• PP19 Use and impact of the pre-hospital 12-lead electrocardiogram in the primary PCI era (PHECG2): mixed methods study protocol

      Munro, Scott; Gavalova, Lucia; Halter, Mary; Snooks, Helen; Gale, Chris P.; Weston, Clive; Watkins, Alan; Davies, Glenn; Hampton, Chelsey; Driscoll, Timothy; et al. (2019-09-24)
      Background The pre-hospital 12-lead electrocardiogram (PHECG) is recommended in patients presenting to emergency medical services (EMS) with suspected acute coronary syndrome (ACS). Prior research found PHECG was associated with improved 30-day survival, but a third of ACS patients under EMS care did not have PHECG. Such patients tended to be female, older and/or with comorbidities. This previous study was undertaken when thrombolytic treatment was the main treatment for ST segment elevation myocardial infarction (STEMI); practice has since shifted to a predominant interventional strategy – primary percutaneous coronary intervention (pPCI). Moreover, the previous study relied solely on data collected by the Myocardial Ischaemia National Audit Project (MINAP), which does not include information on symptoms, EMS personnel gender, and other factors that may influence decision-making. The PHECG2 study addresses the following research questions: a) Is there a difference in 30-day mortality and reperfusion between those who do and do not receive PHECG? b) Has the proportion of eligible patients who receive PHECG changed since the introduction of pPCI networks? c) Are patients that receive PHECG different from those that do not in social and demographic factors, and in pre-hospital clinical presentation? d) What factors do EMS clinicians report as influencing their decision to perform PHECG? Methods Explanatory sequential Quan-Qual mixed methods study comprising 4 Work Packages (WPs): WP1 a population based, linked data analysis of MINAP from 2010–2017 (n=510,000); WP2 retrospective chart review of EMS records from 3 EMS; WP3 focus groups with personnel from 3 EMS. WP4 will synthesise findings from WP1-3. Conclusions Gaining an understanding into the clinical and non-clinical factors influencing EMS clinicians’ decisions to record PHECG will enable us to develop (and later test through a randomised trial) an intervention to improve PHECG uptake and patient outcomes following an ACS event., https://emj.bmj.com/content/36/10/e9.1. 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 http://dx.doi.org/10.1136/emermed-2019-999abs.19
    • Pre-hospital anaesthesia and assessment of head injured patients presenting to a UK Helicopter Emergency Medical Service with a high Glasgow Coma Scale: a cohort study

      Bootland, Duncan; Rose, Caroline; Barrett, Jack; Lyon, Richard M.; Kent, Surrey and Sussex Air Ambulance Trust (2019-02)
      Objectives Patients who sustain a head injury but maintain a Glasgow Coma Scale (GCS) of 13–15 may still be suffering from a significant brain injury. We aimed to assess the appropriateness of triage and decision to perform prehospital rapid sequence induction (RSI) in patients attended by a UK Helicopter Emergency Medical Service (HEMS) following head injury. Design A retrospective cohort study of patients attended by Kent Surrey & Sussex Air Ambulance Trust (KSSAAT) HEMS. Setting A mixed urban and rural area of 4.5million people in South East England. Participants GCS score of 13, 14 or 15 on arrival of the HEMS team and clinical findings suggesting head injury. Patients accompanied by the HEMS team to hospital (‘Escorted’), and those that were ‘Assisted’ but conveyed by the ambulance service were reviewed. No age restrictions to inclusion were set. Primary outcome measure Significant brain injury. Secondary outcome measure Recognition of patients requiring prehospital anaesthesia for head injury. Results Of 517 patients, 321 had adequate follow-up, 69% of these were Escorted, 31% Assisted. There was evidence of intracranial injury in 13.7% of patients and clinically important brain injury in 7.8%. There was no difference in the rate of clinically important brain injury between Escorted and Assisted patients (p=0.46). Nineteen patients required an RSI by the HEMS team and this patient group was significantly more likely to have clinically important brain injury (p=0.04). Conclusion In patients attended by a UK HEMS service with a head injury and a GCS of 13–15, a small but significant proportion had a clinically important brain injury and a proportion were appropriately recognised as requiring prehospital RSI. For patients deemed not to need a HEMS intervention, differentiating between those with and without clinically important brain injury appears challenging. https://bmjopen.bmj.com/content/9/2/e023307.long 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/ http://dx.doi.org/10.1136/bmjopen-2018-023307
    • Pre-hospital resuscitation INtra-arrest cooling effectiveness survival – the PRINCESS study

