0000000000000949 [Epub ahead of print]

Evaluation of Non-Invasive Hemoglobin Monitoring in

Trauma Patients with Low Hemoglobin LevelsGamal M1 Abdelhamid B Zakaria D Dayem OAE Rady A Fawzy M Hasanin A

CONCLUSIONS Sp-Hb showed accurate precision in both absolute values and trend values compared to

Lab-Hb measurement in trauma patients with low hemoglobin levels

ED overcrowding has been found tocorrelate with

1) increased patient mortality2) decreased patient satisfaction

Sepsis and septic shock are medical emergencies and we recommend that treatment and resuscitation begin immediatelyBest Practice Statement

Summary

bull Start resuscitation early with source control intravenous fluids and antibiotics

bull Frequent assessment of the patientsrsquo volume status is crucial throughout the resuscitation period

bull We suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion

2Diagnostica - EGA

Egrave la saturazione del sangue della vena cava o dellrsquoatrio destro

Rappresenta lrsquoossigenazione residua del sangue proveniente dai tessuti dopo lrsquoestrazione di ossigeno

Ersquo un indice della relazione tra apporto di O2 (DO2) ed estrazione di O2 (VO2)

Vn gt 70

ScvO2Saturazione venosa centrale

darr DO2

Ipossia tissutale globale

ScvO2 lt 70

uarr Lattati

bull Tonometria gastrica

bull Capnografia sublinguale

bull ∆ (vc ndash a) CO2 gt 5 mmHg

uarr CO2 tissutale

World Society of Abdominal

Compartment Syndrome (WSSCS)

valori normali 5-7 mmHg

pazienti obesi 7-14 mmHg

pz in posizione semiseduta (30ndash45deg) 4ndash9 mmHg

Ipertensione intra-addominale (IAH)

persistente elevazione della IAP ge 12 mmHg

I grado 12-15mmHg II grado 16-20mmHg

III grado 21-25mmHg IV grado gt25mmHg

Sindrome compartimentale addominale (ACS)

incremento della IAP gt 20 mmHg associata ad una disfunzione o insufficienza drsquoorgano di nuova insorgenza

I

A

P

APP=MAP-IAPVn gt60mmHg

Shock 2017 Jul 19 doi 101097SHK0000000000000949 [Epub ahead of print]

Evaluation of Non-Invasive Hemoglobin Monitoring in

Trauma Patients with Low Hemoglobin LevelsGamal M1 Abdelhamid B Zakaria D Dayem OAE Rady A Fawzy M Hasanin A

CONCLUSIONS Sp-Hb showed accurate precision in both absolute values and trend values compared to

Lab-Hb measurement in trauma patients with low hemoglobin levels

Sepsis and septic shock are medical emergencies and we recommend that treatment and resuscitation begin immediatelyBest Practice Statement

Summary

bull Start resuscitation early with source control intravenous fluids and antibiotics

bull Frequent assessment of the patientsrsquo volume status is crucial throughout the resuscitation period

bull We suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion

2Diagnostica - EGA

Egrave la saturazione del sangue della vena cava o dellrsquoatrio destro

Rappresenta lrsquoossigenazione residua del sangue proveniente dai tessuti dopo lrsquoestrazione di ossigeno

Ersquo un indice della relazione tra apporto di O2 (DO2) ed estrazione di O2 (VO2)

Vn gt 70

ScvO2Saturazione venosa centrale

darr DO2

Ipossia tissutale globale

ScvO2 lt 70

uarr Lattati

bull Tonometria gastrica

bull Capnografia sublinguale

bull ∆ (vc ndash a) CO2 gt 5 mmHg

uarr CO2 tissutale

World Society of Abdominal

Compartment Syndrome (WSSCS)

valori normali 5-7 mmHg

pazienti obesi 7-14 mmHg

pz in posizione semiseduta (30ndash45deg) 4ndash9 mmHg

Ipertensione intra-addominale (IAH)

persistente elevazione della IAP ge 12 mmHg

I grado 12-15mmHg II grado 16-20mmHg

III grado 21-25mmHg IV grado gt25mmHg

Sindrome compartimentale addominale (ACS)

incremento della IAP gt 20 mmHg associata ad una disfunzione o insufficienza drsquoorgano di nuova insorgenza

I

A

P

APP=MAP-IAPVn gt60mmHg

Shock 2017 Jul 19 doi 101097SHK0000000000000949 [Epub ahead of print]

Evaluation of Non-Invasive Hemoglobin Monitoring in

Trauma Patients with Low Hemoglobin LevelsGamal M1 Abdelhamid B Zakaria D Dayem OAE Rady A Fawzy M Hasanin A

CONCLUSIONS Sp-Hb showed accurate precision in both absolute values and trend values compared to

Lab-Hb measurement in trauma patients with low hemoglobin levels

Summary

bull Start resuscitation early with source control intravenous fluids and antibiotics

bull Frequent assessment of the patientsrsquo volume status is crucial throughout the resuscitation period

bull We suggest guiding resuscitation to normalize lactate in patients with elevated lactate levels as a marker of tissue hypoperfusion

