Volume 9 Issue 9

Paramedic management of out-of-hospital postpartum haemorrhage with TXA

Background:As a result of some of the factors discussed within this systematic review, UK Paramedics are more likely to manage postpartum haemorrhage (PPH) within the out-of-hospital setting. This systematic review attempts to address the question: ‘Is it suitable for TXA to be implemented within the UK paramedic management of out-of-hospital PPH?’Methods:Randomised control trials (RCTs) focusing on the effect of TXA upon blood loss during PPH were included within this review. A search strategy was created and applied to databases. Critical analysis of the included studies was carried out, and data were presented within tabular format and discussed through the use of narrative synthesis.Results:Eight RCTs were included within this systematic review. All studies found a significant reduction in the volume of blood loss during PPH when TXA was administered.Discussion:Although TXA was found to significantly reduce the volume of blood loss during PPH, existing evidence is insufficient to support its use within the UK paramedic out-of-hospital management of PPH. Without the presence of studies which are solely focused on the target population, it is difficult to generalise the findings directly to the UK out-of-hospital paramedic management of PPH. This systematic review does however support and supplement the findings of past and current research based upon the relationship between TXA and PPH.

TXA for HEMS patients with suspected haemorrhage

Background:Tranexamic Acid (TXA) has been shown by the CRASH-2 study to reduce the risk of death by bleeding. This evaluation assesses the use of TXA by the Great North Air Ambulance (GNAAS), and considers the individual patient outcomes in hospital, including the need for blood products and venous thromboembolism (VTE) rate.Methods:A service evaluation was performed with the analysis of patient outcome by the review of patient report forms over a 1-year period. Patients who received pre-hospital TXA were identified and further analysis of their outcomes was performed at the two receiving local major trauma centres.Results:106 patients received pre-hospital TXA, all within 3 hours. The majority (73%, n=77) had been involved in a road traffic collision. Thirty per cent (n=32) of patients also received a pre-hospital blood transfusion; 73% (n=58) were subsequently shown to have an injury severity score (ISS) ≥15, which traditionally defines major trauma. Six (6.3%) patients were later found to have a VTE (five pulmonary embolism and one deep-vein thrombosis) within 1 month of injury, although no patients died of VTE. Almost half of the patients received an in-hospital transfusion 45% (n= 45).Conclusion:TXA is a life-saving drug in the bleeding trauma patient, and within this study population, TXA was administered promptly and appropriately. A VTE incidence of 6.3% is in line with other literature, and there were no recorded deaths from VTE. TXA is available to pre-hospital clinicians across the UK, where the author believes its use should be encouraged.

Reduction of a finger in the out-of-hospital arena?

Introduction:Paramedics can find themselves called to digit dislocations. This is challenging as a dislocation can present in various ways, bringing residual damage to tissue and underlying structures from prolonged displacement. The aim is to limit impact on the welfare of the patient and the paramedic's objective is always to get the dislocation reduced as soon as a possible in a quick and safe manner.Dislocation:The most common dislocation of the digit is at the proximal interphalangeal joint (PIPJ), also known as the ‘coach's finger’. PIPJ injuries are commonly seen in ball sports; the dislocation is mainly dorsal in presentation, and normally closed and stable. It is vital that the paramedic undertakes an in-depth digit assessment in order to be equipped with an appropriate treatment plan for the presentation, which can manage the dislocated digit.Discussion—pain relief:While there has been extensive study of systemic analgesia in emergency medical services (EMS), there is little out-of-hospital research on digit ring blocks and the use of regional anesthetics by paramedics in the pre-hospital setting.X-ray:The evidence is contradictory as some insist that X-ray must be carried out pre-reduction, where other authors state that reduction first is acceptable, but only after a thorough assessment.Reduction:There is a distinct lack of evidence for out-of-hospital digit reduction, too sparse for any robust argument to be built.Conclusion:The suggestion is that reduction of the PIPJ dislocation in the out-of-hospital arena is not supported, owing to a lack of evidence. Until more studies are carried out and patient follow-up is proved to be negative with no ongoing digit impact, this skill needs to be undertaken in appropriate locations supported by X-ray.

Continuing Professional Development: Considering infections of the heart

OverviewThis Continuing Professional Development (CPD) module discusses the three main groups of cardiac infections (pericarditis, myocarditis, and endocarditis). It then highlights how they can be identified in the pre-hospital setting and how the ambulance service can contribute to the subsequent diagnosis of patients presenting with these conditions.

A day in the life of a paramedic advanced clinical practitioner in primary care

This ‘day-in-the-life’ article is the author's first-person account of his experiences as a paramedic working in an inner-city GP practice, while training to be an advanced clinical practitioner. The author aims to illustrate the range and complexity of the role of paramedics based in primary care, and how this role is developing beyond the traditional scope of paramedic practice. The article presents actual patient encounters, which reflect a typical working day in primary care. Through this approach, the author hopes to demonstrate how paramedics can complement and extend the skills of an established primary care team. Furthermore, studying advanced clinical practice at postgraduate level provides new and extended clinical skills and knowledge, allowing paramedics to work with greater autonomy.

Mental health in emergency care

The BBC recently reported that work-related stress levels in Welsh emergency personnel workers were at their highest levels. A resource aimed at supporting mental health in 999 workers was established by mental health charity, Mind. One aspect of its ‘Blue Light Champion’ programme identifies ‘Champions’—volunteers or peers who can support their colleagues during periods of stress. The programme also aims to destigmatise mental health—encouraging individuals to recognise and act on symptoms, avoiding the traditional ‘stiff upper lip’ approach.

NICE: Advanced paramedics to ease pressures on A&E?

New draft guidance from the National Institute for Health and Care Excellence suggests that the NHS provide more advanced paramedics with enhanced training in order to alleviate pressures on emergency department services. Alistair Quaile takes a closer look at these recommendations and provides some insight into the bigger picture

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