      Nordberg, Per; Taccone, Fabio; Truhlar, Anatolij; Ortiz, Fernando R.; Vermeersch, Nick; Goldstein, Patrick; Cuny, Jerome; Vrankx, Marc; Jimenez, Francesco C.; Lyon, Richard M.; et al. (2015-11)
    • Predictors of survival from out-of-hospital cardiac arrest

      Chamberlain, Douglas (2010-10-21)
      This year is the 50th anniversary of the introduction of modern resuscitation from cardiac arrest, made possible by the combination of closed chest compressions with external defibrillation and effective artificial ventilation.1 Inevitably this was restricted initially to hospitals, but within a few years the need to counter sudden death in the community led to the development of cardiac ambulances. The appreciation that lethal cardiac arrhythmias are not only due to acute myocardial infarction but can also occur unpredictably from a myriad of causes led to more complex responses. In most developed countries we now have public education on the need for rapid access to help, widespread training in cardiopulmonary resuscitation (CPR), means of early defibrillation where relevant and skilled aftercare—the so-called ‘chain of survival’.2 But daunting problems markedly limit success, irrespective of knowledge and training within the community. Even when death strikes suddenly and prematurely, many cases are complicated by severe underlying pathology that is not always amenable to prompt treatment. Even more importantly, only a very few minutes are available for effective resuscitation before apparently irreversible cerebral and cardiac changes make recovery impossible. Survival from out-of-hospital cardiac arrest (OOHCA) is therefore achieved only in a small minority, even of those ‘too young to die’. Investigating the predictors of success can help to prioritise efforts to improve results that are currently so dire. They have also been used as a guide for recognising futility, with the aim of curtailing resuscitation attempts that may have no chance of success. Many studies have been published on the predictors of success for resuscitation of out-of-hospital cardiac arrest (OOHCA), including a recent review.3 As with all data relating to survival from major prehospital events, this topic is bedevilled by difficulties that may lead to inaccurate or misleading data and also to discrepancies that may be more apparent than real. Accurate record keeping in prehospital care of emergencies is challenging; even the identity of victims is often not known initially. Collation of data from emergency services with those from hospitals in order to ascertain discharge status can be very difficult, especially in the UK because of confidentiality rules. Some well-organised groups—particularly in Sweden4 and North America5—have largely overcome such problems and have been able to contribute greatly to our knowledge. But, criteria for inclusion of data vary widely between reports, ranging from all cases in which a resuscitation effort has been made to identifiable subgroups chosen for comparator purposes, designed to eliminate as far as possible variables that cannot be influenced by emergency services. The international Utstein group recommended in 19916 the use for this purpose of only bystander-witnessed adult arrests of presumed cardiac origin in which ventricular fibrillation or pulseless ventricular tachycardia (VF/VT) was the first recorded rhythm. A later review from the same source placed more emphasis on less restrictive data that are of more value in terms of epidemiology.7 The purpose for which data are collected can lead to appreciable differences in inclusion criteria that will have some influence on predictors of a successful outcome. Most predictors of success are widely agreed, however, and are valid for most prehospital cardiac arrest data irrespective of the inclusion criteria. The response interval of the emergency service is an obvious one, although a recent publication highlighted the non-linear effect of delay8; the penalty of time lost in the first 4 min is slight because all short delays are favourable, but the additional penalty when delays are long is also slight because they are all unfavourable. Herlitz et al9 found that the first recordable rhythm scored even more highly than the response interval; VF is favourable because it can usually be reversed, it tends to occur where the underlying pathology is not inevitably fatal, and it also acts as a surrogate for response interval since asystole ensues in all cases within minutes. The same authors listed other factors achieving high statistical significance for success: cardiac arrest outside the home; witness by bystander; CPR given before the arrival of the ambulance; and age. Both the site of the arrest and the availability of a witness also relate to delay to the onset of treatment, so are not totally independent. Age is important principally as a marker of likely comorbidity. As an independent predictor, it seems relatively unimportant when allowance is made for the lower incidence of VF as the first recorded rhythm.10 Several accepted predictors are thus very interdependent but fundamentally reflect the times to effective first aid (CPR) or definitive treatment, together with comorbidity and underlying pathophysiology for which first observed rhythm is a surrogate. Other potential predictors of success depend on observations available only during the resuscitation attempt. Complex analysis of the fibrillatory waveform11 can reveal characteristics that have a strong relationship to the chances of a return of spontaneous circulation (ROSC); the possibility has been explored of its use to determine the appropriate timing of an automated defibrillator shock. More importantly, the occurrence of ROSC during an attempted resuscitation is a variable of clinical significance. If ROSC cannot be achieved at least transiently, then the likelihood of eventual recovery is low; failure in cases presenting with VF has been suggested as an indication for terminating resuscitation efforts. In Ontario12 a guideline designed for terminating an attempt by those qualified to practise only basic life support and defibrillation was found also to be suitable for those who had advanced life support skills. This depended on no ROSC prior to transport, no shock having been required, the arrest unwitnessed by emergency medical services personnel or bystander and no CPR. Many might be uneasy with such guidance even after a careful study of its validity. The Swedish group have made major contributions over at least 12 years to our understanding of the predictors of a successful outcome for resuscitation after cardiac arrest. This issue of the journal contains their latest study13 that differs from others in that it focuses on the survivors of OOHCA rather than on the totality of victims (see page 1826). This new perspective has some important implications that merit attention. The first is the need to be less pessimistic about patients with non-shockable rhythms at first contact; they comprise 20% of this series of nearly 2200, and two-thirds never received a shock. The attitude of professional rescuers has not been investigated as a predictor of success, but its importance should not be doubted. Second and less encouragingly, the outcome in terms of cerebral function tended to be less good for asystolic arrests. This may have been due to longer resuscitation attempts, but one might also speculate on possible effects of adrenaline which has been shown in an animal model to have important adverse effects on cerebral capillary flow.14 Also important is the finding that a third of all survivors had arrests witnessed by ambulance staff; this highlights powerfully the continuing requirement to educate the public in the need to call promptly for unaccustomed chest pain. Less surprisingly, in these new data 79% of survivors had a cardiac aetiology and 90% were witnessed. Women accounted for only 28% of survivors; they were more likely to be at home, less likely than men to have VF and had less CPR. The underlying reasons are understandable and will be hard to counter. We now understand most of the predictors of success in the treatment of OOHCA, but one important lesson is never to equate a lower chance of survival with no chance. This can have a powerful demotivating effect on management, both pre- and in-hospital, with the result that we have fewer successes than our present knowledge base can justify., https://heart.bmj.com/content/96/22/1785. 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 http://dx.doi.org/10.1136/hrt.2010.207076
    • Prehospital amputation: a scoping review

