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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. [ABSTRACT FROM AUTHOR]

This exploratory study addresses the current paucity of knowledge available in UK paramedic practice in relation to cardiac auscultation. There is a recognised lack of data surrounding the efficacy, safety and relevance of patient assessment skills in the pre-hospital setting in general, and cardiac auscultation specifically. This study provides information about current paramedic practice, and provides a basis for further research in this area. An online survey was distributed using convenience and snowball sampling, receiving 328 responses within a 31-day period. The results show that many paramedics rarely, or indeed never, undertake cardiac auscultation and that many lack confidence in recognising normal and abnormal heart sounds. There is also a divided opinion among respondents who provided free-text answers, with some feeling that the skill of cardiac auscultation is vital in pre-hospital care and others firmly disagreeing. This research lays the groundwork for further developments in training, education and continuing professional development for paramedics. [ABSTRACT FROM AUTHOR]

Background: Evidence to support device choice in intraosseous access is lacking in UK paramedic practice. Being unable to access the sternum with devices may result in under-treatment because of the inability to gain timely vascular access. This represents a shortcoming in current practice and a need for further research. Method: A literature review was conducted to find suitable studies and these were critically appraised. The data were synthesised to draw conclusions that could either influence practice or inform research. Study results were analysed in order to examine the following outcomes for devices most successful in terms of insertion rates; insertion times; ease of use; and flow rates. Cost-efficacy was also taken into consideration. Results: Forty-eight relevant articles were identified in the search and 18 were analysed. Of the 18 articles, 7 were randomised controlled trials and 11 were observational studies. Results varied widely with differences in reporting making the synthesis of data problematic. However, there was sufficient evidence to conclude that semi-automatic devices are superior to manual ones. Conclusion: Weaknesses in the evidence and inconsistencies between studies limited the conclusions that could be drawn. There is a strong mandate here for further research. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

In the pre-hospital setting, point-of-care ultrasound (POCUS) is a useful diagnostic tool that can provide additional clinical information to assist with pre-hospital management strategies and choice of hospital destination. Studies describing the clinical utility of paramedic-performed POCUS in the pre-hospital setting are lacking; however with the right training and education, paramedics are able to adequately obtain high-quality ultrasound images. Despite this, education programmes vary widely and a standardised approach is yet to be defined. The technology of ultrasound devices continues to evolve and in future, the transmission of ultrasound images to the receiving hospital should be a minimum requirement. While some studies report that POCUS influences pre-hospital management, data are lacking as to whether this improves patient outcomes. The authors have demonstrated the potentially significant role of POCUS in pre-hospital care; however this assessment modality does not replace physical examination, clinical experience and clinical decision-making. [ABSTRACT FROM AUTHOR]

The management of family during out-of-hospital cardiac arrests and death notification to the family of the deceased in the out-of-hospital setting are topics that are poorly evidenced. Two focus groups consisting of six participants in each were conducted, discussing the two subjects. The results suggest that paramedics prefer family not to be present in the room for a number of reasons and that they don't feel sufficiently trained by their paramedic courses in order to manage family during resuscitation or breaking bad news. The study highlighted a need for more research on both subjects. [ABSTRACT FROM AUTHOR]

Correct initial management of thermal burns is key in promoting patient outcomes. Cooling burns with cool running water (CRW) for 20 minutes has been shown to accelerate the wound healing process, improve cosmetic outcomes and prevent burn progression. This literature review aims to increase understanding of this simple first aid (FA) intervention, help inform paramedic practice, and determine areas for further research. Three themes came to light following systematic searching of the available literature. As a result of a paucity in evidence, a wide range of topics relating to cooling burns have been explored. The topics look at how patients and carers may approach FA in burns, how pre-hospital practitioners currently manage burns patients, and the best methods to use for cooling burns. Findings suggest that there is need for improved education for the lay public and pre-hospital providers in order to improve burn outcomes through FA interventions. While CRW is supported as a beneficial intervention, further research is required into alternative cooling methods to enhance care and evidence-based practice. [ABSTRACT FROM AUTHOR]

