Emergency Services Current Awareness Update - Issue 24, May To August 2014

Prehospital Emergency Services - Current Awareness Update Issue 24, May to August 2014
Prehospital Emergency Services

Current Awareness Update
Issue 24, May to August 2014

Welcome to Issue 24 of the Prehospital Emergency Services Current Awareness Update.

In this issue:

Whats New

Prehospital Care Research Forum Podcasts

Research & Best Practice
Each issue provides summaries of a selection of recent research from open access and Athens
resources which are relevant to prehospital and emergency care.

I hope that you find the Prehospital Emergency Services Current Awareness Update useful.

Feedback

The Emergency Services Current Awareness Update is produced bi-monthly by:

Alison Price, Librarian
Lincolnshire Knowledge and Resource Service
(on behalf of the National Ambulance Research Steering Group)
Email: alison.price@lincolnshire.gov.uk

This Current Awareness Update was commissioned by the National Ambulance Research Steering Group
comprising of research leads from ambulance trusts in England, Scotland and Wales and other experts and groups
supporting prehospital research. The aim of the group is to support the strategic development of ambulance and
prehospital research whether leading, collaborating in or using research.

The aim of this Current Awareness Update is to provide a digest of information
supporting evidence based practice in prehospital emergency services, focusing upon
resources from open access and NHS Evidence journals which are freely available to
Ambulance Trust staff, whether or not they have access to a dedicated library service.


What's New?

10 priorities for resolving the crisis in emergency departments
This document urges stakeholders to work alongside the College to provide a stable long term future for
A&E services whilst tackling short term pressures. These proposals are the collective view of practicing
emergency physicians and aim to represent cost-effective solutions to ensure that safe patient care can
be delivered.
http://secure.collemergencymed.ac.uk/Shop-
Floor/Professional%20Standards/10%20priorities%20for%20Emergency%20Medicine/?dm_i=21A8,
2GZO5,FLWOI3,916S0,1

Ambulance survey 2013-1-2014: technical document Care Quality Commission (CQC)
In this survey almost 3000 people gave their views of Hear and Treat services a 999 service, in
which trained call handlers give medical advice over the telephone to avoid ambulances and paramedics
being sent out when they are not needed. The survey asked people, amongst other things, whether they
felt reassured by staff, whether they were treated with dignity and respect, whether they understood the
advice given to them and whether they received an explanation if an ambulance was not sent out.
www.cqc.org.uk/content/people-who-call-ambulance-are-positive-about-their-telephone-advice-
improvements-still

Urgent and Emergency Care Review update
NHS England has published an update on the Urgent and Emergency Care Review. The publication
reports on work with local commissioners to development their strategic and operational plans and
provides an update on planning to develop demonstrator sites to trial new models, including the new
NHS 111 service specification.

Extract:
Revised commissioning standards will ensure that:
21. In our End of Phase 1 Report we identified that By extending paramedic training and skills, and
supporting them with GPs and specialists, we will develop our 999 ambulances into mobile urgent
treatment services capable of dealing with more people at scene, and avoiding unnecessary journeys to
hospital. Accordingly, we have been working with Health Education England and other stakeholders on
supporting work they are leading which will reform the education and training of paramedics. We have
also, with the help of our Delivery Group, developed drafts of potential guidance which set out a new
specification for how ambulance services could and should be delivered in the future to achieve
important elements of our vision. Again, we are continuing to develop this draft guidance and when this
process is complete we will release it to the service for use in development of local planning.
www.nhs.uk/NHSEngland/keogh-review/Documents/uecreviewupdate.FV.pdf


Discover the UCLA Prehospital Care Research Forum Podcasts

Prehospital Care Research Forum at the University of California, Los Angeles (UCLA)
The UCLA Centre for Prehospital Care established the Prehospital Care Research Forum (PCRF) at
UCLA in 1992. Its mission is to promote, educate and disseminate prehospital research conducted at all
provider levels to advance and challenge the future of emergency medical services.

Just one new podcast has been made available since the last Update for March and April follow
the link to listen and explore.

Improving Overtriage of Aeromedical Transport in Trauma
A study published in Journal of Acute Care Surgery examined the implementation of a Trauma Advisory
Committee (TAC) to perform outreach and education of emergency medical agencies in the use of
Aeromedical Transportation (AMT). This study discovered that after implementation of a process
improvement initiative (PI), there was a marked decrease (14%) in the percentage of AMT overtriage in
counties with implementation of the PI when compared to counties without the PI.
www.fisdap.net/podcasts/pcrf/improving_overtriage_aeromedical_transport_trauma?t=pcrf

Prehospital Resource

Paramedic Network at Liverpool John Moores University

The Paramedic Network collates information, offers opinion and guidance, and promotes, develops and
supports high quality research and knowledge transfer by paramedics for paramedics. It does this by
connecting paramedics to an alliance of other specialists and this further facilitates research and
development that informs the profession and influences patient care in the future.'
www.cph.org.uk/expertise/injury/

The PCRF has produced a range of podcasts which discuss
current research affecting emergency medical services. The
podcasts aim to review methodology and applicability to
prehospital care, promote healthy and respectful discussions,
and inspire new research.
www.fisdap.net/podcasts/pcrf


Research & Best Practice

The following research papers have been published, or made available online, in the last couple
of months. This is not a comprehensive overview, but represents papers which are freely
available in full text, with current internet links provided.

Papers listed as Open Access @ are freely available in full text from the link provided.

Papers with links listed as Athens Access @ require you to log in with a free NHS Athens
username and password to obtain the full text. These links take you to the abstract initially. To read
the whole paper, choose either full text or pdf from the options on the abstract page. The full text
option will present the article as a single webpage, the puff. option will open as a digital copy of the
original paper. Selecting either will open a page with the following link for you to enter your Athens
username and password;

n.b. A number of papers are poster presentations from conferences for these papers, only the
abstract is available. A paper discussing the need for full-text poster publication also features in this
update.

The research papers have been arranged by the topic headings below:

Prehospital Services - Development and Quality

Prehospital Practitioners Professional Development

Prehospital Research Methods and Discussion

Dispatch, Response and Handover

Patient Profile

Helicopter Emergency Medical Services

Diagnosis, Triage and Intervention

Drug Treatment

Airway Management, Resuscitation & CPR

To create your own Athens username
and password, simply visit:
https://register.athensams.net/nhs/

You can find the complete archive of the Prehospital Emergency Services Current
Awareness Update at the link below, with thanks to Matt Holland of the North West
Ambulance Library and Information Service:

www.networks.nhs.uk/nhs-networks/nwas-library-and-information-service/esca


Prehospital Services - Development and Quality

Adherence to Prehospital Traumatic Brain Injury Guidelines
This Danish study investigated adherence to guidelines, reasons for non-adherence, and complications
related to prehospital advanced airway management in traumatic brain injury patients with an initial
Glasgow Coma Scale score of <9. Data on 54 patients from eight anaesthesiologist-staffed prehospital
critical care teams showed adherence to airway management guidelines to be 92.6% but suggest that
the incidence of systolic blood pressure <120 and hyperventilation following prehospital endotracheal
intubation highlights a change in current practice.

Rogns L, Hansen T, Kirkegaard H et al. Poster presentation: Prehospital critical care
anaesthesiologists and traumatic brain injury-guideline adherence. Scandinavian Journal of
Trauma, Resuscitation and Emergency Medicine 2014 , 22 : P7
Open Access @ www.sjtrem.com/content/pdf/1757-7241-22-S1-P7.pdf

Analysis of Regional Intensive Care Transport Systems
Secondary intensive care patient transport missions can be managed by road ambulance, rotor-wing
ambulance, and fixed-wing ambulance. This Swedish paper used prospectively collected data to test the
hypothesis that costs for transport distances would differ between the three systems. Economic
modelling allowed the authors to compare results taking into account cost and time effectiveness,
revealing that helicopters can be effective up to moderate transport distances (400500km), but were
expensive to operate. For longer ICU patient transports, fixed-wing transport systems were found to be
both cost and time effective compared to helicopter-based systems.

Brndstrm H, Wins O, Lindholm L et al. Regional intensive care transports: a prospective
analysis of distance, time and cost for road, helicopter and fixed-wing ambulances. Scandinavian
Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22 :36
Open Access @ www.sjtrem.com/content/pdf/1757-7241-22-36.pdf

Barriers to the Prehospital Management of Acute Pain in Children
Sixteen advanced paramedics participated in focus groups to identify perceived barriers to achieving
optimal prehospital management of acute pain in children. Three themes emerged; education and
training current clinical guidelines; realities of the prehospital environment. Specific issues raised were
limited prehospital experience with children, the difficulties of gauging pain levels in small children and
problems in administering pain relief to children in distress. The authors discuss alternatives for
evidence-based pathways and guidelines.

