Monthly Archives: March 2014

Pharmacologically assisted laryngeal mask insertion: a consensus statement

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Pharmacologically assisted laryngeal mask insertion: a consensus statement

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Emerg Med J 2013;30:1073-1075 

Management of the pre-hospital airway can be challenging.1 A range of techniques and adjuncts are available to the pre-hospital clinician to aid in their efforts to maximise oxygenation and support ventilation. When measures fail, management is escalated through a series of increasingly complex and invasive procedures (‘the airway management ladder’) with the aim of establishing a definitive airway secured with an endotracheal tube or other surgical airway. In the non-arrested patient the gold standard for definitive pre-hospital airway management is pre-hospital rapid sequence induction and tracheal intubation (RSI) delivered by a competent clinical team.

There may, however, be circumstances in which a pre-hospital RSI cannot be delivered, whether due to lack of clinical capability or lack of access to the patient. Some of these patients may benefit from advanced airway management, with the aim of promoting oxygenation, through the technique of pharmacologically assisted laryngeal mask (PALM) insertion. This technique involves sedating the trauma patient and inserting a supraglottic airway device (SAD) with the aim of improving their oxygenation and providing a degree of protection from ongoing airway contamination.

This article reports the conclusions of a consensus meeting held in April 2012. The meeting followed a full literature search which was presented to the meeting, to which there was an open invitation to all relevant stakeholders. The meeting examined the PALM technique and its indications and outlined the competencies required of practitioners performing the procedure. Key points are:

1. The PALM technique is an acceptable tool for managing the pre-hospital airway.

2. The PALM technique is indicated in a rare set of circumstances.

3. The PALM procedure is a rescue technique.

4. The PALM procedure should be checklist driven.

5. At least a second generation SAD should be used.

6. End-tidal CO2 monitoring is mandatory.

7. No preference is expressed for any particular drug.

8. No preference is expressed for any particular dosing regime

9. Flumazenil is highly unlikely to have a role in managing the PALM patient.

10. The PALM procedure should only be carried out by practitioner of level 7 above.

11. The availability of a trained assistant, familiar with the procedure would be advantageous.

12. The training required, to achieve competency in performing the PALM procedure must include in-hospital insertion of supraglottic airway devices, simulation training and training in the transfer of critically ill patients.

13. Data should be collected and collated at a national level for all patients who receive the PALM procedure.

http://emj.bmj.com/content/30/12/1073.extract

Copies of this statement can be downloaded freely here:

http://www.fphc.co.uk/content/Portals/0/Documents/2013-12%20PALM%20Consensus%20COMPLETE.pdf

The prehospital management of pelvic fractures: initial consensus statement

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The prehospital management of pelvic fractures: initial consensus statement

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Emerg Med J 2013;30:1070-1072

Serious pelvic injuries are associated with a high mortality rate which has remained persistently high even with advances in hospital care. Hypovolaemia is often a significant contributing factor to these deaths. If haemorrhage from pelvic injuries could be controlled or reduced in the prehospital environment, then survival rates might increase.

Improved mortality has been seen with catastrophic haemorrhage from limb injuries after the introduction of the battlefield tourniquet and topical haemostatic dressings. However, compared with bleeding from pelvic injuries, external haemorrhage is simple to recognise and the success of intervention easier to observe.

Pelvic binding devices provide a simple alternative to surgical fixators. These devices can be applied in the prehospital environment, potentially allowing control of unseen major haemorrhage.

This article reports the finding of a consensus meeting on the prehospital management of pelvic injuries held in March 2012 and examines the evidence associated with pelvic binding devices and their application. Key findings are:

1. Pelvic Binder is a treatment intervention and should be applied early

2. A select group of patients may not need a binder applied

3. No one pelvic binder device can currently be recommended over another.

4. Adequate training must be provided to avoid misplacement of devices.

5. Associated femoral fractures should also be reduced.

6. Patients should not be log rolled or transported on a spinal board

7. The use of pelvic binders is associated with the risk of low pressure necrosis

8. The pelvic binder should be placed next to skin.

9. A pelvic binder should be applied prior to extrication.

http://emj.bmj.com/content/30/12/1070.extract

Copies of this statement can be downloaded freely here:

http://www.fphc.co.uk/content/Portals/0/Documents/2013-12%20Pelvic%20Consensus%20COMPLETE.pdf

Minimal patient handling: a faculty of prehospital care consensus statement

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Minimal patient handling: a faculty of prehospital care consensus statement

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Emerg Med J 2013;30:1065-1066

This paper outlines the emerging best practice when packaging a prehospital trauma patient while providing spinal immobilisation. The best practice described is based on the recommendations of a consensus meeting held by the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh, in the West Midlands in April 2012, where the opinion of experienced practitioners from across the prehospital and emergency care community considered the currently available evidence and reviewed current clinical practice.