      Gander, Bradley (2020-01)
      Abstract published with permission. Background: Where limbs or extremities become entrapped and it is not possible to extricate a patient in time to prevent death, or because of a deterioration or scene safety emergency, prehospital amputation is an option to enable extrication. Aims: This study aimed to analyse accounts of prehospital amputation and identify factors that may influence practice as well as areas for further research. Methods: A search of multiple databases (AMED, BNI, CINAHL, EMCARE, Google Scholar and PubMed) and additional literature for accounts of prehospital amputation was carried out. Results: Thirteen sources of evidence describing 20 cases of prehospital amputation (18) or dismemberment (2) in a variety of settings between 1975 and 2019 were identified. Prehospital amputation was reported following structural collapse (8), industrial accidents (6), road traffic crashes (5) and rail incidents (1). The procedure was undertaken for a range of reasons, including unsuccessful traditional extrication attempts (7), time-critical patient condition (6), a risk of further extrication attempts causing structural destabilisation (5) and dismemberment of deceased victims (2). The equipment used to perform the amputation was not reported in 14 cases. Outcomes were reported in 17 accounts, with all patients surviving to hospital. Conclusion: Prehospital amputation is performed extremely rarely and accounts in the literature are limited. The situations and environments in which prehospital amputation is reported vary and specialist teams are often required. Further review of guidance and studies on techniques may be beneficial.
    • Prehospital neuromuscular blockade post OHCA: UK's first paramedic-delivered protocol