Murphy A, Barrett M, Cronin J et al. A qualitative study of the barriers to prehospital management
of acute pain in children. Emergency Medicine Journal 2014; 31:493-498
Athens Access @ http://emj.bmj.com/content/31/6/493.abstract.html?etoc

Chest Compression Quality at a Rate Over 120/minute
This study used a CPR contest for students to investigate the relationship between compression rate
and other quality parameters in CPR including compression depth and recoil. The 161 two-person teams
taking part received conventional lay-person CPR training two weeks prior to the contest. Mean
compression depth and rate were measured with significantly deeper depths seen for rates over
120/min. However this rate resulted in significantly more incomplete chest recoils. The authors note their
study had conflicting results in the quality of chest compression and that further evaluation of the upper
limit of chest compression rate is needed to ensure complete full recoil and adequate depth.

Lee SH, Kim K, Lee JH. Does the quality of chest compressions deteriorate when the chest
compression rate is above 120/min? Emergency Medicine Journal 2014; 31:645-648


Compliance with Guidelines for Prehospital Traumatic Brain Injury Management
This study used data from trauma registry and ambulance records to assess compliance with guidelines
for prehospital management of severe traumatic brain injury in Stockholm, looking at assessment and/or
treatment of airway, ventilation, oxygenation, blood pressure, fluid resuscitation, GCS, and pupil
properties. Prehospital management considered compliant only if assessment or treatment was
documented in the ambulance journal. A 65% criterion was used as a lower limit for acceptable
compliance. The results showed practice to be compliant with guidelines to a large extent, and higher
than in previous studies.

Rubenson Wahlin R, Gustavsson J, Castrn M. Poster presentation - Prehospital management of
severe traumatic brain injury- compliance with guidelines. Scandinavian Journal of Trauma,
Resuscitation and Emergency Medicine, 2014, 22:P1

Computerised Decision Support Systems to Support Prehospital Patient Assessment
There is limited evidence relating to the effect of Computerized Decision Support Systems on guideline
compliance in a prehospital setting. This time-series study of medical records evaluated the effect of the
introduction of CDSS on compliance with the basic assessment process set out in a clinical guideline
and the effect of On Scene Time (OST). Analysis of baseline and post-intervention data should that
compliance rose significantly after the introduction of the CDSS and the post-intervention slope was
stable. No effect was demonstrated in relation to On Scene Time.

Andersson HM, Suserud B, Andersson-Gre B et al. The effect of a Computerised Decision Support
System (CDSS) on compliance with the prehospital assessment process: results of an interrupted
time-series study. BMC Medical Informatics and Decision Making, 2014, 14:70
Open Access @ www.biomedcentral.com/content/pdf/1472-6947-14-70.pdf

Integrated Resuscitation Service
This poster describes a prehospital service where the deployment of a specialist physician response unit
(PRU) has enabled the early delivery of critical care interventions (including therapeutic hypothermia
(TH) and immediate percutaneous coronary intervention (PCI)) and the direct transfer of unstable out -of-
hospital cardiac arrest patients to a cardiac intervention centre. Data for 28 patients attended by the PRU
over two months showed overall survival to cardiac intensive care to be 56%, with overall survival to
discharge 48%. The authors note that the PRU service can optimise outcomes in selected cases.

Hunter-Dunn C. Poster presentation: An integrated resuscitation service, combining a pre - hospital
physician response unit with delivery to a dedicated high-volume cardiac arrest centre, optimises
survival following cardiac arrest. Scandinavian Journal of Trauma, Resuscitation and Emergency
Medicine, 2014, 22 : P17

Lessons from the Tokyo Subway Attack
The Japanese Sect Aum Shrinryko launched a terrorist attack on the Tokyo Underground in March 1995,
releasing the nerve agent sarin whose effects include coma, seizure and loss of centre respiratory drive.
Over 5000 people needed medical assistance, 980 of whom were moderately effected, 54 severely
injured and 12 killed. Several papers were published in Japan reflecting on the emergency response,
identifying lessons with a number of common themes including the need for physicians in command and
control centres, the ready availability of personal protective equipment, difficulties in diagnosis and
indetecting the agent which had been released. The authors of this extended essay discuss the lessons
nearly 20 years on with the benefit of hindsight, noting that many of the lessons learnt remain valid but
have in some cases been forgotten or overtaken by more recent events.

Byers M. Extended abstract: Deliberate chemical attack: revisiting the lessons of the Tokyo subway
attack. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2014, 22:A8
Open Access @ www.sjtrem.com/content/pdf/1757-7241-22-S1-A8.pdf


Mobile Videoconferencing for Emergency Medical Communication
This simulation study investigated the role of mobile phone videoconferencing lay bystanders and
Emergency Medical Dispatch operators for initial emergency calls under suboptimal sound and light
conditions. Three different environments were used for the trials: indoors with moderate background
noise, outdoors with daylight and much background noise, and outdoors during nighttime with little
background noise. Video and sound quality were evaluated with video quality found to be significantly
different between the groups, with nighttime the lowest although it was still possible to see actions
performed on site during simulation. The authors conclude that vi deoconferencing on mobile phones
can be used for the initial emergency call during medical emergencies also in suboptimal conditions.

Melbye S, Hotvedt M, Bolle SR. Mobile videoconferencing for enhanced emergency medical
communication - a shot in the dark or a walk in the park? -- A simulation study. Scandinavian

Prehospital Activation of Emergency Transfusion
Major Trauma Centres in England (MTCs) have adopted protocols to enable rapid access to blood
products for emergency transfusion in trauma when ongoing significant bleeding is identified. In some
regions, prehospital services can request protocols and begin transfusion in the field. The authors of this
paper examined the emergency transfusion protocols and associated pack contents for MTCs in
England - 26/28 MTCs responded to their survey, all of whom reported having a written protocol.
The authors report that twelve centres allowed prehospital physicians to remotely activate the protocol,
but wide variation in both activation and provision of emergency transfusion exists. The authors note that
provision of prehospital blood may require MTCs to adapt the ratio of supplied products.

Evens T, Siu J, Russell M et al. Poster presentation: Prehospital activation of emergency
transfusion in trauma. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
2014 , 22 : P9

Prehospital Management of Asthma Barriers and Facilitators
This research used focus groups to explore paramedics attitudes, perceptions and beliefs about
prehospital management of Asthma with the aim of identifying barriers and facilitators to guideline
adherence. The seventeen participants included paramedics, advanced paramedics and paramedic
operational managers at three geographical sites. Five themes emerged from the analysis:
(1) guidelines should be made more relevant to ambulance service care;
(2) there were barriers to assessment;
(3) the approach needed to address conflicts between clinicians and patients expectations;
(4) the complexity of ambulance service processes and equipment needed to be taken into account;
(5) there are opportunities for improved prehospital education, information, communication, support and
care pathways for asthma.

Shaw D, Siriwardena AN. Identifying barriers and facilitators to ambulance service assessment and
treatment of acute asthma: a focus group study. BMC Emergency Medicine, 2014, 14:18
Open Access @ www.biomedcentral.com/content/pdf/1471-227X-14-18.pdf


Prehospital Mortality in Myocardial Infarction with ST-Elevation
Whilst hospital mortality in myocardial infarction with ST-elevation has decreased recently, prehospital
mortality has not. This Spanish observational study used data from a register of patients attended in
Andalusia over three years to idenfity initial complications and factors relating to prehospital mortality.
Just over 2,500 patients were included, 24% were women. Fifty-two (2.1%) of patients died before
reaching hospital. An analysis of the data showed a significant proportion of these patients presented
early complications in the prehospital setting, with prehospital mortality associated with being female and
having an atypical presentation (including pre-existing conditions, hypotension and extensive infarction).

