Volume 8 Issue 11

Is diazepam or lorazepam the most effective benzodiazepine for use in paramedic management of convulsive seizures in adults?

Diazepam, a drug from the benzodiazepine family, has been used for the acute management of status epilepticus outside of hospital since its introduction in 1963 (Roche, 2007). Although known to be an effective treatment for the termination and subsequent prophylaxis of seizures (Dreifuss et al, 1998), there have been a number of developments in benzodiazepine production since its emergence, leading to the discovery of alternative agents.The Human Medicines Regulations (2012) provides registered paramedics with legal exemption in relation to the administration of diazepam, but does not allow for the autonomous use of any other benzodiazepine medications. Therefore, unless patient specific or patient group directions exist, diazepam remains the only benzodiazepine generally available to ambulance clinicians despite the presence of alternatives that may be more effective. This article compares and contrasts the available literature regarding the qualities of diazepam with those of lorazepam in the setting of managing convulsive status epilepticus.The authors found that lorazepam is often reported to be more effective in terminating seizures than diazepam. Lorazepam may offer a more effective, safer and cheaper treatment option for the management of seizures in the pre-hospital environment.

Pre-hospital risk stratification using a modified thrombolysis in myocardial infarction score: a retrospective medical record review

Introduction:Paramedics commonly convey patients with non-ST elevation acute coronary syndrome (NSTEACS) to emergency departments (EDs) where a risk stratification model (RSM) determines the risk of death or adverse cardiovascular events, and thus whether the patient should be transferred to a specialist heart attack centre (HAC) for an invasive procedure. If paramedics were to risk-stratify the patients in the pre-hospital environment using a modified thrombolysis in myocardial infarction (MTIMI) RSM, this could result in primary triage to an appropriate hospital.Methods:A retrospective medical record review was completed using patients from a metropolitan ambulance service, one ED and one HAC comparing the current method of identifying high risk NSTEACS with a new method; the MTIMI RSM. Positive predictive value, negative predictive value, logistic regression and receiver operating statistic area under the curve (c-statistic) were used to compare methods.Results:Notes of 108 patients were used in this study. Current practice produced a c-statistic (c) of 0.73 (95% CI 0.62 to 0.85) and the MTIMI RSM (c=0.72, CI 0.61 to 0.83). The best RSM overall was the abbreviated MTIMI RSM with only three variables identified through logistic regression (c=0.79, 0.68 to 0.89).Conclusions:Both methods of identifying high-risk NSTEACS were similar as they both used the ECG variable, which was approximately twelve times more prognostic than any other variable. The need to identify a pre-hospital RSM with a good prognostic power still exists; therefore, other RSMs should be explored in a prospective study.

Continuing Professional Development: Ethical aspects of consent, duty of care, and negligence in paramedic practice

OverviewThis CPD module aims to outline, describe and explain some of the key ethical-legal issues in paramedic practice, and their relation to the concept of consent, a duty of care and negligence. Ethical issues are closely intertwined with legal aspects of care and this module will therefore consider the four ethical principles, focusing on the two key principles of autonomy and nonmaleficence.Learning OutcomesAfter completing this module the paramedic will be able to:develop an awareness of the four key ethical principlesappreciate the concept of consent and capacity.comprehend the issue of negligence in clinical practice.understand the issue of a duty of care.

Appropriate pain assessment tools for use in patients with dementia in the out-of-hospital environment

There is substantial evidence to suggest adults with cognitive impairment, caused by degenerative conditions such as dementia, are at a significantly higher risk of suboptimal pain assessment and management in the acute care setting when compared to adults without cognitive impairment. This paper aims to assess the pain assessment tools most appropriate for use in adults with cognitive impairment as a result of dementia within the out-of-hospital setting.A search of the literature was conducted in May 2016. The databases searched were Pubmed (Medline) and Embase. The primary types of literature retrieved were meta-reviews, systematic reviews or reviews. All subcategories of dementia were included in this review. From the search strategies, 12 relevant articles and 35 pain assessment tools for use in patients with dementia were identified.In this review, the Abbey Pain Scale and PAINAD have been identified as tools substantiated in the literature for use in detecting pain in adults with dementia, which likely have applications in the out-of-hospital environment. A trial of either the Abbey Pain Scale or PAINAD in an emergency ambulance service is appropriate and likely warranted to assess their impact on pain assessment in this vulnerable patient group.

Medical Pharmacology at a Glance

The evolution of paramedicine in recent years has been mirrored by parallel developments in both formal education programmes and the accompanying published literature. No more so is this best witnessed than in the field of pharmacology. A topic which could once send paramedics into 3rd stage shock at its very mention, is now an integral part of a modern paramedic's scope of practice.

Sepsis and pre-hospital care: where are we now?

Definitions:In February 2016, the International Consensus Definitions for Sepsis Task Force published recommendations for Sepsis-3. Major changes from earlier definitions included dropping the Systemic Inflammatory Response Syndrome (SIRS) criteria and introducing sequential Sepsis-related Organ Failure Assessment (SOFA) scoring. Sequential scoring will be impossible in some environments (including PH care), in which case the group recommends a quick-SOFA (qSOFA). qSOFA supports the diagnosis of sepsis in patients with suspected infection when two of the following criteria are present:A respiratory rate of 22 breaths per minute or greaterAltered mentationSystolic blood pressure of 100 mm Hg or less.This new sepsis definition has not been prospectively validated and its PH test characteristic is unknown. As such, NICE and the UKST are recommending the National Early Warning Score (NEWS) and the suspicion of infection as a trigger to screen for sepsis.

How patient awareness can beat sepsis

October and November have been a season of numerous conferences in emergency medicine in the UK, and internationally. I had the chance to attend the Sepsis Unplugged conference held in Brighton by the UK Sepsis Trust, aiming for speedy recognition and treatment of sepsis to reduce mortality. A killer of 44000 people per year in the UK, sepsis is still largely unknown to the wider population. The condition recently surfaced in the news however, after a young mother-of-two died of sepsis following a “minor scrape on her hands while gardening”.

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