Background: Studies investigating the transfer of endotracheal intubation skills from simulation training to out-of-hospital patient scenarios are limited. Aims: The aim was to evaluate the outcome of endotracheal intubation simulation training among paramedics and the safe transfer of skills to outof- hospital cardiac arrest (OHCA) patients. Methods: Paramedics participated in a 1-day simulation training course including five Airtraq endotracheal intubation attempts using three different types of mannequins (n=15 attempts). Performance and outcome of transfer of intubation skills to patients were monitored for the next 35 months. European Resuscitation Council international advanced cardiopulmonary resuscitation guidelines (Nolan et al, 2005) were followed to ensure patient safety. Findings: Endotracheal intubation was attempted in a total of 417 patients with OHCA by 51 (96%) of the 53 participating paramedics. In 366 (88%) patients, intubation was successfully performed in the first or second attempt. Aspiration, airway secretion, a high modified Cormack Lehane score and insecure verification of tube placement were the most common reasons for failed intubation. Conclusion: Endotracheal intubation with Airtraq in adult patients with OHCA can be performed safely by paramedics after receiving a 1-day simulation-based training course. [ABSTRACT FROM AUTHOR]

Major haemorrhage remains the highest preventable cause of death following trauma, accounting for 30-40% of trauma mortality (Kauvar et al, 2006). Therefore, pre-hospital intervention is a key aspect of paramedic practice. Paramedics are often first on the scene and have a range of local and systemic treatment options. Pre-hospital medical advances, such as the introduction of tranexamic acid, allow paramedics to deliver a higher standard of care. In addition, the number of patients on anticoagulants and antiplatelet drugs is increasing; therefore, knowledge of how these drugs interact with the haemostatic response would be beneficial. It is important that paramedics fully understand the mechanisms of drugs interacting with the haemostatic response, and the theory underpinning the management of major haemorrhage (Kreuziger et al, 2012). This enables paramedics to understand why they are administering the care they are providing. This article gives a detailed overview of two physiological responses to major haemorrhage: haemostasis and blood pressure. This is followed by an explanation of how these systems are deranged and altered by major haemorrhage through pathophysiological consequences. Finally, recent research covering advances in the understanding of how deranged coagulation occurs is also discussed. [ABSTRACT FROM AUTHOR]

Survival rates for out-of-hospital cardiac arrest (OHCA) patients in the UK are low compared with other developed countries. UK ambulance services are in an important position to influence these survival rates by improving their 'chain of survival' (Nolan et al, 2006). A paramedic-led resource, with enhanced technical and non-technical skills specialising in OHCAs, has been shown to improve patient outcomes in this population group in the UK. The author proposes that this concept should be considered by all UK ambulance services to improve OHCA patient survival. [ABSTRACT FROM AUTHOR]

Background: Qualitative research involving paramedics and their involvement in end-of-life (EoL) care has already been published, but there have been no published attitudinal studies specifically relating to do not attempt cardiopulmonary resuscitation (DNACPR) orders and paramedics working in the pre-hospital setting in the UK. Objective: To gain an understanding of paramedic attitudes towards an increasingly common aspect of paramedic practice, focusing specifically on the pre-hospital environment and identifying any corelation between gender, length of service, and level of educational attainment. Design: A paper-based questionnaire was distributed to all paramedic grades, operational out of two ambulance stations of a regional NHS ambulance service in March 2017. The questionnaires were designed using a combination of free-text boxes and Likert scales. A total of 33 questionnaires were issued and 11 completed questionnaires were returned. Results: Respondents indicated the importance of communication in relation to DNACPR orders, as well as the role of allied health professionals and family members in the process. Respecting the patient's wishes was considered paramount, as was educational provision surrounding DNACPRs. Conclusion: The majority of respondents reported that they were comfortable incorporating DNACPR orders in their clinical practice, although more modest responses were returned regarding the level of education received in this area of paramedicine. [ABSTRACT FROM AUTHOR]

