e-Study Guide for Paramedics
Emergencies in children generate a great deal of anxiety - in the child, the parents, and in the medical and nursing staff who have to deal with them.We hope that this book will shed some light on the subject of paediatric emergency care, and that it will raise the standard of paediatric life support. An understanding of the contents will allow doctors, nurses, and paramedics dealing with seriously ill and injured children to approach their care with confidence.
Whether the LMA is safe for use with a full stomach has been of concern, but its increasing popularity in emergencies by personnel unskilled in tracheal intubation is encouraging. One multicentre trial recorded an incidence of aspiration of only 1.5 . Although competence in LMA insertion can be acquired with minimal training, the high cost of single use versions may preclude its wider acceptance by paramedic and hospital resuscitation services.
Pacing must be instituted very quickly in the treatment or prevention of cardiac arrest. Although transvenous pacing is the ideal, it is seldom possible in the cardiac arrest setting, particularly outside hospital even in hospital it takes time to arrange. Non-invasive pacing is quick and easy to perform and requires minimal training. Therefore, it is suitable to be used by a wide range of personnel including nurses and paramedics. Unfortunately, non-invasive pacing is not entirely reliable and is best considered to be a holding measure to allow time for the institution of temporary transvenous pacing.
Process and provide the appropriate emergency care. In the case of children, the history is often obtained from an accompanying parent, although a history should be sought from the child if possible. Do not forget to ask the paramedic about the child's initial condition and about treatments and response to treatments that have already been given.
Revision A) will support earlier diagnosis and management by allowing an interview and clinical examination of a patient in the field or during transportation by paramedics in an ambulance. Investigators in San Diego recently presented a case series of 25 patients for whom wireless TeleStroke consultation was completed they found excellent inter-rater reliability among 82 of modified NIHSS items.49
The recognition (or validation) of death and formal certification are profoundly different. Formal certification must, by law, be undertaken by a registered medical practitioner, and this requirement will not change. Nevertheless, it is possible to identify patients in whom survival is very unlikely and when resuscitation would be both futile and distressing for relatives, friends, and healthcare personnel, and situations in which time and resources would be wasted in undertaking such measures. In such cases it has been proposed that the recognition of death may be undertaken by someone other than a registered medical practitioner, such as a trained ambulance paramedic or technician. In introducing such a proposal, it is essential to ensure that death is not erroneously diagnosed and a potential survivor is denied resuscitation.
If a general practitioner does not have access to a defibrillator they should attend a case of acute myocardial infarction with the ambulance service If a general practitioner does not have access to a defibrillator they should attend a case of acute myocardial infarction with the ambulance service
In the United Kingdom the remoteness of rural communities often prevents the ambulance service from responding quickly enough to a cardiac arrest or to the early stages of acute myocardial infarction. Increasingly, trained lay people (termed first responders ) living locally and equipped with an AED are dispatched by ambulance control at the same time as the ambulance itself. They are able to reach the patient and provide initial treatment, including defibrillation if necessary, before the ambulance arrives. Other strategies used to decrease response times include equipping the police and fire services with AEDs. The provision of AEDs in large shopping complexes, airports, railway stations, and leisure facilities was introduced as government policy in England in 1999 as the Defibrillators in Public Places initiative. The British Heart Foundation has supported the concept of public access defibrillation enthusiastically and provided many defibrillators for use by trained lay responders...
More attempts are now being made in the community to resuscitate patients who suffer cardiopulmonary arrest. In many cases general practitioners and other members of the primary healthcare team will play a vital part, either by initiating treatment themselves or by working with the ambulance service. Few medical emergencies challenge the skills of a medical professional to the same extent as cardiac arrest, and the ability or otherwise of personnel to deal adequately with this situation may literally mean the difference between life and death for the patient.
She strikes the ground with her chin, causing severe hyperextension of the neck. Emergency medical technicians properly immobilize her neck and transport her to a hospital, but she dies 5 minutes after arrival. An autopsy shows multiple fractures of vertebrae C1, C6, and C7 and extensive damage to the spinal cord. Explain why she died rather than being left quadriplegic.
