bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of granulated sugar therapy in the management of sloughy or necrotic wounds: a pilot study
Authors: Murandu M , Webber M.A , Simms M.H , dealey c
Published: May 2014

Objective: To determine the in vitro antimicrobial efficacy of three types of sugar and conduct a pilot clinical study with a view to developing a protocol for a randomised controlled trial (RCT). Method: In the in vitro studies three types of granulated sugar (Demerara, granulated beet sugar and granulated cane sugar) were tested to determine their minimum inhibitory concentrations (mICs) against 18 Gram-negative and Gram-positive bacteria in a micro-titre broth dilution assay; growth inhibition of Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa in different concentrations of sugar (0.38–25%) was also tested over 12-hours in an agar diffusion assay. The pilot clinical study selected patients from a vascular surgical ward and a vascular outpatient department. all had acute or chronic exuding wounds, some of which were infected. White granulated sugar was applied to the wounds. The following parameters were assessed: surface area; wound characteristics including pain, malodour, appearance (slough/granulation); exudate level; pain level and bacterial load. Patients with diabetes had their blood sugar levels checked daily. all patients completed a short health questionnaire at the start and end of the study. Staff completed a satisfaction questionnaire at the end of the study. The study period was 21 days. Results: In vitro tests demonstrated that sugar inhibits bacterial growth. all three types of sugars had mICs ranging from 6–25% in the bacterial strains tested. The diffusion tests showed that strains were able to grow well in low concentrations of sugar but were completely inhibited in higher concentrations. The two granulated sugars were found to be slightly more effective than Demerara sugar, so the latter was excluded from the clinical pilot study. Twenty-two patients (20 inpatients and two outpatients) with sloughy or necrotic wounds were recruited into the clinical study. Two patients had MRSA and two had Staphylococcus colonisation at baseline. Blood sugar levels remained stable in the seven patients with insulin-dependent diabetes mellitus. All wounds were clean/debrided in a mean of 11.13 days. Pain and malodour reduced markedly. Patient and staff surveys revealed overwhelming support for the sugar therapy. Conclusion: The pilot study achieved its aim of developing a protocol for a RCT. Preliminary data suggest that sugar is an effective wound cleansing and is safe to use in patients with insulin-dependent diabetes. In vitro studies demonstrate that sugar inhibits bacterial growth. Conflict of interest: None.
Effect of amelogenin ECM protein on the healing of chronic leg ulcers with atrophie blanche
Authors: Fogh K. , Nielsen C.B. , Dam W.
Published: May 2014

• Objective:

To determine the effect of topically applied amelogenin extracellular matrix protein (AEMP) in patients with non-healing venous leg ulcers combined with atrophie blanche.

• Method:

This retrospective case series of patients with non-healing venous leg ulcers with atrophie blanche of the distal proportion of their lower legs, where non-healing was defined as no progress toward healing for 3 months previously, under standard therapy. Patient records were reviewed for associated diseases, wound diagnoses, distal blood pressure, previous treatments and changes in wound area. Patients were treated with AEMP once a week, for a period of 12 weeks, or until full healing.

• Results:

Eleven patient records were reviewed retrospectively. The median age of the patients was 81 years (range 40–95 years), with a mean wound size of 4.7 ± 3.5cm2 and median wound duration of 6 months (range 3–444 months). All patients had venous or combined arterial/venous insufficiency. After 12 weeks' treatment with AEMP, complete healing, defined as 100% re-epithelialisation, was documented in four patients (36%), marked improvement (> 50% epithelialisation) in three patients (54%, 55% and 83% wound closure, respectively), slight improvement in one patient (9.4% wound closure), no change for two patients and worsening in one. AEMP was well tolerated, and no patients reported side effects.

• Conclusion:

The results of this retrospective study suggest that AEMP improves healing in chronic venous leg ulcers combined with atrophie blanche.

• Declaration of interest:

Amelogenin extracellular matrix protein (XelmaR) was provided by Mölnlycke Health Care, Denmark. There were no external sources of funding for this study and Mölnlycke Health Care had no role in the study design or data collection. The authors have no conflicts of interest to declare.
The effect of different doses of an arginine-containing supplement on the healing of pressure ulcers
Authors: Leigh B. , Desneves K. , Rafferty J. , Pearce L. , King S. , Woodward M.C. , Brown D. , Martin R. , Crowe T.C.
Published: May 2014

Objective:

To investigate if a lower dose of arginine in the form of an oral nutritional supplement can show similar benefit in the healing rate of pressure ulcers compared with the current evidence for 9g of arginine.