Rosell-Ortiz F, Mellado-Vergel FJ, Fernndez-Valle P et al. Initial complications and factors related
to prehospital mortality in acute myocardial infarction with ST segment elevation. Emergency
Medicine Journal Published 25 July 2014, doi:10.1136/emermed-2014-203780
Athens Access @ http://emj.bmj.com/content/early/2014/07/25/emermed-2014-203780.abstract?papetoc

Rapid Extrication of Entrapped RTA Victims
Prehospital road vehicle entrapment is a risk factor for complications and delays transport to hospital.
The Rapid Extrication (RE) method, which combines winching and cutting and utilises two larger vehicles
to pull car wreckage apart to extricate patients, has been studied previously and found to be an efficient
alternative method. This Norwegian study surveyed all fire departments on their training in and
implementation of RE. Participants at the National Championship in RE, where extraction times were
measured, were also surveyed on training, cooperation and safety issues. The combined results
showed that interdisciplinary and regular training of RE can lead to safe extrication of a critically injured
patient in less than 20 minutes and may be life saving.

Fattah S, Johnsen A, Andersen J et al. Rapid extrication of entrapped victims in motor vehicle
wreckage using a Norwegian chain method - cross-sectional and feasibility study. BMC Emergency
Medicine 2014, 14 :14

Review of Telemedicine in Prehospital Care
This literature review is part of the LiveCity project, examining the history and existing applications of
telemedicine in the prehospital environment. The studies included suggested that overall, telemedicine
had a positive impact on emergency medical care, improving prehospital diagnosis of stroke and
myocardial infarction, enhancing supervision of delivery of tissue thromboplasminogen activator in acute
ischaemic stroke. The authors note that while telemedicine presents an opportunity to enhance patient
management few studies have yet demonstrated whether it has an effect on clinical outcome.

Amadi-Obi A, Gilligan P, Owens N et al. Telemedicine in prehospital care: a review of telemedicine
applications in the prehospital environment. International Journal of Emergency Medicine, 2014,
7:29
Open Access @ www.intjem.com/content/pdf/s12245-014-0029-0.pdf

Secondary Triage in Prehospital Emegency Ambulance Services
This systematic review examined the literature relating to the structure, safety and success of secondary
telephone triage, where low-acuity patients are diverted to to alternative non-ambulance services before
ambulance arrival. This system has been trialled in the UK and USA to manage increased demand.
A low incidence of adverse effects was found and patients appeared to be satisfied with the system.
However the authors note that, while secondary triage appears safe, further research is needed into
service structure and the effect on ambulance demand.

Eastwood K, Morgans A, Smith K et al. Secondary triage in prehospital emergency ambulance
services: a systematic review. Emergency Medicine Journal Published 1 May 2014
Athens Access @ http://emj.bmj.com/content/early/2014/04/30/emermed-2013-
203120.abstract.html?papetoc


Stroke Awareness Campaign in Ireland
Little evidence is available regarding the effectiveness of media messages to influence behaviour after
stroke onset. This study assessed the impact of the introduction of the F.A.S.T. (Face Arm Speech Time)
stroke recognition tool in two Irish emergency departments. The campaign was found to have had an
initial impact on emergency department attendance of patients with stroke symptoms but that this effect
was not sustained. Prehospital delay in accessing acute stroke services was found to be a factor, but the
authors report this is a complex process with involvement of factors other than stroke knowledge and
intention to call 911.

Mellon L, Hickey A, Doyle F et al. Can a media campaign change health service use in a population
with stroke symptoms? Examination of the first Irish stroke awareness campaign. Emergency
Medicine Journal 2014;31:536-540 doi:10.1136/emermed-2012-202280

Unmanned Aerial Vehicle Suppport for Situation Assessment in a Mass Casualty Incident
This study evaluated the feasibility of using a remotely piloted unmanned aerial vehicle (UAV) to gather
information from the air in order to support decision-making in a simulated major mass-casualty incident
(25 children trapped on a school bus after collision). The study provided useful information on how to
collect, interpret and make use of the data to improve the processes of assessing the scene, make
sound decisions and distribute resources according to need. The authors note these devices might be
particularly useful in high-risk environments with limited access to patients.

Abrahamsen H. Poster presentation : How to improve situation assessment and decision-making in
a simulated mass casualty incident by using an unmanned aerial vehicle. Scandinavian Journal of
Trauma, Resuscitation and Emergency Medicine. 2014, 22:P2

Unmanned Aerial Vehical Support for Situation Assessment in Mountain Rescue
This Norwegian study assessed the feasibility of using a radio-controlled rotor-wing unmanned aerial
vehicle to support situation assessment in search and rescue operations in the mountains. Two
simulated scenarios were set up: an avalanche and an injured skier trapped in a narrow canyon with
unstable snow overhead. Live video, turn directions and digital signals were wirelessly transmitted to a
ground station and allowed ski tracks leading to the canyon, and objects in the snow to be identified
remotely. The authors comment that the Unmanned Aerial Vehicle is an effective tool carrier and saves
time by spanning large geographical area in rough terrain. Equipping the vehicle with an avalanche
transceiver and a HD camera provided useful decision-making support for emergency services.
Abrahamsen H. Poster presentation: Use of an unmanned aerial vehicle to support situation
assessment and decision-making in search and rescue operations in the mountains. Scandinavian
Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22 :P16

Wireless Electroencephalography in Prehospital Care
This paper describes the design and testing of a novel six-channel emergency electroencephalography
(EEG) recording system for use in emergency medicine and prehospital care. Bench testing
demonstrated the system's performance to be comparable with a commercial system. The authors
suggest the system could be used to record high-quality EEG data during ambulance transportation,
leading to faster diagnostic, more accurate treatment, and shorter recovery times for patients with
neurological brain disorders.
Jakab A, Kulkas A, Salpavaara T et al. Novel wireless electroencephalography system with a
minimal preparation time for use in emergencies and prehospital care. BioMedical Engineering
OnLine, 2014, 13 :60
Open Access @ www.biomedical-engineering-online.com/content/pdf/1475-925X-13-60.pdf


Prehospital Practitioners Roles, Professional Practice and Development

Impact of Extended Paramedic Skills on the Emergency Care System
Against the background of rising demand for UK emergency services and the fact that just 10% of
emergency calls are life-threatening, this paper systematically reviews the literature on the potential for
paramedics with extended skills to reduce demand on emergency departments. Fourteen relevant
articles were identified, revealing valuable evidence relating to the autonomous assessment and
management of patients by paramedics reducing onward transport to hospital. The authors note that
other evidence was less strong but that they recommend future research particularly regarding
paramedic care of older people.

Evans R, McGovern R, Birch J et al. Which extended paramedic skills are making an impact in
emergency care and can be related to the UK paramedic system? A systematic review of the
literature. Emergency Medicine Journal 2014; 31:594-603 P
Athens Access @ http://emj.bmj.com/content/31/7/594.full.pdf+html

Paramedic Intubation
A controversial topic in emergency medicine is the inclusion of endotracheal intubation within the scope
of practice for non-physician providers in the prehospital environment.
With no clear evidence for or against there is considerable variability in practice throughout the world.
To better understand this topic separate this paper addresses four separate but related issues:
1) the physiological rationale for early intubation during resuscitation
2) the inconsistency of published reports addressing this controversy
3) the possibility that suboptimal performance of ETI and subsequent ventilation can explain a lack of
outcomes benefit
4) the relationship between provider type, training, and airway skills performance.

Davis D. Extended abstract - Paramedic intubation. Scandinavian Journal of Trauma, Resuscitation
and Emergency Medicine, 2014, 22:A2

Patient Experiences of Emergency Care Practitioners
This study used a postal questionnaire to compare patient experiences of care provided by emergency
care practitioners and usual providers in different emergency and urgent care settings. The results
showed users of ECP services were more likely to be highly satisfied with overall care than usual
provider patients in the various study settings.

O'Keeffe C, Mason S, Knowles E. Patient experiences of an extended role in healthcare: comparing
emergency care practitioners (ECPs) with usual providers in different emergency and urgent care
settings. Emergency Medicine Journal

Prehospital Administration of Fascia Iliaca Compartmental Block by Nurses
In the Netherlands, prehospital emergency care is mostly provided by emergency medical service
nurses. This study examined whether, after training, EMS-nurses could successfully perform a fascia
iliaca compartment block on-scene (usually performed by physicians) as an alternative to intravenous
analgesics in patients with proximal femur fracture. Ten EMS-nurses received training, and were
included on ambulance teams dispatched to patients with suspected proximal femur fracture. One
hundred patients received the block which was effective in 96 with very high patient satisfaction and no
reported complication.

