Volume 4 Issue 12

Continuing Professional Development: Assessment of the 12 lead ECG in transient loss of consciousness

OverviewCardiac arrhythmia affects more than 700 000 people in England, and is consistently in the top ten reasons for admission, placing a significant strain on emergency department time and bed availability (DH, 2005). Following the introduction of pre-hospital thrombolysis as part of the National Service Framework (NSF) for Coronary Heart Disease (CHD), the acquisition and interpretation of 12 lead ECGs has become a routine part of UK paramedic practice. Although training models have varied nationally, the main focus has been on the use of 12 lead ECGs to identify changes associated with ST elevation myocardial infarction (STEMI) in order to facilitate early reperfusion measures.Learning OutcomesAfter completing this module you will:• Undertake initial assessment of patients with T-LOC• Describe significant ‘red flag’ findings in patients experiencing T-LOC• List ECG abnormalities requiring referral in T-LOC• Apply the ABCDER mnemonic to screen the ECG in T-LOC

Raising a profession

The babyHaving someone read to him/ her helps the brain develop (2–3 months)Is able to sit alone for a short time (7–9 months)Copies speech sounds (7–9 months) Likes being read to (10–12 months)This of course had to begin with a birth and in the context of the paramedic profession the birth came about when groups of doctors in several parts of the UK formulated plans aimed at improving outcomes for patients suffering from cardiac and other acute events. These doctors trained small teams of ambulance service personnel initially with advanced skills which then led to the first national courses in the mid–1980’s which were known as ‘extended training’. These were very much based on a training methodology and there was an eagerness and enthusiasm to learn from the individuals involved. The term ‘extended trained ambulance staff’ was quickly replaced with the term ‘paramedic’.

Book review

This book provides a well written and accessible text for paramedics who wish to begin engaging with research in pre-hosptial care. Written and edited by a number of high–calibre professionals who are involved with paramedic research and education, the book provides a good platform to assist the profession in developing towards more evidence– based medicine.

Recognising supraventricular tachycardia in children: An arrhythmia not to miss

CaseA paramedic team was requested to attend a children's party when a previously healthy two-year-old boy had became acutely unwell. He was sweaty, clammy and his parents reported that his heart was racing when they cuddled him. The initial observations by the paramedic team revealed a heart rate well over 200 bpm, temperature of 37.7 ° C and blood glucose of 5.9 mmol/l. He was immediately transferred to the nearest emergency department. High flow oxygen was administered by face mask during the transfer. His parents were requested to accompany him during the transfer to keep the child comfortable and avoiding further distress.A heart rate of 230 bpm was recorded in the emergency department and a 12 lead ECG confirmed the diagnosis of SVT (Figure 1 shows an ECG with SVT). The ECG showed narrow complex tachycardia with no preceding P-waves. There were no other abnormalities detected. Continuous ECG monitoring was commenced and the paediatric team was urgently summoned. Vagal manoeuvres of applying ice-packs on his face were attempted but this failed to revert back the rhythm to normal sinus rhythm. An intravenous cannula was inserted and a dose of IV adenosine at 100 mcg/kg was given followed by a quick saline bolus. The boy responded well and the rhythm reverted back to normal.Figure 1.ECG showing SVT in a child(Garg and Paul, 2012)The boy was admitted to the paediatric ward for cardiac monitoring which remained normal and the boy well. He was discharged home with advice to return if he became unwell. He is also currently being followed by a paediatrician at the local hospital.

Stroke or heart attack: First encounters with pre-hospital care

This paper reports on a qualitative study that appears to have been motivated, in part, by a need to develop patient reported experience measures (PREMs) suitable for use in pre-hospital care. It is a valuable addition to our understanding of both patients' and clinicians' experiences of pre-hospital care for individuals with suspected stroke or acute myocardial infarction (AMI).

Induced hypothermia in the management of head trauma: A literature review

Mild hypothermia treatment (MHT) involves a controlled decrease of core temperature in order to mitigate the secondary damage to organs that follows post primary injury. In the case of traumatic brain injury (TBI) suggestions that the brain could be conserved by cooling go back as far as the 1940s. The idea was to reduce cerebral metabolism and hypoxic insult by using MHT. However, more recent research suggests that this is a ‘simplistic view’ of brain cooling when there is in fact a much more complex web of effects that need to be understood and accounted. There clearly needs to be a variety of multi-disciplinary team based simultaneous pre-hospital and then in-hospital treatments to ameliorate harm (Nonmaleficence ) and enhance brain healing processes (Beneficence). Examination will take place of the varied probable mechanisms of action and contemporary evidence for and against the use of MHT in TBI. Discussion will range across issues such as target range of MHT, time to achieve this range, duration of cooling, and finally re-warming rates on neurological outcomes following TBI. This in turn, should create a clearer evidence base, for the UK paramedic practitioner who is considering using MHT in the pre-hospital setting in the minutes following TBI and inform decisions around: methods and timing of cooling; shivering prevention using sedation; reliable on-going monitoring of core temperature and team building with hospital services.