Method:

Twenty-three inpatients with category II, III or IV pressure ulcers were randomised to receive daily, for 3 weeks, the standard hospital diet plus 4.5 or 9g arginine in the form of a commercial supplement. Pressure ulcer size and severity was measured weekly (by PUSH tool; pressure ulcer scale for healing; 0= completely healed, 17= greatest severity). Nutritional status was determined by Subjective Global Assessment.

Results:

There were no significant differences in patients' age, gender, BMI, haemoglobin levels, albumin levels and diagnosis of diabetes between treatment groups. There was a significant decrease in pressure ulcer severity over time (p < 0.001), with no evidence of a difference in healing rate between the two arginine dosages (p=0.991). Based on expected healing time, patients in both treatment groups were estimated to achieve an almost 2-fold improvement compared with the historical control group. Patients categorised as malnourished showed clinically significant impaired healing rates compared with well-nourished patients (p=0.057), although this was unaffected by arginine dosage (p=0.727).

Conclusion:

Similar clinical benefits in healing of pressure ulcers can be achieved with a lower dosage of arginine, which can translate into improved concordance and significant cost-savings for both the health-care facilities and for patients.

Declaration of interest:

There were no external sources of funding for this study. The authors have no conflicts of interest to declare.
Reducing the cost of lower limb wound management through industry partnership and staff education
Authors: Norris R. , Staines K. , Vogwill V.
Published: May 2014

Following an audit of practice in North East London Foundation Trust (NELFT), obstacles in the management of lower limb conditions were identified. An appraisal of needs in terms of skills and theory updates for staff led to a fixed-term ‘honorary contract’ between the trust and a wound-care company to facilitate a rolling programme of education, to upskill staff in terms of assessment and treatment, and develop standardised care pathways. After 3 months, a repeated practice audit revealed a reduction in nurse contact hours of 1156 hours. The partnership with industry proved to be beneficial and did not compromise care, and trust staff were not obligated to use their product.
Bacteria identification on NPWT foams: clinical relevance or contamination?
Authors: Anagnostakos K. , Mosser P.
Published: May 2014

• Objective: To compare and interpret the microbiological findings of tissue samples prior to and during negative pressure wound therapy (NPWT), as well as those of NPWT foams. • Method: A retrospective evaluation of 101 NPWT dressings (29 polyurethane, 72 polyvinylalcohol; 43 deeply inserted, 56 superficially, two combined deeply and superficially; 67 hardware present and 34 no hardware present) in 64 patients was conducted. All foam and tissue samples were cultured over a period of 7 days. Tissue and foam samples were incubated on blood agar plates and in tryptic soya broth. Positive results indicated a microbial growth with > 105 colony forming units (CFU)/ml. • Results: Total mean implantation period was 6 ± 2 days (2–14 days). On 39 foams (39%), at least one organism could be identified. While S. aureus and S. epidermidis were the most common organisms prior to NPWT, during therapy S. epidermidis and S. aureus were most frequently identified in the tissue samples, with E. faecalis and S. epidermidis on the foams. In 12 cases (31%), the organisms in the tissue samples during NPWT and on the foams were identical, whereas in two cases a different organism was evident on the foam. In 6 cases (15%) the microbiological examination of the tissue samples was negative while positive on the foam. In the remaining 19 cases (54%), an organism could be identified on the foams while no tissue samples were microbiologically examined. • Conclusion: This study shows that, in at least 20% of the cases, a bacterium might be solely identified on the NPWT foam or differ to those isolated in the tissue; whether this is a contamination, bacterial switch or the results of insufficient microbiological diagnostics prior to NPWT cannot be surely stated. • Declaration of interest: There were no external sources of funding for this study. The authors have no conflicts of interest to declare.
Life-style advice and self-care strategies for venous leg ulcer patients: what is the evidence?
Authors: Brown A.
Published: May 2014

• Objective: To ascertain the evidence for lifestyle changes and self-care activities encouraged by health professionals to prevent venous leg ulcer recurrence. • Method: A literature search was undertaken using online databases: Medline, CINAHL, Psychinfo and Cochrane for relevant literature between 1990 and 2012. • Results: A total of 16 papers were identified, with recurrent themes of physical activity, exercise, mobility and leg elevation emerging. The evidence for the efficacy of compression therapy in preventing recurrence is substantial and is not discussed here. • Conclusion: There is some evidence that increasing physical activity, improving mobility and foot exercises may be beneficial in preventing ulcer recurrence. The evidence on the benefits of leg elevation on recurrence prevention is unclear and further research is needed. • Declaration of interest: There were no external sources of funding for this study. The author has no additional conflicts of interest to declare.
An experience with paediatric burn wounds treated with a plant-derived wound therapeutic
Authors: Mainetti S. , Carnevali F.
Published: May 2014

Objective:

To observe the efficacy of a plant-derived wound dressing (1 Primary Wound Dressing®), a mixture of hypericum and neem oil, in different types of paediatric burns.

