• Acute cocaine toxicity: assessment and cardiac risk

      Gardner, Karen (2009-11-27)
      The UK has the highest prevalence of drug use within Europe, with a 13% increase in cocaine and ecstasy related deaths reported between 2004 and 2005. This is significant to emergency medical personnel because cocaine toxicity can present clinically as acute coronary syndrome (ACS) minus typical associated risk factors. Cocaine use has an immediate effect on the body, having an onset of action seconds to minutes after administration. The resultant effect is manyfold, but can be divided into the two broad categories of central nervous system and cardiovascular effects. Cocaine misuse is a trigger of ACS, acute myocardial infarction and sudden death in a population of patients largely free of classic cardiovascular risk factors. Emergency medical staff are in a position to provide early and effective management through history-taking and assessment tools in conjunction with therapeutic intervention. The aim of this article is to highlight the presentation and consequence of acute cocaine toxicity in relation to its assessment, management and cardiac emergencies within the prehospital setting. Abstract published with permission.
    • Advanced prehospital stroke triage in the era of mechanical thrombectomy

      Morrison, Luke (2019-04)
      Abstract published with permission. Direct transport to a comprehensive stroke centre that is capable of endovascular thrombectomy may improve outcomes in patients with large vessel occlusive stroke. A number of prehospital triage tools have been developed to see if clinicians can predict which patients would benefit from this procedure, allowing them to bypass a primary stroke centre in preference for a comprehensive stroke centre. A literature search was performed across a number of medical databases; six triage tools were selected for analysis based on their reported accuracy and prevalence in clinical trials. Additionally, a number of articles were isolated for the analysis of changing systems of care for patients who had had a stroke. This narrative review integrates how these variously accurate triage tools could benefit patients and outlines why changes to the system of care for stroke patients require a ground-upwards, local approach. The accuracy of the triage tools analysed varied, with some lacking specificity and others sensitivity. Triage tools are evolving, and simplistic tools offer comparable accuracy when contrasted with comprehensive alternatives, which require a significantly increased level of assessment skill and time demand. While there is evidence in support of prehospital bypass protocols, this evidence is poorly generalisable owing to a number of variables, with geographical layout being a significant compounding factor.
    • Airway management in UK ambulance services: where are we now?

      George, Jason; Smith, Joanne; Moore, Fionna (2012-06)
    • Algorithms to guide ambulance clinicians in the management of emergencies in patients with implanted rotary left ventricular assist devices

      Bowles, Christopher T.; Hards, Rachel; Wrightson, Neil; Lincoln, Paul; Kore, Shishir; Marley, Laura; Dalzell, Jonathan R.; Raj, Binu; Baker, Tracey A.; Goodwin, Diane; et al. (2017-12)
      Advances in left ventricular assist device (LVAD) therapy have resulted in increasing numbers of adult LVAD recipients in the community. However, device failure, stroke, bleeding, LVAD thrombosis and systemic infection can be life-threatening emergencies. Currently, four LVAD systems are implanted in six UK transplant centres, each of which provides device-specific information to local emergency services. This has resulted in inconsistent availability and content of information with the risks of delayed or inappropriate decision-making. In order to improve patient safety, a consortium of UK healthcare professionals with expertise in LVADs developed universally applicable prehospital emergency algorithms. Guidance was framed as closely as possible on the standard ABCDE approach to the assessment of critically ill patients. https://emj.bmj.com/content/emermed/34/12/842.full.pdf 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/emermed-2016-206172
    • Ambulance clinician assessment and management of transient loss of consciousness: a retrospective clinical audit

      Shaw, Joanna; Ulrich, Alex; Fothergill, Rachael T.; Whitbread, Mark (2016-01)
      Abstract published with permission. Introduction: Transient loss of consciousness (T-LOC) is thought to be underestimated and under-managed in the pre-hospital setting. This clinical audit aims to assess the compliance of ambulance clinicians against the National Institute of Clinical Excellence guidance on the management of patients with T-LOC. Method: Ninety-four patients’ clinical records and electrocardiograms (ECGs) were reviewed to determine appropriateness of assessment and patient management. Results: In this limited sample, findings show standard assessments and history documented for all patients were equally well recorded for T-LOC patients, but those specific to T-LOC were not. The number of ECGs conducted and interpreted correctly was an additional area of concern. Conclusions: Further assessments and history specific to T-LOC are required in the pre-hospital setting to ensure any potentially serious causes are recognised and these patients are taken to hospital.
    • Ambulance identification score for ruptured abdominal aortic aneurysm