2Diagnostica - EGA

Egrave la saturazione del sangue della vena cava o dellrsquoatrio destro

Rappresenta lrsquoossigenazione residua del sangue proveniente dai tessuti dopo lrsquoestrazione di ossigeno

Ersquo un indice della relazione tra apporto di O2 (DO2) ed estrazione di O2 (VO2)

Vn gt 70

ScvO2Saturazione venosa centrale

darr DO2

Ipossia tissutale globale

ScvO2 lt 70

uarr Lattati

bull Tonometria gastrica

bull Capnografia sublinguale

bull ∆ (vc ndash a) CO2 gt 5 mmHg

uarr CO2 tissutale

World Society of Abdominal

Compartment Syndrome (WSSCS)

valori normali 5-7 mmHg

pazienti obesi 7-14 mmHg

pz in posizione semiseduta (30ndash45deg) 4ndash9 mmHg

Ipertensione intra-addominale (IAH)

persistente elevazione della IAP ge 12 mmHg

I grado 12-15mmHg II grado 16-20mmHg

III grado 21-25mmHg IV grado gt25mmHg

Sindrome compartimentale addominale (ACS)

incremento della IAP gt 20 mmHg associata ad una disfunzione o insufficienza drsquoorgano di nuova insorgenza

I

A

P

APP=MAP-IAPVn gt60mmHg

Shock 2017 Jul 19 doi 101097SHK0000000000000949 [Epub ahead of print]

Evaluation of Non-Invasive Hemoglobin Monitoring in

Trauma Patients with Low Hemoglobin LevelsGamal M1 Abdelhamid B Zakaria D Dayem OAE Rady A Fawzy M Hasanin A

CONCLUSIONS Sp-Hb showed accurate precision in both absolute values and trend values compared to

Lab-Hb measurement in trauma patients with low hemoglobin levels

2Diagnostica - EGA

Egrave la saturazione del sangue della vena cava o dellrsquoatrio destro

Rappresenta lrsquoossigenazione residua del sangue proveniente dai tessuti dopo lrsquoestrazione di ossigeno

Ersquo un indice della relazione tra apporto di O2 (DO2) ed estrazione di O2 (VO2)

Vn gt 70

ScvO2Saturazione venosa centrale

darr DO2

Ipossia tissutale globale

ScvO2 lt 70

uarr Lattati

bull Tonometria gastrica

bull Capnografia sublinguale

bull ∆ (vc ndash a) CO2 gt 5 mmHg

uarr CO2 tissutale

World Society of Abdominal

Compartment Syndrome (WSSCS)

valori normali 5-7 mmHg

pazienti obesi 7-14 mmHg

pz in posizione semiseduta (30ndash45deg) 4ndash9 mmHg

Ipertensione intra-addominale (IAH)

persistente elevazione della IAP ge 12 mmHg

I grado 12-15mmHg II grado 16-20mmHg

III grado 21-25mmHg IV grado gt25mmHg

Sindrome compartimentale addominale (ACS)

incremento della IAP gt 20 mmHg associata ad una disfunzione o insufficienza drsquoorgano di nuova insorgenza

I

A

P

APP=MAP-IAPVn gt60mmHg

Shock 2017 Jul 19 doi 101097SHK0000000000000949 [Epub ahead of print]

Evaluation of Non-Invasive Hemoglobin Monitoring in

Trauma Patients with Low Hemoglobin LevelsGamal M1 Abdelhamid B Zakaria D Dayem OAE Rady A Fawzy M Hasanin A

CONCLUSIONS Sp-Hb showed accurate precision in both absolute values and trend values compared to

Lab-Hb measurement in trauma patients with low hemoglobin levels

darr DO2

Ipossia tissutale globale

ScvO2 lt 70

uarr Lattati

bull Tonometria gastrica

bull Capnografia sublinguale

bull ∆ (vc ndash a) CO2 gt 5 mmHg

uarr CO2 tissutale

World Society of Abdominal

Compartment Syndrome (WSSCS)

valori normali 5-7 mmHg

pazienti obesi 7-14 mmHg

pz in posizione semiseduta (30ndash45deg) 4ndash9 mmHg

Ipertensione intra-addominale (IAH)

persistente elevazione della IAP ge 12 mmHg

I grado 12-15mmHg II grado 16-20mmHg

III grado 21-25mmHg IV grado gt25mmHg

Sindrome compartimentale addominale (ACS)

incremento della IAP gt 20 mmHg associata ad una disfunzione o insufficienza drsquoorgano di nuova insorgenza

I

A

P

APP=MAP-IAPVn gt60mmHg

Shock 2017 Jul 19 doi 101097SHK0000000000000949 [Epub ahead of print]

