Abdelouahab Bellou

Recommendations on pre-hospital & early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergenc: Recommendations on pre-hospital & early hospital management of acute heart failure

Acute heart failure is a fatal syndrome. Emergency physicians, cardiologists, intensivists, nurses and other health care providers have to cooperate to provide optimal benefit. However, many treatment decisions are opinion‐based and few are evidenced‐based. This consensus paper provides guidance to practicing physicians and nurses to manage acute heart failure in the pre‐hospital and hospital setting. Criteria of hospitalization and of discharge are described. Gaps in knowledge and perspectives in the management of acute heart failure are also detailed. This consensus paper on acute heart failure might help enable contiguous practice.

Recommendations on pre-hospital and early hospital management of acute heart failure : a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine - short version

Despite several critical steps forward in the management of chronic heart failure (CHF), the area of acute heart failure (AHF) has remained relatively stagnant. As stated in the updated ESC HF guidelines, clinicians responsible for managing patients with AHF must frequently make treatment decisions without adequate evidence, usually on the basis of expert opinion consensus.2 Specifically, the treatment of acute HF remains largely opinion-based with little good evidence to guide therapy. n nAcute heart failure is a syndrome in which emergency physicians, cardiologists, intensivists, nurses, and other healthcare providers have to cooperate to provide ‘rapid’ benefit to the patients. We hereby would like to underscore the wider experience grown in different settings of the area of intensive care on acute heart failure, actually larger and more composite than that got in specialized Care Units. The distillate of such different experiences is discussed and integrated in the present document. Hence, the authors of this consensus paper believe a common working definition of AHF covering all dimensions and modes of presentations has to be made, with the understanding that most AHF presentations are either acute decompensations of chronic underlying HF or the abrupt onset of dyspnoea associated with significantly elevated blood pressure. Secondly, recent data show that, much like acute coronary syndrome, AHF might have a ‘time to therapy’ concept. Accordingly, ‘pre-hospital’ management is considered a critical component of care. Thirdly, most patients with AHF have normal or high blood pressure at presentation, and are admitted with symptoms and/or signs of congestion. This is in contradiction to the presentation where low cardiac output leads to symptomatic hypotension and signs/symptoms of hypoperfusion, a circumstance that is relatively rare, present in coronary care unit/intensive care unit (CCU/ICU) but associated with a particularly poor outcome. Hence, it is important to note that appropriate therapy requires appropriate identification of the specific AHF phenotype.3 The aim of the current paper is not to replace guidelines, but, to provide contemporary perspective for early hospital management within the context of the most recent data and to provide guidance, based on expert opinions, to practicing physicians and other healthcare professionals (Figure 1). We believe that the experience accrued in the different settings from the emergency department through to the ICU/CCU is collectivel valuable in determining how best to manage the patients with AHF. Herein, a shortened version mainly including group recommendations is provided. Full version of the consensus paper is provided as Supplementary material online.

Pre-hospital treatment of STEMI patients. A scientific statement of the working group acute cardiac care of the European society of cardiology

In ST-elevation myocardial infarction (STEMI) the pre-hospital phase is the most critical, as the administration of the most appropriate treatment in a timely manner is instrumental for mortality reduction. STEMI systems of care based on networks of medical institutions connected by an efficient emergency medical service are pivotal. The first steps are devoted to minimize the patients delay in seeking care, rapidly dispatch a properly staffed and equipped ambulance to make the diagnosis on scene, deliver initial drug therapy and transport the patient to the most appropriate (not necessarily the closest) cardiac facility. Primary PCI is the treatment of choice, but thrombolysis followed by coronary angiography and possibly PCI is a valid alternative, according to patients baseline risk, time from symptoms onset and primary PCI-related delay. Paramedics and nurses have an important role in pre-hospital STEMI care and their empowerment is essential to increase the effectiveness of the system. Strong cooperation between cardiologists and emergency medicine doctors is mandatory for optimal pre-hospital STEMI care. Scientific societies have an important role in guideline implementation as well as in developing quality indicators and performance measures; health care professionals must overcome existing barriers to optimal care together with political and administrative decision makers.

Guía de práctica clínica para el diagnóstico y manejo del síncope (versión 2009)

Responsabilidad Las Guias de Practica Clinica recogen la opinion de la ESC y se han elaborado tras una consideracion minuciosa de las evidencias disponibles en el momento en que fueron escritas. Se anima a los profesionales de la sanidad a que las tengan en plena consideracion cuando ejerzan su juicio clinico. No obstante, las Guias de Practica Clinica no deben invalidar la responsabilidad individual de los profesionales de la salud a la hora de tomar decisiones adecuadas a las circunstancias individuales de cada paciente, consultando con el propio paciente y, cuando sea necesario y pertinente, con su tutor o representante legal. Tambien es responsabilidad del profesional de la salud verificar las normas y los reglamentos que se aplican a los farmacos o dispositivos en el momento de la prescripcion.

