Volume 4 Issue 5

Continuing Professional Development: Spine immobilisation: professional and lay perspectives

OverviewFor fifty years the liberal use of precautionary spine immobilisation for trauma patients has gone largely unquestioned. Now though some researchers and practitioners are advocating a more selective approach, with some paramedics already empowered to clear spines at the scene of accidents. This Continuing Professional Development (CPD) module approaches pre-hospital spine immobilisation from two different, but related, perspectives. Firstly the module describes the basic anatomy and pathophysiology of cervical spine injury, explores the history of spine immobilisation, limited evidence base behind it and current professional practice. Secondly the module explores how lay members of the public, who are often the first to arrive at the scene of an accident, think about and manage potential spinal injury. Specifically asking whether some members of the public may erroneously prioritise spine immobilisation at the expense of other life-saving interventions.Learning OutcomesAfter completing this module you will:• Have revised the anatomy and pathophysiology of cervical spinal injury• Understand the historical development of spine immobilisation• Appreciate the limited evidence base behind spine immobilisation• Have revised current professional practice• Have learnt how lay members of the public may think about and manage cervical spinal injury patients

Continuing Professional Development: Neutropenic Sepsis

OverviewNeutropenic sepsis is the development of a profound and potentially life-threatening episode in patients that are extremely vulnerable due to their diminished ability to fight off infection. This reduced capacity to respond to infective agents – neutropenia—is caused by a near total absence of the body's specialist white cells, called neutrophils. One of the most commonly found causes of neutropenia are the chemotherapy regimens that patients treated for cancer need to take. There are an increasing number of such regimens being prescribed and, also, a trend towards oncology patients being treated—or recovering from treatment - at home (Dikken, 2009). The initial signs of these patients becoming overwhelmed by an opportunistic infection are easy to miss as the signs and symptoms are vague. The importance of sepsis being suspected and responded to by paramedic staff is of the utmost importance, as the disease process will progress with alarming speed to a point where it is difficult to support or resuscitate the patient either in the community or in hospital settings.This article presents an overview of sepsis and how neutropenia disguises the typical presentation, as well as a discussion of pre-hospital care delivery by paramedic staff.Learning OutcomesAfter completing this module you will be able to:▪ To understand the differences between infection, sepsis, severe sepsis and septic shock▪ To be aware of the term neutropenia and how this complicates sepsis▪ To appreciate the patient groups most likely to be at risk of neutropenic sepsis▪ To recognise the importance of a high ‘index of suspicion’ for these patients▪ To consider some potential prehospital developments in the response and early support of patients with sepsis and neutropenic sepsis.

The ambulance service: the past, present and future

Learning from the past, living in the present, but looking to the futureThe past is indeed another country; they do things differently there. In comparatively recent mid-20th century history ambulance services operated to a simple formula, conceived and designed function essentially as transport providers as even in the earlier days transport was the main, but not sole purpose, with little capability to influence patient outcome. But times have moved on with technological advances, heightened community expectations and changes to the professional, cultural, and economic backdrop.This article argues for an urgent shift in ambulance operations, from predominantly care and transport focused approach, to a more explicitly targeted service delivery model emphasising clinical decision-making and facilitated by an investment in paramedic education and the development of specialised practice at the post-registration level.

Hydrocortisone emergency in pituitary patients: adrenal/addisonian crisis

Secondary adrenal insufficiencyHydrocortisone is a steroid hormone produced by the adrenal gland. A good majority of people with pituitary conditions have to take replacement hydrocortisone daily as they don't produce this naturally. The condition is referred to as a secondary adrenal insufficiency.If any person became ill or were to suffer severe shock, the body would naturally increase the output of cortisol from the adrenals. However, people who need to take replacement hydrocortisone have to increase their ‘chemical' dose to help mimic the cortisol surge they don't naturally have.If the patient has a mild illness such as a basic cold or flu, they would increase their hydrocortisone tablet dose and recover normally. But if the patient is vomiting, has a serious illness, is involved in an accident and suffers severe shock they would, and quite quickly, experience what patients and their families may term a ‘cortisol crisis, or, as more commonly known in medical circles as an ‘adrenal’ or ‘Addisonian crisis’.

Can IV paracetamol be as effective as morphine in pain management?

Intravenous (IV) morphine is frequently used in the emergency department (ED) to control pain in patients with isolated limb trauma. However it can cause several side effects plus, as a controlled drug, it has both storage and administration constraints that may, on occasion, limit its accessibility. On the other hand, IV paracetamol has fewer side effects while still having good analgesic effects thus warranting further investigation around the potential for use of this drug in emergency settings.

Paediatric anaphylaxis: triggers and management

Anaphylaxis is an acute-onset, potentially life-threatening allergic reaction that involves at least two organ systems and usually occurs after exposure to a likely allergen. Anaphylaxis is a common presentation seen in children, and it is critical that ambulance clinicians are able to recognise the symptoms of this condition and appropriately manage it, as prompt treatment has been shown to lead to improved outcomes. This article presents an overview of paediatric anaphylaxis including epidemiology, triggers, diagnosis, clinical manifestations, and management, with a focus on how infants and children are similar and different than adult patients. Also discussed is why paediatric anaphylaxis is often underdiagnosed and undertreated, as well as paediatric populations who may require special attention for the management of anaphylaxis, such as infants, patients with a history of multiple emergency department visits for anaphylaxis, and asthmatics.

