Volume 6 Issue 9

Pre-hospital lactate monitoring for adults with sepsis

Background: Sepsis is a life-threatening condition that claims 37 000 lives in the UK. The sepsis six care bundle was developed by the surviving sepsis campaign in 2002 to address this high mortality rate. Part of this care bundle involves measuring blood lactate which is prognostic of mortality. Lactate can be measured by paramedics in the pre-hospital setting using hand held monitors similar to blood glucose machines, with accuracy that is comparable to laboratory measured lactate.Method: A focused electronic literature search was carried out on a number of different databases as well as a hand search of specific relevant journals. Data was also obtained from reference harvesting, although the limitations of this was appreciated. Experts in the field were also contacted with relevant data obtained. An ongoing pre-hospital trial monitoring lactate was also identified and these researchers were contacted with relevant data obtained.Conclusions: Pre-hospital lactate monitoring would promote better recognition of sepsis in adults and improve the quality of care. It could be used to initiate a specific treatment regime such as intravenous antibiotics. This would reduce the numbers of patients admitted to intensive care, helping to reduce mortality and costs for the NHS.

Rapid sequence induction and the paramedic

It is usually the most obtund and critically ill of patients that receive paramedic pre-hospital endotracheal intubation. Without a patent airway, asphyxia will lead to death rapidly if not corrected. Pre-hospital endotracheal intubation is indicated in patients when there is—or a risk of—apnoea, upper airway blockage and a need for safeguarding against aspiration due to a decreased Glasgow Coma Scale. Endotracheal intubation is currently routinely performed on cardiac arrest patients and traumatic injury patients by paramedics. However, rapid sequence intubation induction, as an advanced paramedical procedure, is not currently advocated for UK paramedic practice. Rapid sequence intubation differs from the normal method of endotracheal intubation in that it can be performed on originally conscious and/or semi-conscious patients and that it uses sedation and paralytic pharmacological agents coupled with protective airway manoeuvres to induce a state of sedation suitable to facilitate endotracheal intubation. This paper explores some of the issues surrounding whether it is feasible for paramedics to routinely perform RSI in the future.

Recipe for success: baking in Boston strong-observations on Boston's success

On 15 April 2013 at 14:29 hours, two improvised explosive devices (IED) exploded within 15 seconds of each other in Boston. The explosions occurred approximately 200 yards apart at the Boston Marathon finish line.In the follow on to the event it became quickly apparent that Boston EMS, in collaboration with the health community had achieved, by any standard, an effective response. One determining factor was the survival of victims; in Boston no victims died who survived the initial blast. This success did not happen by chance. In the wake and review of the events it became apparent that the successful response during the Boston Marathon was the result of decades of preparedness.This article will not dwell on the actual response events as other reports and articles have done that well. The intent is to discuss the underlying principles that led to a successful response by Boston EMS and the other parts of the community response system. As will be discussed, the whole community of Boston participated in not only the response that day, but was integral parts of the recipe that created such a successful response.

Pre-hospital assessment and treatment of meningococcal meningitis

This article highlights ambiguities in current UK ambulance clinical guidelines for meningococcal meningitis and presents a discussion of the difficulty of diagnosing and treating the condition within a pre-hospital context. It recommends the development of a meningitis diagnostics scale in order to aid ambulance clinicians with a thorough patient assessment and to determine when treatment should be initiated. It suggests additionally that there should be further research into the benefits or detrimental effects of pre-hospital antibiotic treatment and adjunctive treatments, and whether non-penicillin antibiotics should start to be considered as the primary course of treatment for the UK ambulance service in relation to a world-wide increase in penicillin-resistant strains of meningococcal meningitis.

Documentation: are we writing it right?

While the need to keep accurate patient records is acknowledged by the bodies that govern healthcare practice, there is currently little evidence to support a specific standard of record keeping, with advice on following one of several recognised models. For many ambulance Trusts, documentation guidelines are based on expert opinion of what should constitute good medical records and documentation, but this can vary from region to region. However, whichever model is used, there are several core principles that should be used when writing medical documentation.This article aims to provide ambulance staff with general information on documentation in an attempt to enable readers to understand why records are kept, the standard to which records should be kept, and the legal and regulatory issues relating to record-keeping for paramedics.

Challenge your thinking: mechanical direct pressure device

Nothing newThe control of compressible catastrophic haemorrhage prior to airway, breathing and circulation (CABCDE) is not a new approach, being advocated for civilian use by Hodgetts et al in 2006, and implemented by most ambulance services (including the South Western Ambulance Service NHS Foundation Trust) in 2008. It includes strategies for tourniquet use, pressure dressings and haemostatic agents, and while all have a place in the control of haemorrhage, they also require accurate teaching and practise.However, despite these implementations, it seems that we still have some way to go to ensure that all paramedic and ambulance staff are drilled in the use of their haemorrhage control equipment.

Ministerial approval for commencement of work on paramedic prescribing

The Allied Health Professions (AHP) Medicines Project is a joint initiative by NHS England and the Department of Health to extend prescribing, supply and administration of medicines to Allied Health Professions, with the aim of facilitating service redesign; increasing patient choice; improving access to medicines; and making the best use of allied health professionals’ skills, while maintaining patient safety.

Management of SVT downunder: is it all upside-down?

This paper describes a retrospective study of supraventricular tachycardia (SVT) management in the pre-hospital setting of an Australian embulance service. Using patient data from the Victoria Ambulance Clinical Information System (VACIS), accuracy of rhythm recognition and the efficacy of differing treatment modalities in reverting SVT was examined; additional analysis examined patient characteristics, response data and adverse events (AE) related to treatment.

Continuing Professional Development: An outline of acute and chronic complications of diabetes

OverviewAlthough a common condition, the mechanisms of diabetes are not always simple to understand, and requires concentration as well as an appreciation of multiple body systems. This Continuing Professional Development (CPD) module will hopefully further your knowledge of the physiology of diabetes and help you to understand why diabetes and its complications present as a particular set of symptoms.Learning OutcomesAfter completing this module you will be able to:• Understand the physiology of type 1 and type 2 diabetes mellitus.• Know why diabetes and its complications present as a particular set of symptoms.• Be able to recognise the different problems that can arise as a result of diabetes.• Learn about the long-term complications of diabetes.

Book Review

An initial glance at the title of this book may have the majority of paramedics reaching for their JRCALC pocket book (still too big) to see if a clinical update had surreptitiously made its way into its hallowed pages. In actual fact, an increasing number of paramedics are able to perform surgical airways, as the everexpanding scope of practice for our profession continues to incorporate advanced clinical interventions.

A response to ‘Paramedic Pathfinder: is it really better than current practice?’

In his letter of response published in last month's Journal of Paramedic Practice (JPP), Goulding (2014) raises several concerns regarding the validity and necessity for a recently implemented Paramedic Pathfinder (Newton et al, 2013), while attempting to develop an argument against its wider application to UK EMS practice. His reasoning is broadly underpinned by three key assertions:

Prescribing for paramedics?

This month, the Journal of Paramedic Practice contains an article from the College of Paramedics on the recent ministerial approval for the commencement of preparatory work to take paramedic independent prescribing proposals forward to public consultation.

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