Lamentably, a number of patients who have suffered rupture of an AAA are transferred by ambulance technicians or paramedics after having been volume-resuscitated aggressively to a normal blood pressure. Too often these patients then suffer a second and now refractory collapse, in fact actually rerupturing their aneurysmal leak. Bickell and colleagues in Houston, evaluating hypovolemic shock in a variety of trauma and emergency vascular patients, have advanced the thesis that partial volume resuscitation is more harmful than none at all.4 These assertions remain controversial but we attempt to control volume resuscitation in the prehospital setting to result in a systolic blood pressure of no more than 90 mm Hg. The in-hospital mortality for ruptured AAA remains approximately at 50 , a toll which has not changed significantly in three decades. Prior studies in jurisdictions in which all deaths result in a post mortem examination appear to suggest that the community mortality rate of...
Members of the public and the ambulance service should be aware of the additional problems associated with resuscitation in late pregnancy. The training of ambulance staff is of particular importance as paramedics are likely to be the primary responders to community obstetric emergency calls. Paramedics are often the primary responders to obstetric emergency calls, and so awareness of problems associated with resuscitation in late pregnancy is important Paramedics are often the primary responders to obstetric emergency calls, and so awareness of problems associated with resuscitation in late pregnancy is important
The standardised course used to train paramedics builds on the substantial basic training and experience given to ambulance technicians. It emphasises the extended skills of venous cannulation, recording and interpreting electrocardiograms (ECGs), intubation, infusion, defibrillation, and the use of selected drugs. In 1992 the Medicines Act was amended to permit ambulance paramedics to administer approved drugs from a range of prescription only medicines. The paramedic training course covers, in a modular form, the theoretical and practical knowledge needed for the extended care of emergency conditions in a minimum instruction time of 400 hours. Four weeks of the course is provided in hospital under the supervision of clinical tutors in cardiology, accident and emergency medicine, anaesthesia, and intensive care. Training in emergency paediatrics and obstetric care (including neonatal resuscitation) is also provided. All grades of ambulance staff are subject to review and audit as...
The overwhelming prerogative, in thrombolysis for acute ischemic stroke, is the need for rapid, yet complete, evaluation of potential therapeutic candidates within the 3-hour treatment window. Time is the acute stroke clinician's worst enemy.33 The acute stroke protocol should begin at the first of point of contact with the healthcare system the call to an ambulance dispatcher. Stroke symptoms should be recognized and given high priority for dispatch. Emergency medical technicians (EMTs) should be trained to identify potential thrombolysis candidates in the field by recognizing signs of stroke,73,74 and several simple scales have been created for this purpose.75-78 Prenotification by the EMTs, before hospital arrival, allows time for notification of the acute stroke team and preparation of the CT scanner before patient arrival, and has been associated with fewer in-hospital delays in treatment.79,80 The initial evaluation, after arrival in the emergency department, should include a...
The resuscitation officer should be an approved instructor in advanced life support, often also in paediatric advanced life support and sometimes in advanced trauma life support. The background of resuscitation officers is usually that of a nurse with several years' experience in a critical care unit, an operating department assistant, or a very experienced ambulance paramedic. The resuscitation officer is directly responsible to the chair of the resuscitation committee and receives full backing in carrying out the role as defined by that committee. It is essential that a dedicated resuscitation training room is available and that adequate secretarial help, a computer, telephone, fax machine, and office space are provided to enable the resuscitation officer to work efficiently. As well as conducting the in-hospital audit of resuscitation, he or she should be encouraged to undertake research studies to further their career development.
We would like to thank the following people for their help in providing photographs Michael Colquhoun Cliff Randall, Welsh Ambulance Service NHS Trust Dr Rupert Evans and staff of the accident and emergency department, University Hospital of Wales, Cardiff the resuscitation training department, Worcester Royal Hospitals, Worcester Gavin D Perkins, Simon Giles, and John Dodds at Birmingham Heartlands Hospital.
The use of emergency vehicles carrying only paramedic staff, who were either in telephone contact with a hospital or acting entirely without supervision, was explored in the early 1970s, most extensively in the United States. The Medic 1 scheme started in Seattle in 1970 by Dr Leonard Cobb used the fire tenders of a highly coordinated fire service that could reach an emergency in any part of the city within four minutes. All firefighters were trained in basic life support and defibrillation and were supported by well-equipped Medic 1 ambulances crewed by paramedics with at least 12 months full-time training in emergency care. In the United Kingdom the development of civilian paramedic schemes was slow. The Brighton experiment in ambulance training began in 1971 and schemes in other centres followed independently over the next few years. It was only due to individual enthusiasm (by pioneers like Baskett, Chamberlain, and Ward) and private donations for equipment that any progress was...
