Volume 7 Issue 1

Does adrenaline improve long-term outcomes after out-of-hospital cardiac arrest?

Adrenaline has been an integral component of advanced life support from the birth of modern cardiopulmonary resuscitation (CPR) in the early 1960s.The findings from randomised trials and observational studies indicate that giving adrenaline in out-of-hospital cardiac arrest (OHCA) increases the rate of return of spontaneous circulation (ROSC) but that longer-term outcomes (survival to hospital discharge and neurologically favourable survival) are either worse or, at best, neutral.PARAMEDIC2: The Adrenaline Trial should answer once and for all the question of whether giving doses of adrenaline 1 mg during CPR improves long-term outcome from OHCA. As such, it is the most important cardiac arrest research study ever to be undertaken in the United Kingdom.

Intra-cardiac arrest thrombolysis in the pre-hospital setting: four cases worth considering

Background:It has been estimated that over 400 000 people have an out-of-hospital cardiac arrest (OHCA) annually in the United States and Europe combined, of whom fewer than 10% survive to hospital discharge. In up to 70% of cases OHCA is caused by underlying acute coronary disease or pulmonary embolism, and as such the benefits of thrombolytic therapy during resuscitation attempts have been explored without there being a clear conclusion.This paper presents a case series of four victims of OHCA who received thrombolysis, with adjunctive antithrombotic therapy, in the pre-hospital phase of their treatment. Three of these were attended by a critical care paramedic (CCP)—a paramedic with advanced training in emergency care—who received online physician support. The other victim was attended by paramedics and a physician who is experienced in pre-hospital emergency care.Discussion:Although there is much debate about the efficacy of routine administration of thrombolytic therapy during OHCA, cases such as those featured in this paper indicate a need for clinicians to consider the merits of pre-hospital thrombolysis (PHT) based on individual patient characteristics and the circumstances leading to their presenting condition.Conclusions:Lives can be saved with the timely administration of intra-arrest PHT but candidates should be selected with great care. This may be best delivered in systems where clinicians at scene are supported by expert medical advice, allowing clinicians to recognise and treat this small but important group of survivors.

Essex and Herts Air Ambulance: a focused case series for pre-hospital practice

Pelvic fractures cause significant mortality and morbidity in major trauma patients and contribute to early deaths both pre-hospital and in-hospital. Traditional teaching that few pre-hospital interventions benefit patients with major pelvic fractures has been challenged in recent years and a number of key early interventions are now seeing many such patients survive to reach a surgeon or interventional radiologist for definitive care. We outline the case of a 38-year-old male who sustained a crush injury resulting in a severe lateral compression fracture of his pelvis with associated haemodynamic instability. Fundamental principles of pre-hospital pelvic fracture management are explained including core techniques of patient handling, splinting and packaging along with analgesic strategies and triage principles. Novel theories and interventions for haemostasis are described. The additional care that can be provided by an enhanced care team is also discussed.

The use of polyvinyl chloride film (clingfilm) with burn injury in the pre-hospital setting—the clear facts

Responding to burn patients within the pre-hospital setting, ‘stop the burning process, cool the burn injury, assess and then cover’ is the recommended management procedure included in the standard trauma protocol pathway, endorsed by international burn associations throughout the world. However, the introduction of the use of polyvinyl chloride film (clingfilm) in the pre-hospital setting continues to generate considerable confusion among emergency medical and rescue practitioners responding to burn-injured patients. The use of polyvinyl chloride film (clingfilm) does have a supportive role in burn injury management—just not in the immediate phase of emergency burn care.This paper provides an overview of the clinically-evidenced pathway for the potential use of polyvinyl chloride film (clingfilm), as advocated by leading international emergency burn care and trauma associations.

Considering the implications of changing ambulance response time targets

A document leaked on 21 December outlining proposals to change the response times for some Red 2 patients caused notable sensationalism within the national media. Pete Gregory looks at some of the concerns raised by the document, while Martin Flaherty provides a response on behalf of the Association of Ambulance Chief Executives.

Election fever and the football: a game of rhetoric

With the general election looming ever closer and political parties doing all they can to secure votes, Ian Peate argues that Governments should stop game playing with the NHS and engage in meaningful and open debate with key stakeholders about its future, the level of funding available and the quality and scope of services that they can realistically deliver through the staff they have.