Method:

A retrospective review was conducted over the complete healing course of 9 paediatric patients with a mean age of 8.17±3.35 (1–11 years), presenting mixed, partial or full-thickness burns. The treatment applied by the wound care specialist consisted of daily cleansing of the wound with a saline solution and application of 1 Primary Wound Dressing on the whole wound surface. There was no application of a secondary dressing. The time to heal, wound size, ease of handling, pain and complications were recorded. Procedural and background pain were observed in six of the patients older than 5 years (mean age 9.6±2.39, range 8–11 years). Due to the small number of patients examined during the period studied, it was not possible to perform statistical analyses.

Results:

The mean wound size was 50.76±48.32cm2 (4.63–132.0cm2). A rapid induction of granulation tissue and re-epithelialisation was observed. Time to complete healing was 16.6±4.69 days (10–22 days). No complications related to wound infection was observed. The 6 patients older than five years reported a strong relief of pain, from an initial value of 7–8 out of 10 to 0 out of 10 within the first week of treatment. This remained at the 0 out of 10 level during the second and third weeks of treatment.

Conclusion:

This retrospective, non-controlled examination suggests that 1 Primary Wound Dressing could be an effective therapy for the treatment of burn wounds, with benefits including pain reduction and simplicity of use. Further evaluations with a larger population are required to document the effectiveness of this plant-derived wound dressing in a controlled fashion.

Declaration of interest:

There were no external sources of funding for this study. F. Carnevali is a researcher and co-inventor of 1 Primary Wound Dressing®.
Guideline-directed wound care: a patient with a post kidney transplant surgical site infection
Authors: Cottrill R.
Published: May 2014

Clinical guidelines are developed to consolidate the growing body of evidence in wound care, allowing clinicians to provide a systematic approach to wound management. This article examines applying the Canadian Association of Wound Care's best practice guidelines for post-surgical wounds to in the case of a 56-year-old patient with recent kidney transplant, displaying signs of surgical-site infection, as an example of how best practice guidelines can be used to guide care.
Feelings of powerlessness and hope for cure in patients with chronic lower-limb ulcers
Authors: Salomé G.M. , Alves S.G. , Costa V.F. , Pereira V.R. , Ferreira L.M.
Published: May 2014

Objective: To assess feelings of powerlessness and hope for cure in patients with chronic venous leg ulcers (VLUs) and diabetic foot ulcers (DFUs).

Method: A clinical, analytical, descriptive study was conducted from April to September 2012 in a wound-care clinic in Brazil, on consecutive patients presenting with VLUS and DFUS. The Powerlessness Assessment Tool for Adult Patients (PAT) and the Herth Hope Index (HHI) were used. Total PAT scores range 12–60 and the higher the score, the stronger the feelings of powerlessness. The HHI ranges 12–48, with higher scores indicating higher levels of hope

Results: In total, 80 consecutive patients were recruited (40 VLU and 40 DFU). Mean PAT score was 53.3 ± 9.6 (range 21–60) for DFU patients and 34.3 ± 7.7 (range 21–60; p=0.001) for VLU patients, suggesting these individuals had strong feelings of powerlessness. The mean HHI was 16.5 ± 16.5 (range 12–40) for DFU patients and 27.5 ± 27.5 (range 12–40; p=0.001) for patients with VLUs, indicating low levels of hope.

Conclusion: The results suggest that patients with DFUs had stronger feelings of powerlessness regarding their condition and less hope of recovery compared with patients with VLUs.

Declaration of interest: There were no external sources of funding for this study. SGA and VFC received a scholarship from the Research Support Foundation of the State of Minas Gerais (FAPEMIG). The scholarship provider had no roles in the design and conduct of the study, including collection, management, analysis and interpretation of data, preparation, review, and approval of the article. The authors have no conflicts of interest to declare.
Management of post road traffic accident compound leg defects using fasciocutaneous flaps
Authors: Masoodi Z. , Ahmad I. , Khurram F. , Haq A.
Published: May 2014

Objective: To highlight the role of fasciocutaneous flaps in the management of leg and foot defects sustained after trauma, in rural India.