      Durham, Mark; Westhead, Pete; Griffiths, David; Lyon, Richard; Lau-Walker, Margaret (2020-05-05)
      Background: Since 2016, critical care paramedics from the South East Coast Ambulance Service have offered neuromuscular blockade to patients for ventilatory/airway control after cardiac arrest. Aims: To examine the first cases of paramedic-delivered neuromuscular blockade, and evaluate the prevalence of its use and safety. Methods: Retrospective service evaluation of patients receiving post-arrest paralysis during the study period from 1 April 2016 until 31 July 2017. Findings: The study included 127 patients. The mean age of administration was 63 years, mean weight was 80 kg (SD: 19 kg), dose was 1 mg/kg and median time from rocuronium administration to hospital was 32 minutes (IQR 20–43 minutes). Three patients (2.3%) experienced a minor adverse incident. There were no major airway complications, nor other significant adverse incidents. Thirty-seven patients (31%) survived to discharge. Conclusion: From this patient group, paramedic-administered rocuronium in intubated patients who have experienced a cardiac arrest and a return of spontaneous circulation appears to be safe, but further interventional research is required to determine whether this improves patient outcomes. Abstract published with permission.
    • Prehospital thrombolysis for STEMI where PPCI delays are unavoidable

      Lashwood, David (2020-09-07)
      Primary percutaneous coronary intervention (PPCI) is the gold standard for treating patients experiencing ST-elevation acute myocardial infarction (STEMI). More than 30 000 patients experience cardiac arrest out of a hospital setting in the UK every year and may be some distance from a PPCI facility. Aims: To analyse and consider if a better outcome could be achieved for patients if PPCI was an adjunct to thrombolytic therapy, where delays of ≥60 minutes are inevitable or unavoidable. Methods: The current review examined a range of articles, research materials and databases. Results: Some studies suggested the use of prehospital thrombolysis while others compared the effectiveness of drug-eluting stents. While the ‘gold standard’ for the treatment of patients experiencing a myocardial infarction is still PPCI, several factors can delay patients from receiving this treatment at an appropriate facility within the recommended time frame. Conclusion: Patients may not be able to access PPCI within 60, 90 or 120 minutes for reasons including increasing urbanisation, population growth and NHS hospital funding cuts. If the PPCI unit is some distance away, ambulance crews could start thrombolysis treatment and transmit clinical findings to a specialist cardiologist in the PPCI facility, or stop at a local hospital that could provide thrombolysis. Abstract published with permission.
    • Presence of a pre-hospital enhanced care team reduces on scene time and improves triage compliance for stab trauma

      Cowley, Alan; Durham, Mark; Aldred, Duncan; Crabb, Richard; Crouch, Paul; Heywood, Adam; McBride, Andy; Williams, Julia; Lyon, Richard M. (2019-09-06)
    • The primacy of basics in advanced life support

      Chamberlain, Douglas; Frenneaux, Michael; Fletcher, David (2009-06)
    • Professionalism in paramedic practice: the views of paramedics and paramedic students

      Gallagher, Ann; Vyvyan, Emma; Juniper, Joan; Snook, Verity; Horsfield, Claire; Collen, Andy; Rutland, Stuart (2016-09)
      Abstract published with permission. Paramedic practice is complex and involves decision-making in situations that are often complex and pressured. A high level of professionalism is required to respond appropriately. There has been little previous research in this area. The aim of the Consensus towards Understanding and Sustaining Professionalism in Paramedic Practice project was to develop an in-depth understanding of professionalism in paramedic practice (CUSPPP). This article reports findings from the qualitative component of the CUSPPP project. Interviews were conducted with clinical managers, specialist paramedics and student paramedics. A favourable ethical opinion was obtained from the University of Surrey Ethics Committee. Data were analysed thematically and three themes identified are discussed in this article: components of paramedic professionalism; professionalism enablers; and professionalism inhibitors. Components of paramedic professionalism include: the conduct of paramedics; the role of regulation; professional education; and values for paramedic practice. Paramedic professionalism enablers and inhibitors relate to three levels: individual, organisational and regulatory/societal levels. On-going education and interventions that promote paramedics’ well-being should be discussed with ambulance trusts and collaboration established to promote the development of educational materials and further research.
    • Protocol C: a nonguidelines - compliant approach to improve survival of patients with out-of-hospital cardiac arrest