Dochez E, van Geffen GJ, Bruhn J et al. Prehospital administered fascia iliaca compartment block
by emergency medical service nurses, a feasibility study. Scandinavian Journal of Trauma,
Resuscitation and Emergency Medicine 2014, 22 :38 (23 June 2014)


Retired Military Service Volunteers - Readiness to Deploy in Disasters
The Department of Veterans Affairs Disaster Emergency Medical Personnel System (DEMPS)
programme in America provides a system whereby active or retired veteran military personnel can
register to be deployed during national emergencies or disasters, with training provided. This study used
a survey to identify factors impacting upon a willingness to deploy in the event of an emergency.
Findings from the 2,385 survey respondents (a 29% response rate) revealed volunteer experience, a
positive attitude to training were associated with readiness to deploy. Stress and female gender were
associated with being less likely to show a readiness to deploy. The authors discuss how to address
factors which impact upon a willingness to deploy.

Zagelbaum NK, Heslin KC, Stein JA et al. Factors influencing readiness to deploy in disaster
response: findings from a cross-sectional survey of the Department of Veterans Affairs Disaster
Emergency Medical Personnel System. BMC Emergency Medicine 2014, 14 :16

Role of General Practitioners in Prehospital Care
This Norwegian study used focus groups to gain better insight into emergency medical technicians'
experiences with the role of the GPs in the care for critically ill patients in the prehospital setting.
The EMTs reported feeling the need for GP participation in the ambulance when responding to a
critically ill patient, particularly in difficult cases which did not fit into EMT guidelines. The
main contributions of the GPs were described as diagnosis and decision-making, including shortening
transport to hospital time and starting medication earlier. The authors report GP presence to be
perceived as improving patient care. The EMTs did suggest formalised training between themselves and
GPs on call.

Hjortdahl M, Zakariassen E, Wisborg T. The role of general practitioners in the prehospital setting,
as experienced by emergency medicine technicians: a qualitative study. Scandinavian Journal of
Trauma, Resuscitation and Emergency Medicine, 2014, 22:47
Open Access @ www.sjtrem.com/content/pdf/s13049-014-0047-1.pdf

Using Cadavers to Improve Safety in Placing Unconscious Trauma Patients
This study used cadavers to explore the level of motion produced by lateral position techniques
(Recovery Position, Lateral Trauma Position, HAINES position and variations) in unconscious patients
with possible unstable cervical spine injuries. Global ligamentous instability between C5 and C6 was
created in five fresh cadavers. Relative motion was measured using an electromagnetic tracking device.
The results indicated that the LTP or one of the two HAINES techniques was preferable to the classic
recovery position in the setting of an unstable cervical spine injury.

Hyldmo P, Conrad B, Dubose D et al. Oral presentation : Learning from the dead: improving safety
while placing unconscious trauma patients in various lateral positions. Scandinavian Journal of
Trauma, Resuscitation and Emergency Medicine, 2014, 22:O4
Open Access @ www.sjtrem.com/content/pdf/1757-7241-22-S1-O4.pdf

Using Frozen Cadavers to Enhance Simulation Training
Concerned that a reliance on simulation learning using mannequin-based models may sufficiently
prepare paramedic students for variance in human anatomy, the Queensland University of Technology
piloted a three-hour fresh frozen human cadaveric training workshop for second-year undergraduate
paramedic students in 2012. One hundred and fourteen students attended the workshop and an analysis
of evaluations showed a statistically significant improved anatomical knowledge and confidence in
procedural skills including laryngeal mask insertion, airway management, bag-valve-mask,
thoracocentesis and traction splinting. The authors suggest that cadaveric training using fresh frozen
cadavers provides an effective adjunct to simulated learning and clinical placements.

Lim et al. Enhancing paramedics procedural skills using a cadaveric model. BMC Medical
Education 2014, 14:138


Prehospital Research Methods and Discussion

Design of Emergency Research Where Consent Must Be Waived
This commentary paper discusses issues of ethics in emergency care research, where it can be
impossible or inappropriate to obtain the necessary consent and consultation for participating in research
studies at the time of the emergency. This has consequences for the development of an evidence base.
The authors describe a practical framework, developed at a workshop hosted by the UK Health
Research Authority, providing questions and considerations which aim to give a structured approach to
the issues arising when developing or reviewing research that involves a waiver of consent or
consultation.

Davies H, Shakur H, Padkin M et al. Guide to the design and review of emergency research when it
is proposed that consent and consultation be waived. Emergency Medicine Journal 31:794-795
Athens Access @ http://emj.bmj.com/content/31/10/794.extract?etoc

Issues of ethics and consent were discussed in the media in August 2014, when a controlled trial by
Warwick University which would see some cardiac arrest patients given a placebo in place of adrenaline
was granted approval to begin in the Autumn. The study is described as follows:

The University of Warwick Clinical Trials Unit is carrying out this study with five ambulance services across the UK.
We will collect information about 8,000 patients who have been treated for cardiac arrest. Half of the patients will
have been treated with adrenaline and half will have been treated with placebo (dummy). The study will look at
survival at 30 days after cardiac arrest in both groups and explore the effects of adrenaline on brain function. If the
patient wants to take part in the follow up this will involve completing questionnaires about their quality of life and
general health at 3 and 6 months after the cardiac arrest.
www.controlled-trials.com/isrctn/pf/73485024

The BBC reported the story with discussion of the Ethics of life-and-death research.
www.bbc.co.uk/news/health-28770885

Full Text Publication of Emergency Conference Abstracts
This survey investigated the publication rate of papers presented at the Danish Emergency Medicine
Conferences in 2009, 2010 and 2011. The authors note that abstracts presented at conferences and
scientific meetings should ideally be published as articles in peer-reviewed journals regardless of their
findings but found the publication rates for the 2009 and 2010 to be around 30%, with only 14.5% of
papers from the 2011 conference having been published within 18 months. The authors report that the
Danish rates compare with other emergency research communities, but all are lower than for more
established specialties. The authors discuss reasons fro non-publication.

Ravn A, Petersen D, Folkestad L et al. Full-text publication of abstracts in emergency medicine in
Denmark. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22 :33

Future of Traumatic Brain Injury Research
This extended essay presents the evolution of research in Traumatic Brain Injury (TBI) with two changes
in direction in the quest for higher level evidence firstly a move from randomised prospective
interventional trials to an era of big data observational studies and secondly the transfer of monitoring
technologies into the prehospital field. The authors discuss the way that these changes should enable a
better understanding of the spectrum of TBI diseases and foster a future of more precise, personalised
management.

Wilson M, Zolfaghari P, Griffin C et al. Extended abstract - The future of traumatic brain injury
research. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22:A7
Open Access @ www.sjtrem.com/content/22/Suppl%201/A7


Horizon Scanning in Traumatic Brain Injury
With up to 62% of severe injuries in British patients including traumatic brain injury, this project aimed to
evaluate current best-practice for gaps in knowledge, care, and research, to determine what changes
could best improve TBI care, and to project optimum treatment for 2020.

Roberts N, ODochartaigh D, Aleksandrowicz D et al. Poster presentation: Traumatic Brain Injury in
2020 a horizon-scanning project. Scandinavian Journal of Trauma, Resuscitation and Emergency
Medicine 2014, 22:P6

London Trauma and Cardiac Arrest Conference 2013
The seventh London Trauma Conference was held over four days in December 2013. This supplement
provides a selection of seven extended abstracts written by speakers at the conf erence illustrating some
of the diverse subject matter covered and also the scientific abstracts from oral and poster presentations
made at the conference.

Bird F, Avery P. London Trauma and Cardiac Arrest Conference 2013. Scandinavian Journal of
Trauma, Resuscitation and Emergency Medicine. 2014, 22:A1

Prehospital Clinical Trials Feasibility and Practicalities
This study based in ambulance stations in Yorkshire used a questionnaire to explore paramedics
perceptions of prehospital research and barriers to conducti ng prehospital clinical trials. An interest in,
and understanding of, research was reported but limited support for paramedic involvement in trials was
revealed, with barriers included the practicality and ethics of randomisation and consent, and time
pressures.

Hargreaves K, Goodacre S, Mortimer P. Paramedic perceptions of the feasibility and practicalities
of prehospital clinical trials: a questionnaire survey. Emergency Medicine Journal 2014; 31:499-504

Time Series Studies in the Quality of Prehospital Myocardial Infarction Care
This paper examined the strength of interrupted time series design as a methodology to evaluate the
effect of interventions introduced at a specific point in time. The intervention examined with this method
was a collaborative quality improvement intervention in prehospital ambulance care for acute myocardial
infarction and stroke. Segmented regression analysis, the recommended approach, was used to analyse
data. Insufficient evidence of a statistically significant effect on quality of this intervention was found, but
potentially clinically important effects for acute myocardial infarction could not be ruled out.

