• PRe-hospital Evaluation of Sensitive TrOponin (PRESTO) Study: multicentre prospective diagnostic accuracy study protocol

      Alghamdi, Abdulrhman; Cook, Eloïse; Carlton, Edward; Siriwardena, Aloysius; Hann, Mark; Thompson, Alexander; Foulkes, Angela; Phillips, John; Cooper, Jamie; Bell, Steve; et al. (2019-10-07)
      Introduction Within the UK, chest pain is one of the most common reasons for emergency (999) ambulance calls and the most common reason for emergency hospital admission. Diagnosing acute coronary syndromes (ACS) in a patient with chest pain in the prehospital setting by a paramedic is challenging. The Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision rule is a validated tool used in the emergency department (ED) to stratify patients with suspected ACS following a single blood test. We are seeking to evaluate the diagnostic accuracy of the T-MACS decision aid algorithm to ‘rule out’ ACS when used in the prehospital environment with point-of-care troponin assays. If successful, this could allow paramedics to immediately rule out ACS for patients in the ‘very low risk’ group and avoid the need for transport to the ED, while also risk stratifying other patients using a single blood sample taken in the prehospital setting. Methods and analysis We will recruit patients who call emergency (999) ambulance services where the responding paramedic suspects cardiac chest pain. The data required to apply T-MACS will be prospectively recorded by paramedics who are responding to each patient. Paramedics will be required to draw a venous blood sample at the time of arrival to the patient. Blood samples will later be tested in batches for cardiac troponin, using commercially available troponin assays. The primary outcome will be a diagnosis of acute myocardial infarction, established at the time of initial hospital admission. The secondary outcomes will include any major adverse cardiac events within 30 days of enrolment. Ethics and dissemination The study obtained approval from the National Research Ethics Service (reference: 18/ES/0101) and the Health Research Authority. We will publish our findings in a high impact general medical journal.Abstract, URL This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ DOI: 10.1136/bmjopen-2019-032834
    • Pre-hospital surgical cricothyroidotomy by advanced paramedics within a UK regional ambulance service: a service evaluation

      Bell, Steve (2017-09)
      Abstract published with permission. Introduction ‐ Surgical cricothyroidotomy, the insertion of a tracheal tube through an incision in the cricothyroid membrane, is a life-saving intervention utilised when other methods of airway management are ineffective. This evaluation aims to examine the procedural success of the intervention when performed by advanced paramedics within the North West Ambulance Service over a 4-year period. Methods ‐ A retrospective database and patient record evaluation were used, utilising internal data from the North West Ambulance Service. Patients who underwent pre-hospital surgical cricothyroidotomy performed by a North West Ambulance Service advanced paramedic between November 2012 and April 2017 were included. Indications for use, patient demographics, time to insertion and overall success rate data were collected. Results ‐ Pre-hospital surgical cricothyroidotomy was performed on a total of 36 occasions. Medical cardiac arrest accounted for 18 (50%) and traumatic cardiac arrest for 12 (33%) of the interventions. The remaining interventions were performed on patients with cardiac output at the time of the intervention: five (14%) traumatic aetiology and one (3%) medical aetiology. Of the patients, 31 (86%) were male and five (14%) female. The median age was 44.5 years old; ages ranged from 9 years to 88 years old (IQR 29.75). Median time from first cut to insertion of the tracheal tube was 1 minute (range < 30 secs‐5 mins; IQR 75 secs). The overall success rate for pre-hospital surgical cricothyroidotomy was 97% (n = 35). An inability to locate anatomical landmarks was attributed to the only unsuccessful attempt secondary to foreign body airway obstruction. Discussion ‐ Surgical cricothyroidotomy was successfully performed autonomously for a variety of pre-hospital emergency aetiologies across a variety of patient demographics. The success rate (97%) of the intervention, defined as successful ventilation via a surgically inserted tracheal tube, when performed by this cohort of North West Ambulance Service advanced paramedics is highly favourable when compared with other professional groups undertaking the intervention in the pre-hospital environment.