Endotracheal adrenaline in cardiac arrest due to near-fatal asthma: a case study

A case report of respiratory arrest in a patient with an out-of-hospital, near fatal asthma (NFA) attack; successfully resuscitated with treatment that included endotracheal adrenaline is described.This report demonstrates that endotracheal epinephrine (adrenaline may have a role in the resuscitation of asphyxic asthma. Adrenaline is a recognised β2 agonist and its smooth muscle relaxation properties are known to reverse bronchospasm. Ventilating patients with severe bronchospasm resulting from asphyxic asthma is known to be difficult. This report shows that instilling adrenaline via the endotracheal tube to a patient in cardio-respiratory arrest, resulted in relief of bronchospasm, reduction in airways resistance and a subsequent improvement of the operator's ability to ventilate.

Complications from pre-hospital immobilisation

This case report involves a 67-year-old-woman involved in a motor vehicle collision with an isolated complaint of minor hip pain. Pre-hospital personnel responding in the traditional manner quickly immobilized the patient in a cervical collar and long spine board in preparation for transport to a trauma centre. The patient developed progressively worsening respiratory distress while en route to the Emergency Department after immobilization. For unknown reasons, the patient's underlying medical conditions and deterioration were not recognized despite worsening vital signs and continued complaints of shortness of breath. She ultimately required intubation and admission to the Intensive Care Unit likely as a result of unnecessary immobilization. There is little evidence to show that routine spinal immobilization in the pre-hospital environment improves outcomes regardless of whether there is a true spinal injury or not. However, spinal immobilization has been found to cause pain, tissue injury, anxiety and decreased pulmonary function. This case report demonstrates the important role that pre-hospital providers have in deciding whether or not to immobilize a patient and that the consequences of unnecessary immobilization can be life-threatening.

The seizurogenecity of naloxone in tramadol overdose

Tramadol is the most widely prescribed opiate analgesic (National Treatment Agency for Substance Misuse, 2011) and, as a result, is present in a large number of overdoses that present in the pre-hospital arena. Naloxone is indicated for use by ambulance personnel where the GCS is reduced due to a known, or possible, overdose of an opiate containing substance (JRCALC (Joint Royal Colleges Service Liaison Committee), 2006).A case study of a tramadol overdose shows a close temporal relationship between naloxone administration and a seizure. While seizure is a symptom of tramadol intoxication (Saidi et al, 2008), the speed with which it occurred after naloxone administration seemed too fast to be merely coincidence. A study of the literature shows evidence that naloxone can instigate seizure in the case of a tramadol overdose (Rehni et al, 2008; Raffa and Stone, 2008).This information is particularly pertinent to the ambulance clinician as the consequence of a seizure can be important, both practically and clinically. The findings do not suggest that naloxone should be withheld, but that the potential for seizure should be noted and any forthcoming seizure dealt with. More research is needed to further define the factors that affect the seizurogenicity of naloxone in tramadol overdose.

Making the transition to high quality CPR: implications for paramedic practice

Out of hospital cardiac arrest remains a leading cause of mortality. Well known components of good quality cardiopulmonary resuscitation (CPR) include proper chest compression rate and depth, and allowing full chest recoil. Recently, new metrics have been developed that will lead the transition from good to high quality CPR. These include hands-off time, peri-shock pause and chest compression fraction. This article discusses new findings that show how these new metrics are associated with improved survival from out of hospital cardiac arrest and how they can be implemented by paramedics performing cardiac arrest resuscitation using current and evolving defibrillator technology.

Adult sepsis in a pre-hospital environment

Sepsis is a syndrome with a high mortality rate, increasing incidence, and a huge financial impact that must be recognised earlier and treated more effectively both in hospital and pre-hospitally. This article serves to focus on the improvements that need to be made in pre-hospital recognition and management in order to maximise patient outcome, as a high standard of care initiated at an early stage has been demonstrated to decrease morbidity and mortality. There are currently no ratified guidelines for pre-hospital practitioners to follow for the management of sepsis, severe sepsis or septic shock, although the authors recognise that steps are being taken to remedy this. Current guidelines for fluid resuscitation also do not currently support the need for aggressive treatment of sepsis and cryptic shock. Improvements need to focus on education around the sepsis syndrome, recognition of sepsis and early, goal-directed treatment for the benefit of our patients and in order to meet the standards required of paramedics as professionals.

Pre-hospital thrombolysis: end of an era?

For much of the last 20 years thrombolysis has been the preferred initial treatment for ST segment elevation myocardial infarction (STEMI). This treatment was originally given in hospital but was later used extensively and successfully before hospital admission. Primary percutaneous coronary intervention (PPCI) has proved itself to be more efficacious than thrombolysis, if it can be delivered within two hours, despite the extra time it takes to take patients to a Heart Attack Centre. Giving thrombolysis prior to the PPCI does not buy time safely. Prehospital thrombolysis still has a role when events long journies prevent timely access to the catheter laboratory.

The Health and Social Care Act 2012

Many people (myself included) would never have thought they would see the Health and Social Care Act passed given uneasy passage of the Bill through Parliament. The legislation, the largest since the inception of the NHS in 1948 underwent approximately 2 000 amendments and over 50 days of debate before it was passed, and, though some aspects of the bill are needed, many remain challenged by professional bodies, some of whom have called for its abolition, and raise concerns concerning the transition from the old to the new. Now begins the process of embedding the legislation, the Government has already indicated less central control, more devolution of power and and an increase in local accountability with strategic decision making powers that direct service provision and the allocation of budgets locally—what is not clear yet however, is how to accomplish this. Paramedics should remain aware of the changes being made, not only how this impacts them directly, but also the repercussions upon health and social services and patients overall.

Keep up to date with Journal of Paramedic Practice!

Sign up to Journal of Paramedic Practice’s regular newsletters and keep up-to-date with the very latest clinical research and CPD we publish each month.