Evaluation of Non-Invasive Hemoglobin Monitoring in

Trauma Patients with Low Hemoglobin LevelsGamal M1 Abdelhamid B Zakaria D Dayem OAE Rady A Fawzy M Hasanin A

CONCLUSIONS Sp-Hb showed accurate precision in both absolute values and trend values compared to

Lab-Hb measurement in trauma patients with low hemoglobin levels

World Society of Abdominal

Compartment Syndrome (WSSCS)

valori normali 5-7 mmHg

pazienti obesi 7-14 mmHg

pz in posizione semiseduta (30ndash45deg) 4ndash9 mmHg

Ipertensione intra-addominale (IAH)

persistente elevazione della IAP ge 12 mmHg

I grado 12-15mmHg II grado 16-20mmHg

III grado 21-25mmHg IV grado gt25mmHg

Sindrome compartimentale addominale (ACS)

incremento della IAP gt 20 mmHg associata ad una disfunzione o insufficienza drsquoorgano di nuova insorgenza

I

A

P

APP=MAP-IAPVn gt60mmHg

Shock 2017 Jul 19 doi 101097SHK0000000000000949 [Epub ahead of print]

Evaluation of Non-Invasive Hemoglobin Monitoring in

Trauma Patients with Low Hemoglobin LevelsGamal M1 Abdelhamid B Zakaria D Dayem OAE Rady A Fawzy M Hasanin A

CONCLUSIONS Sp-Hb showed accurate precision in both absolute values and trend values compared to

Lab-Hb measurement in trauma patients with low hemoglobin levels

Shock 2017 Jul 19 doi 101097SHK0000000000000949 [Epub ahead of print]

Evaluation of Non-Invasive Hemoglobin Monitoring in

Trauma Patients with Low Hemoglobin LevelsGamal M1 Abdelhamid B Zakaria D Dayem OAE Rady A Fawzy M Hasanin A

CONCLUSIONS Sp-Hb showed accurate precision in both absolute values and trend values compared to

Lab-Hb measurement in trauma patients with low hemoglobin levels

If shock is not resolving quicklyhellip

bull We recommend further hemodynamic assessment (such as assessing cardiac function) to determine the type of shock if the clinical examination does not lead to a clear diagnosis (Best Practice Statement)

bull We suggest that dynamic over static variables be used to predict fluid responsiveness where available (Weak recommendation low quality of evidence)

FLUID RESPONSIVE

Progressive volume loading

Severe tissue edema

Compromised tissueoxygenation

Further compromisedmicrovascular dysfunction

FLUID OVERLOAD ldquoPatients who have the largest cumulative fluid balance have an increased mortalityrdquo

PE Marik2011

Occult Hypovolemia

bull Alto indice di sospetto

bull Monitoraggi piugrave sofisticati

Fluid Challenge Test PLG

R L Metha W C Clark M Schetz Techniques for assessing and achieving fluid balance inacute renal failure Current Opinion in Critical Care 2002 8 535-543

Passive leg raising

In spontaneously breathing patients Descending aorta blood flow (Esophageal Doppler)Velocity-time integral (Transthoracic echocardiography)Femoral artery flow (Arterial Doppler)Transpulmonary ThermodilutionPulse contour derived stroke volume [uncalibrated]Bioreactance

Pulse contour methods

Stroke volume

BIOIMPEDENCE AND

BIOREACTANCE

MONITORAGGIO STATO VOLEMICO E FLUID RESPONSIVENESS

LA METODICA GIUSTA NEL SETTING GIUSTO

Grazie per lrsquoattenzione

Chronic State of Emergency Department (ED) Overcrowding in North America

bull Acute care bed closures

bull Early discharge of patients who are still relatively ill

bull Patients without primary care physicians turn increasingly to Eds for this care

bull Patients with chronic illness face prolonged waits for diagnostic modalities and

specialty consultation ndash delays thet often lead to decompensation and urgent

ED treatment

bull lack of acute care beds patients held in the ED for prolonged periods interfering

with the assessment and management of arriving patient with urgent

CPAP Continuous Positive Airway Pressure

- La pressione applicata durante la fase inspiratoria egrave uguale alla pressione di fine espirazione

- Inizio e fine dellrsquoinspirazione sono determinate dal paziente- Flusso e Volume sono completamente generati dai muscoli del paziente

Il suo uso egrave appropriato quando i muscoli respiratori del paziente sono in grado di generare una forza muscolare sufficiente

bull Ministero della Salute progressivo incremento degli accessi in Pronto Soccorso negli

ultimi anni (21274174 nel 1997 24215174 nel 2009

bull Deospedalizzazione dei processi assistenziali costante riduzione dei posti letto

ordinari (Regione Lazio riduzione del 25)

Crowding occurs when the identified need for emergency servicesexceeds available resources for patient care in the ED hospital or both

