Pharmacologically assisted laryngeal mask insertion: a consensus statement

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.

Copies of this statement can be downloaded freely here:

The prehospital management of pelvic fractures: initial consensus statement

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.

Copies of this statement can be downloaded freely here:

Minimal patient handling: a faculty of prehospital care consensus statement

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.

Copies of these statements can be downloaded freely here:

Pre-hospital spinal immobilisation: an initial consensus statement

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.

From the FPHC (full text):

Paramedic rapid sequence intubation in patients with non-traumatic coma

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.

The feasibility of civilian prehospital trauma teams carrying and administering packed red blood cells

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

The feasibility of civilian prehospital trauma teams carrying and administering packed red blood cells

Emerg Med J 2014;31:93-95

To evaluate the feasibility, limitations and costs involved in providing prehospital trauma teams with packed red blood cells (pRBCs) for use in the prehospital setting.

Methods A retrospective cohort study, examining 18 months of historical data collated by the Queensland Ambulance Service Trauma Response Team (TRT) and the Pathology Queensland Central Transfusion Laboratory was undertaken.

Results Over an 18-month period (1 January 2011–30 June 2012), of 500 pRBC units provided to the TRT, 130 (26%) were administered to patients in the prehospital environment. Of the non-transfused units, 97.8% were returned to a hospital blood bank and were available for reissue. No instances of equipment failure directly contributed to wastage of pRBCs. The cost of providing pRBCs for prehospital use was $A551 (£361) for each unit transfused.

Conclusions The authors found it is feasible and practical to provide prehospital trauma teams with pRBCs for use in the field. Use of pRBCs in the prehospital setting is associated with similar rates of pRBC wastage to that reported in emergency departments.

Improvement in the prehospital recognition of tension pneumothorax

Improvement in the prehospital recognition of tension pneumothorax: The effect of a change to paramedic guidelines and education

Injury. Volume 45, Issue 1, January 2014, Pages 71–76

An audit of ambulance service clinical records from 2001 to 2002 in Melbourne, Australia revealed 10 patients with tension pneumothorax on arrival at hospital which had been undetected or untreated by paramedics. The clinical practice guideline for paramedic recognition of tension pneumothorax was subsequently changed to emphasise heightened clinical suspicion of a tension pneumothorax in the setting of chest trauma, especially when patients were managed with positive pressure ventilation.

This study was undertaken to determine whether the number of undetected or untreated tension pneumothoraces had decreased after the new clinical practice guideline and associated education program; if there were unintended consequences arising from earlier paramedic intervention; and what effect, if any, this change had on subsequent hospital treatment.

Retrospective case note review of all patients requiring intercostal catheter (ICC) insertion at The Alfred Hospital, Melbourne, Australia, using records from Ambulance Victoria, the Alfred Trauma Registry and the National Coronial Information System.

In 2001–2002 paramedics treated 22 patients with suspected tension pneumothorax before transport to the Alfred Hospital. In 2006–2007 this number had increased to 81. There was a decrease from ten to four in the number of unrecognised or untreated tension pneumothoraces between the two time periods. No unintended or adverse consequences of prehospital needle decompression could be found. However, there was an increase in the number of patients who had prehospital needle decompression that needed further treatment for tension pneumothorax on arrival at hospital. This need for further treatment was associated with use of shorter cannulas and unilateral needle decompression by paramedics.

A small change in clinical practice guidelines, supported by an education and audit program, led to a reduction in unrecognised untreated tension pneumothoraces by paramedics without an increase in complications. Paramedics should be aware that a shorter cannula may fail to reach the pleural space and that both sides of the chest may require decompression.

Prehospital anaesthesia performed in a rural and suburban air ambulance service staffed by a physician and paramedic

Prehospital anaesthesia performed in a rural and suburban air ambulance service staffed by a physician and paramedic: a 16-month review of practice

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Emerg Med J 2014;31:65-68 

This paper describes the first 16-months experience of prehospital rapid sequence intubation (RSI) in a rural and suburban helicopter-based doctor-paramedic service after the introduction of a standard operating procedure (SOP) already proven in an urban trauma environment.

Method A retrospective database review of all missions between October 2010 and January 2012 was carried out. Any RSI or intubation carried out was included, regardless of age or indication. Patients who were intubated by Ambulance Service personnel prior to the arrival of the East Anglian Air Ambulance (EAAA) team were excluded.

Results The team was activated 1156 times and attended 763 cases. A total of 88 RSIs occurring within the study period were identified as having been carried out by the EAAA team and meeting inclusion criteria for review. There were no failed intubations that required a rescue surgical airway or the placement of a supraglottic airway device. For road traffic collisions (RTCs), the overall on-scene time for patients who required an RSI was 40 min (range 15–72 min). For all other trauma, the average on-scene time was 48 min (range 25–77 min), and for medical patients, the average time spent at scene was 41 min (range 15–94 min).