      Chamberlain, Douglas; Fletcher, David; Woollard, Malcolm; Handley, Anthony (2012-06)
    • A qualitative study of decision-making and safety in ambulance service transitions

      O'Hara, Rachel; Johnson, Maxine; Hirst, Enid; Weyman, Andrew; Shaw, Deborah; Mortimer, Peter; Newman, Chris; Storey, Matthew; Turner, Janette; Mason, Suzanne; et al. (2014-12)
    • A qualitative study of systemic influences on paramedic decision making : care transitions and patient safety

      Shaw, Deborah; Mortimer, Peter; Newman, Chris; Storey, Matthew; Shewan, Jane; O'Hara, Rachel; Johnson, Maxine; Siriwardena, Aloysius; Weyman, Andrew; Turner, Janette; et al. (2015-01)
    • A randomized trial of epinephrine in out-of-hospital cardiac arrest

      Perkins, Gavin D.; Ji, Chen; Deakin, Charles D.; Quinn, Tom; Nolan, Jerry P.; Scomparin, Charlotte; Regan, Scott; Long, John; Slowther, Anne-Marie; Pocock, Helen; et al. (2018-08)
    • A retrospective analysis of ketamine administration by critical care paramedics in a pre-hospital care setting

      Cowley, Alan; Williams, Julia; Westhead, Pete; Gray, Nick; Watts, Adam; Moore, Fionna (2018-03)
      Abstract published with permission. Objective: This project aims to describe pre-hospital use of ketamine in trauma by South East Coast Ambulance Service critical care paramedics and evaluate the occurrence of any side effects or adverse events. Methods: A retrospective analysis of patients receiving pre-hospital ketamine for trauma between 16 March 2013 and 30 April 2017. Administrations were identified from Advanced Life Saving Interventions and Procedures reports submitted by the clinician and, later, from an electronic database. Each was scrutinised for patient demographics, doses and reports of side effects or adverse events. Results: A total of 510 unique administrations were identified. Following the exclusion of 61 records, 449 (88.0%) administrations remained. The most common indication for administration of ketamine was lower limb injury, with 228 (50.8%) administrations. Ketamine was only administered intravenously, and the median dose of ketamine for all administrations was 30 mg (interquartile range 20‐40 mg). The gender split was dominated by males who accounted for 302 (67.3%) administrations compared to 147 (32.7%) females. The median age of patients was 44 years (interquartile range 28‐58 years), with women on average being older than men. Telephone calls to a consultant were made for 243/449 (54.1%) of the administrations, reflecting a need for sanctioning of the drug, advice on dosages or indications, for example. Conclusions: Critical care paramedics within a well governed system are able to safely administer ketamine within an approved dosing regimen under a Patient Group Direction. Median doses are in keeping with nationally approved guidelines. Reported side effects were within the described frequencies in the British National Formulary. Prospective studies are now needed in order to confirm the safety and efficacy of ketamine administration among the advanced paramedic population.
    • A retrospective review of patients with significant traumatic brain injury transported by emergency medical services within the south east of England

      Barrett, Jack (2019-03)
      Traumatic brain injury (TBI) will be a leading cause of death and disability within the Western world by 2020. Currently, 80% of all TBI patients in England are transported to hospital by an ambulance service. The aim of this retrospective study is to compare TBI patients transported to a major trauma centre (MTC) against those transported to a trauma unit (TU). Abstract published with permission.
    • A review of the burden of trauma pain in emergency settings in Europe

      Dissman, Patrick D.; Maignan, Maxime; Cloves, Paul D.; Gutierrez Parres, Blanca; Dickerson, Sara; Eberhardt, Alice (2018-12)
    • Rudolf Juchems — A pioneer of cardiopulmonary resuscitation in Germany

      Böttiger, Bernd W.; Chamberlain, Douglas; Bossaert, Leo; Juchems, Markus (2009-10)