This UK study showed that paramedics could successfully acquire and identify lung ultrasound images after a two day course. The course covered the identification and management of patients who present with serious thoracic injury, with a specific focus on the use of thoracic ultrasound during early prehospital assessment. Standard 2D images for pleural sliding and comet tails and M-Mode for the ‘seashore sign’ were acquired, and colour Doppler was also used to assist in the identification of pleural sliding.
Objective This trial investigated whether advanced paramedics from a UK regional ambulance service have the ability to acquire and interpret diagnostic quality ultrasound images following a 2-day programme of education and training covering the fundamental aspects of lung ultrasound.
Method The participants were tested using a two-part examination; assessing both their theoretical understanding of image interpretation and their practical ability to acquire diagnostic quality ultrasound images. The results obtained were subsequently compared with those obtained from expert physician sonographers.
Results The advanced paramedics demonstrated an overall accuracy in identifying the presence or absence of pneumothorax in M-mode clips of 0.94 (CI 0.86 to 0.99), compared with the experts who achieved 0.93 (CI 0.67 to 1.0). In two-dimensional mode, the advanced paramedics demonstrated an overall accuracy of 0.78 (CI 0.72 to 0.83), compared with the experts who achieved 0.76 (CI 0.62 to 0.86). In total, the advanced paramedics demonstrated an overall accuracy at identifying the presence or absence of pneumothorax in prerecorded video clip images of 0.82 (CI 0.77 to 0.86), in comparison
with the expert users of 0.80 (CI 0.68 to 0.88). All of the advanced paramedics passed the objective structured clinical examination and achieved a practical standard considered by the examiners to be equivalent to that which would be expected from candidates enrolled on the thoracic module of the College of Emergency Medicine level 2 ultrasound programme.
Conclusion This trial demonstrated that ultrasound-naive practitioners can achieve an acceptable standard of competency in a simulated environment in a relatively short period of time.
The purpose of this study was to evaluate the frequency of inadequate needle chest thoracostomy in the prehospital setting in trauma patients suspected of having a pneumothorax (PTX) on the basis of physical examination.
This study took place at a level I trauma center. All trauma patients arriving via emergency medical services with a suspected PTX and a needle thoracostomy were evaluated for a PTX with bedside ultrasound. Patients too unstable for ultrasound evaluation before tube thoracostomy were excluded, and convenience sampling was used. All patients were scanned while supine. Examinations began at the midclavicular line and included the second through fifth ribs. If no sliding lung sign (SLS) was noted, a PTX was suspected, and the lung point was sought for definitive confirmation. When an SLS was noted throughout and a PTX was ruled out on ultrasound imaging, the thoracostomy catheter was removed. Descriptive statistics were calculated.
A total of 57 patients were evaluated over a 3-year period. All had at least 1 needle thoracostomy attempted; 1 patient underwent 3 attempts. Fifteen patients (26%) had a normal SLS on ultrasound examination and no PTX after the thoracostomy catheter was removed. None of the 15 patients were later discovered to have a PTX on subsequent computed tomography.
In this study, 26% of patients who received needle thoracostomy in the prehospital setting for a suspected PTX appeared not to have had a PTX originally, nor had 1 induced by the needle thoracostomy. It may be prudent to evaluate such patients with bedside ultrasound instead of automatically converting all needle thoracostomies to tube thoracostomies. Inadequate needle thoracostomy rate in the prehospital setting for presumed pneumothorax: an ultrasound study J Ultrasound Med. 2010 Sep;29(9):1285-9
A prospective, randomized, controlled trial compared paramedic rapid sequence intubation with hospital intubation in adults with severe traumatic brain injury in four cities in Victoria, Australia. The primary outcome was neurologic outcome at 6 months postinjury. Training
Paramedics already experienced in ‘cold’ intubation (without drugs) undertook an additional 16-hour training program in the theory and practice of RSI, including class time (4 hours), practical intubating experience in the operating room under the supervision of an anesthesiologist (8 hours), and completion of a simulation-based examination (4 hours). Methods
Patients included in the study were those assessed by paramedics on road ambulances as having all the following: evidence of head trauma, Glasgow Coma Score ≤9, age ≥15 years, and ‘intact airway reflexes’, although this is not defined or explained. Patients were excluded if any of the following applied: within 10 minutes of a designated trauma hospital, no intravenous access, allergy to any of the RSI drugs (as stated by relatives or a medical alert bracelet), or transport planned by medical helicopter. Drug therapy for intubation consisted of fentanyl (100μg), midazolam (0.1 mg/kg), and succinylcholine (1.5 mg/kg) administered in rapid succession. Atropine (1.2 mg) was administered for a heart rate <60/min. A minimum 500 mL fluid bolus (lactated Ringers Solution) was administered. A half dose of the sedative drugs was used in patients with hypotension (systolic blood pressure <100 mm Hg) or older age (>60 years).