Hyperkalaemia is a potentially life-threatening metabolic emergency and is the most common electrolyte disorder associated with death. The author attended an incident where a patient suffered asystolic cardiac arrest from hyperkalaemia and was subsequently resuscitated successfully to hospital discharge with good neurological outcome. This piece intends to review all relevant available literature with the aim of developing recommendations to aid paramedics in managing cardiac arrest secondary to Hyperkalaemia. Despite the lack of current goodquality evidence for pharmacological interventions, systematic reviews available have led to the development of clear guidelines. The use of calcium chloride and sodium bicarbonate is recommended, and these are both carried by Critical Care Paramedics (CCPs). Salbutamol therapy has the strongest evidence base of any intervention available out of hospital. It should be considered after the use of the aforementioned medications if the patient achieves ROSC. Consideration must also be taken as to whether the patient would benefit from being moved to hospital to reach vital interventions such as insulin/dextrose therapy and dialysis. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Sepsis is increasingly common and has a high mortality rate. Sepsis can be difficult to identify and patients with severe sepsis often initially present to the ambulance service. Lactate testing has been utilised successfully in other healthcare settings to assist with the identification of septic patients and stratification of illness severity. A focused literature review has revealed that pre-hospital lactate testing has shown benefits to clinicians pre-hospitally in the identification of septic patients presenting to the ambulance service. Only four pieces of primary research were identified and small sample sizes and variability of lactate testing limit the generalisation of the findings. Further research is required to fully investigate the potential benefits of using pre-hospital lactate testing to identify those patients with sepsis, severe sepsis and septic shock presenting to the ambulance service. [ABSTRACT FROM AUTHOR]

In 2010 the National Institute for Health and Care Excellence (NICE) published a guideline to assist clinicians, across various healthcare settings, to diagnose and subsequently manage patients experiencing a transient loss of consciousness (TLoC). The guideline emphasises that patients who are diagnosed as having had an 'uncomplicated faint' or 'situational syncope', from the initial assessment process, may not require conveyance to the nearest emergency department. JRCALC have included these recommendations within the latest published guidelines. Evidently, this may reduce inappropriate admissions and reduce unnecessary NHS expenditure. In addition it enables clinicians to provide care to patients within their home environment thus improving their experience and outcome as a service user. Furthermore, non-conveyance may reduce ambulance turn-around times enabling clinicians to become available to respond to life-threatening emergencies sooner. However, to utilise the guideline, clinicians are expected to be proficient in aspects of history taking, physical examination and 12-lead ECG interpretation. The current paucity of pre-hospital evidence base provides no support for use of the guideline by paramedics. It is questionable as to whether further education and training are required, before paramedics can utilise the guideline, to diagnose and discharge patients at scene without causing any detriment to patient outcome. [ABSTRACT FROM AUTHOR]

This article aims to find and evaluate current available evidence to determine whether the known clinical benefits of orally administered single dose activated charcoal would justify its use in a pre-hospital ambulance setting. A search of medical databases resulted in evaluation of four studies considered to be of sufficient quality to answer the clinical question. The article acknowledges that further research is desirable into the long-term benefits of pre-hospital charcoal and that much current evidence relies on a reasonable extrapolation of benefit from toxin biomarker data in clinical trials. Nevertheless, it recommends that sufficient evidence now exists for ambulance services to consider its use in cases of self-poisoning attended by ambulance paramedics within one hour of toxin ingestion as recommended by NICE (2004) Clinical Practice Guideline Number 16: Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. Recent recommendations lowering the threshold of hepatotoxicity requiring hospital admission to 75 mg paracetamol per kg bodyweight (National Poisons Information Service, 2012) will undoubtedly increase the number of overdoses of the drug encountered by crews where charcoal may prove of benefit. [ABSTRACT FROM AUTHOR]

A study of sepsis patients pre-alerted into hospitals was conducted in the North East of England from October 2011 to March 2013. This study was conducted to assess the effectiveness of the introduction of a sepsis education programme, which included a sepsis screening tool, and to try and establish the number of sepsis cases encountered by paramedics in the region. The results of this study show that the number of cases pre-alerted into the hospitals increased with the introduction of the screening tool, and gave some indications as to the number of sepsis patients encountered in pre-hospital care. We interpret the increase in pre-alerts as an increased awareness of sepsis, but see little impact on the treatment delivered by paramedics. We draw some conclusions on the number of suspected cases of sepsis seen in the pre-hospital environment but without linking to hospital data are unable to give definitive figures. [ABSTRACT FROM AUTHOR]

Paramedic practice is progressing at a more rapid pace now than at any time in its history. Paramedics need to align their method of assessing patients to integrate into the multi-disciplinary team involved in the patient's journey of care and treatment. The review of systems (RoS) approach is widely used and accepted in healthcare, and easily assimilates into paramedic practice. RoS improves patient care by holistically assessing the patient, and can make the inter-professional handover of a patient to another team more professionally acceptable. Documentation using the RoS is more comprehensive and less prone to errors. [ABSTRACT FROM AUTHOR]