Conclusions The authors have demonstrated the successful introduction of a prehospital care SOP, already tested in the urban trauma environment, to a rural and suburban air ambulance service operating a fulltime doctor-paramedic model. The authors have shown a zero failed intubation rate over 16 months of practice during which time over 750 missions were flown, with 11.5% of these resulting in an RSI.

Further details on the UK air ambulances SOP for RSI can be found here: HEMS SOP and RSI checklist.  The research article lists “six indications for an RSI in the prehospital setting:

(1) actual or impending airway failure;
(2) ventilatory failure;
(3) unconsciousness;
(4) humanitarian indications;
(5) injured patients who are unmanageable or severely agitated after a head injury and
(6) anticipated clinical course.

“The patient is placed in a position away from direct sunlight, ideally with 360o access space. After adequate preoxygenation, a standard sequence of etomidate followed by suxamethonium is administered, and the tracheal tube is placed under direct vision and always over an intubating bougie. Following confirmation of correct tracheal tube placement, anaesthesia is maintained with boluses of morphine and midazolam, and neuromuscular blockade is continued with pancuronium. In the event of a failed intubation, there is a well-rehearsed sequence of immediate ‘drills’ to perform in order to improve intubation conditions, and after a second failed attempt, or if there is failure to adequately oxygenate or ventilate at any time, a supraglottic airway is placed, or a surgical airway is performed.”

Performance of Experienced Versus Less Experienced Paramedics in Managing challenging scenarios

Performance of Experienced Versus Less Experienced Paramedics in Managing Challenging Scenarios: A Cognitive Task Analysis Study

Annals of Emergency Medicine. Volume 62, Issue 4, October 2013, Pages 367–379

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Out-of-hospital care is becoming more complex, thus placing greater reliance on the cognitive abilities of paramedics to manage difficult situations. In adapting to the challenges in their work, paramedics develop expertise. We study the cognitive strategies used by expert paramedics to contribute to understanding how paramedics and the EMS system can adapt to new challenges.

The authors conducted a “staged-world” cognitive task analysis to explore paramedics’ handling of cognitive challenges related to sense-making and to resource and task management. A mixed-fidelity simulation was used to present paramedics with 2 challenging scenarios: a pulmonary embolism initially presenting as a myocardial infarction and a 2-person shooting with limited resources available.

Participants were 10 paramedics, 6 more experienced and 4 less experienced. Analysis involved comparing the performance of the 2 groups to identify strategies associated with expertise. The more experienced paramedics made more assessments, explored a wider variety of presumptive diagnoses, and identified the pulmonary embolism earlier. They switched attention between the 2 shooting victims more, used their emergency medical technician–basic level partners more, and provided more advanced level care for both patients. Their patients arrived at the emergency department more prepared for specialized emergency care.

The authors’findings correspond to general cognitive attributes of expertise: greater cue gathering and inferential reasoning, and more functional and strategic thinking. These results suggest potential areas and methods to facilitate development of expertise, as well as ways to better support use of expertise. Future studies should expand on these findings through larger sample sizes and more complex scenarios.

Therapeutic hypothermia following out-of-hospital cardiac arrest

Another study questioning therapeutic hypothermia has been published following the recent publication of two research studies which resulting in several organisations, including the European Resuscitation Council and ILCOR to issue statements on targeted temperature management.

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Comparative Effectiveness of Therapeutic Hypothermia After Out-of-Hospital Cardiac Arrest: Insight from a Large Data Registry

Therapeutic Hypothermia and Temperature Management. Online Ahead of Print: December 28, 2013

This study was undertaken by the authors to determine the effectiveness of therapeutic hypothermia (TH) after out-of-hospital cardiac arrest (OHCA) among a large cohort of adults in the Cardiac Arrest Registry to Enhance Survival (CARES), with an emphasis on subgroups with a non-shockable first documented rhythm.

All adult index events at participating sites from November 2010 to December 2013 were study eligible. All patient data elements were provided with summary statistics calculated for all patients with and without TH. For multivariate adjustment, a multilevel (i.e., hierarchical), mixed-effects logistic regression (MLR) model was used with hospitals treated as random effects. Propensity score matching (PSM) on both shockable and non-shockable patients was done as a sensitivity analysis. After predefined exclusions, our final sample size was 6369 records for analysis: shockable=2992 (47.0%); asystole=1657 (26.0%); pulseless electrical activity=1249 (19.6%); other unspecified non-shockable=471 (7.4%). Unadjusted differences in neurological status at hospital discharge with and without TH were similar (p=0.295).

After multivariate adjustment, TH had either no association with good neurological status at hospital discharge or that TH was actually associated with worse neurological outcome, particularly in patients with a non-shockable first documented rhythm (i.e., for NS patients, MLR odds ratio for TH=1.444; 95% CI [1.039, 2.006] p=0.029, and OR=1.017, p=0.927 via PSM).

Highlighting the limitations, the authors concluded that when TH is indiscriminately provided to a large population of OHCA survivors with a non-shockable first documented rhythm, evidence for its effectiveness is diminished. The authors suggest more uniform and rigid guidelines for the application of TH.

