Volume 6 Issue 5

Continuing Professional Development: Venous thromboembolism

OverviewThis Continued Professional Development article will outline the epidemiology and risk factors surrounding venous thromboembolism (VTE), a disease which encompasses the pathology of both deep vein thrombosis (DVT) and pulmonary embolism (PE). This article will allow the reader to understand the subtypes of VTE and their management in an acute setting.

Spotlight on Research

Reducing peri-shock pauses in out-of-hospital cardiac arrest increases odds of survivalFollowing publication of the 2010 American Heart Association-International Liaison Committee on Resuscitation (AHA-ILCOR) guidelines, there has been an increased focus on the characteristic components of cardiopulmonary resuscitation (CPR) including length of peri-shock pause, chest compression fraction (CCF), chest compression depth, chest compression rate and chest compression recoil.This study set out to examine the association between the length of the peri-shock pause and survival from shockable out-of-hospital cardiac arrest (OHCA) using data from patients enrolled in a randomised control trial known as the Resuscitation Outcomes Consortium Prehospital Resuscitation Impedance Valve and Early versus Delayed Analysis (ROC PRIMED).Peri-shock pause is the sum total of both pre- and post-shock pauses. Preshock pause is the time between cessation of chest compressions and the shock being delivered, and postshock pause is the time between shock delivery and resumption of chest compressions.For this study, 2 006 patients (from a total of 15 794 in ROC PRIMED) met the inclusion criteria: adults aged 18 years or older, who had sustained a non-traumatic OHCA and had an initial presenting rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) for which CPR process data for at least one shock was obtainable.The primary outcome was survival to hospital discharge and the secondary outcome involved assessment of neurological function using a Modified Rankin Score.During analysis the shock pause length (seconds) was examined categorically, <10, 10–20, ≥20 for pre-shock pauses, <5, 5-10, ≥10 for post-shock pauses and <20, 20–40, ≥40 for peri-shock pauses.Comparison of CPR components demonstrated no significant difference for CCF, compression rate or depth between survivors and non-survivors. For shock pause duration, however, pre-shock pause was 18% shorter (14 seconds versus 17 seconds) for survivors compared to non-survivors; 17% shorter for both postshock pauses (5s vs. 6s) and peri-shock pauses (20 seconds versus 24 seconds) for survivors compared to non-survivors. Pre-, post- and peri-shock pause durations were significantly different (p<0.001) between survivors and non-survivors.Odds ratios were calculated to examine the relationship between pre-, post-, and peri-shock pause duration and survival to hospital discharge. Shorter pre- and peri-shock pauses were significantly associated (p<0.001) with survival to hospital discharge. Specifically, patients experiencing a pre-shock pause of <10 seconds had a higher odds of survival to hospital discharge (OR: 1.52, 95%: 1.09, 2.11) when compared to episodes with a median pre-shock pause of ≥20 seconds. For perishock pause duration, a peri-shock pause of <20 seconds produced a higher odds of survival to hospital discharge (OR; 1.82, 95%: 1.17, 2.85) when compared to peri-shock pause duration of ≥40 seconds. Interestingly, post-shock pause was not significantly associated with survival to hospital discharge.When looking at the relationship between shock pause duration and a positive neurologically intact survival (MRS ≤3), lower pre- and peri-shock pause duration were significantly associated (p<0.001) with positive neurological outcome. The odds of neurologically intact survival were significantly higher with a pre-shock pause <10 seconds (OR: 1.49, 95%: 10.05, 2.13) compared to ≥20 seconds; similarly with the peri-shock pause, the odds of neurologically intact survival were significantly higher if the pause was <20 seconds (OR: 1.99, 95%: 1.21, 3.29) when compared to duration ≥40 seconds.Limitations to the study are that the data are taken retrospectively from other research and are observational. Further investigation would be needed to determine whether the effects of peri-shock pause duration is of a causal relationship. The authors also note that the study is undertaken in a region with a heavily monitored EMS system, with overall rapid response times and high CPR quality, therefore they caution against generalisation to other EMS systems which may not have similar characteristics.The results of this research reinforce the importance of minimising ‘time off the chest’ during CPR attempts, especially during the pre-shock phase supporting the practice of performing chest compressions during the charging phase when using an AED, or using defibrillators in manual mode to reduce pre-shock pause length. Although further research is required, these findings indicate that shortening the peri-shock pause (especially pre-shock) could possibly improve the odds of patients surviving to hospital discharge with favourable neurological outcomes after out-of-hospital cardiac arrest.