Objective: To determine the incidence of unrecognized oesophageal intubation by paramedics in a metropolitan setting. Methods: A retrospective observational analysis was conducted. Patient health care records from the Ambulance Service of New South Wales were used to identify patients who had been intubated by paramedics between 1 January 2007 and 31 December 2010, and transported to St George Hospital, Sydney. Medical records from St George Hospital were reviewed to determine the position of the endotracheal tube (ETT) on arrival in the Emergency Department. Results: During the study period, 196 patients were identified as having an ETT in-situ on arrival to the emergency department. There was inadequate documentation for 67 patients to determine ETT placement. Of the 129 patients included in the final analysis, 4 (3.1%, 95% confidence interval (CI) 0.9-7.8%) had an unrecognized oesophageal intubation. The final ETT positions of the remaining 125 patients were 85.3% (95% CI 78-90.9%) located in the trachea, 10.1% (95% CI 5.5-16.6%) located in a primary bronchus, 0.8% (95% CI 0-4.2%) in the larynx and 0.8% (95% CI 0-4.2%) in the pharynx. Conclusion: The incidence of unrecognized oesophageal intubations in this study was consistent with other reports in the literature, although higher than expected given the training and equipment used in this setting. An incidence of unrecognized oesophageal intubations of zero should be the goal of emergency medical services. The incidence of unrecognized oesophageal intubations may be reduced through recursive training programs and the use of quantitative waveform capnography. [ABSTRACT FROM AUTHOR]

This paper discusses the pre-hospital clinical management of cystic fibrosis (CF) patients suffering with haemoptysis. While clear guidelines and procedures exist within hospitals in regard to the management of such patients, the same cannot be said for the pre-hospital setting, with very limited clinical practice guidance. Massive haemoptysis is a serious threat to life, though for some patients such as the CF population, even a minor bleed can have devastating effect on quality of life. This paper proposes a pre-hospital clinical guideline based on a retrospective case series from a large Australian tertiary hospital. It is hoped this paper will provide important clinical information regarding CF patients suffering with haemoptysis as it is imperative the management of these patients is undertaken promptly and is well-informed. [ABSTRACT FROM AUTHOR]

This article explores the benefits of intranasal as a recommended route for drug delivery in the pre-hospital setting for healthcare professionals. It is currently used in Australia.USA and some UK Ambulance services and remains a preferred route in certain patient groups. Intranasal can lead to a reduction in needle stick injuries for the healthcare professional and allowing immediate drug therapy in a emergency setting for bystanders. Randomised control trial's and evidence- based practice to discuss the absorption rate and different drugs that could be used through this route. After reading this article paramedics should be more aware of this safe route and its benefits in the emergency setting. [ABSTRACT FROM AUTHOR]

Right ventricular infarction (RVI) can occur in isolation but is more commonly associated with inferior myocardial infarction (IMI). It has a higher mortality rate compared to isolated left ventricular infarction and often presents with complications. Early recognition of RVI in paramedic practice is key to decreasing patient mortality. This article focuses on RVI within the pre-hospital environment. Particular emphasis is placed on right precordial electrocardiogram (ECG) lead placement, judicious administration of intravenous fluids in the hypotensive patient, and specific complications associated with vasodilatory drugs in RVI. [ABSTRACT FROM AUTHOR]

Abstract: Chronic obstructive pulmonary disease (COPD) affects thousands of peopleacross the UK. It accounts for a large amount of hospital admissions, which areoften seen by the ambulance service during acute exacerbations. Discussionhas surrounded the amount of oxygen this type of patient should be receivingduring acute exacerbations. Research to provide evidence-based practicefor the use of oxygen in the hospital and pre-hospital environment has beenongoing for several years. In 2009 the Joint Royal Colleges Ambulance LiaisonCommittee (JRCALC) changed their guidance following the British ThoracicSociety's (BTS) release of new guidelines in oxygen use in adult patients, thusdetermining that oxygen should be delivered in a more precise manner. Howeverin light of current evidence could further changes be made in the delivery ofoxygen, by using air-driven nebulisation during the delivery of drugs to patientspresenting in the pre-hospital environment with an acute exacerbation ofchronic obstructive pulmonary disease (AECOPD). This would allow patientsto receive an appropriate amount of oxygen during their transfer to hospital,giving improved care and treatment of patients at risk of hypercapnic respiratoryfailure. This article will discuss the changes to practice which have already beenidentified and recommended and also discuss the potential implications thesechanges may have on patient care. [ABSTRACT FROM AUTHOR]