This was published only a month after the European Resuscitation Council issued a statement ( on target temperature management following two studies into the treatment of patients with ROSC after out-of-hospital cardiac arrest (OHCA) arise from these studies, questioning whether:

1. Should ice-cold intravenous fluid continue to be used for inducing hypothermia prehospital?
2. Should the target temperature be 32-34 °C or 36 °C for the management of comatose cardiac arrest survivors with ROSC?

Shortly after the European Resuscitation Council (ERC) released the statement, International Liaison Committee on Resuscitation (ILCOR)  published an advisory statement to guide clinicians on the use of temperature management in post cardiac arrest patients (

According to ILCOR: “A key message from this study is that targeted temperature management (TTM) remains an important component of the post resuscitation care of the unconscious cardiac arrest patient and that similar results were obtained when either 33ºC or 36ºC were selected as target temperature.”

With regard to choosing that temperature to cool your patients, the following advice was issued: ” Pending formal consensus on the optimal temperature, we suggest that clinicians provide post-resuscitation care based on the current treatment recommendations” and “We accept that some clinicians may make a local decision to use a target temperature of 36°C pending this further guidance”. Further formal discussions are being undertaken by ILCOR regarding future decisions on targeted temperature management.

Below are details on the original two studies which sparked the release of the advisory statements:

Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest found no difference in survival when lowering cardiac arrest patients’ temperature to 33 °C vs. 36 °C. [N Engl J Med 2013; 369:2197-2206 December 5, 2013]

Unconscious survivors of out-of-hospital cardiac arrest have a high risk of death or poor neurologic function. Therapeutic hypothermia is recommended by international guidelines, but the supporting evidence is limited, and the target temperature associated with the best outcome is unknown. The authors objective was to compare two target temperatures, both intended to prevent fever.

In an international trial, the authors randomly assigned 950 unconscious adults after out-of-hospital cardiac arrest of presumed cardiac cause to targeted temperature management at either 33°C or 36°C. The primary outcome was all-cause mortality through the end of the trial. Secondary outcomes included a composite of poor neurologic function or death at 180 days, as evaluated with the Cerebral Performance Category (CPC) scale and the modified Rankin scale.

In total, 939 patients were included in the primary analysis. At the end of the trial, 50% of the patients in the 33°C group (235 of 473 patients) had died, as compared with 48% of the patients in the 36°C group (225 of 466 patients) (hazard ratio with a temperature of 33°C, 1.06; 95% confidence interval [CI], 0.89 to 1.28; P=0.51). At the 180-day follow-up, 54% of the patients in the 33°C group had died or had poor neurologic function according to the CPC, as compared with 52% of patients in the 36°C group (risk ratio, 1.02; 95% CI, 0.88 to 1.16; P=0.78). In the analysis using the modified Rankin scale, the comparable rate was 52% in both groups (risk ratio, 1.01; 95% CI, 0.89 to 1.14; P=0.87). The results of analyses adjusted for known prognostic factors were similar.

In unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause, hypothermia at a targeted temperature of 33°C did not confer a benefit as compared with a targeted temperature of 36°C.

Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest: A Randomized Clinical Trial was the second study which resulted in the statement. (JAMA. 2014;311(1):45-52.)

Objective To determine whether prehospital cooling improves outcomes after resuscitation from cardiac arrest in patients with ventricular fibrillation (VF) and without VF.

Design, Setting, and Participants A randomised clinical trial that assigned adults with prehospital cardiac arrest to standard care with or without prehospital cooling, accomplished by infusing up to 2 L of 4°C normal saline as soon as possible following return of spontaneous circulation. Adults in King County, Washington, with prehospital cardiac arrest and resuscitated by paramedics were eligible and 1359 patients (583 with VF and 776 without VF) were randomized between December 15, 2007, and December 7, 2012. Patient follow-up was completed by May 1, 2013. Nearly all of the patients resuscitated from VF and admitted to the hospital received hospital cooling regardless of their randomisation.

Main Outcomes and Measures The primary outcomes were survival to hospital discharge and neurological status at discharge.

Results The intervention decreased mean core temperature by 1.20°C  in patients with VF and by 1.30°C  in patients without VF by hospital arrival and reduced the time to achieve a temperature of less than 34°C by about 1 hour compared with the control group. However, survival to hospital discharge was similar among the intervention and control groups among patients with VF (62.7% vs 64.3%) and among patients without VF (19.2% vs 16.3%). The intervention was also not associated with improved neurological status of full recovery or mild impairment at discharge for either patients with VF (57.5% of cases had full recovery or mild impairment vs 61.9% or those without VF (14.4% of cases vs 13.4% of controls). Overall, the intervention group experienced rearrest in the field more than the control group (26%  vs 21% ), as well as increased diuretic use and pulmonary oedema on first chest x-ray, which resolved within 24 hours after admission.

Conclusion and Relevance Although use of prehospital cooling reduced core temperature by hospital arrival and reduced the time to reach a temperature of 34°C, it did not improve survival or neurological status among patients resuscitated from prehospital VF or those without VF.