Continuing Professional Development: Tramadol overdose and the potential for seizure after naloxone administration

OverviewTramadol 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 level of conciousness is reduced due to a known, or possible, overdose of an opiate containing substance (JRCALC, 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 (Raffa and Stone, 2008; Rehni et al, 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.Learning OutcomesAfter completing this module you will:• Understand the use of tramadol and its mechanism of action• Have an awareness of the potential presentations of a patient with Tramadol poisoning• Understand the pre-hospital management of tramadol poisoning, and the measures that can assist with hospital care• Be aware of the potential for seizure following naloxone administration, and the steps needed to manage it

Setting the standards for specialist practice

Over the last decade programmes have been established throughout the country that have prepared paramedics for specialist practice in primary care. As the need for safe and appropriate out-of-hospital treatment and/or referral for low-acuity cases increases, it is inevitable that the paramedic profession will take responsibility for recommending the curriculum and standards. In this article Stuart Rutland describes the approach taken in the South East Coast Ambulance Service which aims to provide an appropriate and defensible examination for paramedic practitioners.

Reference management software for students, researchers and academics

Why would I want to use RMS?RMS has been around for over two decades. The software is well developed and major database and information providers anticipate that users will be able to operate it with little difficulty. They have added functionality to make it easy to integrate RMS into the research process, for example, one-click export of results. Librarians have been making the case for RMS for many years and arguments for using RMS are both prolific and well rehearsed (Kent, 2011).However, there are many reasons why researchers do not use RMS, for example they They may not be aware of RMS, see it as too difficult to use, too expensive to buy or too time consuming to learn. Current RMS is more user friendly than earlier versions and there is more choice, including free-to-use web-based software. The ability to use RMS can be seen as a useful research skill in itself, which, once learned, may then be transferred to other projects.A recent review of RMS (Buckley and Owen, 2011) described it as an essential research tool. Evidence from research into the behaviours of young researchers (generation Y or those researchers under the age of 30) suggest 58% of them use RMS, with a high proportion in the medical discipline (British Library/ Joint Information Systems Committee (JISC), 2011).

Interruptions in CPR when using mechanical chest compression devices

Spotlight on Research is edited by Julia Williams, principal lecturer, paramedic science, University of Hertfordshire, Hatfeld, Hertfordshire UK. To fnd out how you can contribute to future issues, please email her at: j.williams@herts.ac.uk

Intubation in cardiac arrest: the ROC of our salvation?

The Resuscitation Outcomes Consortium (ROC) is a North American clinical trials research network focussing on out-of-hospital cardiac arrest (OHCA) and traumatic injury. In this study, Wang and colleagues performed a secondary analysis of clinical data collected prospectively as part of an earlier trial (ROC PRIMED, 2011).

The art and science of mentorship in action

The authors have collaborated to produce this article bringing together more than 60years of combined experience of paramedic practice, education and management. All maintain their paramedic registration and have among their goals the advancement and development of knowledge, skills and professionalism to promote an effective contemporary paramedic who continues to meet the care needs of the communities they serve.Practice mentors are pivotal to the success of a modern, fit-for-purpose paramedic curriculum that requires a significant proportion of learning and assessment to take place in the practice setting. This article focuses on the support that is needed for mentors during major professional and organisational change. Change which is aligned to localised multifaceted organisational strategies and change which includes supporting mentors, enabling them to carry out their function professionally, effectively and with confidence. This article discusses experiences of a collaborative, structured approach to mentorship support which is achieved through organisational, educational and professional alliances. It also explores other approaches and suggests a way forward in terms of a national governance framework.

Public health campaign to increase awareness of the risks of high blood pressure

The traditional role of the ambulance service as an emergency medical provider has evolved in recent times, with an emerging role being the promotion of public health. The current study explores this concept by evaluating one event in the ‘know your blood pressure’ (KYBP) campaign, conducted across Greater London by the London Ambulance Service NHS Trust (LAS) in April 2010. The event allowed members of the public to have blood pressure (BP) measurements and to receive advice on the health risks of high BP including stroke. Attendees with BP ≥ 140/90 were referred to their general practitioners (GPs).A subsequent telephone survey was conducted to assess campaign effectiveness. The event was attended by 2 274 people, 23% of whom had a high BP measurement. Overall 625 individuals participated in the telephone survey, over half of whom were referred for further medical attention. More than half of these individuals (56%) contacted their GP's surgery as advised. A number of individuals were either prescribed antihypertensive medication for the first time or were subsequently put on a higher dose or an alternative antihypertensive agent. An increase in knowledge of the risks of high BP was also reported. The positive findings demonstrate that ambulance services can have a role in promoting public health.

