# NEW Algorithms of the year 2020

Here we introduce new algorithms created in the academic year 2019/2020 within the subject Independent work at the Faculty of Medicine of Masaryk University. The nine-month process of creating 18 new interactive algorithms was attended by 29 students of the 4th to 6th years of study, led by 27 doctors. All algorithms have been reviewed by an expert in the field.

Now the algorithms are going through a peer review process, here you will find completed and published two of the most up-to-date ones on coronavirus infections: resuscitation and anesthesia of a patient with COVID-19.

Czech version

The general director of the World Health Organization (WHO) declared the COVID-19 infection a world pandemic situation on the 11 th March 2020. At the time, there is neither specific treatment nor vaccination available against COVID-19 infection. Everyone in the population is considered to be susceptible to this infection. The clinical features of COVID-19 infection vary from asymptomatic presentation to severe pneumonia and in the gravest cases can lead to death. In most of the cases (80%), the clinical presentation would correlate to mild respiratory infection and pneumonia. The severe cases with the high risk of death are connected with the elderly patients with comorbidities and chronic medical impairment. This algorithm aims to guide you through the essential safety precautions and deviations from the standard CPR approach, taking into account the risk of spreading the COVID-19 infection from the patient to the medical staff.

23. 3. 2020 | Martina Kosinová, MD, PhD, Tamara Skříšovská, Tereza Prokopová. Illustrations: Anita Bauerová

The times we live in bring with them almost unlimited travel opportunities. It is this fact that can cause the spread of a highly contagious disease in our extremities. Such a situation affects not only doctors and paramedics, but also other units of the Integrated Rescue System. The algorithm offers the opportunity to look under the hood of how to deal with an extraordinary situation with a suspected presence of a highly contagious disease, from emergency calls and pre-hospital care to clean-up operations.

6. 8. 2020 | Anna Štorchová, MSc

Whether performing high-altitude work or recreational and sport climbing activities, you may encounter the issue of suspension syndrome. It is a life-threatening situation characterized by syncope as a result of brain hypoperfusion, which can develop due to prolonged passive sitting in a harness. Resolving this algorithm, you will gain the knowledge of suspension syndrome prevention, which can be utilized by anyone in such a situation, as well as the knowledge of necessary steps in mountain rescue of two climbers, one conscious and one unconscious.

8. 5. 2020 | Deana Slovjaková, MD, Tomáš Gyönyör, Tatiana Králiková

Number of patients infected with COVID-19 worldwide is still growing. The risk of transfer of infection to the medical personnel is high, especially when aerosol generating procedures are done, for example intubation. Anaesthesia of COVID-19 positive patients has it's specifics, which must be taken into account, due to safety of the patient and due to safety of the medical personnel as well. Algorithm will guide you through the basic steps of preparing anaesthesia team and workplace, correct use of personal protective equipment and uncomplicated airway management of COVID-19 positive patient undergoing surgery in general anaesthesia.

6. 4. 2020 | Deana Slovjaková, MD, Eva Klabusayová, MD. Illustrations: Eva Klabusayová

Perioperative pain management and bridging to postoperative period is an important task and has a great impact on chronification of pain in the future. We present you revised algorithm using both paravertebral or epidural block in patient undergoing thoracotomy.

Other version of this algorithm: Acute postoperative pain management - 2009
8. 5. 2020 | Ivo Křikava, MD, PhD, Henrieta Hricová, Štěpán Janíček

It is very probable that everyone has encountered a mild case of hypothermia at some point in their life. Nevertheless, severe hypothermia is a life threatening condition that can lead to cardiac arrest, metabolic decompensation and multiorgan failure. Therefore, it is necessary to treat it adequately. This algorithm will guide you through the process of treating a hypothermic person, which begins by the first aid in the field, continues by the care of EMS members and doctors in the emergency department and is later completed by the treatment of frostbites.

8. 5. 2020 | Jan Filip Sýkora, MD, Martina Valachová, Šárka Raková

Lactic acidosis is serious acid-base balance disorder, that can occur in patients on metformin therapy. Metformin is currently still one of the most used drugs in the treatment of the type 2 diabetes mellitus. Metformin is still one of the most commonly used drug in therapy of Diabettes Mellitus type 2. The aim of this algorithm is to encounter the solver with this condition and its correct therapy.

7. 5. 2020 | Jitka Chlupová, MD, Dominik Nedoma, Barbora Pernová

Respiratory failure is a life-threatening condition in which respiratory system is unable to ensure adequate gas exchange which results in hypercapnia (insufficient elimination of carbon dioxide from the blood), hypoxaemia (insufficient oxygen supply to arterial blood) or both. In acute respiratory failure compensatory mechanisms occur − hyperventilation, tachypnoea and tachycardia. The algorithm presents possibilities of oxygen therapy and ventilatory support in a patient with severe respiratory failure. Regarding patient's clinical condition (vital signs, laboratory, physical examination) you will be able to recognize the (in)effectiveness of therapy and understand ventilation parameters such as PEEP, FiO2 and oxygen flow. Knowledge of individual methods, their limitations and settings is crucial for correct indication in a given patient.