Answering that frequently asked question

The regulatorAs part of the essential legal framework surrounding a registered profession, a regulator has to be identified or established with certain key duties focusing upon protection of the public, which are defined by statute. The regulator's role is to protect the public and it does this by: • a) Setting standards, defined in the Standards of Proficiency (Health and Care Professions Council (HCPC), 2007) and the Standards of Conduct, Performance and Ethics (HCPC, 2008), for the profession and approving education programmes that lead to registration. The regulator can, and indeed in the case of paramedics, quite frequently does, take action against professionals who do not meet the standards it has set• b) Holding and maintaining a register of professionals who meet the standards set by the regulator.There are parallels with medicine, which is self-regulating, but also some differences. For example, the General Medical Council (GMC) sets the standards and maintains the register for doctors whilst each arm of medicine has its own professional body such as the Royal College of Surgeons or the College of Emergency Medicine. Paramedics, along with 14 other health professions, are not self-regulating, but are all regulated by the HCPC. The HCPC is a statutory body which is independent of the 15 professions it regulates. Its primary purpose is therefore to protect the public by setting standards and holding professionals to account where necessary. Read more at www.hpc-uk.org.

Pharmacologically assisted laryngeal mask insertion: a consensus statement

PALM: what is it?The PALM technique has been described in polytrauma patients with a reduced Glasgow Coma Scale (GCS) and ongoing airway obstruction as well as airway soiling from facial injuries. The patients have often been trapped. With basic airway manoeuvres and adjuncts failing to maintain oxygenation, the patient's level of consciousness is reduced further pharmacologically, without the use of neuromuscular blockade. This allows insertion, and ongoing tolerance, of a SAD with the option of assisting ventilation if this is required.

Application of the iTClamp™ in the clinical management of haemorrhage: a case study

A case studyA male patient was stabbed below the jaw line to the left side of the face/neck. The initial call suggested a catastrophic haemorrhage. On scene, the male patient had an obvious and considerable haemorrhage, with his friend applying direct pressure with his thumbs to the wound, stating it was a ‘spurter’. On examination the wound/haemorrhage did not appear to be arterial but was free flowing and considerable. Direct pressure was applied with gauze and the area around the wound cleaned to expose what was thought to be potentially other wounds but were actually clots forming on the patients chin stubble. No foreign bodies were visible in the wound and the iTClamp™ was prepared. The patient was warned that it may cause pain but on application the patient did not appear to be in any discomfort though was heavily intoxicated. Minor bleeding did continue and the device was reapplied without further complication and controlled the haemorrhage well. On arrival at hospital the device was easily removed and the wound easily managed with no visible additional tissue damage from the device. Figures 1 and 2 represent the pictures taken immediately before device applied (extensive wound cleaning and exploration) and after application. The patient's distinguishing features have been hidden to maintain anonymity.Figure 1.Extensive wound cleaning and exploration of the patientFigure 2.Patient after application of iTClamp™Figure 3.iTClamp™The ED consultant was impressed by the device and its application but did have concerns about being used in more vascular areas of the neck (I gather the clamp has since been used in several severe neck wounds in the UK with success and without incident).