Taljaard M, McKenzie J, Ramsay C et al. The use of segmented regression in analysing interrupted
time series studies: an example in prehospital ambulance care. Implementation Science, 2014, 9:77
Open Access @ www.implementationscience.com/content/pdf/1748-5908-9-77.pdf

Dispatch, Response and Handover

Clinical Handovers Between Prehospital and Hospital Staff
This paper reviewed the published research on the interface between prehospital and hospital settings in
clinical handovers. Twenty-one studies met the literature search inclusion criteria and themes around
communication and information transfer within varying environmental and professional relationship
contexts were raised. The quality of existing research was found to be relatively poor and the authors of
this review note the need for more research to understand this complex issue before enable tools and
techniques for standardisation can be developed.

Wood K, Crouch R, Rowland E et al. Clinical handovers between prehospital and hospital staff:
literature review. Emergency Medicine Journal Published 1 September 2014


Comparing Actual Versus Predicted Emergency Ambulance Journey Times
This study retrospective cohort study of emergency ambulance admissions in the northeast of England
examined how accurately commercially available GIS packages could predict emergency ambulance
journey times under differing conditions. The study results showed statistically significant under-
prediction of journey times for all population densities, but the authors suggest this is not likely to be
significant clinically and that it would be reasonable to use generic GIS software with small adjustments
to account for under-prediction.

McMeekin P, Gray J, Ford GA et al. A comparison of actual versus predicted emergency ambulance
journey times using generic Geographic Information System software. Emergency Medicine
Journal Emergency Medicine Journal 2014; 31:758-762
Athens Access @ http://emj.bmj.com/content/31/9/758.abstract?etoc

Clinical Deterioration During Long Ambulance Journeys
This research used a retrospective chart review of 991 patients to investigate whether clinical
deterioration occured in patients during long ambulance journeys (up to 70 miles) to hospital in a rural
area of Wales. The NHS Early Warning Score was used to estimate illness severity on ambulance arrival
at scene and at the emergency department, and relationship with distance from hospital analysed.
No statistically significant relationship was found, for the patients as a single group or when sub-
categorised into clinical groups. The authors suggest that adult patients living further from hospital are
not more unwell on pick-up, they are not deteriorating en-route, and longer journeys to hospital do not
necessarily lead to patients coming to harm. The authors note they did not explore any relationship to
later mortality/morbidity and call for this research to be replicated in other areas to provide more
evidence.

Thorp V, Kang S, Dykes L. The Long And Winding Road: Do Patients Deteriorate During Long
Ambulance Journeys To Hospital. Emergency Medicine Journal 2014; 31:785
Athens Access @ http://emj.bmj.com/content/31/9/785.1.abstract?etoc

Patient Profile

Care Home Resident Use of Emergency Ambulances
This paper reports on a longitudinal study that tracked 133 older people with dementia, resident in care
homes in the East of England with no on-site nursing providing personal care only, to examine the
frequency and reasons for emergency ambulance call-outs, outcomes and factors associated with
emergency ambulance service use. The tracking showed that 56% of residents used ambulance
services with 43% of all call-outs resulting in an unscheduled admission to hospital. In addition to trauma
following a following a fall a reasonable proportion of ambulance contacts were shown to be for
ambulatory care sensitive conditions. The authors call for further examination of this vulnerable
population, to take account of important contextual factors including the presence or absence of on-site
nursing, GP involvement, and access to residents family, alongside resident health characteristics.

Amador S, Goodman C, King D et al. Emergency ambulance service involvement with residential
care homes in the support of older people with dementia: an observational study. BMC Geriatrics,
2014, 14:95


Does Patient Gender Affect Prehospital Care?
Research in fields of emergency medicine including cardiovascular and intensive care has shown that
women receive inferior care. This observational retrospective study of 305 patients investigated whet her
there were gender differences in the prehospital care given to severely injured adult trauma patients in
Stockholm. Variables including age, injury mechanism and 30-day mortality were comparable between
genders and no statistically significant gender differences were found in airway management,
administration of oxygen, fluids, analgesics, and stabilization of neck and spine. On-scene time nor total
prehospital time did not significantly differ between.

Rubenson Wahlin R, Lvbrand H, Castrn M et al. Oral presentation : Evaluating prehospital trauma
care in Stockholm from a gender perspective. Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine, 2014, 22:O2

Emergency Service Frequent Callers and Users
The authors of this systematic review searched for primary research examining the characteristics and
impact of frequent users upon emergency medical services of research on frequent users of EMS.
Eighteen relevant studies were retrieved. No two studies used the same definition for frequent users,
and the percentage of patients identified as frequent callers reported ranged from 0.2% to 23%. None of
the studies focused upon the callers characteristics. The authors call for research to identify predictors
and characteristics of frequent users and a consistent definition of a frequent caller to or user of
emergency medical services.

Scott J, Strickland AP, Warner K et al. Frequent callers to and users of emergency medical
systems: a systematic review. Emergency Medicine Journal 2014; 31:684-691

Exercise Related Sudden Cardiac Death Incidence and Bystander Response
This retrospective observation study used data from the London Ambulance Service Cardiac Arrest
Registry to assess the incidence of, and survival from, exercise-related sudden cardiac arrest in London.
Incidence was found to be rare, estimated at 6.1 per million per population per year, with the majority of
cases male. Incidence increased from age 40. The most common activities engaged in at the time of
SCA were running/jogging, football and cycling. Just under one third of patients survived to hospital
discharge. Three-quarters of arrests were witnessed by a bystander. Bystander CPR was initiated in
62% of cases. Public defibrillators were available in 7% of arrests but only used in 4% of arrests.

Edwards M, Fothergill R, Whitbread M. Oral presentation: Exercise-related sudden cardiac arrest in
London: incidence, survival, and bystander response. Scandinavian Journal of Trauma,
Resuscitation and Emergency Medicine 2014, 22:O3

Patients who Call Ambulances for Primary Care Problems
This research used semi-structure interviews to aim to understand the decision making process by both
patients and carers when an ambulance has been called for problems which could be dealt with
appropriately in primary care. Analysis showed many calls were based on a fundamental misconception
of types of urgent care other than calling an ambulance, such as community-based urgent care services.
Chronically ill patients with frequent exacerbations were identified as a group for whom education might
be suitable. Decisions made by carers were found to be driven by lower tolerance of perceived risk. The
authors note that perceived distances between urgent primary care and ambulance responses might
influence decision making and discuss the potential for a greater role in detailed triage.

Booker MJ, Simmonds RL, Purdy S. Patients who call emergency ambulances for primary care
problems: a qualitative study of the decision-making process.
Emergency Medicine Journal


Penetrating Trauma Incidence Over Time in London
Using a retrospective review of the London Air Ambulance database to identify patients sustaining
deliberate penetrating trauma from 2007 to 2012 the authors of this study aimed to assess whether a
trend towards an annual rise in these injuries reported between 1991 and 2006 had continued.
The median number of penetrating trauma cases attended per year was 95 between 1991 and 2006,
and 352.5 from 2007 to 2012 representing 9.9% and 19.3% of the annual trauma caseload respectively.
The authors discuss the rise and the impact on the provision of trauma services and policing.

Crewdson K, Weaver A, Davies G et al. Poster presentation : The incidence of penetrating trauma in
London: have previously reported increases persisted in the last six years? Scandinavian Journal
of Trauma, Resuscitation and Emergency Medicine, 2014, 22:P3

Helicopter Emergency Medical Services

Analysis of Regional Intensive Care Transport Systems
Secondary intensive care patient transport missions can be managed by road ambulance, rotor-wing
ambulance, and fixed-wing ambulance. This Swedish paper used prospectively collected data to test the
hypothesis that costs for transport distances would differ between the three systems. Economic
modelling allowed the authors to compare results taking into account cost and time effectiveness,
revealing that helicopters can be effective up to moderate transport distances (400500km), but were
expensive to operate. For longer ICU patient transports, fixed-wing transport systems were found to be
both cost and time effective compared to helicopter-based systems.

Brndstrm H, Wins O, Lindholm L et al. Regional intensive care transports: a prospective
analysis of distance, time and cost for road, helicopter and fixed-wing ambulances. Scandinavian

Clotted Haemopericardium in Traumatic Cardiac Arrest
Current guidelines emphasise the use of emergency thoracotomy rather than needle pericardiocentesis
to treat cardiac tamponade. Londons Air Ambulance service has performed the procedure for traumatic
cardiac arrest since 1993. This five year retrospective study of data aimed to validate the swing from
pericardiocentris to thoracotomy. Data for 152 patients revealed a significant percentage of tamponades
(47%) to be clotted haemopericardium, making the shift in trauma management appropriate.