The European curriculum for geriatric emergency medicine

The United Nations has defined old age as at least 60 years [1], although in the developing world old age is often defined by a change in role rather than by years. There are more older individuals alive now than at any other time in history [2]. There will be 1.2 billion individuals aged at least 60 by 2025, increasing to 1.9 billion in 2050 [3]. Europe has 23 of the world’s 25 ‘oldest’ countries, and older people will represent 28.7% of the European Union (EU) population by 2080 compared with 18.5% in 2014 [4]. The EU’s old-age dependency ratio is projected to increase from 28.1% in 2014 to 51% by 2080 [4]. This demographic transition demands action at all levels. Older individuals must not be seen as a burden on society, but as an asset. With the support of the European Society for Emergency Medicine (EuSEM), emergency medicine (EM) is now recognized as a primary specialty in most EU countries. The Council of the Union of European Medical Specialists approved the European Curriculum of Emergency Medicine in 2009 [5,6]. The curriculum defines EM as a symptom-oriented specialty in which a global clinical approach is essential for generating diagnostic hypotheses, starting the best treatment, and deciding an appropriate destination for the patient after emergency department (ED) care. Geriatric medicine (GM) is also a symptom-based medical specialty in which somatic, psychological, and social dimensions are simultaneously involved in older patients who require a holistic approach. Multiple organs and systems can be involved at the same time, increasing the complexity of older patients’ care. The major challenges faced by GM and EM are usually observed in older patients (typically ≥ 75 years old) who are frail and have loss of autonomy. ED visits of older patients are often precipitated by a crisis, and frailty is a critical risk factor for negative outcomes. The early detection of frailty in older patients in the ED setting could improve outcomes. Because many acute clinical presentations are atypical, diagnosis and treatment are often delayed. The complexity of older patient ED care is one of the factors involved in ED boarding. The evidence base for geriatric emergency medicine (GEM) is not strong. Most very elderly individuals (≥85 years) are excluded from clinical trials despite being major users of ED services. Data registries for older patients for emergency care are still lacking. The complexity of acute ED care of older patients requires a multidisciplinary approach involving teams of geriatricians and emergency physicians. The GEM care model concept was first described in the USA in 1996 [7], but little is known on GEM in Europe. To address this, the EuSEM Section of GEM and the GEM Special Interest Group of the European Union of Geriatric Medicine Society (EUGMS) worked together, through the European GEM Task Force, to create a European Curriculum for GEM to improve the quality of care of older patients in European EM settings. The task force has created a GEM curriculum that outlines competencies that are relevant to the care of older individuals, especially those with frailty, in emergency settings. After a modified Delphi process, 15 areas of knowledge were recommended for the training of geriatricians and emergency physicians. The detailed curriculum is available on the EuSEM and EUGMS websites [8]. The GEM Curriculum has been approved by the Executive Committee and Council of EuSEM, the Board and Council of EUGMS, and the Union of EuropeanMedical Specialists sections of EM and GM. A comprehensive report of the development of the GEM curriculum has just been published [9]. The new curriculum could significantly improve the quality of care of older patients in emergency settings throughout Europe.

Towards chronic emergency response communities for anaphylaxis

Smartphones and location-based social networking technologies present an opportunity to re-engineer certain aspects of emergency medical response. Life-saving prescription medication extended in an emergency by one individual to another occurs on a micro level, anecdotally documented. Anaphylaxis in particular, with a combination of stable prescriptions, narrow medical regimens, and high availability, presents a common basis for community formation. In the context of introducing a system for chronic emergency response communities we present an ecosystem that has the potential to change key aspects of emergency response for certain chronic conditions.

Management of Sepsis in Older Patients in the Emergency Department

Sepsis is a serious problem among the older population as its incidence and mortality rates dramatically increase with advanced age. Although sepsis is a serious life-threatening disease, there is an under recognition as compared to other age-related diseases.

Secondary Assessment of Life-Threatening Conditions of Older Patients

People aged 65 years and older have higher rate of emergency department (ED) use than other age groups. Critically ill older ED people have specific characteristics. Older patients with life-threatening conditions often present with atypical signs and symptoms unspecific of the altered organ or tissue, and often usual severity criteria are missing. Some symptoms such as delirium, faintness, general malaise, digestive problems, fatigue, balance impairments, or falls can be incorrectly regarded as mild, whereas they are the only sign of a life-threatening condition. Even small initial insults in patients with multisystem deterioration and loss of physiological reserve (frailty) can induce a disabling cascade of adverse effects, called the “domino” effect, which can threaten the life of older patients. Determining whether the older patient is frail, i.e., his (her) medical, psychological, and functional ability to cope with the acute condition, is therefore crucial in older ED patients for optimizing therapeutic options and anticipating treatment adverse effects. Ethical consideration and whether the patient has an advanced directive, health-care power of attorney, or living will on admission are also crucial parts of the assessment of older ED patients. The present chapter displays a model of geriatric secondary assessment adapted to critically ill older ED patients that takes into account the above specificities and particular needs of these patients.

Primary Assessment and Stabilization of Life-Threatening Conditions in Older Patients

Although the main approach to life-threatening conditions in older patients does not differ from younger adults, the evaluation of the severity and the decision to start resuscitation are much more challenging. The clinical presentation of instability and life-threatening situations is often atypical in older patients. When the instability and severity are confirmed, the classical chain of basic and advanced life support recommended by the European and international guidelines must be respected for improving outcomes in older patients. The decision of stopping or not starting resuscitation in older patients should not be taken too quickly just because it is thought that it can appear futile or of a result of advanced age. The decision depends also on patients’ and relatives’ wishes and respects individual patient’s needs for end-of-life care. As in younger people, resuscitation in older patients is appropriate when its likely benefits in term of quantity and quality of life outweigh over its adverse consequences. This is especially important for older patients in continuing care settings, which might potentially divert staff time and resources away from core elements of care.