      Karthikesalingam, Alan; Fothergill, Rachael T.; Holt, P.; Patterson, B.; Vidal-Diez, A. (2016-07)
    • Ambulance response times and mortality in elderly fallers

      Cannon, Emily; Shaw, Joanna; Fothergill, Rachael T.; Lindridge, Jaqualine (2016-09)
      Background Worldwide, the number of people aged over 60 is growing faster than any other age group. Increased age is associated with a higher risk of falling and roughly a third of individuals aged 65 and over experience a fall each year. One way in which ambulance services may impact the outcome of patients is the time taken for a response to arrive on scene. Lying on the floor for a long time has been found to be strongly associated with serious injuries, admission to hospital, and mortality. However, previous research has not assessed the impact of ambulance response times on mortality. Methods To determine whether there is a relationship between the time elderly fallers (aged 65 and over) spend on the floor and mortality, an observational study was undertaken. A convenience sample of 503 ambulance response times, patient records detailing the amount of time spent on the floor, and patient outcomes at 90 days were analysed using logistic regression. Results Eight percent of patients in the sample died within 90 days of their fall (n=38). Patients who were deceased at 90-day follow-up (n=38) did not wait significantly longer for an ambulance than patients who were still alive (n=464) (means= 34 min vs 37 min, p=.678). Of the patients who were still on the floor upon LAS arrival (n=178), those who had died within 90 days following their fall (n=14) spent less time in total on the floor than patients who were still alive at 90-day follow-up (n=164) (means= 59 min vs 98 min, p=.296). Conclusions Increased ambulance response time or prolonged time spent on the floor was not associated with 90-day mortality in elderly fallers who presented to the ambulance service. Whilst any delays in attending elderly fallers require monitoring, we can be reassured that long waits are not leading to mortality in this patient group. https://emj.bmj.com/content/emermed/33/9/e9.1.full.pdf 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/emermed-2016-206139.29
    • Ambulance smartphone tool for field triage of ruptured aortic aneurysms (FILTR): study protocol for a prospective observational validation of diagnostic accuracy

      Lewis, Thomas L.; Fothergill, Rachael T.; Aneurysm-FILTR Study Group; Karthikesalingam, Alan (2016-10)
      Introduction: Rupture of an abdominal aortic aneurysm (rAAA) carries a considerable mortality rate and is often fatal. rAAA can be treated through open or endovascular surgical intervention and it is possible that more rapid access to definitive intervention might be a key aspect of improving mortality for rAAA. Diagnosis is not always straightforward with up to 42% of rAAA initially misdiagnosed, introducing potentially harmful delay. There is a need for an effective clinical decision support tool for accurate prehospital diagnosis and triage to enable transfer to an appropriate centre. Methods and analysis: Prospective multicentre observational study assessing the diagnostic accuracy of a prehospital smartphone triage tool for detection of rAAA. The study will be conducted across London in conjunction with London Ambulance Service (LAS). A logistic score predicting the risk of rAAA by assessing ten key parameters was developed and retrospectively validated through logistic regression analysis of ambulance records and Hospital Episode Statistics data for 2200 patients from 2005 to 2010. The triage tool is integrated into a secure mobile app for major smartphone platforms. Key parameters collected from the app will be retrospectively matched with final hospital discharge diagnosis for each patient encounter. The primary outcome is to assess the sensitivity, specificity and positive predictive value of the rAAA triage tool logistic score in prospective use as a mob app for prehospital ambulance clinicians. Data collection started in November 2014 and the study will recruit a minimum of 1150 non-consecutive patients over a time period of 2 years. Ethics and dissemination: Full ethical approval has been gained for this study. The results of this study will be disseminated in peer-reviewed publications, and international/national presentations https://bmjopen.bmj.com/content/6/10/e011308.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-2016-011308
    • Anatomical and physiological mechanisms of heartblock associated with AMI