Abstract: Severe sepsis is a complex medical condition in which the immune system overreacts to an infection leading to circulatory shock and organ failure. Patients with severe sepsis are critically ill and have a high mortality rate in the absence of early aggressive treatment, however, recognition and treatment of the condition remains poor. Recent improvements in the care of patients with myocardial infarction, stroke and multiple trauma have demonstrated how pre-hospital recognition and treatment can greatly improve outcomes for patients, and paramedics are well placed to provide similar improvements to the care of patients with severe sepsis. This article will explore the pathophysiology of sepsis, the recommended treatment bundles suggested by the 'sepsis six campaign' and the difficulties faced in implementing such treatments. Finally, it will explore the interventions that could be undertaken by Paramedics to improve patient care [ABSTRACT FROM AUTHOR]

Background: Weight estimation in pre-hospital paediatric emergencies is often required for the calculation of drug dosages, fluid therapy and defibrillation. In the pre-hospital field the treatment of a patient needs to occur in a timely and accurate fashion, this necessity drives the need for an accurate weight estimation formula. The objective of this study was to identify a paediatric weight estimation formula relevant to the pre-hospital field. Methods: A literature review was undertaken using a variety of electronic medical databases from their commencement date until the end of May 2012. Keywords used in the search included: Weight estimation, drug calculations, pediatric, paediatric, EMS, EMT, paramedic, emergency medical service, emergency medical technician, pre-hospital, out-of-hospital and ambulance. The keywords were used individually and in combination. The inclusion criterion was any study type that described the development or evaluation of a paediatric weight calculation in the pre-hospital or hospital setting. Findings: There were 635 articles located with 25 meeting the inclusion criteria. The commonly used APLS weight estimation formula significantly underestimates a child's weight. The best guess formula appears to be more accurate at estimating the weight; however more research needs to be conducted to validate this method for the pre-hospital field. Conclusion: As the average weight of children increases, the accuracy of weight estimation formulas decreases, suggesting that these methods will be unable to sufficiently adjust to deal with future rises in average weights of children. Further research is required to determine the most appropriate formula for paramedics to use in the pre-hospital setting. [ABSTRACT FROM AUTHOR]

Femoral neck fractures affect up to 75 000 elderly people per year, with up to a third of these patients dying within twelve months. While there is a paucity of research specific to the pre-hospital field, current evidence demonstrates that optimal treatments include appropriate and adequate analgesia, fluid management and correct immobilisation of the injured leg. Analgesia should be considered in a step-wise approach and should be progressive to the patients' needs. Pain relief should be sought through the variety of options open to paramedics and should be initiated immediately. Transfer to the ambulance should be done in a safe manner, ensuring the patient is immobilised and remains pain free. This pre-hospital management of the patient with a femoral neck fracture ensures they receive adequate analgesia and fluid replacement before any definitive treatment at hospital. [ABSTRACT FROM AUTHOR]

Primary postpartum haemorrhage is the most common form of obstetric haemorrhage. Poor recognition and treatment of this condition has been linked to cases of mortality in recent years. Greater choice over birth settings for mothers and a national shortage of midwives are likely to result in more frequent exposure to maternity cases for paramedics in future years. Active management of the third stage of labour reduces the risks of primary postpartum haemorrhage and shortens the length of the third stage of labour. UK ambulance service guidelines are currently based upon physiological management of the third stage of labour, so in the absence of a midwife, paramedics cannot actively manage the third stage. Paramedic training has moved to higher education university programmes in recent years and undergraduate paramedic students receive additional training about the management of obstetric emergencies. This article discusses current clinical practice and recommends that paramedics adopt active management of the third stage of labour, in order to reduce the risk of primary postpartum haemorrhage. In addition, the author asks whether current paramedic practice is effective in treating primary postpartum haemorrhage within the pre-hospital setting, when a midwife is not present at the scene. [ABSTRACT FROM AUTHOR]