Cricoid pressure was applied in all patients. After intubation and confirmation of the position of the endotracheal tube using the presence of the characteristic waveform on a capnograph, patients received a single dose of pancuronium (0.1 mg/kg), and an intravenous infusion of morphine and midazolam at 5 to 10 mg/h each. If intubation was not achieved at the first attempt, or the larynx was not visible, one further attempt at placement of the endotracheal tube over a plastic airway bougie was permitted. If this was unsuccessful, ventilation with oxygen using a bag/mask and an oral airway was commenced and continued until spontaneous respirations returned. Insertion of a laryngeal mask airway was indicated if bag/mask ventilation using an oral airway appeared to provide inadequate ventilation. Cricothyroidotomy was indicated if adequate ventilation could not be achieved with the above interventions. In all patients, a cervical collar was fitted, and hypotension (systolic blood pressure <100 mm Hg) was treated with a 20 mL/kg bolus of lactated Ringers Solution that could be repeated as indicated. Other injuries such as fractures were treated as required. In the hospital emergency department, patients who were not intubated underwent immediate RSI by a physician prior to chest x-ray and computed tomography head scan. Follow up
At 6 months following injury, surviving patients or their next-of-kin were interviewed by telephone using a structured questionnaire and allocated a score from 1 (deceased) to 8 (normal) using the extended Glasgow Outcome Scale (GOSe). The interviewer was blinded to the treatment allocation. Statistical power
A sample size of 312 patients was calculated to achieve 80% power at an alpha error of 0.05. Three hundred twenty-eight patients met the enrollment criteria. Three hundred twelve patients were randomly allocated to either paramedic intubation (160 patients) or hospital intubation (152 patients). A mean Injury Severity Score of 25 indicated that many patients had multiple injuries. Success of intubation
Of the 157 patients administered RSI drugs, intubation was successful in 152 (97%) patients. The remaining 5 patients had esophageal placement of the endotracheal tube recognized immediately on capnography. The endotracheal tube was removed and the patients were managed with an oropharyngeal airway and bag/mask ventilation with oxygen and transported to hospital. There were no cases of unrecognised esophageal intubation on arrival at the emergency department during this study and no patient underwent cricothyroidotomy. Outcome
After admission to hospital, both groups appeared to receive similar rates of neurosurgical interventions, including initial CT scan, urgent craniotomy (if indicated), and monitoring of intracranial pressure in the intensive care unit.
Favorable neurologic outcome was increased in the paramedic intubation patients (51%) compared with the hospital intubation patients (39%), just reaching statistical significance with P = 0.046. A limitation is that 13 of 312 patients were lost to follow-up and the majority of these were in the hospital intubation group. The authors do point out that the difference in outcomes would no longer be statistically significant whether one more patient had a positive outcome in the treatment group (P = 0.059) or one less in the control group (P = 0.061). The median GOSe was higher in the paramedic intubation group compared with hospital intubation (5 vs. 3), however, this did not reach statistical significance (P = 0.28).