American College of Emegency Physician (ACEP) 2006

Spoken interactions can be especiallychallenging in Emergency Department

bull time constraintsbull interruptionsbull staff changesbull overcrowdingbull heterogeneity in the types of

patientsbull heterogeneity in the types of

medical problems

Insufficienza Renale AcutaValutazione Diagnostica in Urgenza

Laboratory Evaluation

bull Creatinina

bull Potassiemia

bull BUNCr

bull FENa

bull Es Urine

Eco reni e vie urinarieECG RX Torace EGA

Volume status

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

FLUID RESPONSIVE

Progressive volume loading

Severe tissue edema

Compromised tissueoxygenation

Further compromisedmicrovascular dysfunction

FLUID OVERLOAD ldquoPatients who have the largest cumulative fluid balance have an increased mortalityrdquo

PE Marik2011

Occult Hypovolemia

bull Alto indice di sospetto

bull Monitoraggi piugrave sofisticati

Fluid Challenge Test PLG

R L Metha W C Clark M Schetz Techniques for assessing and achieving fluid balance inacute renal failure Current Opinion in Critical Care 2002 8 535-543

Passive leg raising

In spontaneously breathing patients Descending aorta blood flow (Esophageal Doppler)Velocity-time integral (Transthoracic echocardiography)Femoral artery flow (Arterial Doppler)Transpulmonary ThermodilutionPulse contour derived stroke volume [uncalibrated]Bioreactance

Pulse contour methods

Stroke volume

BIOIMPEDENCE AND

BIOREACTANCE

MONITORAGGIO STATO VOLEMICO E FLUID RESPONSIVENESS

LA METODICA GIUSTA NEL SETTING GIUSTO

Grazie per lrsquoattenzione

Chronic State of Emergency Department (ED) Overcrowding in North America

bull Acute care bed closures

bull Early discharge of patients who are still relatively ill

bull Patients without primary care physicians turn increasingly to Eds for this care

bull Patients with chronic illness face prolonged waits for diagnostic modalities and

specialty consultation ndash delays thet often lead to decompensation and urgent

ED treatment

bull lack of acute care beds patients held in the ED for prolonged periods interfering

with the assessment and management of arriving patient with urgent

CPAP Continuous Positive Airway Pressure

- La pressione applicata durante la fase inspiratoria egrave uguale alla pressione di fine espirazione

- Inizio e fine dellrsquoinspirazione sono determinate dal paziente- Flusso e Volume sono completamente generati dai muscoli del paziente

Il suo uso egrave appropriato quando i muscoli respiratori del paziente sono in grado di generare una forza muscolare sufficiente

bull Ministero della Salute progressivo incremento degli accessi in Pronto Soccorso negli

ultimi anni (21274174 nel 1997 24215174 nel 2009

bull Deospedalizzazione dei processi assistenziali costante riduzione dei posti letto

ordinari (Regione Lazio riduzione del 25)

Crowding occurs when the identified need for emergency servicesexceeds available resources for patient care in the ED hospital or both

American College of Emegency Physician (ACEP) 2006

Spoken interactions can be especiallychallenging in Emergency Department

bull time constraintsbull interruptionsbull staff changesbull overcrowdingbull heterogeneity in the types of

patientsbull heterogeneity in the types of

medical problems

Insufficienza Renale AcutaValutazione Diagnostica in Urgenza

Laboratory Evaluation

bull Creatinina

bull Potassiemia

bull BUNCr

bull FENa

bull Es Urine

Eco reni e vie urinarieECG RX Torace EGA

Volume status

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

Progressive volume loading

Severe tissue edema

Compromised tissueoxygenation

Further compromisedmicrovascular dysfunction

FLUID OVERLOAD ldquoPatients who have the largest cumulative fluid balance have an increased mortalityrdquo

PE Marik2011

Occult Hypovolemia

bull Alto indice di sospetto

bull Monitoraggi piugrave sofisticati

Fluid Challenge Test PLG

R L Metha W C Clark M Schetz Techniques for assessing and achieving fluid balance inacute renal failure Current Opinion in Critical Care 2002 8 535-543

Passive leg raising

In spontaneously breathing patients Descending aorta blood flow (Esophageal Doppler)Velocity-time integral (Transthoracic echocardiography)Femoral artery flow (Arterial Doppler)Transpulmonary ThermodilutionPulse contour derived stroke volume [uncalibrated]Bioreactance

Pulse contour methods

Stroke volume

BIOIMPEDENCE AND

BIOREACTANCE

MONITORAGGIO STATO VOLEMICO E FLUID RESPONSIVENESS

LA METODICA GIUSTA NEL SETTING GIUSTO

Grazie per lrsquoattenzione

Chronic State of Emergency Department (ED) Overcrowding in North America

bull Acute care bed closures

bull Early discharge of patients who are still relatively ill

bull Patients without primary care physicians turn increasingly to Eds for this care

bull Patients with chronic illness face prolonged waits for diagnostic modalities and

specialty consultation ndash delays thet often lead to decompensation and urgent

ED treatment

bull lack of acute care beds patients held in the ED for prolonged periods interfering

with the assessment and management of arriving patient with urgent

CPAP Continuous Positive Airway Pressure

- La pressione applicata durante la fase inspiratoria egrave uguale alla pressione di fine espirazione