Developing communication skills in occupational therapy, and paramedic students

Communication is considered to be a core skill for healthcare professionals. The teaching, learning and development of communication skills are discussed with a focus upon occupational therapy and paramedic practitioner students.A mixed methods approach was taken to gather data; questionnaires were administered to evaluate the final year student opinions regarding how they are taught and learn about communication skills, and how well prepared they felt for practice. Programme Lead feedback was gained regarding student opinions and programme handbooks were analysed to further inform the research.The majority of students prioritised listening skills as the most important communication skill required for practice and held the pre-course expectation to be taught communication skills required for practice. Difference in opinion was highlighted regarding how adequately taught and prepared students felt, with a proportion of OT students feeling inadequately taught communication skills.Findings provide a clear indication of student opinions regarding how they are taught, learn about and are prepared for the communication skills required for practice; students value this training and would welcome more to be included in their programmes. The difference in learning experience is attributed to there being no specific module for communication skills on the OT programme.

Use of intranasal drug administration in the pre-hospital setting

This article explores the benefits of intranasal as a recommended route for drug delivery in the pre-hospital setting for healthcare professionals. It is currently used in Australia, USA and some UK Ambulance services and remains a preferred route in certain patient groups. Intranasal can lead to a reduction in needle stick injuries for the healthcare professional and allowing immediate drug therapy in a emergency setting for bystanders. Randomised control trial's and evidence-based practice to discuss the absorption rate and different drugs that could be used through this route. After reading this article paramedics should be more aware of this safe route and its benefits in the emergency setting.

Right ventricular infarction in the pre-hospital setting: A hidden complication

Right ventricular infarction (RVI) can occur in isolation but is more commonly associated with inferior myocardial infarction (IMI). It has a higher mortality rate compared to isolated left ventricular infarction and often presents with complications. Early recognition of RVI in paramedic practice is key to decreasing patient mortality. This article focuses on RVI within the pre-hospital environment. Particular emphasis is placed on right precordial electrocardiogram (ECG) lead placement, judicious administration of intravenous fluids in the hypotensive patient, and specific complications associated with vasodilatory drugs in RVI.

The Emergency Services Show 2012

New developmentsOne of the most notable aspects of the show was the huge array of products and services available, in particular those exhibitors bringing new technology, or pre-existing technology which has now become affordable for the majority rather than the few. Seemingly the complete range of products and gadgets now available to the emergency services were on display, from high protection anti-riot vehicles on display in Hall 1, air reconnaissance pilotless drones in Hall 3 and the hyper-real manikin and faux-trauma dummies in Hall 2. Affordable infrared and heat detection technology, high-tech protective clothing and ultra-realistic training manikins are some examples of products, traditionally only available on a mass scale to institutions such as the military, but now obtainable for fire and rescue, first responder and police institutions and trusts.

Weather or not?

The Department of Health (DH) has published a renewed strategy for combating the 25 000 ‘avoidable’ deaths that occur each year as a result of cold weather in the UK (DH, 2012). Since 2010, when the country was gripped by a particularly disruptive cold stint, in which Heathrow airport was closed for three consecutive days and the UK economy lost an estimated £840 million (UK Parliament, 2011), the government has focused attention on combating the UK's susceptibility to, so-called ‘extreme’ weather.

Hyperoxia, hypocapnia and hypercapnia: useful predictors in paediatric cardiac arrest?

This prospective multi-centre study enrolled patients aged between one month and 18 years who achieved return of spontaneous circulation (ROSC) after in-hospital cardiac arrest and had arterial blood gas (ABG) analysis performed at ROSC and 24 hours post event. Treating clinicians completed case report forms including details such as patient demographics, cause of the arrest, first recorded electrocardiogram, staff undertaking resuscitation, ventilator support, drug administration, duration of arrest, and ABG results.

The concept of a ‘good’ death in pre-hospital care

Paramedicine has changed dramatically throughout the last twenty years. With significant changes in both the education that underpins paramedic practice and the technology now used to enhance it. The quality of care being provided to the service-user has arguably never been so high.

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