Tools and Techniques for basic and advanced support in critically ill patients.

An effective and quick airway control it is a priority objective in all emergency situations.

The gold standard remains orotracheal intubation but numerous supraglottic devices have been developed to allow advanced management of the airway in emergencies. The obstruction from the ways aerial from foreign body e requires the application of unblocking maneuvers (see PRE-ARRIVAL instructions).

Basic Airway support includes:

Open the airways with hyperextension of the neck, aspiration of secretions, mask ventilation with insertion of an oropharyngeal cannula, oxygen administration, pulse oximetry detection.

In the traumatized patient, it is essential to immobilize the cervical spine with a collar and the maneuver of subluxation of the mandible (Jaw thrust) or lifting of the chin (Chin Lift).

Advanced Airway Support includes:

Supraglottic devices such as the laryngeal mask and esophagus-tracheal combitube

useful in selected cases of difficult intubation.

Non-invasive ventilation (NIV) positive pressure (CPAP and BPAP),

in patients with hypoxemia despite the administration of oxygen at high concentrations (PAO2 / FiO2 <200 mmHg)

Oro-tracheal intubation: consider the anterior cricoid pressure (Sellick’s maneuver) before and during intubation to avoid passive regurgitation; to facilitate intubation, sedatives and muscle relaxants are usually administered to conscious or semi-conscious traumatized patients prior to laryngoscopy (RSI).

The measurement of the End Tidal CO2 is the most accurate index of correct positioning of the tube, both in the course of Cardiac Arrest and in the case of ROSC.

Surgical Airway

Tirocrichotomy with insertion of a tracheostomy tube is indicated in the case of a patient who cannot be intubated or ventilated.

Needle decompression of hypertensive PNX is the life-saving maneuver that transforms a rapidly deadly condition of open PNX to open.

Point-of-care blood gas analysis, if available, allows definition of the acute respiratory failure type1 and 2 and acid-base disturbances.

The stabilization of hemodynamic conditions of patients is the second priority goal in all emergency situations.

Unsynchronized defibrillation

In cardiac arrest sustained by shockable rhythms, a transthoracic DC shock of sufficient magnitude is able to depolarize the entire myocardium, making the whole heart temporarily refractory to new depolarizations. Thus the step marker with the greatest intrinsic frequency, usually the sinus node, is able to regain control of the rhythm.

Cardioversion (Synchronized Defibrillation)

Cardioversion is the delivery of shock synchronized with the QRS complex. This synchronization prevents the delivered shock from falling on the refractory period of the cardiac cycle when the shock could produce ventricular fibrillation. The shock intensity used for a synchronized shock is less than that used for defibrillation.

Cardioversion can become a necessary procedure when drugs alone are unable to convert an arrhythmia into a normal heart rhythm. Cardioversion restores normal heart rate and rhythm, allowing the heart to pump more effectively.

Usemore common than cardioversion is to treat atrial fibrillation or atrial flutter in the hemodynamically unstable patient. Cardioversion can also be used to treat supraventricular or unstable ventricular tachycardias.

As the procedure is painful and worrying for the patient, a brief procedural analgo-sedation is required (fentanyl 1 mcg / kg followed by midazolam 1-2 mg every 2 min up to a maximum of 5 mg). Staff and tools must be present to ensure airway control.

Transcutaneous pacing

It is an electrical therapy of the heart carried out with the non-invasive stimulation technique (with mild procedural sedation) to restore an effective cardiac output in the course of hemodynamically significant bradi-arrhythmias.

12D ECG with tele-transmission is essential for reducing pre-coronary times in acute coronary syndromes.

Non-invasive hemodynamic monitoring during trauma helps in deciding which hospital is suitable for definitive treatment.

Bladder catheterization allows you to monitor diuresis.

US-guided pericardiocentesis, if available, can be used to stabilize cardiac tamponade shock.

Administration of fluids and drugs for volume control

EV access or Intraosseous access.

Traumatic emergencies:

In addition to the control of the airways and the stabilization of haemodynamic conditions in traumatized patients, correct immobilization and the precocious stop bleeding both external and internal, with ultrasound aid.

Immobilization techniques according to ATLS protocols:

x Extrication with KED

x Application of cervical collar

x Immobilization with spine board and spoon board

x Vacuum mattress

x Pelvic fracture stabilization with aids

x Stabilization of limb fractures

x Amputated limbs conservation kit

Techniques of stopping traumatic bleeding Tamponade of external hemorrhages of the limbs with Tourniquet. REBOA system (currently only experimental)

E-FAST ultrasound. The main indication is represented by thoraco-abdominal trauma with diagnostic suspicion of haemoperitoneum, hemothorax, PNX and cardiac tamponade, not only for patients who have shown haemodynamic instability, but also for those who present situations of substantial stability.

Emergencies in Pregnancy:

Clamping and cutting of the umbilical cord not earlier than one minute after birth in term or premature babies who do not require CPR.

Poisoning and Infections:

CO detection in the event of a potentially dangerous scenario. Use of specific Personal Protective Equipment.

Maxi-Emergencies Major Events:

Advanced Medical Post for the selection and treatment of victims.


Personal Protective Equipment supplied:


Tracksuitswhole ones equipped with incorporated hood and equipped with detachable gloves and boots but with liquid-tight connections, so that the garment can offer protection on the entire body from the continuous jet of aggressive chemical-biological agents in the liquid state. Type 3 equipment is made of airtight materials and is always shaped in such a way that it can be worn in conjunction with respiratory protective equipment.


one-piece suit capable of completely enveloping the operator wearing an open-cycle self-contained breathing apparatus.