- Inizio e fine dellrsquoinspirazione sono determinate dal paziente- Flusso e Volume sono completamente generati dai muscoli del paziente

Il suo uso egrave appropriato quando i muscoli respiratori del paziente sono in grado di generare una forza muscolare sufficiente

bull Ministero della Salute progressivo incremento degli accessi in Pronto Soccorso negli

ultimi anni (21274174 nel 1997 24215174 nel 2009

bull Deospedalizzazione dei processi assistenziali costante riduzione dei posti letto

ordinari (Regione Lazio riduzione del 25)

Crowding occurs when the identified need for emergency servicesexceeds available resources for patient care in the ED hospital or both

American College of Emegency Physician (ACEP) 2006

Spoken interactions can be especiallychallenging in Emergency Department

bull time constraintsbull interruptionsbull staff changesbull overcrowdingbull heterogeneity in the types of

patientsbull heterogeneity in the types of

medical problems

Insufficienza Renale AcutaValutazione Diagnostica in Urgenza

Laboratory Evaluation

bull Creatinina

bull Potassiemia

bull BUNCr

bull FENa

bull Es Urine

Eco reni e vie urinarieECG RX Torace EGA

Volume status

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

Occult Hypovolemia

bull Alto indice di sospetto

bull Monitoraggi piugrave sofisticati

Fluid Challenge Test PLG

R L Metha W C Clark M Schetz Techniques for assessing and achieving fluid balance inacute renal failure Current Opinion in Critical Care 2002 8 535-543

Passive leg raising

In spontaneously breathing patients Descending aorta blood flow (Esophageal Doppler)Velocity-time integral (Transthoracic echocardiography)Femoral artery flow (Arterial Doppler)Transpulmonary ThermodilutionPulse contour derived stroke volume [uncalibrated]Bioreactance

Pulse contour methods

Stroke volume

BIOIMPEDENCE AND

BIOREACTANCE

MONITORAGGIO STATO VOLEMICO E FLUID RESPONSIVENESS

LA METODICA GIUSTA NEL SETTING GIUSTO

Grazie per lrsquoattenzione

Chronic State of Emergency Department (ED) Overcrowding in North America

bull Acute care bed closures

bull Early discharge of patients who are still relatively ill

bull Patients without primary care physicians turn increasingly to Eds for this care

bull Patients with chronic illness face prolonged waits for diagnostic modalities and

specialty consultation ndash delays thet often lead to decompensation and urgent

ED treatment

bull lack of acute care beds patients held in the ED for prolonged periods interfering

with the assessment and management of arriving patient with urgent

CPAP Continuous Positive Airway Pressure

- La pressione applicata durante la fase inspiratoria egrave uguale alla pressione di fine espirazione

- Inizio e fine dellrsquoinspirazione sono determinate dal paziente- Flusso e Volume sono completamente generati dai muscoli del paziente

Il suo uso egrave appropriato quando i muscoli respiratori del paziente sono in grado di generare una forza muscolare sufficiente

bull Ministero della Salute progressivo incremento degli accessi in Pronto Soccorso negli

ultimi anni (21274174 nel 1997 24215174 nel 2009

bull Deospedalizzazione dei processi assistenziali costante riduzione dei posti letto

ordinari (Regione Lazio riduzione del 25)

Crowding occurs when the identified need for emergency servicesexceeds available resources for patient care in the ED hospital or both

American College of Emegency Physician (ACEP) 2006

Spoken interactions can be especiallychallenging in Emergency Department

bull time constraintsbull interruptionsbull staff changesbull overcrowdingbull heterogeneity in the types of

patientsbull heterogeneity in the types of

medical problems

Insufficienza Renale AcutaValutazione Diagnostica in Urgenza

Laboratory Evaluation

bull Creatinina

bull Potassiemia

bull BUNCr

bull FENa

bull Es Urine

Eco reni e vie urinarieECG RX Torace EGA

Volume status

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

Passive leg raising

In spontaneously breathing patients Descending aorta blood flow (Esophageal Doppler)Velocity-time integral (Transthoracic echocardiography)Femoral artery flow (Arterial Doppler)Transpulmonary ThermodilutionPulse contour derived stroke volume [uncalibrated]Bioreactance

Pulse contour methods

Stroke volume

BIOIMPEDENCE AND

BIOREACTANCE

MONITORAGGIO STATO VOLEMICO E FLUID RESPONSIVENESS

LA METODICA GIUSTA NEL SETTING GIUSTO

Grazie per lrsquoattenzione

Chronic State of Emergency Department (ED) Overcrowding in North America

bull Acute care bed closures

bull Early discharge of patients who are still relatively ill

bull Patients without primary care physicians turn increasingly to Eds for this care

bull Patients with chronic illness face prolonged waits for diagnostic modalities and

specialty consultation ndash delays thet often lead to decompensation and urgent

ED treatment

bull lack of acute care beds patients held in the ED for prolonged periods interfering

with the assessment and management of arriving patient with urgent

CPAP Continuous Positive Airway Pressure

- La pressione applicata durante la fase inspiratoria egrave uguale alla pressione di fine espirazione