More patients in the paramedic intubation group suffered prehospital cardiac arrest. There were 10 cardiac arrests prior to hospital arrival in the paramedic RSI group and 2 in the patients allocated to hospital intubation. Further detail on these patients is provided in the paper. The authors state that it is likely that the administration of sedative drugs followed by positive pressure ventilation had adverse hemodynamic consequences in patients with uncontrolled bleeding, and that it is possible that the doses of sedative drugs administered in this study to hemodynamically unstable patients were excessive and consideration should be given to a decreasing the dose of sedation. Authors’ conclusions
The authors overall conclusion is that patients with severe TBI should undergo prehospital intubation using a rapid sequence approach to increase the proportion of patients with favorable neurologic outcome at 6 months postinjury. Further studies to determine the optimal protocol for paramedic rapid sequence intubation that minimize the risk of cardiac arrest should be undertaken. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg. 2010 Dec;252(6):959-65. Victorian Ambulance Service protocols are available here, which include their current paramedic RSI protocol
Ketamine was used by clinical staff from the The Shock Trauma Air Rescue Society (STARS) in Alberta to facilitate intubation in both the pre-hospital & in-hospital setting (with a neuromuscular blocker in only three quarters of cases). Changes in vital signs were small despite the severity of illness in the study population. A prospective review of the use of ketamine to facilitate endotracheal intubation in the helicopter emergency medical services (HEMS) setting Emerg Med J. 2010 Oct 6. [Epub ahead of print]
A Scottish study of 628 pre-hospital intubation attempts in cardiac arrest patients records the rate of successful intubations, oesophageal intubations, and endobronchial intubations. Prehospital tracheal intubation was associated with decreased rates of survival to admission. This study has the limitations of a retrospective series but indirectly provides some further muscle to the supraglottic airway lobby. Field intubation of cardiac arrest patients: a dying art? Emerg Med J. 2010 Apr;27(4):321-3
Articles in this month’s EMJ demonstrate an interesting conflict within UK pre-hospital care. The Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, heavily represented by anaesthetists, recommend the removal of tracheal intubation from UK paramedic practice. The College of Paramedics reject this recommendation, providing a robust critique of the paper and calling for better evidence before changing current practice. A fascinating read. A critical reassessment of ambulance service airway management in prehospital care: Joint Royal Colleges Ambulance Liaison Committee Airway Working Group, June 2008 Emerg Med J 2010;27:226-233 Full Text The College of Paramedics (British Paramedic Association) position paper regarding the Joint Royal Colleges Ambulance Liaison Committee recommendations on paramedic intubation Emerg Med J 2010;27:167-170 Full Text
A poster presentation at the Australasian College of Emergency Medicine’s Annual Scientific Conference in Melbourne in November 2009 reports 100 cases of pre-hospital ketamine use for analgesia by paramedics in New Zealand – reproduced below with permission of the author: Ketamine is a safe and effective analgesic for pre-hospital paramedic led pain relief
HM Hussey & BC Ellis
Introduction: There have been a number of reports on the use of ketamine by pre-hospital physicians, with many advocating its use as the ideal pre-hospital analgesic and sedative due to its airway and cardiovascular stability. There however is little published on its use by paramedics. This study aims to review its effectiveness and safety when administered pre-hospital by paramedics.
Method: Prospective observational study of 100 consecutive administrations by St Johns ambulance paramedics in 2008–09 using a specifically designed data sheet. Demographic data, adjuvant analgesics used, ketamine dose, pre and post dose pain scores on VNRS and physiological parameters were collected. In addition paramedics and patients completed a satisfaction rating score.
Results: The mean dose of ketamine used was 30.2 mg and the mean improvement in pain was 5.10. Ketamine was used both as a lone agent and with morphine; excellent analgesia was achieved in both groups. The most common reason for use was limb trauma followed by burns and extractions from scene. There were no episodes of hypotension or airway compromise. 15% of patients had an adverse reaction all mild and mostly comprising minor psychotropic effects. The median satisfaction rating for both paramedics and patients was ‘Good’.
Conclusion: These results back the use of Ketamine by St John’s Ambulance paramedics and the authors support its use by other pre-hospital services as a safe and effective analgesic.
Emergency Medicine Australasia 2010;22(S1):A30
All medical out of hospital cardiac arrests attended by the Warwickshire and Northamptonshire Air Ambulance (WNAA) over a 64-month period were reviewed. There were no significant differences in self-reported intubation failure rate, morbidity or clinical outcome between doctor-led and paramedic-led cases. The authors conclude that experienced paramedics regularly operating with physicians have a low tracheal intubation failure rate at out of hospital cardiac arrests, whether practicing independently or as part of a doctor-led team, and that this is likely due to increased and regular clinical exposure. Can experienced paramedics perform tracheal intubation at cardiac arrests? Five years experience of a regional air ambulance service in the UK Resuscitation. 2009 Dec;80(12):1342-5
Paramedics intubated simulated patients positioned supine on the floor by direct laryngoscopy (DL) and by using the Airtraq device. Ventilation was achieved more quickly with the Airtraq in a difficult airway scenario (tongue oedema), and after a short training period the Airtraq was faster at intubating a ‘normal’ airway. Comparison of use of the Airtraq with direct laryngoscopy by paramedics in the simulated airway. Prehosp Emerg Care. 2009 Jan-Mar;13(1):75-80