Manz E, Nofz L, Norman A et al. Poster presentation: Incidence of clotted haemopericardium in
traumatic cardiac arrest in 152 thoracotomy patients. Scandinavian Journal of Trauma,
Resuscitation and Emergency Medicine 2014, 22:P20

Intranasal Analgesia in UK Air Ambulance Services
Londons Air Ambulance (LAA) is considering introducing an intranasal analgesia standard operating
procedure and this study used a telephone survey to determine the current use, or planned introduction,
of INA in 19 other air ambulance providers in the UK. Data was obtained for 16 of the providers
revealing that 75% of these providers either currently use or plan to introduce INA in the near future. The
authors note that this represents a large pool of clinical experience and expertise which can guide LAA in
their decision to introduce INA to their current analgesia SOPs.

Pascoe C, James S, Smith C et al. Poster presentation: What UK prehospital providers use
intranasal analgesia? A survey of its current and planned use by air ambulance services in the
United Kingdom. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014,
22 : P15


Obstetric Caseload of a Physician-Based Helicopter Emergency Medical Service
Retrieval records over 4 years for the Greater Sydney Area Helicopter Emergency Medical Service were
searched to identify keywords associated with pregnancy or obstetric complications with the aim of
quantifying the obstetric caseload for the service and then to provide targeted training. Of the 66 cases
found, half were retrieved for non-obstetric diagnoses and obstetric interventions by HEMS physicians
were rare. The authors note that educational resources should prioritise general critical care of the
pregnant woman rather than specific obstetric procedures.

Kaye R, Shewry E, Reid C et al. The obstetric caseload of a physician-based helicopter emergency
medical service: case review and recommendations for retrieval physician training. Emergency
Medicine Journal2014; 31:665-668

Parents Accompanying Injured Children in Emergency Helicopters
This non-systematic literature review aimed to examine the impact of parents accompanying their
children in an air ambulance after paediatric trauma, in order to assist prehospital clinicians in deciding
whether this is beneficial this patient group. The authors report, although accompaniment is the
preference in emergency transport over land, a lack of published data does not allow a recommendation
of parental accompaniment in a helicopter to be mandated. The authors call for further research into the
emotional recovery of children after trauma, and patient, parent and staff experiences during transport.

Cowley A, Durge N. The impact of parental accompaniment in paediatric trauma: a helicopter
emergency medical service (HEMS) perspective. Scandinavian Journal of Trauma, Resuscitation
and Emergency Medicine 2014, 22 :32

Shift Alertness of Helicopter Emergency Medical Service Crew
This project aimed to measure in-shift alertness levels amongst HEMS clinical crew members across
seven 12-hour day shifts at Kent, Sussex and Surrey Air Ambulance Trust. Background data recorded
included age, gender, role, experience, hours of sleep pre-shift and number of shifts worked in previous
3 days. In-shift data included activities since last test and consumption of food and drink. Alertness was
measured every two hours using two computer based tests. The results showed alertness to vary during
the day shift but that the crew maintained alertness despite fatigue. Background and in-shift activity did
not seem to impact on alertness but in-shift testing was found to be difficult to conduct due to operational
activities and further research is recommended.

Cullip T, Hudson A, Lyon R et al. Oral presentation - Testing alertness of Helicopter Emergency
Medical Service (HEMS) crews a feasibility study. Scandinavian Journal of Trauma, Resuscitation
and Emergency Medicine, 2014, 22:O1

Stand Downs of a Helicopter Emergency Medical Service
Standing down of Helicopter Emergency Medical Service crews after deployment renders a vital
resource unavailable whilst costing charities money and requiring crews to take unnecessary risks.
This study reviewed data from the Kent, Surrey & Sussex Air Ambulance Trust to identify activation
triggers and reasons for stand down (38% of deployments in the study period). Only 10% were found to
be due to technical issues (including the weather and re-direction); Most occurred at night with peaks at
paramedic shift changes. Immediate dispatches accounted for 61%, with 30% resulting after
interrogation. The authors suggested an improvement in the quality of initial information could reduce
stand-downs, along with more staff training and developing dispatch criteria.

Evans E, Hudson A, McWhirter E et al. Poster presentation : A review of the activation triggers and
reasons for stand downs of a Helicopter Emergency Medical Service (HEMS). Scandinavian Journal
of Trauma, Resuscitation and Emergency Medicine 2014, 22:P5


Drug Administration & Treatment

Intraosseous Access in Trauma Care
Although intraosseous access is an increasingly accepted alternative to peripheral vascular access in
adults there is insufficient evidence in large patient groups supporting its use. This retrospective study of
over 1,000 patients investigated its use over a 7-year period during combat operations in Afghanistan.
The results showed IO access could be used to administer a wide variety of life-saving medications
quickly, easily and with low-complication rates highlighting its role as an alternative method of obtaining
vascular access, vital when resuscitating the critically injured trauma patient.

Lewis P, Wright C. Saving the critically injured trauma patient: a retrospective analysis of 1000 uses
of intraosseous access. Emergency Medicine Journal Published 30 June 2014

Intraosseous Rapid Sequence Induction of Anaesthesia
Intraosseous drug infusion is often used in trauma to obtain rapid, reliable access. This prospective
observational study undertaken in a combat hospital in Afghanistan aimed to build upon the few case
reports which have described intraosseous infusion to for rapid sequence induction of anaesthesia,
assessing its feasibility. Data on drug use was recorded by the prehospital, physician-led Medical
Emergency Response Team and by inhospital physicians. Data for 34 patients showed IO drug
administration to be successfully used for trauma RSI, with a comparable first pass intubation success
than published studies describing the IV route

Barnard EBG, Moy RJ, Kehoe AD et al. Rapid sequence induction of anaesthesia via the
intraosseous route: a prospective observational study. Emergency Medicine Journal 24 June 2014

Methoxyflurane for the Treatment of Acute Pain
The STOP! randomised, double-blind, multicentre, placebo-controlled study involved 300 patients and
was conducted at six UK sites to evaluate the short-term efficacy and safety of methoxyflurane to treat
acute pain in patients presenting to emergency departments with minor trauma. Half of the patents
received methoxyflurane, and half a placebo. Pain severity reduction with methoxyflurane was
significantly more than placebo and the authors note their results suggest that methoxyflurane
administered via a Penthrox inhaler is an efficacious, safe, and rapidly acting analgesic.

Coffey F, Wright J, Hartshorn S et al. STOP!: a randomised, double-blind, placebo-controlled study
of the efficacy and safety of methoxyflurane for the treatment of acute pain. Emergency Medicine
Journal 2014; 31:613-618

This article is discussed in the following commentary which invites readers to ask interesting and important
questions

Carley S, Body R. Methoxyflurane is a better painkiller than placebo: but do we want to know more?
Emergency Medicine Journal 2014; 31:610 Published Online First: 17 Apr 2014
Athens Access @ http://emj.bmj.com/content/31/8/610.extract.html?etoc


Pain Management in Major Trauma
Over a 3 week period, this study aimed to gauge the efficacy of pain control in major trauma, determining
the time taken to get pain under control for 16 patients, looking at the analgesia used and investigating
the efficacy of prehospital analgesia. An average time of 80 minutes was taken to achieve pain control.
A higher time was reported for females than for males, and varying times for IV or oral paracetamol and
morphine, provided individually or in combination. The authors suggest methods to achieve faster and
better intervention for pain control in major trauma, including a review of pain management in prehospital
services.

Dodd K, Hudson A, Jarman H. Poster presentation: A study on the effective management of pain in
major traumas. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2014,
22:P14

Diagnosis, Triage and Intervention

Bispectral Index to Monitor Sedation Depth
This prospective study of mechanically ventilated patients in the prehospital setting examined whether
the bispectral index of the EEG (BIS) might be useful as a tool to evaluate the depth of sedation. The
results showed a poor correlation between BIS values and clinical assessment of sedation depth, the
authors concluding that its use as a tool cannot be recommended.

