Fatal poisoning with 2,4-Dinitrophenol: learning via case study

2,4-Dinitrophenol (DNP) is an industrial chemical. It is illegal to sell it for human consumption in countries including the UK and the US. However, as DNP is available illegally online, accidental or deliberate DNP poisoning may be seen in people using it for weight loss or bodybuilding. Aggressive, multidisciplinary medical management is required to manage the ensuing hyperthermia, respiratory failure, cardiovascular collapse and multi-organ failure; there is a high risk of cardiac arrest. Emergency services should be vigilant in both initiating prompt treatment and alerting the receiving emergency department as well as taking precautions to minimise their own exposure. This case report concerns a deliberate, fatal DNP poisoning and considers DNP's history, resurgence and toxicity management.

Spotlight on Research

Daring to fail

In a society that discourages mistakes and—inadvertently—learning, Jolyon Price reflects upon the importance of facing failures to increase confidence and skill in paramedicine

Are cervical collars effective and safe in prehospital spinal cord injury management?

Background: In the UK, around 500–600 people a year sustain traumatic injuries to the spinal cord, half of which involve the cervical spine. UK ambulance guidelines stipulate that if immobilisation is indicated, the entire spine should be immobilised using an orthopaedic scoop stretcher, head restraints and a rigid cervical collar. However, the use of cervical collars is being debated in the paramedic profession. Although they were originally considered harmless and used as a precautionary measure, an increasing amount of evidence suggests otherwise and it is argued that they can do more harm than good. Therefore, it is debatable whether using them is consistent with the principles of patient safety and evidence-based practice. Aim: A literature review was carried out to comprehensively examine research surrounding the adverse effects of cervical collars and the range of movement they allow to gain a comprehensive understanding of their efficacy. Methods: The EBSCOhost Health Science Research database was searched. Seven articles were found and chosen for inclusion in the literature review. Results: Two themes were identified regarding cervical collars: adverse effects and range of movement. Conclusion: Evidence suggests that cervical collars can cause more harm than good, and UK ambulance guidelines for spinal immobilisation should be reconsidered.

Improving pressure ulcer risk identification: a pilot project by ambulance staff

Background: A quality improvement initiative was designed to identify patients at risk of compromised tissue viability before they were admitted to hospital. Paramedics were educated to better identify patients with pressure ulcers or pressure damage, or those at risk of compromised tissue viability, and these patients were fitted with a pressure ulcer alert bracelet so that emergency department staff could identify them. Aims: The aims of the current initiative were to educate paramedics to better identify patients with pressure ulcers or those at risk of compromised tissue viability to emergency department staff, and fit them with a pressure ulcer alert bracelet to highlight them to emergency department staff so they would receive prompt intervention. Methods: A plan, do, study, act improvement methodology was used, and data from a 3-month period were retrospectively analysed. Patients identified as being at risk of compromised tissue viability were flagged as requiring assessment via a pressure ulcer risk assessment tool to enable prevention. Results: Paramedics identified 130 at-risk patients (aged 23–100 years), and data from 127 patients were analysed. Most at-risk patients fitted with pressure ulcer alert bracelets were aged 70 years or over, and there was an even female/male division. More than half (53%) of patients were found to have a pressure ulcer and alerted to emergency department staff. More than one in four (27%) patients who were identified as being at risk of pressure ulcers lived in nursing or residential homes, and 43% lived alone or in warden-controlled accommodation. Conclusions: Paramedics effectively identified potential risk factors for pressure ulcer development, indicating a need for immediate intervention. This study gives insight into how pressure ulcer risk assessment using an alert bracelet may be used in paramedic practice in emergency department handovers. Success depends on hospital staff acting upon paramedic recommendation.

Changing perspectives in the prehospital management of patients with severe burns

Treatment for burn injuries has typically involved the immediate cooling of the affected area with water to reduce pain and halt the progression of heat-induced tissue necrosis. For patients suspected to be at risk of airway compromise following inhalation burn injury, historical research has long advocated early prophylactic endotracheal intubation. In contrast, current literature is showing a change in the evidence base. To investigate this, a literature review was carried out and the evidence scrutinised in conjunction with local and national guidance. Controversy has more recently emerged over whether prophylactic endotracheal intubation is appropriate in the initial emergency management of suspected inhalation burn injury. Compounding this, it appears that no appropriate evidence-based guidelines have yet been made available. Traditional indications for prophylactic endotracheal intubation are sensitive but not specific. Research has subsequently demonstrated that large numbers of patients are being unnecessarily intubated and thus placed at risk of avoidable iatrogenic harm. A higher threshold for airway intervention is warranted. Additionally, a consensus remains over the use of prehospital cooling for burn injuries. This practice is, however, informed primarily by anecdotal and animal evidence. Patients with severe burns are at significant risk of hypothermia, which is associated with mortality. There is significantly more literature demonstrating the detrimental effects of hypothermia over the benefits of burn injury cooling in patients with severe burns. Treatment should therefore focus on the maintenance of normothermia as a priority. If cooling burned areas risks inducing hypothermia, it should be postponed.

Bushfires and burns

Cranial nerves: part 1

The clinical examination is an important part of any patient consultation. After the primary survey and patient history, a more in-depth examination of the patient is sometimes required to aid the working diagnosis and help negate other differential diagnoses. The extent of this depends on the stability of the patient and may not be possible in time-critical circumstances. However, it is becoming an increasing part of paramedic practice owing to the continued expansion of the scope of the paramedic role in both urgent and emergency care. Educational delivery of clinical examinations of each of the main body systems is now an integral part of undergraduate paramedic curricula.The forthcoming clinical examination series will provide a step-by-step overview for each of the main body systems. Continuing professional development (CPD) is an essential requirement for all clinicians in order to maintain and demonstrate currency and advancement within their roles. This series will therefore provide an overview of each examination to support students, newly qualified paramedics and paramedics wishing to use these as a CPD development activity and an aide-memoire for clinical practice. This article will provide an overview of initial examination considerations, including first impressions. In this month's edition, cranial nerves I–VI will be explored.