Factors which influence morphine administration by paramedics

Morphine administration by Paramedics: An application of the Theory of Planned Behaviour

Injury. Volume 43, Issue 9 , Pages 1393-1396, September 2012

Timely and appropriate pain management in the pre-hospital environment is paramount to effective patient care. Experts agree that there are many factors that hinder the delivery of adequate pain management to patients with pain. The purpose of this study was to use the Theory of Planned Behaviour (TPB) model to identify the factors influencing Ambulance Paramedics’ intention to administer morphine to patients with pain.

The authors attribute the failure to deliver adequate pain management to patients with pain to a variety of barriers, including lack of education of health professionals, as well as attitudes that interfere with appropriate clinical care of those patients with significant pain.

Participants of this study were Queensland Advanced Care and Intensive Care Paramedics who were deemed competent in morphine administration. Data were collected by means of a questionnaire that used the constructs of the TPB, including subjective norm, perceived behavioural control and attitude. Whilst participants reported strong intentions to administer morphine they also reported negative attitudes towards the behaviour. The authors found that paramedics were concerned with auditing of cases, danger and complications to patients and extra responsibility were factors that negatively impacted on their intentions to administer morphine to patients with pain.

The constructs of the TPB explained 26% of the variance in intention to administer morphine with subjective norm being the strongest significant predictor. The findings related to specific attitudes and normative pressures provide an understanding into paramedic’s pain management behaviour.

© Gary Wilson/ Pre-hospital Research Forum

According to the authors, findings from this study propose that interventions which target attitudinal change and increase perceptions of control should be used to aid in motivating the paramedics to develop a positive decision to act on their intentions to administer morphine to patients with pain. This could be achieved by increasing education on the benefits of morphine administration and that development of a supportive peer learning environment would probably result in positive pain management behaviour.

At the end of the day, we should all be attempting to manage the patient’s pain as failure can result in deleterious physiological, biochemical and behavioural effects. While morphine may not be the only form of analgesia utilised by paramedics, all paramedics should be aiming to assess and manage the patient’s pain and should not allow barriers, such as clinical auditing or a belief that they will get triaged higher if they are in pain, as reasons to withhold analgesia. While education is important with regard to identifying the risks and potential complications of analgesia, it should also be the role of colleagues to support less experienced or confident paramedics in delivering optimum analgesia as a failure to deliver this education and support is likely to have a negative affect on that paramedic’s intention to use analgesia in the future.



Is needle-first or incision-first the easiest option for emergency cricothyroidotomy?

Emergency Cricothyroidotomy: A Randomized Crossover Trial Comparing Percutaneous Techniques: Classic Needle First Versus “Incision First”

Academic Emergency Medicine 2012; 19:1061–1067

Emergency cricothyroidotomy is potentially lifesaving in patients with airway compromise who cannot be intubated, ventilated or oxygenated by conventional means. According to the authors, the literature remains divided on the best insertion technique, namely, the open/surgical and percutaneous methods. The two are not mutually exclusive, and the study hypothesis was that an “incision-first” modification (IF) may improve the traditional needle-first (NF) percutaneous approach. This study assessed the IF technique compared to the NF method. While the study is not associated with paramedics or pre-hospital emergency care, the skill of cricothyroidotomy is one performed by paramedics and the identification of the most appropriate approach should be of interest.

A randomised controlled crossover design with concealed allocation was completed for 180 simulated tracheal models. Attending and resident emergency physicians were enrolled. The primary outcome was time to successful cannulation; secondary outcomes included needle insertion(s), incision, and dilatation attempts. Finally, proportions of intratracheal insertion on the first attempt and subjective ease of insertion were compared.

The IF technique was significantly faster than the standard NF technique (median = 53 seconds, interquartile range [IQR] = 45.0 to 86.4 seconds vs. median = 90 seconds, IQR = 55.2 to 108.6 seconds; p < 0.001). The median number of needle insertions was significantly higher for the NF technique (p = 0.018); there was no significant difference in dilation or incision attempts. Intratracheal insertion on the first attempt was documented in 90 and 93% of the NF and IF techniques, respectively (p = 0.317). All the study participants found the IF hybrid approach easier.