Initial consensus points were then subject to further review and dialogue with stakeholders from the initial meeting. The recommendations drawn from the meeting and subsequent dialogue represent a ‘general agreement’ to the principles and practices described in the paper. The recommendations will provide guidance for clinical practice and governance alongside other consensus statements from the Faculty of Pre-Hospital Care that seek to address prehospital spinal immobilisation and pelvic immobilisation.

Key points are:

1. The long spinal board is an extrication device and should no longer be used for providing spinal immobilisation during transport to definitive care.

2. The scoop stretcher should be used for patient transfer and to provide spinal immobilisation.

3. Patients should be managed according to a package of ‘Minimal Handling Considerations’.

4. The patient should be immobilised on the Scoop Stretcher with ‘scoop-to-skin’

5. When the total time immobilised on a Scoop Stretcher is likely to exceed 45 minutes consideration should be given to using a Vacuum Mattress.

http://emj.bmj.com/content/30/12/1065.abstract

Copies of these statements can be downloaded freely here:

http://www.fphc.co.uk/content/EducationEvents/ConsensusStatements.aspx

Pre-hospital spinal immobilisation: an initial consensus statement

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Pre-hospital spinal immobilisation: an initial consensus statement

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Emerg Med J 2013;30:1067-1069 

This paper reviews the current evidence available on the practice of spinal immobilisation in the prehospital environment. Following this, initial conclusions from a consensus meeting held by the Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh in March 2012 are presented.

The consensus meeting held by the Faculty of Pre-hospital Care aimed to clarify the practice of immobilisation. Preliminary discussions highlighted salient points that required discussion. The conclusions of the consensus group are:

1. The long spinal board is an extrication device solely. Manual-in-line stabilisation is a suitable alternative to a cervical collar.

2. An immobilisation algorithm may be adopted although the content of this remains undefined.

3. There may be potential to vary the immobilisation algorithm based on the conscious level of the patient.

4. Penetrating trauma with no neurological signs does not require immobilisation.

5. ‘Standing take down’ practice should be avoided.

6. In a conscious patient with no overt drugs or alcohol on board and with no major distracting injuries, the patient, unless physically trapped should be invited to self-extricate and lie on the trolley cot. Likewise, for the non-trapped patient who has self-extricated, they can be walked to the vehicle and then laid supine, examined and if necessary immobilised.

7. Further research into effective, practical and safe immobilisation practice, and dissemination of this, is required.

http://emj.bmj.com/content/30/12/1067.abstract

From the FPHC (full text):

http://www.fphc.co.uk/content/Portals/0/Documents/2013-12%20Spinal%20Consensus%20COMPLETE.pdf

Paramedic rapid sequence intubation in patients with non-traumatic coma

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Paramedic rapid sequence intubation in patients with non-traumatic coma

© Gary Wilson

© Gary Wilson

Emerg Med J doi:10.1136

Pre-hospital intubation by paramedics is widely used in comatose patients prior to transportation to hospital, but the optimal technique for intubation is uncertain. One approach is paramedic rapid sequence intubation (RSI), which may improve outcomes in adult patients with traumatic brain injury. However, many patients present to emergency medical services with coma of non-traumatic cause and the role of paramedic RSI in these patients remains uncertain.

Methods The electronic Victorian Ambulance Clinical Information System was searched for the term ‘suxamethonium’ between 2008 and 2011. We reviewed the patient care records and included patients with suspected non-traumatic coma who were treated and transported by road-based paramedics. Demographics, intubation conditions, vital signs (before and after drug administration) and complications were recorded. Younger patients (<60 years) were compared with older patients.

Results There were 1152 paramedic RSI attempts of which 551 were for non-traumatic coma. The success rate for intubation was 97.5%. There was a significant drop in blood pressure in younger patients (<60 years) with the mean systolic blood pressure decreasing by 16 mm Hg (95% CI 11 to 21). In older patients, the systolic blood pressure also decreased significantly by 20 mm Hg (95% CI 17 to 24). Four patients suffered brief cardiac arrest during pre-hospital care, all of whom were successfully resuscitated and transported to hospital.

Conclusions Paramedic RSI in patients with non-traumatic coma has a high procedural success rate. Further studies are required to determine whether this procedure improves outcomes.

http://emj.bmj.com/content/early/2014/01/28/emermed-2013-202930.abstract