• Interesting articles this week

    by Alan Batt. Last modified: 02/02/14

    Excerpts below for some interesting articles worth reading.

    Paramedic rapid sequence intubation in patients with non-traumatic coma

    Bernard SA, Smith K, Porter R, Jones C, Gailey A, Cresswell B, Cudini D, Hill S, Moore B, St Clair T

    Emergency medicine journal : EMJ – Emerg Med J 2014 Jan;

    PMID: (click to view) 24473409

    Abstract

    INTRODUCTION: 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 (

    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 (

    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.

     

    Paramedic Intubation: Patient Position Might Matter

    Clemency BM, Roginski M, Lindstrom HA, Billittier AJ

    Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors – Prehosp Emerg Care 2014 Jan;

    PMID: (click to view) 24460424

    Abstract

    Abstract Objective. Paramedics often intubate in challenging environments. We evaluated whether patient position might affect prehospital intubation success rates utilizing a cadaver model.

    Methods. The study was conducted in two phases: a cross-sectional survey and an experimental model in which paramedics were asked to demonstrate intubation skills on cadavers in three positions. New York State certified paid and volunteer paramedics and critical care emergency medical technicians were recruited from multiple agencies. To assess past experience, participants self-reported the number of patients they attempted to intubate in the previous 12 months and the patient positions in which they attempted those intubations. Participants attempted to intubate nonembalmed cadavers in a controlled environment in three positions: on the floor, on a low stretcher to simulate the patient care compartment of an ambulance, and on an elevated stretcher. Paramedics were allowed a maximum of three intubation attempts of one minute each per cadaver. Endotracheal tube placement was verified by a single attending emergency physician using direct visualization.

    Results. Self-reports of intubation attempts in the previous 12 months indicated that participants had attempted to intubate a mean of 6.4 patients per paramedic. Self-reported positions of patient intubations were 57% on the floor, 33% in the ambulance, 7% on a stretcher of unspecified height, and 3% in some other position. During the study, 84 paramedics performed 251 intubations on 42 cadavers. First-attempt and cumulative first- and second-attempt success rates were 77.4 and 89.3% for the floor position, 74.7 and 94.0% for the low stretcher (ambulance) position, and 86.9 and 96.4% for the elevated stretcher position, respectively. First attempt success was higher in the elevated stretcher position compared to the low stretcher position (OR = 2.25, 95% CI 1.01-5.00). No other position contributed to greater odds of ETI success either on the first or second attempt.

    Conclusions. Endotracheal intubation success was higher with the cadaver positioned on an elevated stretcher compared to a low stretcher. Paramedics must be aware of patient position when performing prehospital intubation.

     

    The quality of manual chest compressions during transport – effect of the mattress assessed by dual accelerometers

    Hellevuo H, Sainio M, Huhtala H, Olkkola KT, Tenhunen J, Hoppu S

    Acta anaesthesiologica Scandinavica – Acta Anaesthesiol Scand 2013 Dec;

    PMID: (click to view) 24372080

    Abstract

    BACKGROUND: The quality of cardiopulmonary resuscitation (CPR) has an impact on survival. The quality may be impaired if the patient needs to be transported to the hospital with ongoing CPR. The aim of this study was to analyse whether the quality of CPR can be improved during transportation by using real-time audiovisual feedback. In addition, we sought to evaluate the real compression depths taking into account the mattress and stretcher effect.

    METHODS: Paramedics (n = 24) performed standard CPR on a Resusci Anne Mannequin in a moving ambulance. Participants were instructed to perform CPR according to European Resuscitation Council Resuscitation guidelines 2010. Each pair acted as their own controls performing CPR first without and then with the feedback device. Compression depth, rate and no-flow fraction and also the mattress effect were recorded by using dual accelerometers by two Philips, HeartStart MRx Q-CPR defibrillators.

    RESULTS: In the feedback phase, the mean compression depth increased from 51 (10) to 56 (5) mm (P < 0.001), and the percentage of compression fractions with adequate depth was 60% vs. 89% (P < 0.001). However, taking account of the mattress effect, the real depth was only 41 (8) vs. 44 (5) mm without and with feedback, respectively (P < 0.001). The values for compression rate did not differ.

    CONCLUSIONS: CPR quality was good during transportation in general. However, the results suggest that the feedback system improves CPR quality. Dual accelerometer measurements show, on the other hand, that the mattress effect may be a clinically relevant impediment to high quality CPR.

     

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    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.

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