- Inizio e fine dellrsquoinspirazione sono determinate dal paziente- Flusso e Volume sono completamente generati dai muscoli del paziente

Il suo uso egrave appropriato quando i muscoli respiratori del paziente sono in grado di generare una forza muscolare sufficiente

bull Ministero della Salute progressivo incremento degli accessi in Pronto Soccorso negli

ultimi anni (21274174 nel 1997 24215174 nel 2009

bull Deospedalizzazione dei processi assistenziali costante riduzione dei posti letto

ordinari (Regione Lazio riduzione del 25)

Crowding occurs when the identified need for emergency servicesexceeds available resources for patient care in the ED hospital or both

American College of Emegency Physician (ACEP) 2006

Spoken interactions can be especiallychallenging in Emergency Department

bull time constraintsbull interruptionsbull staff changesbull overcrowdingbull heterogeneity in the types of

patientsbull heterogeneity in the types of

medical problems

Insufficienza Renale AcutaValutazione Diagnostica in Urgenza

Laboratory Evaluation

bull Creatinina

bull Potassiemia

bull BUNCr

bull FENa

bull Es Urine

Eco reni e vie urinarieECG RX Torace EGA

Volume status

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

Pulse contour methods

Stroke volume

BIOIMPEDENCE AND

BIOREACTANCE

MONITORAGGIO STATO VOLEMICO E FLUID RESPONSIVENESS

LA METODICA GIUSTA NEL SETTING GIUSTO

Grazie per lrsquoattenzione

Chronic State of Emergency Department (ED) Overcrowding in North America

bull Acute care bed closures

bull Early discharge of patients who are still relatively ill

bull Patients without primary care physicians turn increasingly to Eds for this care

bull Patients with chronic illness face prolonged waits for diagnostic modalities and

specialty consultation ndash delays thet often lead to decompensation and urgent

ED treatment

bull lack of acute care beds patients held in the ED for prolonged periods interfering

with the assessment and management of arriving patient with urgent

CPAP Continuous Positive Airway Pressure

- La pressione applicata durante la fase inspiratoria egrave uguale alla pressione di fine espirazione

- Inizio e fine dellrsquoinspirazione sono determinate dal paziente- Flusso e Volume sono completamente generati dai muscoli del paziente

Il suo uso egrave appropriato quando i muscoli respiratori del paziente sono in grado di generare una forza muscolare sufficiente

bull Ministero della Salute progressivo incremento degli accessi in Pronto Soccorso negli

ultimi anni (21274174 nel 1997 24215174 nel 2009

bull Deospedalizzazione dei processi assistenziali costante riduzione dei posti letto

ordinari (Regione Lazio riduzione del 25)

Crowding occurs when the identified need for emergency servicesexceeds available resources for patient care in the ED hospital or both

American College of Emegency Physician (ACEP) 2006

Spoken interactions can be especiallychallenging in Emergency Department

bull time constraintsbull interruptionsbull staff changesbull overcrowdingbull heterogeneity in the types of

patientsbull heterogeneity in the types of

medical problems

Insufficienza Renale AcutaValutazione Diagnostica in Urgenza

Laboratory Evaluation

bull Creatinina

bull Potassiemia

bull BUNCr

bull FENa

bull Es Urine

Eco reni e vie urinarieECG RX Torace EGA

Volume status

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

Stroke volume

BIOIMPEDENCE AND

BIOREACTANCE

MONITORAGGIO STATO VOLEMICO E FLUID RESPONSIVENESS

LA METODICA GIUSTA NEL SETTING GIUSTO

Grazie per lrsquoattenzione

Chronic State of Emergency Department (ED) Overcrowding in North America

bull Acute care bed closures

bull Early discharge of patients who are still relatively ill

bull Patients without primary care physicians turn increasingly to Eds for this care

bull Patients with chronic illness face prolonged waits for diagnostic modalities and

specialty consultation ndash delays thet often lead to decompensation and urgent

ED treatment

bull lack of acute care beds patients held in the ED for prolonged periods interfering

with the assessment and management of arriving patient with urgent

CPAP Continuous Positive Airway Pressure

- La pressione applicata durante la fase inspiratoria egrave uguale alla pressione di fine espirazione

- Inizio e fine dellrsquoinspirazione sono determinate dal paziente- Flusso e Volume sono completamente generati dai muscoli del paziente

Il suo uso egrave appropriato quando i muscoli respiratori del paziente sono in grado di generare una forza muscolare sufficiente

bull Ministero della Salute progressivo incremento degli accessi in Pronto Soccorso negli

ultimi anni (21274174 nel 1997 24215174 nel 2009

bull Deospedalizzazione dei processi assistenziali costante riduzione dei posti letto

ordinari (Regione Lazio riduzione del 25)