Magnesium is involved in multiple processes relevant to cerebral ischemia, including inhibition of presynaptic glutamate release 180 , NMDA receptor blockade 181 , calcium channel antagonism, and maintenance of cerebral blood flow 182 . In animal models of stroke, administration of intravenous magnesium as late as 6 h after stroke onset, in doses that double its physiological serum concentration, was found to reduce infarct volumes 183, 184 . In pilot clinical studies, magnesium was found to reduce death and disability from stroke, raising expectations that magnesium could be a safe and inexpensive treatment 185 . However, in a large multicenter trial involving 2589 patients, magnesium given within 12 h after acute stroke did not significantly reduce the risk of death or disability, although some benefit was documented in lacunar strokes 131 .Further studies are ongoing to determine whether paramedic initiation of magnesium, by reducing the time to treatment, yields benefit in stroke...
The simplicity of operation of the AED has greatly reduced training requirements and extended the range of people that are able to provide defibrillation. The advent of the AED has allowed defibrillation by all grades of ambulance staff (not just specially trained paramedics) and in the United Kingdom the goal of equipping every emergency ambulance with a defibrillator has been achieved. Many other categories of healthcare professionals are able to defibrillate using an AED, and in most acute hospital wards and many other departments defibrillation can be undertaken by the staff present (usually nurses), well before the arrival of the cardiac arrest team.
Always question witnesses family members. Ask about the patient's own drugs, access to other drugs and any empty packets or bottles found at the scene of the overdose. The attending paramedics are a good source of information. Try and identify the likely poison as soon as possible. Common features relating to specific drugs are
The weekly round-up meeting had started and the case managers were making their presentations about the patients. Quickly, the usual petty envies began to emerge between the various professional groups. The occupational therapists crossed swords with the physiotherapists, the social workers looked askance at the psychologists and the psychologists looked askance at everyone, particularly the doctors. The doctors looked down their noses, or so it seemed to the paramedics.
Non-invasive external pacing utilises cutaneous electrodes attached to the skin surface and provides a quick method of achieving pacing in an emergency situation. It is relatively easy to perform and can, therefore, be instigated by a wide range of personnel and used in environments in which invasive methods cannot be employed. Increasingly, the defibrillators used in the ambulance service and the coronary care unit incorporate the facility to use this type of pacing.
Videos, and a variety of other support materials. Trainers are recruited from the statutory ambulance service and the voluntary first aid and life saving societies many schemes have trained their own instructors. Practising the techniques on training manikins is an essential part of these classes and enforces the theoretical instruction provided.
Accidental oesophageal intubation or tracheal tube dislodgement after initial successful intubation may pass undetected in clothed, restless patients intubated in dark or restricted conditions, or during long transits. The incidence of incorrect intubation varies with experience but some publications report rates of oesophageal intubation by paramedic and emergency medical technicians as high as 1750 . Simple clinical observation of a rising chest or precordial, lung, and stomach auscultation may be misleading. Confirmation of correct tracheal placement by other techniques is advised. These include the use of an oesophageal
In light of the difficulties of HBO, several groups have begun to investigate the therapeutic potential of normobaric hyperoxia therapy (NBO) 236-241 . NBO has several advantages it is simple to administer, well tolerated, inexpensive, widely available, can be started very quickly after stroke onset (e.g., by paramedics), and is noninvasive. In animal studies, NBO has been shown to reduce infarct volumes, improve neurobehavioral deficits, improve diffusion and perfusion MRI parameters of ischemia, and increase brain interstitial pO2 in penumbral tissues 236-238, 241 . In a small pilot clinical study of patients with acute ischemic stroke and diffusion-perfusion mismatch on MRI, NBO improved clinical deficits and reversed diffusion-MRI abnormalities, suggesting that similar beneficial effects can be obtained in humans 239 .As compared to HBO, NBO is relatively ineffective in raising brain ptiO2, and the mechanism of neuroprotection remains unclear. An indirect hemodynamic mechanism (...