Tourniquets in the treatment of prehospital haemorrhage

Background:During recent conflicts in Iraq and Afghanistan, tourniquets were a useful tool in the management of non-compressible prehospital catastrophic haemorrhage. Recommendations for use within the civilian setting were then made. However, civilian research supporting this change in practice is limited.Aims:The aim of the research is to evaluate the utility of prehospital tourniquet application through description of the complications associated with use, as well as identification of mortality following prehospital application.Methods:A literature search was completed using PubMed and Embase for research studies on prehospital tourniquet use in extremity trauma. Study relevance was confirmed via their abstracts and final selection was made through reviewing the full publication. Data were extracted on mortality, complications, indication for use, effective application and application duration of tourniquet use. This was tabulated, and a descriptive analysis performed.Results:The research reported a mortality range of 3–14% with an associated complication rate of 2.1–32.4%. The effectiveness of prehospital application was in the 88.8–98.7% range, with tourniquet application durations of 48–103.2 minutes.Conclusions:The tourniquet should continue to be available to UK paramedics for the management of prehospital non-compressible catastrophic haemorrhage. Application is likely to provide a mortality benefit with limited morbidity and associated complications.

Paramedics' perceptions and experiences of pelvic injuries in prehospital situations

Mortality rates remain high in patients with pelvic injuries despite improvements in trauma care in recent years. Pelvic injuries are associated with patients with a high Injury Severity Score (ISS); it can therefore be difficult to distinguish whether the pelvic injury was a primary causative factor of mortality. ‘Open book’ fractures carry a mortality rate as high as 50% and clinicians should therefore have a low threshold for suspecting a pelvic injury. Paramedics should follow the latest guidance found in the UK Ambulance Service Clinical Practice Guidelines (Joint Royal Colleges Ambulance Liaison Committee (JRCALC), 2016; 2017). Additionally, log rolling and/or ‘springing’ the pelvis of a patient with a pelvic injury will cause pain, disrupt clots and distort a potential fracture. Furthermore, pelvic binders/splints can reduce the area into which a patient can haemorrhage, if they are placed correctly. Lastly, triage of these patients can be difficult and major trauma centres should be considered for definitive care.

Pelvic binder placement in a regional trauma centre

Background:Pelvic circumferential compression devices (PCCDs) are a life-saving prehospital adjunct to trauma care. Correct positioning at the level of the trochanters maximises their efficacy.Methods:To examine the positioning of PCCDs in a regional trauma centre in England, a retrospective analysis of patients who had experienced major trauma was carried out over a 6-month period. The primary outcome of PCCD position was assessed using computerised tomography imaging and recorded as ‘high’, ‘centred’ or ‘low’ (depending on trochanter level). Secondary outcomes, including patient demographics, mechanism, pattern, number and types of injury were also collected.Results:Eighty-nine patients were identified with a PCCD in situ, in whom 28 (31%) devices were positioned too high and eight (10%) too low. There was no correlation between mechanism, pattern, number or type of injury and PCCD position.Conclusions:Despite published evidence on PCCD position and training for personnel, many PCCDs are still poorly placed. Further education for professionals involved in PCCD application is recommended.

Implications for reflective practice and safer care in paramedicine: The Bawa-Garba case

Dear Editor,

Clinical skills in paramedic practice

Aysha Mendes

Emergency headache: a ‘proper’ desktop reference

Three Key TakeawaysExcellent advice on history-taking and examination, with tips and ‘clinical pearls’This is not a quick reference or ‘pocket guide’Well imparted expert knowledge will help all readers in managing those with headache far more confidently

Rapid recognition tools for subarachnoid haemorrhage

Subarachnoid haemorrhage (SAH) carries a substantial burden of morbidity and mortality—therefore, the development of methods to rapidly detect SAH with high sensitivity is very important. Paramedics are frequently called to patients complaining of headache and the treatment for patients with clinically likely SAH is mostly straightforward for prehospital clinicians. However, a number of patients present with atypical symptoms and 12% of all SAHs are overlooked on initial assessment (Kowalski et al, 2004).

Correct pulse measurement

In each issue, the paramedic education team at Edge Hill University focuses on the clinical skills carried out by paramedics on the frontline, highlighting the importance of these skills and how to perform them. In this month's instalment, Andrew Kirk discusses common pulse sites and correct technique for obtaining a patient's pulse

The toughest but best years of my life

In her last column before transitioning to practice, Abbygail Elsey reflects on the highs and lows, and on the tough and very rewarding experiences of being a student paramedic