Continuing Professional Development: Abdominal Aortic Aneurysm (AAA)

OverviewAn abdominal aortic aneurysm (AAA) is a localized dilatation of the abdominal aorta resulting from degenerative cardiovascular disease. Such aneurysmal arteries pose few problems for many patients and are simply monitored and managed conservatively within the community. However, the ruptured abdominal aortic aneurysm is a time-critical medical emergency requiring timely surgical intervention in order to offer any chance of survival. Even when recognized early, 90% of patients will suffer an out-of-hospital cardiac arrest prior to arriving at the emergency department, and of those who reach theatre, only 40% will survive. This article aims to increase the paramedic practitioner's knowledge and understanding of AAA through a holistic discussion of the prehospital recognition and early management. Particular emphasis will be placed on fluid replacement therapy and analgesia, with specific reference to the issues associated with aggressive fluid resuscitation and the potential benefits elicited through the use of opiate analgesia and subsequent pharmacologically induced hypotension. This article further aims to set the prehospital management into the wider context, thus providing paramedic practitioner's with an insight into how prehospital interventions affect the patients' ultimate outcome and post-operative quality of life.Learning OutcomesAfter completing this module you will be able to:• Have an understanding of the pathophysiology, risk factors and diagnosis of abdominal aortic aneurysm (AAA)• Understand the cardinal signs and symptoms indicative of the ruptured AAA• Gain further insight into the potential benefits of opiate analgesia• Gain an appreciation of appropriate fluid replacement therapy and potential complications• Gain an insight into surgical repair methodologies and post-operative prognosis.

Assessment and treatment of trauma: an accredited course

Concise, highly interactive, and expeditiousLearn at your own place, at your own pace with the 2-6 hour online pre-course module which reviews essential information related to each type of injury. The on-site portion, presented in a convenient 1-day format, expands on the information presented in the textbook through lectures and hands-on scenario-based, small-group discussions and live-action videos.

Does prehospital intubation make a difference to survival rates in out-of-hospital cardiac arrest?

Spotlight on Research is edited by Julia Williams, Principal Lecturer, Paramedic Science, University of Hertfordshire, Hatfield, Hertfordshire UK. To find out how you can contribute to future issues, please email her at j.williams@herts.ac.uk (to avoid disappointment or duplication we recommend an initial email before beginning any writing).

C-spine clearance should not be a pain in the neck

In the UK, neck injury from blunt trauma is not an uncommon presentation in the emergency department (ED). However, the incidence of actual c-spine injury is low. Nevertheless, the majority of patients who present with blunt trauma neck pain are usually referred for radiography. It has been argued that this cautious approach is justified because of the potentially catastrophic consequences that may occur, should such an injury be misdiagnosed.

Hypoglycaemia: a case report

Diabetes mellitus is one of the most important medical conditions, in terms of morbidity and mortality, and financial cost. Hypoglycaemia is the most common complication of diabetes, and can also be associated with other conditions. The role of the paramedic in the initial assessment and management of this presentation is paramount. A huge number of hypoglycaemic episodes occur on a day-to-day basis, and the recognition of those patients requiring hospital admission is of vital importance. Through a case study, and a review of the condition, this article acts as a guide to the patient journey, from initial symptoms through to hospital discharge. We also highlight important issues such as prolonged hypoglycaemic episodes, and a mental health review of those who have taken a deliberate anti-hypoglycaemic agent overdose.

Book Review

I frequently use my allocated monthly word count to bemoan the lack of clinical texts aimed at the prehospital arena or better still, paramedic practice (UK) in particular. But every once in a while, I review a text which surprises even this cynical reviewer, and this is one of them.

Book Review

Earlier this year, I reviewed ‘Disaster Rules’ which documented 100 rules in relation to the management and treatment of mass casualties. I gave it a positive review and this book, which follows a similar format, has equally impressed me. Adopting a systematic approach to the management of trauma, 71 rules are presented which address the key issues in this field of prehospital care.

Out-of-hospital cardiac arrests in older age groups

Cardiopulmonary resuscitation (CPR) in elderly patients requires careful consideration. As the population ages and the burden of chronic diseases grow, paramedics will inevitably encounter, with greater frequency, out-of-hospital cardiac arrests (OHCA) in this population. Attitudes toward resuscitation in elders have shown to vary, based on the perceived likelihood of a successful outcome. Therefore, it is important that the paramedic has available age specific results on what the likelihood is of their patient, who they are deciding to resuscitate, achieving return of spontaneous circulation (ROSC) and, more importantly, surviving to leave hospital. Likewise, it is important for paramedics to understand OHCA outcomes when they are communicating with families of elderly victims of OHCA. Rates of survival to hospital discharge have recently been reported as 8% for those aged 65–79 years, 4% for octogenarians and 2% for nonagenarians. In patients aged 65 years or older, ROSC rates have improved for shockable and non-shockable rhythm OHCAs over the last decade, though survival to hospital discharge has improved in the shockable rhythm group only. Future research needs to address functional and quality of life outcomes for this age group and consider a community-wide approach to expected natural deaths occurring outside of hospital, so that inappropriate resuscitation efforts are avoided.