      Edwards, Timothy (2013-12)
      Abstract published with permission. Heart block (HB) is a recognised complication of acute myocardial infarction (AMI) and is often a marker for increased mortality and morbidity. An appreciation of the anatomical and physiological mechanisms associated with the development of HB in AMI is important for the prediction and management of complications when dealing with such cases. Certain forms of HB are classically linked to infarction of specific anatomical territories in AMI. However, variations in pre-morbid state and anatomy of the coronary vessels provide potential for the development of HB in any patient experiencing AMI, regardless of the territory affected.
    • Appropriate pain assessment tools for use in patients with dementia in the out-of-hospital environment

      Armour, Richard; Murphy-Jones, Barry (2016-11)
      Abstract published with permission. There is substantial evidence to suggest adults with cognitive impairment, caused by degenerative conditions such as dementia, are at a significantly higher risk of suboptimal pain assessment and management in the acute care setting when compared to adults without cognitive impairment. This paper aims to assess the pain assessment tools most appropriate for use in adults with cognitive impairment as a result of dementia within the out-of-hospital setting. A search of the literature was conducted in May 2016. The databases searched were Pubmed (Medline) and Embase. The primary types of literature retrieved were meta-reviews, systematic reviews or reviews. All subcategories of dementia were included in this review. From the search strategies, 12 relevant articles and 35 pain assessment tools for use in patients with dementia were identified. In this review, the Abbey Pain Scale and PAINAD have been identified as tools substantiated in the literature for use in detecting pain in adults with dementia, which likely have applications in the out-of-hospital environment. A trial of either the Abbey Pain Scale or PAINAD in an emergency ambulance service is appropriate and likely warranted to assess their impact on pain assessment in this vulnerable patient group.
    • Aspirin administration by emergency medical dispatchers using a protocol-driven aspirin diagnostic and instruction tool

      Barron, Tracey; Clawson, Jeff; Scott, Greg; Patterson, Brett; Shiner, Ronald; Robinson, Donald; Wrigley, Fenella; Gummett, James; Olola, Christopher H.O. (2013-07)
      Background The American College of Cardiology and the American Heart Association recommend early aspirin administration to patients with symptoms of acute coronary syndrome (ACS)/acute myocardial infarction (AMI). The primary objective of this study was to determine if Emergency Medical Dispatchers (EMD) can provide chest pain/heart attack patients with standardised instructions effectively, using an aspirin diagnostic and instruction tool (ADxT) within the Medical Priority Dispatch System (MPDS) before arrival of an emergency response crew. Methods This retrospective study involved three dispatch centres in the UK and USA. We analysed 6 months of data involving chest pain/heart attack symptoms taken using the MPDS chest pain and heart problems/automated internal cardiac defibrillator protocols. Results The EMDs successfully completed the ADxT on 69.8% of the 44 141 cases analysed. The patient's mean age was higher when the ADxT was completed, than when it was not (mean±SD: 53.9±19.9 and 49.9±20.2; p<0.001, respectively). The ADxT completion rate was higher for second-party than first-party calls (70.3% and 69.0%; p=0.024, respectively). A higher percentage of male than female patients took aspirin (91.3% and 88.9%; p=0.001, respectively). Patients who took aspirin were significantly younger than those who did not (mean±SD: 61.8±17.5 and 64.7±17.9, respectively). Unavailability of aspirin was the major reason (44.4%) why eligible patients did not take aspirin when advised. Conclusions EMDs, using a standardised protocol, can enable early aspirin therapy to treat potential ACS/AMI prior to responders' arrival. Further research is required to assess reasons for not using the protocol, and the significance of the various associations discovered. https://emj.bmj.com/content/emermed/30/7/572.full.pdf 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/ http://dx.doi.org/10.1136/emermed-2012-201339
    • Attitudes to cardiopulmonary resuscitation and defibrillator use: a survey of UK adults in 2017

      Hawkes, Claire A.; Brown, Terry P.; Booth, Scott J.; Fothergill, Rachael T.; Siriwardena, Aloysius Niroshan; Zakaria, Sana; Askew, Sara; Williams, Julia; Rees, Nigel; Ji, Chen; et al. (2019-04)
    • Attitudes to CPR and public access defibrillation: A survey of the UK public

      Hawkes, Claire A.; Booth, Scott J.; Brown, Terry P.; Fothergill, Rachael T.; Zakaria, Sana; Askew, Sara; Siriwardena, Aloysius Niroshan; Williams, Julia; Rees, Nigel; Perkins, Gavin D. (2017-09)
    • Barriers and facilitators to public access defibrillation in out-of-hospital cardiac arrest: a systematic review