Crowding occurs when the identified need for emergency servicesexceeds available resources for patient care in the ED hospital or both

American College of Emegency Physician (ACEP) 2006

Spoken interactions can be especiallychallenging in Emergency Department

bull time constraintsbull interruptionsbull staff changesbull overcrowdingbull heterogeneity in the types of

patientsbull heterogeneity in the types of

medical problems

Insufficienza Renale AcutaValutazione Diagnostica in Urgenza

Laboratory Evaluation

bull Creatinina

bull Potassiemia

bull BUNCr

bull FENa

bull Es Urine

Eco reni e vie urinarieECG RX Torace EGA

Volume status

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

MONITORAGGIO STATO VOLEMICO E FLUID RESPONSIVENESS

LA METODICA GIUSTA NEL SETTING GIUSTO

Grazie per lrsquoattenzione

Chronic State of Emergency Department (ED) Overcrowding in North America

bull Acute care bed closures

bull Early discharge of patients who are still relatively ill

bull Patients without primary care physicians turn increasingly to Eds for this care

bull Patients with chronic illness face prolonged waits for diagnostic modalities and

specialty consultation ndash delays thet often lead to decompensation and urgent

ED treatment

bull lack of acute care beds patients held in the ED for prolonged periods interfering

with the assessment and management of arriving patient with urgent

CPAP Continuous Positive Airway Pressure

- La pressione applicata durante la fase inspiratoria egrave uguale alla pressione di fine espirazione

- Inizio e fine dellrsquoinspirazione sono determinate dal paziente- Flusso e Volume sono completamente generati dai muscoli del paziente

Il suo uso egrave appropriato quando i muscoli respiratori del paziente sono in grado di generare una forza muscolare sufficiente

bull Ministero della Salute progressivo incremento degli accessi in Pronto Soccorso negli

ultimi anni (21274174 nel 1997 24215174 nel 2009

bull Deospedalizzazione dei processi assistenziali costante riduzione dei posti letto

ordinari (Regione Lazio riduzione del 25)

Crowding occurs when the identified need for emergency servicesexceeds available resources for patient care in the ED hospital or both

American College of Emegency Physician (ACEP) 2006

Spoken interactions can be especiallychallenging in Emergency Department

bull time constraintsbull interruptionsbull staff changesbull overcrowdingbull heterogeneity in the types of

patientsbull heterogeneity in the types of

medical problems

Insufficienza Renale AcutaValutazione Diagnostica in Urgenza

Laboratory Evaluation

bull Creatinina

bull Potassiemia

bull BUNCr

bull FENa

bull Es Urine

Eco reni e vie urinarieECG RX Torace EGA

Volume status

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

Grazie per lrsquoattenzione

Chronic State of Emergency Department (ED) Overcrowding in North America

bull Acute care bed closures

bull Early discharge of patients who are still relatively ill

bull Patients without primary care physicians turn increasingly to Eds for this care

bull Patients with chronic illness face prolonged waits for diagnostic modalities and

specialty consultation ndash delays thet often lead to decompensation and urgent

ED treatment

bull lack of acute care beds patients held in the ED for prolonged periods interfering

with the assessment and management of arriving patient with urgent

CPAP Continuous Positive Airway Pressure

- La pressione applicata durante la fase inspiratoria egrave uguale alla pressione di fine espirazione

- Inizio e fine dellrsquoinspirazione sono determinate dal paziente- Flusso e Volume sono completamente generati dai muscoli del paziente

Il suo uso egrave appropriato quando i muscoli respiratori del paziente sono in grado di generare una forza muscolare sufficiente

bull Ministero della Salute progressivo incremento degli accessi in Pronto Soccorso negli

ultimi anni (21274174 nel 1997 24215174 nel 2009

bull Deospedalizzazione dei processi assistenziali costante riduzione dei posti letto

ordinari (Regione Lazio riduzione del 25)

Crowding occurs when the identified need for emergency servicesexceeds available resources for patient care in the ED hospital or both

American College of Emegency Physician (ACEP) 2006

Spoken interactions can be especiallychallenging in Emergency Department

bull time constraintsbull interruptionsbull staff changesbull overcrowdingbull heterogeneity in the types of

patientsbull heterogeneity in the types of

medical problems

Insufficienza Renale AcutaValutazione Diagnostica in Urgenza

Laboratory Evaluation

bull Creatinina

bull Potassiemia

bull BUNCr

bull FENa

bull Es Urine

Eco reni e vie urinarieECG RX Torace EGA

Volume status

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

Chronic State of Emergency Department (ED) Overcrowding in North America

bull Acute care bed closures

bull Early discharge of patients who are still relatively ill

bull Patients without primary care physicians turn increasingly to Eds for this care

bull Patients with chronic illness face prolonged waits for diagnostic modalities and

specialty consultation ndash delays thet often lead to decompensation and urgent

ED treatment

bull lack of acute care beds patients held in the ED for prolonged periods interfering

with the assessment and management of arriving patient with urgent

CPAP Continuous Positive Airway Pressure

- La pressione applicata durante la fase inspiratoria egrave uguale alla pressione di fine espirazione