Duchateau F-X, Saunier M, Larroque B et al. Use of bispectral index to monitor the depth of
sedation in mechanically ventilated patients in the prehospital setting. Emergency Medicine
Journal

Effective Prehospital Use of Magill Forceps
This retrospective review of ambulance records in Osaka City aimed to assess characteristics of foreign
body airway obstruction in out-of-hospital cardiac arrest patients transported to hospitals by emergency
medical service personnel, and examine the relationship between prehospital Magill forceps use and
outcomes. The results showed prehospital Magill forceps use to be associated with improved outcome of
bystander-witnessed OHCA patients with FBAO.

Sakai T, Kitamura T, Iwami T et al. Effectiveness of prehospital Magill forceps use for out-of-
hospital cardiac arrest due to foreign body airway obstruction in Osaka City. Scandinavian Journal
of Trauma, Resuscitation and Emergency Medicine, 2014, 22:53

Evaluation of a Heated Ambulance Mattress
This experimental Swedish study evaluated the effect of a heated ambulance mattress-prototype on
body temperatures and thermal comfort. Data were collected from 23 participants both inside and
outside a cold chamber, both with and without the heated mattress, during four November days.
Outcomes were back, finger and core body temperature, Cold Discomfort Scale (CDS), anxiety and
personal experience of the mattresses.
Statistical difference between the regular and the heated mattress was found in the back temperature
while qualitative analyses of experience showed that the heated mattress was warm, comfortable,
provided security and was easier to relax on.

Alx J, Karlsson S, Saveman B. Effect evaluation of a heated ambulance mattress-prototype on
body temperatures and thermal comfort-an experimental study. Scandinavian Journal of Trauma,
Resuscitation and Emergency Medicine, 2014, 22:43


Focused Cardiopulmonary Ultrasound in Prehospital Care
This paper presents two cases from the Helicopter Emergency Medical Services in Denmark where
prehospital physicians trained in cardiac ultrasound (FATE) disclosed significant pathology leading to
radical changes for the critical patients course.

Jakobsen LK, Btker MT, Lawrence LP et al. Case report: Systematic training in focused
cardiopulmonary ultrasound affects decision-making in the prehospital setting - two case reports.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22:29

Prehospital Administration of Packed Red Blood Cells
This retrospective study of data from emergency services including the Queensland Ambulance Service
examined the characteristics, interventions and the outcomes of patients receiving packed red blood
cells from a road based, doctor-paramedic trauma response team. The results from 71 patients show the
Revised Trauma Score may be a useful tool in determining patients for whom administration of pRBC in
an integrated civilian trauma system.

Bodnar D, Rashford S, Hurn C et al. Characteristics and outcomes of patients administered blood in
the prehospital environment by a road based trauma response team. Emergency Medicine Journal
2014; 31:583-588

Prehospital Continuous Positive Airway Pressure for Acute Respiratory Failure:
This study reports on the development of an economic model to compare the cost-effectiveness of
prehospital CPAP with standard care for adults presenting to the emergency services with acute
respiratory failure. The model assigned a hypothetical cohort of patients with the probability of intubation
or death depending upon their characteristics and whether they had prehospital CPAP or standard care.
Analysis showed prehospital CPAP to be more effective than standard care, but more expensive. The
probability of prehospital CPAP being cost-effective at a 20,000/QALY threshold varied from 35.4% to
91.3%. The authors calculate that an ambulance service treating 175 appropriate patients per year could
save around 11 lives while incurring 241,250 additional costs, treating 2000 appropriate patients per
year could save 124 lives while incurring 876,480 additional costs. The authors report the cost-
effectiveness of prehospital CPAP to be uncertain and current evidence is insufficient to support
widespread implementation.

Goodacre S, Thokala P. Poster 009: Prehospital Continuous Positive Airway Pressure (Cpap) For
Acute Respiratory Failure: An Economic Analysis. Emergency Medicine Journal 2014; 31:780-781,

Prehospital Differentiation Between Cardiac and Obstructive Causes of Dyspnoea
To assist the prehospital differentiation between cardiac and obstructive causes of dyspnoea, this
retrospective study of 106 patients aimed to assess whether differences in prehospital levels of end-tidal
carbon dioxide (ETCO2) in obstructive compared to cardiac causes of dyspnoea might suggest one
diagnosis over the other. Lower levels of ETCO2 were found to be associated with CHF. The authors
suggest this may serve as an objective diagnostic adjunct to predict this cause of dyspnoea in the
prehospital setting.

Hunter CL, Silvestri S, Ralls G et al. Prehospital end-tidal carbon dioxide differentiates between
cardiac and obstructive causes of dyspnoea. Emergency Medicine Journal Published 1 July 2014,
doi:10.1136/emermed-2013-203405


Prehospital Haemorrhage Control
Haemorrhage following major injury remains the most common potentially preventable cause of
traumatic death with exsanguination typically occurring within three hours of injury.
A care bundle of measures to facilitate early diagnosis, rapid haemorrhage control, systemic and
topical haemostatic support and short scene times are key to improving outcomes.
A paradigm shift in treatment strategies and transfusion algorithms over the last decade has seen
emphasis on haemostatic or damage control resuscitation (DCR).
This article focuses on advanced interventions without discussing the fundamentals of prehospital
haemorrhage control.

Davenport R. Extended abstract - Haemorrhage control of the prehospital trauma patient.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2014, 22:A4

Prehospital Non-Invasive Ventilation for Acute Respiratory Failure
A systematic review of literature was undertaken to determine the effectiveness of prehospital
continuous positive airway pressure (CPAP) or bi-level inspiratory positive airway pressure (BiPAP)
compared with usual care for adults presenting to the emergency services with acute respiratory failure.
Eight randomised and two quasi-randomised controlled trials were identified from the literature and a
meta-analysis of the results suggested that CPAP was the most effective treatment in terms of mortality
and intubation rate, reducing both mortality compared to standard care. The effect of BiPAP upon
mortality and intubation rate was uncertain. The analysis suggested that sex was a modifier of the effect
of treatment on mortality.

Goodacre S. Poster: Prehospital Non-Invasive Ventilation for Acute Respiratory Failure: A
Systematic Review and Network Meta Analysis. Emergency Medicine Journal 2014; 31:778

Vital Signs for the Prediction of Trauma Outcome
This study evaluated differences between traditional vital signs of trauma patients - systolic blood
pressure, heart rate, respiratory rate and shock index - taken in the prehospital and emergency
department. These differences were assessed for their predictive value relating to patient outcome,
mainly mortality at 48 hours. The results showed that systolic blood pressure and respiratory rate were
the best overall predictors of outcome, with shock index the best performer for moderately injured
patients. The authors discuss the role of vital sign values in supplementing trauma treatment decisions.

Bruijns SR, Guly HR, Bouamra O et al. The value of the difference between ED and prehospital vital
signs in predicting outcome in trauma. Emergency Medicine Journal 2014; 31:579-582

Airway Management, Resuscitation & CPR

Advanced Airway Management in Prehospital Care
This UK study aimed to establish the frequency of prehospital airway compromise in trauma patients
attended by an enhanced physician-led prehospital service, and the role of advanced airway
interventions in its treatment. Data showing the level of airway compromise and the interventions needs
suggest that on-scene advanced airway management is needed in a relatively small number of severely
injured trauma patients but also that standard ambulance service interventions do not appear to
adequately treat airway compromise in a small proportion of trauma patients. Intubation without drugs
was found to have a high failure rate and the authors note their results suggest that the airway
management problems reported in the NCEPOD report: Trauma who cares? in 2007 still exist.

Lockey D, Healey B, Weaver A et al. Poster : Is there a requirement for advanced airway
management for trauma patients in the prehospital phase of care? Scandinavian Journal of
Trauma, Resuscitation and Emergency Medicine, 2014, 22:P8
Open Access @ www.sjtrem.com/con - - - -


Biomechanical Analysis of Spinal Immobilisation
In this study a crew of two paramedics and four fire-fighter first responders simulated extracting a
conscious patient from a motor vehicle using nine different extraction techniques. Biomechanical
analysis was used to establish which technique resulted in the minimal deviation of the cervical spine
from a neutral inline position. Conventional extrication techniques record up to four times more cervical
spine movement than controlled self-extrication. The authors call for further evaluation of current rescue
techniques.