Understanding flu

OverviewInfluenza is a viral infection that causes seasonal illness and sporadic epidemics and pandemics. Immunisation remains the single most effective way of preventing influenza, although seasonal vaccines cannot prevent all cases. This Continuing Professional Development (CPD) module reviews the prevention and management of flu, and dispels the many myths that still exist about vaccination.Learning OutcomesAfter completing this module you will be able to:▪ Recognise the differences between seasonal, epidemic and pandemic flu.▪ Identify the at-risk groups eligible for seasonal flu vaccines.▪ List the benefits, contraindications and side effects of flu vaccines.▪ Know what appropriate pre-hospital treatment can be given to a patient with suspected influenza.

The waiting game: resolving the crisis

Last month saw the highest number of patients who waited more than 4 hours in Type 1 A&E units (major A&E) before they were treated since figures began in 2010 (Campbell, 2014).

Book Review

A familiar topic to kick-start the new year and as activity levels across ambulance services continue to be unrelenting, there are no shortage of opportunities to practise!

Spotlight on Research

Clinical handover: where are we now?Over the years the quality of clinical handover has been identified as an important determinant in patient care when aiming for a smooth transition for the patient from one area of health care provision to another. This paper outlines the findings of a literature search that was undertaken to answer the question: ‘what does published research tell us about handover in pre-hospital settings?’At first glance you would be forgiven for wondering whether this will only include handovers literally in ‘pre-hospital settings’ rather than at the point of handover from ambulance staff to hospital staff. However, the authors explicitly define their interpretation of the term ‘pre-hospital’ and this clearly includes both work outside the hospital as well as at the point of handover between ambulance staff and hospital-based staff.The literature search included papers published between January 2000 and March 2014. Clear inclusion and exclusion criteria are stated within the paper and using these criteria a total of 401 papers were identified.During the subsequent process of screening, 350 papers were excluded as they did not focus on pre-hospital written or verbal handover; and a further 30 papers were excluded as they were either secondary research, conference abstracts or editorials. The remaining papers were assessed for quality using tools based on the work of Greenhalgh (2010) and influenced by the critical appraisal skills programme (CASP).In total 21 papers were included within the review and in Figure 1 (which provides a useful flow-diagram of the review process), the authors identify that 3 were mixed methods, 11 were quantitative and 7 were qualitative studies. Although this is an interesting paper which is for the most part clearly written, there is some confusion in their results section about the total number of papers included in this review as they make reference to 11 quantitative, 8 qualitative and 4 mixed methods studies. This would total 23 studies, which does not tally with the information presented in Figure 1. Having checked the online supplementary information, I can confirm that the total number of studies was, indeed, 21. Don't forget that published papers frequently come with additional information that is supplementary to the main paper which is usually available online—this was useful additional information on this occasion.Final analysis of all 21 papers used a thematic approach which initially produced 32 subthemes which were ultimately reconstructed into four main themes: communication, context, interprofessional relationships, standardisation of handovers.The paper presents insightful discussion around all of these themes using specific examples from the included research studies. Perhaps unsurprisingly there are several studies that identify frustration expressed by paramedics if they experience a lack of ‘active listening’ by their hospital colleagues during clinical handover.Interestingly the authors report that use of mnemonics (such as ASHICE—age, sex, history, injury/illness, condition, expected time of arrival; or MIST—mechanism, injury, signs, treatment) to standardise handover improved structure and consistency in approach and content; however, the literature lacks consensus as to whether this approach improves retention of information by emergency department staff.In conclusion, the authors make recommendations for future research to include focus on organisational and social factors as well as undertaking research on clinical handover once electronic patient report forms are implemented, as this may well impact further on the dynamics of this important element of patient care.This is a valuable paper which summarises relevant literature on ‘pre-hospital’ clinical handover, highlighting that there is still a need to develop in this area of patient care in order to improve patient safety and enhance patient experience.Spotlight on Research is edited by Julia Williams, principal lecturer, paramedic science, University of Hertfordshire, Hatfield, Hertfordshire, UK. To find out how you can contribute to future issues, please email her at j.williams@herts.ac.uk

Air Ambulance and Pre-hospital Care Day tackles key topics in trauma medicine

The eighth London Trauma Conference took place at the Royal Geographical Society, Kensington Gore, between 9 December and 12 December 2014. In a similar vein to previous years, a main programme of presentations was supplemented by breakaway sessions held parallel to the main conference. Speakers addressed a number of topical questions in trauma and emergency medicine. This year, conference organisers decided to run the concurrent London Cardiac Arrest Symposium over two days rather than the usual one, and an advanced paramedic masterclass was introduced covering areas such as analgesia, education, governance, plus a variety of clinical topics. The Journal of Paramedic Practice attended the Air Ambulance and Pre-hospital Care Day held on 11 December, which focused on trauma issues directly relevant to professionals working in the pre-hospital setting.

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