Method: This was a prospective study conducted on patients with traumatic defects of the leg and foot, admitted between May 2001 and April 2007. Selection of flaps was done on the basis of defect size, site and condition of surrounding tissue. Ipsilateral flaps (proximally- and distally-based), contralateral-leg flaps and free flaps (anterolateral thigh and radial forearm) were raised according to standard techniques and wounds resurfaced accordingly. The outcome was considered ‘excellent’ when there was no flap necrosis and no donor site morbidity, ‘good’ when there was some infection, either at the donor or recipient site, but no necrosis, ‘satisfactory’ when partial flap necrosis and ‘poor’ when there was flap loss.

Results: One-hundred and ten patients (86 males and 24 females) with post-traumatic leg defects underwent reconstruction with different fasciocutaneous flaps. The ages of the patients ranged from 6 years to 58 years, with a mean age of 28.2 ± 11.5 years. Forty cases (37%) underwent immediate reconstruction within the first 72 hours and in 70 cases (63%) delayed reconstruction was done. Hospital stay of the patients ranged from 8 days to 54 days, with a mean of 20.2 ± 1.9 days. There were no complications recorded at donor site. The overall results were considered excellent in 92 cases (84%), good in 12 (11%), satisfactory in four (3.6%) and poor in two cases (1.8%), where flap necrosis occurred.

Conclusion: Our results suggest fasciocutaneous flaps are convenient, simple, reliable and easy to manage. The majority of compound leg defects can be reconstructed with fasciocutaneous flaps either from the ipsilateral leg, contralateral leg or in the form of free flaps.

Declaration of interest: There were no external sources of funding for this study. The authors have no conflicts of interest to declare.
Back to basics: biophysical methods in tissue viability research
Authors: worsley P. , Voegeli D.
Published: May 2014

Dr Peter Worsley and Dr David Voegeli provide an outline of several well-established methods of biophysical measurement used in tissue viability research, which have begun to crossover into clinical practice.
Evaluation of a pilot Pressure Ulcer Prevention Initiative (PUPI) for patients with traumatic spinal cord injury
Authors: Cobb J.E. , Bélanger L.M.A. , Park S.E. , Shen T. , Rivers C.S. , Dvorak M.F. , Street J.T. , Noonan V.K.
Published: May 2014

Objective:

The purpose of this study was to determine whether implementation of a Pressure Ulcer Prevention Initiative (PUPI) changed the assessment and treatment of patients with a traumatic spinal cord injury (SCI) in an acute care setting, and improved patient outcomes.

Method:

The success of implementation was evaluated by examining the percentage of patients with completed occupational therapist (OT) skin care assessments and prescriptions for therapeutic support surfaces (TSS; i.e., mattresses) before implementation (historical, cohort 1) and after implementation (experimental, cohort 2). Patient outcomes were evaluated by examining changes in PU incidence, severity, timing and recurrence, as well as PU prevalence and satisfaction with life in the community.

Results:

Final analysis included 70 patients in cohort 1 and 73 in cohort 2. OT skin care assessment documentation (31% to 60%; p<0.001) and TSS prescriptions (31% to 60%; p=0.02) signifcantly increased following the implementation. The PU incidence based on patient charts (both nursing and OT assessments) did not increase signifcantly (26% to 36%; p=0.2). However, documented PU incidence according to OT assessments showed a substantial increase (14% to 33%; p=0.002). No effect of the PUPI was seen on immediate or long-term patient outcomes during the study period.

Conclusion:

PUPI was successful in changing clinical practice in PU prevention but no statistically signifcant improvements in PU-related patient outcomes were demonstrated. Results from this study identifed facilitators and barriers to implementation and highlighted the complexity and diffculty of instituting effective preventative or therapeutic interventions for this population in an acute care setting. This information will assist with refnements of the PUPI and inform similar future initiatives.

Declaration of interest:

This study was supported by fnancial contribution from the Government of Canada through Health Canada and Western Economic Diversifcation Canada. The views expressed herein represent the views of the authors. JC, LB, MD, JS are employees of the study hospital. S P, CR, TS and VN are employees of the Rick Hansen Institute.
The use of a specialised amino acid mixture for pressure ulcers: A placebo-controlled trial
Authors: Wong A. , Chew A. , Wang C.M. , Ong L. , Zhang S.H. , Young S.
Published: May 2014

Objective:

To compare pressure ulcer healing rates in patients supplemented with a specialised amino acid mixture containing β-hydroxy β-methylbutyrate (HMB), arginine and glutamine, and standard oral nutritional supplements versus patients supplemented with oral nutritional supplements and a placebo mixture.