RCSEd Consensus Documents: improving the evidence base for pre-hospital practice

Being part of a pre-hospital teamIn the pre-hospital context the response teams are doing all they can to save lives. A terrifying ordeal or horrific accident comes without warning at any time of the day or night. With lives at risk, the rescue and pre-hospital care teams need to work fast and in harmony with each other. Everyone has to be clear about their role, with multi-agency teams working seamlessly together. Each situation is unique and may present real dangers; not just for the patient but also for the medics. Blending of services within health and social care allows for the provision of meaningful governance with timely and appropriate interventions throughout the patient pathway. To enable this, many of the processes need to be well thought through and described beforehand, allowing all to work through the same methodology towards a common goal. The consensus process is one tool in the decision-support process. The development of these guidelines needs to follow a transparent system to result in the best evidence-supported practice that is auditable and accountable, balances risk and benefit in most circumstances and remains financially viable.These areas of practice need to work with and further develop other regulation and guidance, e.g. the paramedic curriculum and soon to be competency framework, JRCALC, etc.Therefore, the way forward will need to deliver the ‘best for most’. There requires a pragmatic approach trying to overcome prejudice along with personal and traditional preferences, organisational agendas and semantics. Such models would require systems that are appropriately resourced, resilient and adaptable. At the end of the day, we should be striving for the best clinical care and quality assurance, without any significant geographical variation in the quality and level of care, using finite resources in the most cost-effective way. Appropriately trained pre-hospital clinicians should work within a well thought-out and structured integrated governance framework, alongside effective leadership and technology aimed at providing resilient and high-level guidance, decision support and triage.The FPHC in conjunction with key and leading stakeholders produces systematically developed guidelines to assist pre-hospital emergency care practitioners to deliver a high standard of care. They are designed to assimilate, evaluate and then introduce changes to clinical practice based on the contemporary and evolving evidence base where available. Quality assurance is maintained by a systematic literature review, consultation and transparent peer review. The process allows for updates if there are any essential changes and each topic to be revisited after a set period of time.The consensus guidelines aim to educate healthcare professionals and assist in agreeing appropriate management. They should be regarded as an aid to clinical judgement and not to replace it.Looking to the future, however, there are issues as to how we develop systems to improve these services, save more lives, value our colleagues, operate more safely and work more efficiently: rather than simply continuing based on current expertise available, a better way forward, might be to continue to develop the systems that support the wider body of pre-hospital practitioners and allow them to progress both their technical and non-technical skills. The consensus process is a small step towards this. However, we do need all those involved and in particular the paramedic profession, to increase the amount of meaningful research that will help support, change and develop clinical practice.Therefore, to conclude, in all forms, pre-hospital care is an exciting area of medicine. Increased demands are being placed upon it. It forms an integral part in the development of numerous patient pathways and systems, including trauma, unscheduled and social care. Furthermore, it has a developing, ongoing evidence base that cannot always be extrapolated from in-hospital care. There have been marked developments in the systems that enable both safe and effective delivery of care in this context, but this is often based on anecdotal areas of practice. Improving the care and support of the people who deliver the pre-hospital services and further development of an evidence base, should be a priority and will lead to even better care of the casualties, patients, staff and colleagues.‘We do need all those involved and in particular the paramedic profession, to increase the amount of meaningful research that will help support, change and develop clinical practice’‘Ten good soldiers wisely led will beat a hundred without a head’ Euripides 480–406 BC.

Minimal patient handling: a Faculty of Pre-Hospital Care consensus statement

BackgroundSpinal immobilisation is a common intervention for the pre-hospital patient following trauma. Most commonly the patient is log-rolled on to a rigid long spinal board. Once on the long spinal board, the patient, with a cervical collar applied, will be immobilised using head blocks and straps and secured to the board for transportation to definitive care.Once at definitive care, the patient may again be log-rolled to facilitate removal of the spinal board, removal of clothing and examination of the back and spinal columns. Further movement of the patient will usually occur again during transfer for CT imaging.Spinal immobilisation using these techniques is not without negative sequelae (Abram and Bulstrode, 2010). There is the potential for harm to be caused by the log-rolling used to place and remove the patient on the spinal board and by the immobilisation on the spinal board. Consequently, a number of pre-hospital clinicians are using alternative techniques to provide spinal immobilisation and to package patients either using a scoop stretcher or a vacuum mattress.This consensus statement will outline emerging best practice when packaging the pre-hospital trauma patient and providing spinal immobilisation. The best practice described is based on the recommendations of a consensus meeting held in the West Midlands in April 2012, where the opinion of experienced practitioners from across the pre-hospital and emergency care community considered the currently available evidence and reviewed current clinical practice.The indications for spinal immobilisation are not considered in this statement as they are addressed in other consensus statements.