      Smith, Christopher M.; Lim Choi Keung, Sarah N.; Khan, Mohammed O.; Arvanitis, Theodoros N.; Fothergill, Rachael T.; Hartley-Sharpe, Christopher; Wilson, Mark H.; Perkins, Gavin D. (2017-10)
    • Barriers to Automated External Defibrillation in a volunteer first-responder system

      Smith, Christopher M.; Griffiths, Frances; Hartley-Sharpe, Christopher; Fothergill, Rachael T.; Wilson, Mark H.; Perkins, Gavin D. (2018-09)
    • The Brook Greenwich (1957)

      Whatling, Andy (2019-02-04)
      Photograph courtesy of London Ambulance Service. Abstract published with permission.
    • Bystander cardiopulmonary resuscitation: Impact of training initiatives

      Brown, Terry P.; Booth, Scott; Lockey, Andrew S.; Askew, Sara; Hawkes, Claire A.; Fothergill, Rachael T.; Black, Sarah; Pocock, Helen; Gunson, Imogen; Soar, Jasmeet; et al. (2018-09)
    • Can the prehospital National Early Warning Score identify patients most at risk from subsequent deterioration?

      Shaw, Joanna; Fothergill, Rachael T.; Clark, Sophie; Moore, Fionna (2017-08)
      Introduction The National Early Warning Score (NEWS) aids the early recognition of those at risk of becoming critically ill. NEWS has been recommended for use by ambulance services, but very little work has been undertaken to date to determine its suitability. This paper examines whether a prehospital NEWS derived from ambulance service clinical observations is associated with the hospital ED disposition. Methods Prehospital NEWS was retrospectively calculated from the ambulance service clinical records of 287 patients who were treated by the ambulance service and transported to hospital. In this cohort study, derived NEWS scores were compared with ED disposition data and patients were categorised into the following groups depending on their outcome: discharged from ED, admitted to a ward, admitted to intensive therapy unit (ITU) or died. Results Prehospital NEWS-based ambulance service clinical observations were significantly associated with discharge disposition groups (p<0.001), with scores escalating in line with increasing severity of outcome. Patients who died or were admitted to ITU had higher scores than those admitted to a ward or discharged from ED (mean NEWS 7.2 and 7.5 vs 2.6 and 1.7, respectively), and in turn those who were admitted to a ward had higher pre-hospital NEWS than those who were discharged (2.6 vs 1.7). Conclusion Our findings suggest that the NEWS could successfully be used by ambulance services to identify patients most at risk from subsequent deterioration. The implementation of this early warning system has the potential to support ambulance clinician decision making, providing an additional tool to identify and appropriately escalate care for acutely unwell patients https://emj.bmj.com/content/emermed/34/8/533.full.pdf 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/emermed-2016-206115
    • Cerebral oximetry monitoring in OHCA

      Burrell, Lisa; Rice, Alan (2018-12)
      Abstract published with permission. Background: Cerebral oximetry allows non-invasive, real-time monitoring information of cerebral blood flow. It has recently been used to provide information about cerebral perfusion during resuscitation efforts in cases of cardiac arrest and may give an indication of neurological survival. Most of this information has been obtained during the hospital phase of treatment and little is known about cerebral flow in the prehospital phase. Methods: A systematic review was carried out, with the PubMed and EMBASE databases searched to identify clinical trials where cerebral oximetry monitoring was performed in the prehospital phase of out-of-hospital cardiac arrest. It aimed specifically to answer the following questions: is cerebral oximetry monitoring feasible in the prehospital environment? Can cerebral oximetry be used as a useful marker of the quality of cardiopulmonary resuscitation in the prehospital setting? Can cerebral oximetry be used to assist decisions around prognostication and futility for out-of-hospital cardiac arrest? Results: Five studies were identified for review. Feasibility was demonstrated in four of these. The usefulness of cerebral oximetry in monitoring cardiopulmonary resuscitation has not been well explored in out-of-hospital cardiac arrest. Similarly, data linking intra-arrest cerebral oximetry values and prognosis in out-of-hospital cardiac arrest is sparse. Conclusions: Cerebral oximetry is feasible in out-of-hospital cardiac arrest but its usefulness in guiding resuscitation attempts in this environment remains largely unknown.