Clinical Practice

Methoxyflurane (Penthrox®)—a case series of use in the prehospital setting

  • February 2019

Methoxyflurane (Penthrox®) is a fluorinated hydrocarbon, which when first used in general anaesthesia was noted to have strong analgesic properties in subanaesthetic dosage. More than 5 million doses have been sold for use in Australia since 1978 and have been found to have an excellent safety profile. After rigorous review by the Medicines and Healthcare Regulatory Agency, methoxyflurane was granted a product licence in 2015 in the UK and Europe for the relief of pain in patients with moderate-to-severe trauma. This paper presents the first reported case series of patients treated with methoxyflurane in the UK and Ireland in the prehospital environment. The results show a statistically significant improvement in patient pain scores at 1, 2 and 5 minutes following administration of methoxyflurane. With its use increasing in prehospital care and emergency departments, methoxyflurane is recognised as a useful adjunct to the choice of analgesia for trauma patients with moderate-to-severe pain.

Human factors, cognitive bias and the paramedic

  • January 2019

The consequences of human factors and cognitive bias can be catastrophic if unrecognised. Errors can lead to loss of life because of the flawed nature of human cognition and the way we interact with our environment. Seemingly small mistakes or miscommunications can lead to negative outcomes for patients and clinicians alike. It is easy to see therefore why the College of Paramedics now recommends the teaching of human factors at higher education institutions. Using a problem-based approach, this article aims to inform prehospital clinicians about how human factors and cognitive bias can affect them and their practice, and how these can be mitigated.

Splinting of injuries: best practice guidance

  • December 2018

In each issue, the paramedic education team at Edge Hill University focuses on the clinical skills carried out by paramedics on the frontline, highlighting the importance of these skills and how to perform them. In this instalment, Rory McKelvin discusses the application of splints to fractures and sets out a best practice step-wise approach to assessment, decision-making and application in prehospital settings

Acute traumatic coagulopathy: the lethal triad of trauma

  • December 2018

Trauma is the leading cause of death for people in the UK and North America, especially for those aged 15–24 years. However, if early management regimes of permissive hypotension, high-flow oxygen and administration of tranexamic acid are applied, mortality risk can be reduced significantly. Acute traumatic coagulopathy (ATC) is an internal process that is initiated by significant or massive trauma because of hypoperfusion resulting in hypovolaemic shock, activation of protein C, platelet dysfunction and disruption to the endothelial glycocalyx. ATC can be exacerbated by hypothermia, acidosis and dilution coagulopathy—the ‘lethal triad’ of trauma. This article discusses the pathophysiology of ATC and treatment strategies via the management of the lethal triad.

Correct pulse measurement

  • November 2018

In each issue, the paramedic education team at Edge Hill University focuses on the clinical skills carried out by paramedics on the frontline, highlighting the importance of these skills and how to perform them. In this month's instalment, Andrew Kirk discusses common pulse sites and correct technique for obtaining a patient's pulse

Tourniquets in the treatment of prehospital haemorrhage

  • November 2018

Background:During recent conflicts in Iraq and Afghanistan, tourniquets were a useful tool in the management of non-compressible prehospital catastrophic haemorrhage. Recommendations for use within the civilian setting were then made. However, civilian research supporting this change in practice is limited.Aims:The aim of the research is to evaluate the utility of prehospital tourniquet application through description of the complications associated with use, as well as identification of mortality following prehospital application.Methods:A literature search was completed using PubMed and Embase for research studies on prehospital tourniquet use in extremity trauma. Study relevance was confirmed via their abstracts and final selection was made through reviewing the full publication. Data were extracted on mortality, complications, indication for use, effective application and application duration of tourniquet use. This was tabulated, and a descriptive analysis performed.Results:The research reported a mortality range of 3–14% with an associated complication rate of 2.1–32.4%. The effectiveness of prehospital application was in the 88.8–98.7% range, with tourniquet application durations of 48–103.2 minutes.Conclusions:The tourniquet should continue to be available to UK paramedics for the management of prehospital non-compressible catastrophic haemorrhage. Application is likely to provide a mortality benefit with limited morbidity and associated complications.

Hyperventilation syndrome: diagnosis and reassurance

  • September 2018

This article provides an overview of hyperventilation syndrome (HVS). Hyperventilation is to breathe in excess of metabolic requirements; in the absence of an underlying organic cause, it is defined as HVS. Alternative terms used in literature are panic or anxiety attack, panic or anxiety disorder, dysfunctional breathing and breathing pattern disorder. This article explores HVS signs and symptoms beyond the familiar clinical signposts of tachypnoea, chest tightness, paraesthesia and anxiety. It will also discuss differential diagnoses and pre-hospital treatment of HVS, focusing on reassuring patients and assisting them in establishing a good respiratory pattern. Patients with HVS use a significant amount of hospital and emergency service resources, ideally placing paramedics to diagnose and treat HVS in the pre-hospital setting to avoid unnecessary and costly hospital admissions. Further research is needed to evaluate the pre-hospital prevalence and diagnostic accuracy of HVS, identify clear diagnostic criteria and design screening tools.

Recognising ECG landmarks

  • September 2018

In each issue, the paramedic education team at Edge Hill University focuses on the clinical skills carried out by paramedics on the frontline, highlighting the importance of these skills and how to perform them. In this instalment, Karen Simpson-Scott takes an in-depth look at electrocardiograms and the vital readings they provide for clinicians

A brief guide to borderline personality disorder in an emergency setting

  • August 2018

OverviewParamedics and ambulance staff are frequently in contact with patients who have mental health diagnoses This may be the primary reason for contacting the emergency services (e.g. self-harm, crisis or suicide ideation) or it may be incidental to their primary clinical concern. Patients in mental health crisis can be challenging and demanding. Most paramedics will not have had specific guidance on identifying or understanding the features, aetiology and responses to treatment of patients with a diagnosis of borderline personality disorder. Borderline personality disorder is associated with a high risk of self-harm, risk-taking behaviour and suicide. Building a rapport with patients is often crucial to paramedics achieving optimum patient care. There are features of borderline personality disorder that may make rapport-building more complex, and the establishment of trust harder for the clinician to achieve and maintain. There is potential for frustration and a lack of understanding to interfere with the successful delivery of person-centred care. In order to support patients with borderline personality disorder, ambulance staff need to be aware of the particular characteristics of this condition and the current best practice guidance.

Best practice technique in intramuscular injection

  • July 2018

In each issue, the paramedic education team at Edge Hill University focuses on the clinical skills carried out by paramedics on the frontlines, highlighting the importance of these skills and how to perform them. In this issue, Andrew Kirk discusses the administration of intramuscular injection in pre-hospital care in line with best practice.

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