The IF modification allows faster access, fewer complications, and more favorable clinician endorsement than the classic NF percutaneous technique in a validated model of cricothyroidotomy. The authors suggest therefore that the IF technique be considered as an improved method for insertion of an emergency cricothyroidotomy. This study, however, was performed on simulated tracheal models with attending and resident emergency physicians. As cricothyroidotomy is often a ‘once in a career’ procedure for the average paramedic it could be interesting to compare the two procedures for pre-hospital providers. Paramedics who do not regularly undertake the skill may find the increased confidence of performing NF cricothyroidotomy first the easier approach in a stressful situation.


Intranasal Glucagon for pre-hospital hypoglycaemia

Successful Administration of Intranasal Glucagon in the Out-of-Hospital Environment

Prehospital Emergency Care Posted online on September 12, 2012.

The effectiveness of the intranasal (IN) drug route has been reported for several drugs in the pre-hospital environment, for example fentanyl, midazolam and naloxone, this article presents a case of successful prehospital treatment of hypoglycemia with IN glucagon.

Episodes of hypoglycemia can be of varying severity and often requires quick reversal to prevent alteration in mental status or hypoglycemic coma. Glucagon has been shown to be as effective as glucose for the treatment of hypoglycemia. The inability to obtain intravenous (IV) access often impairs delivery of this peptide and is therefore frequently given via the intramuscular (IM) route. Intranasal administration of glucagon has been shown to be as effective as the IV route and may be used for rapid correction of hypoglycemic episodes where IV access is difficult or unavailable and IM administration is undesirable.

The authors describe what they believe is the first documentation in the peer-reviewed literature of the successful treatment and reversal of an insulin-induced hypoglycemic episode with IN glucagon in the prehospital setting. The article also presents a review of the literature regarding this novel medication administration route.


Is there evidence to support magnesium for Irukandjii syndrome?

Randomised trial of magnesium in the treatment of Irukandji syndrome

Emergency Medicine Australasia,  Article first published online: 11 SEP 2012

Irukandji syndrome is a distressing condition characterised by pain, hypertension and tachycardia with some patients developing cardiac failure. According to the authors, magnesium sulphate has become the standard of care despite minimal evidence. The aim of this study was to investigate if magnesium would reduce analgesic requirement and length of stay for patients with Irukandji syndrome.

This was a double-blind, randomised controlled clinical trial. Patients with Irukandji syndrome who required parenteral opioid analgesia were randomised to receive either 10 mmol of magnesium as a bolus, and then a 5 mmol/h magnesium infusion for 6 h or saline. Fentanyl patient-controlled analgesia was commenced to allow patients to self-regulate their pain relief. The primary outcome measure of the study was comparison of total analgesic requirements between the two groups. The secondary outcome measure was to compare length of stay.

The study ran from November 2003 to May 2007. Thirty-nine patients were enrolled in the study; 26 were male with a median age of 28. Twenty-two received magnesium. It was found that there was no significant difference in the morphine equivalent dose used, peak CK, peak troponin, peak pulse, peak blood pressure, peak mean arterial pressure (MAP), percentage MAP rise and length of stay for those receiving magnesium compared with placebo.

According to the authors, the study did not demonstrate a benefit in the use of magnesium in the treatment of Irukandji syndrome. As such the current use of magnesium needs to be reconsidered until there is good evidence to support its use.


Fluid resuscitation in severe trauma

© Gary Wilson/ Pre-hospital Research Forum

© Gary Wilson/ Pre-hospital Research Forum

Early fluid resuscitation in severe trauma

BMJ 2012;345:e5752

Critically injured trauma patients may have normal cardiovascular and respiratory parameters (pulse, blood pressure, respiratory rate), and no single physiological or metabolic factor accurately identifies all patients in this group.