The pre-hospital management of pelvic fractures: initial consensus statement

Method of literature searchA review of the literature was undertaken prior to the consensus meeting. The Medline Database was searched using PubMed and Google Scholar was also used. The search terms were Pre-hospital management of pelvic injuries, Pelvic circumferential compression devices, pelvic binders, SAM pelvic sling, T-POD, PelvicBinder, Geneva belt and London pelvic sling. Further articles were identified from the references of retrieved articles. Manufacturers' websites were reviewed for further information regarding specific products.Consensus outcomes1. A pelvic binder is a treatment intervention rather than a packaging intervention and should be applied earlyThe initial management of any patient with a suspected pelvic injury must include the usual safety precautions. During scene assessment, visual clues to the mechanism of injury will help determine the likelihood of a pelvic injury.The primary survey should deal with external catastrophic haemorrhage then any significant airway and/or breathing issues prior to circulatory assessment. If the patient is haemodynamically compromised with a significant mechanism suggestive of a pelvic injury, a pelvic binder should be applied.Applying a pelvic binder early provides stability and allows clot formation. This may prevent ongoing haemorrhage and the often-lethal trauma-induced coagulopathy.The consensus group emphasised that the pelvic binder is a treatment intervention rather than a packaging device and if the device is thought of as a haemorrhage control device this should promote early application.2. A select group of patients may not need a binder appliedPre-hospital diagnosis of a pelvic fracture can be extremely difficult (Lee and Porter, 2007). There is no obvious external bleeding and deformities can be difficult to detect. Grant 1990 found that ‘springing the pelvis’ had a poor sensitivity (59%) and specificity (71%).5 There is also concern that compressing the pelvis can cause further haemorrhage and as a result this technique is no longer recommended (Grant, 1990; Lee and Porter, 2007).Significant pelvic trauma can be excluded from a small group of patients preventing the unnecessary use of pelvic binders.These patients must be haemodynamically stable with a normal Glasgow Coma Scale (Sauerland et al, 2004; den Boer et al, 2011). The following flow diagram is an illustration of how patients can be stratified according to the risk of pelvic injury (Figure 1).Figure 1.Indications for the application of a pelvic binder3. No one pelvic binder device can currently be recommended over anotherThe ideal pelvic binder should stabilise the pelvis in order to reduce haemorrhage and pain. It should be easy to apply, not cause further harm and allow radiological and surgical intervention without need for removal. In addition, it should not be too expensive to purchase or maintain.A number of pelvic binding devices currently exist. There is limited evidence regarding their use in the pre-hospital environment. Cadaver and some clinical evidence suggest that pelvic stabilisation can be achieved with these devices (Bottlang et al, 2002a; 2002b; Bonner et al, 2011). A number of case series and reports suggest an improvement in haemodynamic stability and a reduction in blood transfusions after a pelvic binder has been applied (Simpson et al, 2002; Warme and Todd, 2002; Tan et al, 2010).Currently, there is insufficient evidence to support one device over another. The two devices with the strongest evidence base are the SAM pelvic sling and T-POD devices.Manufacturers of new devices should provide evidence that their device provides a similar level of stabilisation to these in cadaver models at least prior to them being made available for clinical use.4. Adequate training must be provided to avoid misplacement of devicesThere is evidence that misplacement of pelvic binders can reduce the degree of fracture reduction Bonner et al, 2010). It is important that pre-hospital providers are trained appropriately to optimise correct placement (Bonner et al, 2010.While there is evidence that these devices are often incorrectly placed, this was felt to be a training issue rather than an inherent design fault. Pre-hospital providers must ensure that their members/employees are appropriately trained with clinical governance structures in place to provide constructive feedback.5. Associated femoral fractures should also be reducedSignificant pelvic fractures require large energy transfers and are often associated with other lower limb bony injuries. There is no evidence that pelvic binders are harmful when applied to patients with proximal femur or acetabular fracture Chesser et al, 2012).Patients who also have suspected or obvious femoral fractures should have these stabilised, ideally using a traction splint. In the haemodynamically stable patient with a femoral fracture who is also at risk of pelvic fracture, consideration may be given to the use of one of the varieties of traction splint which does not exert pressure using traction against the pelvis in the midline.If the patient has significant haemodynamic compromise, in order to prevent delay in transfer to hospital, consideration should be given to pulling the leg(s) out to length (with appropriate analgesia), applying a pelvic splint and then binding the legs together with figure of eight bandages or straps. If attempts to pull the leg out to length appear to worsen the patient's cardiovascular status, immobilisation should be carried out with the legs in the position ‘as found’.6. Patients should not be log rolled or transported on a spinal boardThere is evidence that logrolling patients with significant pelvic fractures can cause clot disruption and further haemodynamic compromise (Lee and Porter, 2007). Patient handling must therefore be approached with care in these patients. Logrolling only has a place in turning a patient onto their back to allow access to their airway. There is no place for routine logrolling in blunt trauma victims. Patients should be moved with the aid of a scoop stretcher. No patient should be logrolled onto or off a spinal board with a pelvic injury.7. The use of pelvic binders is associated with the risk of low pressure skin necrosisThere is evidence that with a pelvic binder in place, tissue under the binder is at risk of pressure necrosis (Jowett and Bowyer, 2007; Knops et al, 2010; 2011). There are a few case reports in the literature of this complication (Krieg et al, 2005). A study in healthy volunteers demonstrates that the pressure exerted by some of these devices is close to or even over the level capable of compromising tissue perfusion (Knops et al, 2011). In patients with a low blood pressure this is likely to be even more exaggerated. This problem is compounded if the patient is also on a spinal board (Knops et al, 2011).Using a device that controls the pressure exerted, such as the SAM pelvic sling, might help prevent pressure necrosis, but there is limited clinical evidence to support this recommendation. Providers must be aware of this problem and avoid transporting these patients on spinal boards.8. The pelvic binder should be placed next to skinThere is limited information regarding this in the literature. Most of the studies have been performed in accident and emergency departments where clothes were removed. Studies examining the effect of pressure exerted by these devices have been undertaken with only thin undergarments on. There is no evidence that placement over clothes provides the same degree of stabilisation or risk of pressure damage. Ideally, pelvic binders should be placed either directly to skin or just over thin underwear. Placement next to skin may allow more accurate positioning of these devices; it will also help prevent the pelvic binder device being removed on arrival at hospital.In certain scenarios, it may be appropriate to place the binder over clothes and the fear of undressing someone should not prevent the use of these devices.9. A pelvic binder should be applied prior to extricationThere is no evidence in literature to help guide a recommendation. If early placement controls haemorrhage and movement of an unstable fracture can disrupt clot formation, it would seem logical that placement occurs prior to extrication where possible. This area requires further investigation to find the optimal method for placement of binder. A pragmatic approach is also required as there are likely to be scenarios when placement is not practical prior to extrication.

