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Introduction: AIRWAYS-2 was a cluster randomised controlled trial (RCT) comparing the clinical and cost effectiveness of the i-gel supraglottic airway device with tracheal intubation in the initial airway management of out-of-hospital cardiac arrest (OHCA). In order to successfully conduct this clinical trial, it was necessary for research paramedics to overcome multiple challenges, many of which will be relevant to future emergency medical service (EMS) research. This article aims to describe a number of the challenges that were encountered during the out-of-hospital phase of the AIRWAYS-2 trial and how these were overcome.Methods: The research paramedics responsible for conducting the pre-hospital phase of the trial were asked to reflect on their experience of facilitating the AIRWAYS-2 trial. Responses were then collated by the lead author. A process of iterative revision and review was undertaken by the research paramedics to produce a consensus of opinion.Results: The main challenges identified by the trial research paramedics related to the recruitment and training of paramedics, screening of eligible patients and investigation of protocol deviations / reporting errors. Even though a feasibility study was conducted prior to the commencement of AIRWAYS-2, the scale of these challenges was underestimated.Conclusion: Large-scale pragmatic cluster randomised trials are being successfully undertaken in out-of-hospital care. However, they require intensive engagement with EMS clinicians and local research paramedics, particularly when the intervention is contentious. Feasibility studies are an important part of research but may fail to identify all potential challenges. Therefore, flexibility is required to manage unforeseen difficulties.

This consensus statement provides profession-specific guidance in relation to tracheal intubation by paramedics - a procedure that the College of Paramedics supports. Tracheal intubation by paramedics has been the subject of professional and legal debate as well as crown investigation. It is therefore timely that the College of Paramedics, through this consensus group, reviews the available evidence and expert opinion in order to prevent patient harm and promote patient safety, clinical effectiveness and professional standards. It is not the purpose of this consensus statement to remove the skill of tracheal intubation from paramedics. Neither is it intended to debate the efficacy of intubation or the effect on mortality or morbidity, as other formal research studies will answer those questions. The consensus of this group is that paramedics can perform tracheal intubation safely and effectively. However, a safe, well-governed system of continual training, education and competency must be in place to serve both patients and the paramedics delivering their care.

Background/rationale ‐ Although defibrillation has been shown to improve outcome from cardiac arrest, there is a group of patients that presents with ventricular fibrillation/pulseless ventricular tachycardia that is resistant to defibrillation. In these patients, amiodarone has been shown to improve short-term outcome of survival to hospital admission and improve the response to defibrillation. In addition, refractory ventricular fibrillation may fail to be terminated by pads placed in the standard sternal-apical position, and consideration of a pad-position change is advocated by current UK and European resuscitation guidelines.\ud \ud The aim of this audit was to determine Yorkshire Ambulance Service ambulance crew compliance with current resuscitation guidelines, for adult patients with shockable rhythms that are resistant to defibrillation.\ud \ud Methods ‐ All adult (≥ 18 years) medical cardiac arrests during the audit period (1 July 2016‐30 September 2016) presenting with ventricular fibrillation/pulseless ventricular tachycardia, and requiring three or more shocks, were reviewed for compliance with three standards. These standards related to the appropriate administration of amiodarone (first 300 mg dose and second 150 mg dose), and pad position change (or consideration of change) for refractory ventricular fibrillation/pulseless ventricular tachycardia after five shocks.\ud \ud Results ‐ Within the audit period dates, there were 1584 adult cardiac arrests, with resuscitation attempted in 635 incidents. The presenting rhythm was ventricular fibrillation/pulseless ventricular tachycardia in 176 of cases. In the audit sample, there were 53 documented 300 mg amiodarone administrations and 22 documented 150 mg amiodarone administrations. One patient received 150 mg amiodarone but not a first dose of 300 mg. Of the patients who received three or more shocks, 94.9% (94/99) had IV access. It was possible to determine the sequence of rhythms for 76.3% (29/38) of the cardiac arrests that received more than five shocks. Of these patients, 26 had a refractory ventricular fibrillation/pulseless ventricular tachycardia and one patient had a pad position change, or documented consideration of a pad position change.\ud \ud Conclusion ‐ Compliance with amiodarone administration in shock-resistant arrhythmias is poor and pad position change is not being considered by clinicians for patients in refractory ventricular fibrillation/pulseless ventricular tachycardia. A review of advanced life support training provision and assessment is required within Yorkshire Ambulance Service, and strategies for increasing awareness of amiodarone administration in eligible patients and pad position change are needed.

Introduction ‐ Although there are published studies examining UK paramedic airway management in the out-of-hospital setting, there has been no sizeable survey of practicing UK paramedics that examines their advanced airway management practice, training and confidence. Therefore, the Airway Management Group of the College of Paramedics commissioned a survey to gain an up to date snapshot of advanced airway management practice across the UK among paramedics.\ud \ud Methods ‐ An online questionnaire was created, and a convenience sample of Health and Care Professions Council (HCPC) registered paramedics was invited to participate in the survey. Invitations were made using the College of Paramedics e-mail mailing list, the College website, as well as social media services such as Twitter and Facebook. The survey ran online for 28 days from 21 October to 18 November 2014 to allow as many paramedics to participate as possible. The survey questions considered a range of topics including which supraglottic airway devices are most commonly available in practice and whether or not tracheal intubation also formed a part of individual skillsets. In relation to intubation, respondents were asked a range of questions including which education programmes had been used for original skill acquisition, how skills were maintained, what techniques and equipment were available for intubation attempts, individual practitioner confidence in intubation and how intubation attempts were documented.\ud \ud Results ‐ A total of 1658 responses to the survey were received. Following data cleansing, 152 respondents were removed from the survey, leaving a total of 1506. This represented 7.3% of paramedics registered with the HCPC (20,565) at the time the survey was conducted. The majority of respondents were employed within NHS ambulance services.\ud \ud Summary ‐ This is the largest survey of UK paramedics conducted to date, in relation to advanced airway management. It provides an overview of advanced airway management, with a particular focus on intubation, being conducted by UK paramedics.

INTRODUCTION: Evidence from the past 20 years has highlighted that acute pain is not managed well in the emergency setting, in particular with children. Inadequate management of pain can result in long-term changes in both physical and mental health. This service evaluation aimed to determine how paediatric pain is assessed and managed by ambulance clinicians in a large region in England. METHODS: This retrospective service evaluation analysed electronic patient record (ePR) data routinely collected between September and December 2018. All paediatric patients (< 18 years of age) with pain documented narratively, or a pain score of ≥ 1/10, were included. The primary outcome measure was the proportion of patients with severe pain (defined as a pain score of ≥ 7/10) who achieve effective pain management (reduction in pain score of ≥ 2/10). RESULTS: A total of 2801 paediatric patients who had documented pain were included in the analysis and the median age of patients was three years (interquartile range, 1–12 years). Most had a medical cause of pain (2387/2801, 85.2%), and analgesia was administered by the ambulance crew in 403/2801 (14.4%) patients. Multiple pain scores were recorded for 667 patients. Effective pain management was achieved in 233/271 (86%) patients in moderate pain and 204/210 (97.1%) patients in severe pain. However, of the 437 children in moderate to severe pain who achieved effective pain management, 381 (87%) received no analgesia. CONCLUSION: Children in severe pain received effective pain management, despite the majority not receiving any analgesia. This should be investigated further since non-pharmacological methods of analgesia are unlikely to explain a reduction of this magnitude. Ambulance staff need to be encouraged to record a pain score promptly after arriving on scene and ensure it is repeated. Pain score should be documented as part of the physiological observations and not in the free text of ePRs to ensure that it is identified during audits.