According to the authors, initial resuscitation for severely injured patients is based on a strategy of permissive hypovolaemia (hypotension) (that is, fluid resuscitation delivered to increase blood pressure without reaching normotension, aiming for cerebration in the awake patient, or 70-80 mm Hg in penetrating trauma and 90 mm Hg in blunt trauma) and blood product based resuscitation. The authors believe:

This period of hypovolaemia (hypotension) should be kept to a minimum, with rapid transfer to the operating theatre for definitive care.

Crystalloid or colloid based resuscitation in severely injured patients is associated with worse outcome.

Once haemostasis has been achieved, resuscitation targeted to measures of cardiac output or oxygen delivery or use improves outcome.

Tranexamic acid administered intravenously within 3 h of injury improves mortality in patients who are thought to be bleeding.


Survival for adult and paediatric patients following a pre-hospital traumatic cardiac arrest

Survival and neurologic outcome after traumatic out-of-hospital cardiopulmonary arrest in a pediatric and adult population: a systematic review

Critical Care, 2012 Volume 16 Issue 4

This systematic review is focused on the in-hospital mortality and neurological outcome of survivors after prehospital resuscitation following trauma. Data were analysed for adults/pediatric patients and for blunt/penetrating trauma.

A systematic review was performed using the data available in Ovid Medline. 476 articles from 1/1964 – 5/2011 were identified by two independent investigators and 47 studies fulfilled the requirements (admission to hospital after prehospital resuscitation following trauma). Neurological outcome was evaluated using the Glasgow outcome scale.

34 studies/5391 patients with a potentially mixed population (no information was found in most studies if and how many children were included) and 13 paediatric studies/1243 children (age ≤ 18 years) were investigated. The overall mortality was 92.8% (mixed population: 238 survivors, lethality 96.7%; paediatric group: 237 survivors, lethality 86.4% = p < 0.001).

Penetrating trauma was found in 19 studies/1891 patients in the mixed population (69 survivors, lethality: 96.4%) and in 3 pediatric studies/91 children (2 survivors lethality 97.8%).

44.3% of the survivors in the mixed population and 38.3% in the group of children had a good neurological recovery. A moderate disability could be evaluated in 13.1% in the mixed population and in 12.8% in children. A severe disability was found in 29.5% of the survivors in the mixed patients and in 38.3% in the group of children. A persistent vegetative state was the neurological status in 9.8% in the mixed population and in 10.6% in children.

For each year prior to 2010, the estimated log-odds for survival decreased by 0.022 (95%-CI: [0.038;0.006]). When jointly analysing the studies on adults and children, the proportion of survivors for children is estimated to be 17.8% (95%-CI: [15.1%;20.8%]). According to the authors, the difference of the paediatric compared to the adult proportion is significant (p < 0.001).

The authors found that children have a higher chance of survival after resuscitation of an out-of-hospital traumatic cardiac arrest compared to adults but tend to have a poorer neurological outcome at discharge. According to the authors, the key messages are:

• Children have a higher chance of survival after resuscitation of an OHCA compared to adults, but tend to have a poorer neurological outcome on discharge from hospital.

• Long-term survival is significantly different with 3.3% in a mixed adult/child population and 13.6% in a paediatric population.

• Survival after blunt trauma is significantly higher in the paediatric group.

• Long-term survival is good and moderate neurological recovery is reported in 57.4% of all survivors in a mixed adult/child population and in 51.1% of a paediatric population.

• Starting CPR in trauma patients may be worthwhile and trauma management programs should be discussed critically.

http://ccforum.com/content/16/4/R117 (Full text link)

What are normal oxygen saturation levels?

SpO2 values in acute medical admissions breathing air—Implications for the British Thoracic Society guideline for emergency oxygen use in adult patients?