8. 5. 2020 | Assoc. Prof. Jozef Klučka, MD, PhD, Lucienne Michnáčová. Illustrations: Priska Liptáková

Delirium is a life-threatening and highly underdiagnosed condition. It is a reaction of CNS to damage, manifested by a qualitative impairment of consciousness, decreased attention. Delirium usually starts suddenly in the evening and has a fluctuating course. It can have many causes: organic, toxic (caused by the administration of anticholinergics, dopaminergic antiparkinsonian drugs), and may be caused by withdrawal state as well (D. tremens). According to symptoms we distinguish hypoactive, hyperactive or mixed delirium.

Malignant hyperthermia is a rare, life-threatening disease that is charactarized by pathologic hypermetabolic state in muscular tissues that is triggered by specific anaesthetic agents. Firstly, our educational algorithm will lead you step by step through a situation with unexpected case of MH during surgery, show you how to remain calm, assess the situation and save the patient's life. The other part of the algorithm is dedicated to anaesthetic care of a patient who can have genetic predisposition for delevoping MH. It is crucial to prepare your workplace and medical staff for the specifics of anaesthesiological management of this patient and the possibility of further complications. Last but not least, you will learn about means of diagnostics of MH in the Czech Republic.

Other version of this algorithm: Malignant Hypertermia - 2014
8. 5. 2020 | Martina Klincová, MD, Dagmar Štěpánková, MD, PhD, Petra Kostroňová, Pavlína Kotrhová

Malignant arrhythmias are disorders of a cardiac rhythm, which can lead to a cardiac arrest. They are usually developed in children due to hereditary syndromes like catecholaminergic polymorphic ventricular tachycardia or long QT syndrome. Unfortunately, up to 30 %, the first sign of this disease is a sudden cardiac arrest, which requires immediate intervention. Triggers of these acute states are common situations like higher physical activity, emotional burden, shock or even sleep.

8. 5. 2020 | Martina Kosinová, MD, PhD, Tereza Musilová, MD, Kateřina Popková, Barbora Pitmausová. Illustrations: Kateřina Popková (ilustration), Barbora Pitsmausová (animation)

The young athlete Michal was with his friend riding freeride bikes. Michal overestimated his forces and had an accident in which he caused a tension pneumothorax. In this algorithm we will learn how to proceed in such a situation. In the first part we will give first aid in the role of Michal's friend. Then we put ourselfs into position of the EMS physician and show how this situation needs to be solved before the patient is taken to the hospital. Finally, as emergency doctors, we will continue to treat pneumothorax.

8. 5. 2020 | Michal Vondráček, MD, Jakub Švec, Svatava Janků

Knowledge of hemodynamics is not the only domain of anesthesia. It is an integral part of almost all medical disciplines. In our algorithm, the investigator can try several possibilities of monitoring hemodynamics in anesthetized patient: non-invasive blood pressure measurement, continuous blood pressure measurement by invasive and non-invasive method, but also advanced monitoring by pulse contour analysis. It is necessary to realize that correct evaluation of the patient's physiological functions has a significant effect on his outcome, long-term hypotension increases risk of perioperative perioperative myocardial infarction, stroke and acute kidney injury; in contrast, fluid overload can cause pulmonary edema or heart failure.

Acetaminophen (Paracetamol) intoxication is a life-threatening condition leading potentially to hepatic failure. Acetaminophen has antipyretic and analgesic effect, it does not have anti-inflammatory effect. It is widely used by the general public in the form of over-the-counter medicines. Due to large number of different types and easy availability of drugs containing acetaminophen on the Czech market, accidental or intentional ingestion of a toxic dose may occur. One of these situations is shown by our algorithm.

Difficult airway management during pregnancy is a life-threatening situation not only for the mother but also for the fetus. In the third trimester of pregnancy, the risk of difficult airway management is ten times higher compared to the non-pregnant population. Therefore, difficult airway management should be recognised in time, it’s important to proceed quickly and to achieve adequate ventilation, otherwise there are serious consequences such as hypoxic brain injury, fetal or maternal death. This algorithm will give you a chance to deal with two situations of difficult airway management. We use different muscle relaxants in each situation.

The educational algorithm Anesthesia in lung pathologies offers the possibility of solving two cases of different pulmonary diseases. Specifically, it is a patient with COPD and a patient with IPF, ie. a restrictive lung disease. The aim of the algorithm is to emphasize the importance of preoperative patient preparation and at the same time to point out possible complications and their subsequent solution, which may occur in patients with lung disease.

8. 5. 2020 | Veronika Tomášková, MD, Vanda Hořínková, Kristýna Cahová

Trauma accounts for 10 per cent of the world's mortality, about 5 million victims each year. And this trend is expected to increase. Conversely, good organization of care for the injured can reduce this trend, especially in the acute phase. Since 1978, the American College of Surgeons has been trying to systematize and improve this component of care by the Advanced Trauma Life Support protocol. The interactive algorithm approaches the use of the ATLS protocol in pre-hospital care and emergency room to transport to the operating room. It describes the basic scheme of examination, securing and therapy of traumatized patients.

8. 5. 2020 | Zbyněk Šimek, MD, Daniel Barvík, Tereza Kramplová