- Inizio e fine dellrsquoinspirazione sono determinate dal paziente- Flusso e Volume sono completamente generati dai muscoli del paziente

Il suo uso egrave appropriato quando i muscoli respiratori del paziente sono in grado di generare una forza muscolare sufficiente

bull Ministero della Salute progressivo incremento degli accessi in Pronto Soccorso negli

ultimi anni (21274174 nel 1997 24215174 nel 2009

bull Deospedalizzazione dei processi assistenziali costante riduzione dei posti letto

ordinari (Regione Lazio riduzione del 25)

Crowding occurs when the identified need for emergency servicesexceeds available resources for patient care in the ED hospital or both

American College of Emegency Physician (ACEP) 2006

Spoken interactions can be especiallychallenging in Emergency Department

bull time constraintsbull interruptionsbull staff changesbull overcrowdingbull heterogeneity in the types of

patientsbull heterogeneity in the types of

medical problems

Insufficienza Renale AcutaValutazione Diagnostica in Urgenza

Laboratory Evaluation

bull Creatinina

bull Potassiemia

bull BUNCr

bull FENa

bull Es Urine

Eco reni e vie urinarieECG RX Torace EGA

Volume status

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

CPAP Continuous Positive Airway Pressure

- La pressione applicata durante la fase inspiratoria egrave uguale alla pressione di fine espirazione

- Inizio e fine dellrsquoinspirazione sono determinate dal paziente- Flusso e Volume sono completamente generati dai muscoli del paziente

Il suo uso egrave appropriato quando i muscoli respiratori del paziente sono in grado di generare una forza muscolare sufficiente

bull Ministero della Salute progressivo incremento degli accessi in Pronto Soccorso negli

ultimi anni (21274174 nel 1997 24215174 nel 2009

bull Deospedalizzazione dei processi assistenziali costante riduzione dei posti letto

ordinari (Regione Lazio riduzione del 25)

Crowding occurs when the identified need for emergency servicesexceeds available resources for patient care in the ED hospital or both

American College of Emegency Physician (ACEP) 2006

Spoken interactions can be especiallychallenging in Emergency Department

bull time constraintsbull interruptionsbull staff changesbull overcrowdingbull heterogeneity in the types of

patientsbull heterogeneity in the types of

medical problems

Insufficienza Renale AcutaValutazione Diagnostica in Urgenza

Laboratory Evaluation

bull Creatinina

bull Potassiemia

bull BUNCr

bull FENa

bull Es Urine

Eco reni e vie urinarieECG RX Torace EGA

Volume status

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

bull Ministero della Salute progressivo incremento degli accessi in Pronto Soccorso negli

ultimi anni (21274174 nel 1997 24215174 nel 2009

bull Deospedalizzazione dei processi assistenziali costante riduzione dei posti letto

ordinari (Regione Lazio riduzione del 25)

Crowding occurs when the identified need for emergency servicesexceeds available resources for patient care in the ED hospital or both

American College of Emegency Physician (ACEP) 2006

Spoken interactions can be especiallychallenging in Emergency Department

bull time constraintsbull interruptionsbull staff changesbull overcrowdingbull heterogeneity in the types of

patientsbull heterogeneity in the types of

medical problems

Insufficienza Renale AcutaValutazione Diagnostica in Urgenza

Laboratory Evaluation

bull Creatinina

bull Potassiemia

bull BUNCr

bull FENa

bull Es Urine

Eco reni e vie urinarieECG RX Torace EGA

Volume status

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

Spoken interactions can be especiallychallenging in Emergency Department

bull time constraintsbull interruptionsbull staff changesbull overcrowdingbull heterogeneity in the types of

patientsbull heterogeneity in the types of

medical problems

Insufficienza Renale AcutaValutazione Diagnostica in Urgenza

Laboratory Evaluation

bull Creatinina

bull Potassiemia

bull BUNCr

bull FENa

bull Es Urine

Eco reni e vie urinarieECG RX Torace EGA

Volume status

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

Insufficienza Renale AcutaValutazione Diagnostica in Urgenza

Laboratory Evaluation

bull Creatinina

bull Potassiemia

bull BUNCr

bull FENa

bull Es Urine

Eco reni e vie urinarieECG RX Torace EGA

Volume status

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

Surviving Sepsis Campaign International Guidelines for Management of Sepsis

and Septic Shock 2016

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were

The Riverrsquos work was usefulhellip

bull As it provided us a construct on how to understand resuscitationbull Start early- (give antibiotics ndash Source control)

bull Correct hypovolaemia

bull Restore perfusion pressure

bull And in some cases a little more may be required

bull These concepts are as important today as they ever were