Resuscitation,Volume 83, Issue 10, October 2012, Pages 1201–1205

Oxygen saturations (SpO2) are routinely used to assess the well-being of patients, but it is difficult to find an evidence-based description of its normal range. In 2008 the British Thoracic Society (BTS) published guidance for oxygen administration and recommended a target SpO2 of 94–98% for most adult patients. These recommendations rely on consensus opinion and small studies using arterial blood gas measurements of saturation (SaO2). The authors used large datasets of routinely collected vital signs from four hospitals and analysed the SpO2 range of 37,593 acute general medical inpatients (males: 47%) observed to be breathing room air. Age at admission ranged from 16 to 105 years with a mean (SD) of 64 (21) years. 19,642 admissions (52%) were aged <70 years.

The authors found that SpO2 levels ranged from 70% to 100% with a median (IQR) of 97% (95–98%). SpO2 values for males and females were similar. In-hospital mortality for the study patients was 5.27% (range 4.80–6.27%). Mortality (95% CI) for patients with initial SpO2 values of 97%, 96% and 95% was 3.65% (3.22–4.13); 4.47% (3.99–5.00); and 5.67% (5.03–6.38), respectively. Additional analyses of SpO2 values for 37,299 medical admissions aged ≥18 years provided results that the authors believe are distinctly different to those upon which the current BTS guidelines based their definition of normality.

The authors suggest that the BTS should consider changing its target saturation for actively treated patients not at risk of hypercapnic respiratory failure to 96–98%. The update to the British Thoracic Society Guidelines, due for publication in 2013, should make interesting reading, as it could reflect five years worth of research on titrated oxygen delivery, rather than just routine administration of medium of high concentrations of oxygen, regardless of the patient’s oxygen levels.


Chest compression quality management and ROSC

Chest compression quality management and return of spontaneous circulation: A matched-pair registry study

Resuscitation, Volume 83, Issue 10, October 2012, Pages 1212–1218

Investigating the effects of any intervention during cardiac arrest remains difficult. The ROSC after cardiac arrest score was introduced to facilitate comparison of rates of return of spontaneous circulation (ROSC) between different ambulance services. The authors choose to study the influence of chest compression quality management (including training, real-time feedback devices, and debriefing) in comparison with conventional cardiopulmonary resuscitation (CPR). A matched-pair analysis was conducted using data from the German Resuscitation Registry, with the calculated ROSC after cardiac arrest score as the baseline.

Matching for independent ROSC after cardiac arrest score variables yielded 319 matched cases from the study period (January 2007–March 2011). The score predicted a 45% ROSC rate for the matched pairs. The observed ROSC increased significantly with chest compression quality management, to 52%. No significant differences were seen in the conventional CPR group . The difference between the observed ROSC rates was not statistically significant.

The authors found that chest compression quality management leads to significantly higher ROSC rates than those predicted by the prognostic score (ROSC after cardiac arrest score). Matched-pair analysis shows that with conventional CPR, the observed ROSC rate was not significantly different from the predicted rate. Analysis shows a trend toward a higher ROSC rate for chest compression quality management in comparison with conventional CPR. According to the authors it is unclear whether a single aspect of chest compression quality management or the combination of training, real-time feedback, and debriefing contributed to this result.


How reliable are pre-hospital troponin results?

Prehospital Point-of-Care Testing for Troponin: Are the Results Reliable?

Prehospital Emergency Care. Posted online on September 6, 2012.

Rapid assessment of patients experiencing a myocardial infact (MI) results in improved outcomes, especially if the patient is transported directly to a specialist cardiac centre. While it is common for patient’s experiencing a STEMI  to be transported to a cardiac centre which undertakes percutaneous coronary intervention (PCI), non-STEMI patients often are conveyed to the nearest emergency department, have to wait for blood results and are then transferred to a cardiac centre.  By allowing ambulance crews to use point-of-care (POC) devices to measure cardiac troponin I levels during transport of patients to the emergency department (ED) may result in earlier diagnosis of acute myocardial infarction, particularly in those patients without ST-segment elevation and, if necessary, also ensure transportation to an appropriate treatment  facility.