Dixon M, O'Halloran J, Cummins NM. Biomechanical analysis of spinal immobilisation during
prehospital extrication. Emergency Medicine Journal online Emergency Medicine Journal 2014;
31:745-749

Design and Testing of a Novel Cervical Immobilisation Device
This study reports on the design and testing of a novel cervical immobilisation device the 'Necksafe'
that aimed to improve immobilisation of the cervical spine whilst minimising the risk of neurological
damage. Necksafe was compared with a conventional collar (the AMBU Perfit ACE) on volunteers,
assessing cervical range of movement during scripted movements of the head and neck and the effect of
the devices on jugular vein dimensions. Analysis showed the Necksafe device to cervical immobilisation
at least equivalent to the conventional collar, and superior in extension, lateral flexion and rotation. No
differences in jugular venous diameter or flow were shown. Paramedic feedback was positive and the
authors conclude their results are highly supportive of the Necksafe design, wi th improved cervical
immobilisation, comfort and access to the airway.

Sparke A, Torlei K, Voss S et al. The Necksafe head articulation control system: a novel cervical
immobilisation device. Emergency Medicine Journal Published 4 August 2014

Efficacy and Safety of Cervical Trauma Collars
In light of concerns that cervical collars may increase intracranial pressure in traumatic brain injury this
study compared four types of cervical collars on healthy volunteers to assess the efficacy of immobilizing
the neck and, in place of effect on intracranial pressure, the effect of each on jugular venous pressure.
Stifneck and Miami J collars were found to provide the most efficient immobilization with the least effect
on jugular venous pressure. Vista and Miami J were the most comfortable.

Karason S, Reynisson K, Sigvaldason K et al. Evaluation of clinical efficacy and safety of cervical
trauma collars: differences in immobilization, effect on jugular venous pressure and patient
comfort. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22 :37

I-Gel Supraglottic Airway Device
This audit and re-audit aimed to review basic and advanced prehospital airway management for cardiac
arrest within the North East Ambulance Service NHS Foundation Trust after the introduction of the i -gel
supraglottic airway device. The audit results showed the i-gel gaining popularity for maintaining and
securing airways with insertion success rates slightly above those for endotracheal tubes. Staff choosing
not to use i-gel gave reasons related to confidence with a new device and authors anticipate that the i -
gel will emerge as the first choice of airway management device.

Duckett J, Fell P, Han K et al. Introduction of the i-gel supraglottic airway device for prehospital
airway management in a UK ambulance service. Emergency Medicine Journal 2014; 31:505-507


Inter-Shock Intervals in Out of Hospital Cardiac Arrest
This study, based in Edinburgh, assessed inter-shock intervals during resuscitation after out-of-hospital-
cardiac-arrest to determine compliance with guidelines. Data from defibrillators was used to analyse
arrests where >1 consecutive shocks were delivered over a one year period. For the 70 eligible cases,
mean time between shocks was found to be 3:06 min. Only 26% of intervals were compliant with ALS
guidelines of two minutes. The authors discuss possible on-scene barriers to guideline compliance and
call for further work to establish the cause of deviation in order to develop strategies to optimise practice.

Mitchell K, Short S, Clegg G et al. The Shocking TruthTime Between Defibrillation Attempts
During Prehospital Resuscitation of VF Cardiac Arrest. Emergency Medicine Journal 2014; 31:781-
782

Laryngeal Mask Airway Use
This Dutch study evaluated the effectiveness and suitability a novel Laryngeal Mask Airway Supreme
(LMA-S) as an alternative to bag-valve mask ventilation in patients who cannot be intubated by
ambulance paramedics. After training and use in practice on 50 occasions over nine months,
paramedics were unanimous that the LMA-S was an easy to insert and valuable resource. The authors
conclude that the device is safe and effective.

Bosch J, de Nooij J, de Visser M et al. Prehospital use in emergency patients of a laryngeal mask
airway by ambulance paramedics is a safe and effective alternative for endotracheal Intubation.
Emergency Medicine Journal Emergency Medicine Journal 2014; 31:750-753

Passive Leg Raise During CPR
Passive leg raise during cardiopulmonary resuscitation has been found to improve cardiac
preload and blood flow during chest compressions. This paper describes the protocol for a prospective,
randomized, controlled trial which aims to evaluate whether early PLR during CPR improved one-month
survival in sudden and unexpected out-of-hospital cardiac arrest. To achieve passive leg raise,
ambulance crew will use a special folding stool to elevated patients' legs in the study groups to about 20
degrees. The authors report hope to recruit enough sites for this study to reach 3,000 patients in order to
achieve study power*.

*Statistical power - The ability of a study to demonstrate an association or causal relationship between two variables,
given that an association exists.
www.medicine.ox.ac.uk/bandolier/booth/glossary/statpow.html

Jimnez-Herrera MF, Azeli Y, Valero-Mora E et al. Study Protocol. Passive leg raise (PLR) during
cardiopulmonary (CPR) a method article on a randomised study of survival in out-of-hospital
cardiac arrest (OHCA). BMC Emergency Medicine 2014, 14 :15

Physician-Led Prehospital Intubation Success Rate
This study used a retrospective review of data on over 7,000 trauma patients who had undergone
prehospital advanced airway management between 1991 and 2012 to establish intubation success rates
in physician-led prehospital intubation. The frequency and management of failed intubation for doctors
in a prehospital team was examined, distinguishing with failed intubation rates of anaesthetists and non-
anaesthetists in this group. The reported success rate was found to be 99.3%, with non-anaesthetists
twice as likely to have to perform a rescue airway intervention than anaesthetists, a statistically
significant difference.

Crewdson K, Lockey D. Poster presentation: An observational study of intubation success rates
and rescue airway techniques among 7256 prehospital physician intubations of trauma patients.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22:P13


Prehospital Resuscitative Endovascular Balloon Occlusion of the Aorta
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive procedure
used successfully in emergency departments and theatres to stop internal bleeding from pelvic fractures.
This study investigated the feasibility of using REBOA in the prehospital setting through the use of two
supplementary training methods a gelatin-mannequin and a porcine model. An insertion time of
approximately 3 minutes was achieved after training. The authors suggest the technique appears to be
feasible prehospitally but requires decision-making skills for prehospital practitioners.

Andersen N, Rehn M, Oropeza-Moe M et al. Poster presentation: Prehospital resuscitative
endovascular balloon occlusion of the aorta. Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine 2014 , 22 : P19

Public Opinion of Automated Versus Manual Chest Compression
The authors used a web-based survey incorporating two videos to investigate whether bystanders might
be more likely to start external chest compression if an automated device was available. The
questionnaire was completed by 1769 people and showed that 58% preferred use of the device, 35%
preferred manual chest compressions and (7% had no preference. No significant gender difference was
reported although older people preferred the device.

Lapostolle F, Bertrand P, Agostinucci J-F et al. Web-based general public opinion study of
automated versus manual external chest compression. Emergency Medicine Journal
2014; 31:488-492

Training Package for Prehospital Resuscitative Endovascular Balloon Occlusion of the Aorta
This paper describes a training package developed to introduce zone III REBOA (positioning the balloon
at the aortic bifurcation) at a UK Major Trauma Centre. A multidisciplinary working group including
consultants in Prehospital Care reviewed the REBOA literature and developed a six-component training
package to enable procedural knowledge and competence.

Lendrum R, Perkins Z, Davies G. Poster presentation:. A training package for zone III Resuscitative
Endovascular Balloon Occlusion of the Aorta (REBOA). Scandinavian Journal of Trauma,
Resuscitation and Emergency Medicine, 2014, 22 : P18

Ultra-Acute Blood Glucose Levels in the Prehospital Phase
This retrospective Finnish study investigated the association of blood glucose changes in ultra-acute
phase in patients with ST-elevation myocardial infarction (STEMI) with patient outcome. Data from 152
patients treated from 2006 to 2010 showed that a change in blood glucose from prehospital phase to
emergency department admission was associated with increased mortality, impaired cardiac function
and increased size of infarct.

Vihonen H, Tierala I, Kuisma M et al. Ultra-acute increase in blood glucose during prehospital phase
is associated with worse short-term and long-term survival in ST-elevation myocardial infarction.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2014, 22 :30

Video Laryngoscopy in Prehospital Care
This extended abstract presents an overview of video laryngoscopy. Whilst present data does not
sufficiently address specific aspects of intubation in the prehospital environment, and problems such as
on-going bleeding or vomitus in the upper airway have not been evaluated in prehospital randomised
controlled trials, the authors discuss the rapidly growing technology of videolaryngoscopy and its
potential to dominate the field of emergency airway management.

Voelckel W. Extended abstract - What is the role of video laryngoscopy in prehospital care?
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2014, 22 : A6

Emergency Services Current Awareness Update - Issue 24, May To August 2014

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Prehospital Emergency Services

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