A non-guidelines approach to cardiocerebral resuscitation

Cardiovascular disease is a leading cause of death in most Western industrialized nations, making out-of-hospital cardiac arrest (OHCA) a major public health problem (Atwood et al, 2005; Lloyd-Jones, 2010). Unfortunately, the first sign of cardiovascular disease is often the last, as the first sign is often sudden cardiac arrest (Roger et al, 2011). It is not just a problem of the elderly as the average decade of adults with OHCA is the sixth (Bobrow et al, 2010). In the US, a 40 year-old-male has a 1 in 8 chance of dying from cardiac arrest (Lloyd-Jones, 2010). This article will present a non-guidelines approach to the management of patients with primary OHCA that significantly improves survival. It is called ‘cardiocerebral resuscitation’ as it limits interruptions of blood flow to the heart and the brain by emphasizing near continuous chest compressions not only by bystanders but also by advanced life support (ALS) providers. It deemphasizes assisted ventilation, as patients with primary cardiac arrest have nearly normal arterial blood oxygenation at the onset of their arrest. We present the details of cardiocerebral resuscitation and the published studies that have documented improved survival of patients with OHCA so treated. It emphasized that guideline cardiopulmonary resuscitation (CPR) and ALS should be reserved for patients with secondary cardiac arrest; secondary to drowning, drug overdose and other forms cardiac arrest that are secondary to respiratory failure.

Paramedic non-technical skills: aviation style behavioural rating systems

The Department of Health (DH) estimated that in 2000, approximately 10% of patients were harmed in some way while being cared for by the NHS. This equates to 850 000 patients and approximately £2 million in extended bed stays (DH, 2000). These adverse events are found in all areas of health care. For example, it is estimated that errors in surgery can be attributed to poor communication between members of the surgical team in 43% of cases (Gawande et al, 2003). In addition, cognitive and diagnostic errors contributed to 27% of claims against a healthcare organization (Wilson, 1999). Such errors, once analyzed, often show no lack of technical knowledge or skills on the part of the clinicians, and instead may be attributed to a failure in the non-technical skills of the clinicians and clinical team involved. Non-technical skills are defined as the cognitive (thinking) and social (team working) skills that, when combined with technical knowledge and skills, allow a practitioner to deliver safe and effective patient care (Flin et al, 2008). They help to reduce the frequency of errors and reduce the chance of adverse events. There appears to be little published literature detailing errors made by paramedics or discussing their non-technical skills. Generally, errors made by paramedics in the UK are highlighted through complaints from either hospital clinicians, patients’ families, or patients themselves. These complaints could result in lengthy investigations and often place stress on the ‘offending’ paramedic. It could also be argued that few lessons are learnt by the investigating organization or the profession as a whole. Once the error has occurred, it is too late for the patient, and a pro-active error avoidance approach is required.

Prehospital management of paediatric supracondylar fractures

Supracondylar humeral fractures are common in paediatric trauma. Prehospital management should focus on assessing and preserving the neurovascular integrity of the affected limb and on reducing pain. Secure immobilization and adequate analgesia are vital to achieving these aims. Currently, there is no consensus as to how to best immobilize the limb or to provide analgesia in the prehospital setting for a suspected supracondylar fracture. This article suggests an examination technique to assess the neurovascular status of the injured limb, and reviews some of the current methods of immobilization and analgesia used for prehospital management of supracondylar fractures.

Paramedics in need of user friendly body armour

Robert Kaiser, CEO of PPSS Group, Knaresborough, UK, discusses the results of a recent survey, highlighing the issue of paramedics using body armour.

Student fitness to practice

There could be interesting times ahead for students on paramedic courses as the Health Professions Council (HPC) launches a consultation on the most effective way of assuring student fitness to practice. Currently the Nursing and Midwifery Council (NMC) and the General Social Care Council (GSCC) maintain voluntary registers of students studying on programmes that lead to registration with the respective registering bodies but the HPC does not have the power to register students. The Health and Social Care Bill 2011, currently before parliament, would change that position and allow the HPC to set up voluntary registers of students studying on programmes that lead to registration.

Paediatric tricyclic antidepressant overdose

A case of paediatric tricyclic antidepressant (TCA) ingestion is discussed in this article. Ingestions, especially from TCAs, are potentially life-threatening, requiring prompt recognition and treatment. Successfully treating a TCA ingestion hinges on the recognition of both the availability of TCAs to the patient and the signs and symptoms of TCA ingestion. Unfortunately, once TCA ingestion is identified, there is variability in management by emergency medical services (EMS), leading to variability in outcomes. The diagnosis and management of TCA ingestion are reviewed in this case study, as well as barriers that prehospital care providers encounter in diagnosing and treatment.