The authors conducted the study to determine whether POC devices (i-STAT System) operated in a moving ambulance reliably duplicate the measurement of cardiac troponin I levels obtained by POC devices in the ED.

Blood samples were obtained in the ED and the hospital from patients reporting chest pain or other cardiac complaints. Troponin I assays were then performed in a moving ambulance using two POC devices. The POC devices were placed on flat surfaces in the rear of the ambulance. The ambulance driver was instructed to keep the ambulance moving in traffic while each assay was completed. A variety of routes were taken. Each set of two assays was completed entirely during a single simulated run. The results of the two assays performed in the moving ambulance were then compared with the results of the control assay, which was performed simultaneously in the ED on the same sample.

Forty-two whole-blood samples underwent troponin I assays in a moving ambulance. Thirteen (30.9%) assays were positive. One (2.4%) was excluded because of cartridge error. Two (4.8%) were excluded because of interfering substance. No significant difference in whole-blood troponin results was found between the assays performed in the moving ambulance and those performed in the ED (intraclass correlation coefficient 0.997; 95% confidence interval 0.994 to 0.998; p < 0.005).

The authors found that when used in a moving ambulance, the POC device provided results of cardiac troponin I assays that were highly correlated to the results when the device was used in the ED. While the authors recognise that the feasibility, practicality, and clinical utility of prehospital use of POC devices must still be assessed, these POC devices may offer another tool in the rapid identification of patients with an MI.


Shoulder dystocia: Does axillary traction work?

Shoulder dystocia: A qualitative exploration of what works

Midwifery Volume 28, Issue 4 , Pages e521-e528

The authors sought to explore expert practitioners’ methods of managing shoulder dystocia through a qualitative interpretive study which enabled a descriptive, hermeneutic analysis of data collected. Data were collected via tape recorded interviews, transcribed and analysed to explore themes and meanings.

Participants five clinicians (four midwives and one obstetrician) who have significant experience in the management of shoulder dystocia and work in high risk maternity practice were interviewed by the authors.

Key findings

• the management of shoulder dystocia has been influenced by HELPERR, so that practitioners are led to believe they should follow the sequence of the mnemonic,

• in the reality of experience, some manoeuvres of HELPERR are difficult, if not impossible, to perform,

• in moments of trying ‘anything’ practitioners have discovered the manoeuvre of axillary traction, and

• axillary traction is a simpler and more effective manoeuvre to perform in any circumstance, than the sequence of manoeuvres suggested in HELPERR.

Axillary traction was identified by the participants as being a ‘way that works’ when managing shoulder dystocia that does not respond to McRoberts manoeuvre and suprapubic pressure. Once shoulder dystocia occurs it is important to focus on moving the baby rather than pulling on the baby. If McRoberts and suprapubic pressure manoeuvres are unsuccessful however, the authors suggest that practitioners could consider the use of axillary traction to move the foetal shoulders as follows by applying axillary traction to follow the curve of the sacrum which should result in the anterior foetal shoulder will pivoting around the symphysis pubis and the posterior shoulder will be delivered first.

The practitioners in the study found that axillary traction had been the manoeuvre they found most successful and they did not need to resort to anything else. If it is not successful at the first attempt, however, then it would be appropriate to move the woman into the all – fours position and attempt axillary traction again. it is suggested that three simple steps of McRoberts – Suprapubic Pressure – Axillary Traction could simplify the way in which shoulder dystocia is managed.

According to the authors the results of this study demonstrate that the actions to be taken in the event of shoulder dystocia should be further examined and possibly reviewed. The three simple steps of McRoberts Manoeuvre – Suprapubic Pressure – Axillary Traction could revolutionise the way in which shoulder dystocia is managed. This study however is based on the opinions and experiences of only five practitioners, asking the same questions to more practitioners, including those from different countries, could be helpful.