Increased threat of suicide attack: a need for NHS ambulance services to adapt?

Suicide attacks are an emerging threat within the UK that carry with it specific risks which must be managed in order to ensure safety and minimise injury and loss of life, both to emergency services personnel and bystanders. Major incident planning is usually based on an ‘all-hazards approach’. The aim of this article is to evaluate the current ‘all-hazards’ approach taken by NHS ambulance services for responding to a major incident and recommend if any changes need to occur as a result of the current threat from suicide attacks. In the same way that chemical, biological, radiological, and nuclear (CBRN) was the new emerging threat a few years ago, it could be argued that suicide attacks are the new emerging threat that requires a rethink on how the ambulance service operates. Scene safety is the main issue raised in this article. Solutions ranged from the adoption of US-style tactical medicine allowing paramedics to work within the ‘hot zone’ to training police firearms officers in triage and more advanced skills of clinical care. Some of these solutions assume deployment to the scene in the first place and it is considered what level of risk is acceptable when operating in a hazardous area such as this.Further issues identified were adaptations required to time on scene and whether to screen casualties for explosives and firearms, so as to avoid an armed terrorist being conveyed to hospital. The recommendations from this report rely heavily on cooperation between emergency responders not only during the time of a suicide attack but also during the pre-incident planning phase. Although modifications to the ambulance service response are suggested within the recommendations they do not present a radical change to how the ambulance service operates at present.

Book review

Much has been written about the use of clinical guidelines versus protocols in paramedic practice these days. But regardless of your particular viewpoint there must be at least a recognition that the likes of Joint Royal Colleges Ambulance Liaison Committee (JRCALC), the Resuscitation Council (UK) and ALS group base their guidelines on the latest research evidence. Here lies the problem with this book.

Leadership within the ambulance service: rhetoric or reality?

BackgroundEffective leadership is central to the success of providing a modern and responsive NHS (Institute for Innovation and Improvement, 2006) but one of the difficulties of looking at leadership for healthcare professionals is that most leadership theories have not been developed within a healthcare context. Typically, leadership theory has been developed within a business arena and then applied to healthcare (Vance and Larson, 2002). For a paramedic profession which is in the process of forming a new identity (Woollard, 2006) and continues to define its unique body of knowledge and practice (Gregory, 2011), this represents a significant challenge.Leadership within the health professions has been borne out of the ‘professionalisation’ process, with the emergence of regulatory bodies such as the Health Professions Council (HPC) (Saks, 2009), yet the role of leaders within the health professions is just as crucial as the various regulatory bodies. Initial research into leadership, however, pre-dates the HPC by several decades. As early as the 1920s, trait theory emerged in an attempt to identify common characteristics of an effective leader and early theorists could be categorised as either descriptive theorists (Wald and Doty, 1954; Ghiselli, 1963) or prescriptive theorists (Barnard, 1938). Into the 1940s, and style theory emerged (McGregor, 1960; Likert, 1961; Blake and Mouton, 1964) as an alternative to the management principles espoused by Frederick Winslow Taylor (Taylor, 1911). Although a greater emphasis was placed on ‘human’ factors, it was not a theory which effectively evaluated leadership in itself.‘Although a greater emphasis was placed on ‘human’ factors, it was not a theory which effectively evaluated leadership in itself?’

International Conference on Emergency Medicine 2012

The fourteenth annual International Conference on Emergency Medicine (ICEM) was held in the newly completed and stunningly presented Dublin convention centre from 27–30 June this year.

Paramedics: ready for terrorism?

Celebrations that followed the 2005 announcement of London's successful winning bid to host the 2012 Olympics were dramatically curtailed the following day as the UK witnessed its first terrorist suicide attack leaving 52 innocent people dead and over 700 injured, many seriously.

High-risk non-ST elevation acute coronary syndromes (NSTEACS) for paramedics

Pre-hospital clinicians frequently encounter patients suffering acute coronary syndromes (ACS) and they form an integral part in recognising and conveying the ST-elevation myocardial infraction (STEMI) patient to the most appropriate destination, namely the heart attack centre (HAC). The emphasis has been upon the recognition and subsequent management of the STEMI patient. The non-ST elevation acute coronary syndrome (NSTEACS) patient has a similar mortality and morbidity yet does not receive the same pathways as STEMI. This article aims to provide an understanding based on a case study around NSTEACS with supporting evidence relating to risk stratification, clinical trials and clinical guidelines of what needs to be developed to enhance the care we provide to the NSTEAC patient in the pre-hospital arena.