Pre-hospital spinal immobilisation: an initial consensus statement

Search strategyPrior to the Faculty meeting in March 2012, a review of the published literature was undertaken using PubMed to search the Medline database. Secondary searches were made using UK PubMed Central and Google Scholar. The search terms included pre-hospital, out-of-hospital, spinal immobilisation, cervical collar and c-spine clearance. A tertiary search analysed the references of retrieved articles to identify further sources.

Twenty-five years of London's Air Ambulance paramedics

Development of the serviceDuring the early years, London's Air Ambulance (LAA) functioned almost entirely as an aeromedical service during daylight hours. A range of drugs were used for anaesthesia and sedation, with individual clinicians employing a variety of approaches to these interventions based on previous experience. Dispatch of the aircraft was handled by specialised emergency medical dispatchers within the LAS control room, and mission cancellation rates were relatively high. The subsequent introduction of LAA paramedics led to improvements in cancellation rates and more clinically focused targeting of the team (Earlam, 1997). The goal of the service has always been to improve patient safety and deliver high-quality clinical interventions, and over time a number of Standard Operating Procedures (SOP) were developed to provide structure and governance of specific aspects of the service, such as the provision of anaesthesia, sedation and analgesia.Roles became more clearly defined for doctors and paramedics, and checklists modelled on those used within the aviation industry were produced to further enhance safety in potentially high-risk procedures such as rapid sequence induction (RSI) anaesthesia. It quickly became clear that whilst the use of a helicopter provided a means of rapid deployment of a specialised trauma team during the day, there were also a number of major trauma patients with unmet clinical needs throughout the night. With this in mind, sponsorship for the provision of a rapid response car was obtained, and the team began to provide cover until midnight or 01:00 hours on certain nights of the week. As staffing levels increased, the frequency and duration of these shifts were increased incrementally, culminating in the introduction of a full 24 hour service in 2010.

Using clinical decision making and reflection strategies to support practice

Clinical decision making and reflection are essential skills for any health care professional to possess in that they underpin and enhance practice by providing a robust framework for structuring one's thinking and subsequent actions.This article highlights the need for the study of clinical decision making which forms a vital part of the paramedic's practice. It provides a background to clinical decision making before presenting an example case study.

Book Review

Completing a trio of research-related reviews, this slender little number provides an alternative focus on research. Not concerned with conducting research or interpreting it, rather how it can be accessed. Gone are the days when a rudimentary search on Google (and other well-known search engines!) will yield a comprehensive list of relevant research to your needs.

Should we change the Mental Health Act 1983 for emergency services?

Following the government's announcement in March that it would be undertaking a review of sections 135 and 136 of the Mental Health Act 1983, Michael Brown considers whether emergency services should be provided with better tools for attending mental health crises in public places and private premises.

Report highlights inadequate UK landing facilities for air ambulances

In April, the Association of Air Ambulances published a report highlighting that landing facilities at UK hospitals were inadequate. Alistair Quaile takes a look some of the reasons for this shortfall and considers the obstacles that have to be overcome if this problem is to be addressed.

FGM: the role of front-line staff

Paramedics and other front-line health and social care professionals have responsibilities to safeguard children and protect adults from the exploitations linked with female genital mutilation (FGM). It is estimated that 66 000 women and girls in the UK have been victims of FGM, with up to 24 000 girls under 15 years of age believed to be at risk (Department for Education (DfE), 2014).

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