Method:

Twenty-three inpatients with stage II, III or IV pressure ulcers in an acute care hospital were randomised to recieve (A) a HMB, arginine and glutamine mixture twice daily alongside oral nutritional supplements (n=11) or (B) standard nutritional care alongside oral nutritional supplements (n=12) for 2 weeks. Pressure ulcers were measured weekly for area, depth and Pressure Ulcer Scale for Healing (PUSH) scores. The proportion of viable tissue was determined based on area of wound tracing. Weekly laboratory tests were performed to measure C-reactive protein and pre-albumin levels. This trial is registered at http://ClinicalTrials.gov under NCT01090076.

Results:

There was no difference between anthropometrical measurements, biochemical parameters and nutritional intake pre- and post- study. Wound area did not decrease significantly in the short term for both groups. The proportion of viable tissues increased within 2 weeks on HMB, arginine and glutamine supplementation (p=0.02). PUSH scores showed significant improvement within 1 week of supplementation for the experimental group (p=0.013).

Conclusion:

The use of specialised amino acid does not appear to reduce wound size and PUSH scores but may improve tissue viability after 2 weeks. Further confirmation on a larger scale is required to determine the benefits of supplementing additional HMB, arginine and glutamine in patients with pressure ulcers.

Declaration of interest:

This study was supported in part by Abbott Laboratories (Singapore) Pte Ltd. The authors have no conflicts of interests to declare. pressure ulcer; wound healing; arginine; glutamine; beta-hydroxy beta-methylbutyrate; HMB.
Spotlight on Research
Authors: Williams Julia
Published: May 2014

Early cooling of resuscitated patients improves neurological outcome, yet out-of-hospital initiation of cooling is uncommon for mainly practical reasons. This pilot study hypothesized that the use of burn cooling dressings in the out-ofhospital environment could initiate brain cooling at an earlier stage and potentially be of value. Burn dressings are readily available in most ambulance services so the method is easily adaptable for ambulance crews.
An introduction to CPD for paramedic practice
Authors: Sibson Lynda
Published: May 2014

This article outlines the concept of continuing professional development (CPD) and its application to the paramedic. CPD has long been an aspect of other health care professions, but is relatively new to the paramedic profession. The Health Professions Council (HPC) standards mean that paramedics will have to provide evidence of CPD from August 2009. The standards apply not only to those in clinical practice, but also to those working in research, management or education.

CPD can initially appear daunting. However, it can, and should be, an enjoyable aspect of developing yourself and your professional practice. This article therefore aims to suggest some CPD activities for paramedic practice, with reference to some of the HPC guidelines and learning from other health care professionals.
How to carry out a search of a bibliographic database
Authors: Lahlafi Alison
Published: May 2014

This article, aimed at the novice, proposes a four-step approach to planning, undertaking and documenting the search for relevant literature, a vital part of any literature review. The main focus is on searching electronic databases to find research papers, but the principles described may also be applied to paper-based sources and the Internet (useful resources for research are considered).

Examples are given to illustrate the process of searching using index terms, grouping concepts and applying limits.
Acute cocaine toxicity: assessment and cardiac risk
Authors: Gardner Karen
Published: May 2014

The UK has the highest prevalence of drug use within Europe, with a 13% increase in cocaine and ecstasy related deaths reported between 2004 and 2005. This is significant to emergency medical personnel because cocaine toxicity can present clinically as acute coronary syndrome (ACS) minus typical associated risk factors. Cocaine use has an immediate effect on the body, having an onset of action seconds to minutes after administration. The resultant effect is manyfold, but can be divided into the two broad categories of central nervous system and cardiovascular effects. Cocaine misuse is a trigger of ACS, acute myocardial infarction and sudden death in a population of patients largely free of classic cardiovascular risk factors. Emergency medical staff are in a position to provide early and effective management through history-taking and assessment tools in conjunction with therapeutic intervention. The aim of this article is to highlight the presentation and consequence of acute cocaine toxicity in relation to its assessment, management and cardiac emergencies within the prehospital setting.
Diagnosing urinary tract infections: an overview
Authors: Isherwood Robert
Published: May 2014

As ambulance services start to develop the role of the emergency care practitioner (ECP), ambulance crews need to understand the types of conditions that can now be referred to and treated by this new group of clinicians. This article sets out to demonstrate how ECPs can assist crews who are concerned that a patient may have a urinary tract infection (UTI), by highlighting the anatomy and physiology of the urinary tract, looking at the common causes of UTIs, showing how a practitioner would formulate a diagnosis and setting out current best treatment options. The article hope to show that by making informed referrals to ECPs the full benefit of the role can be achieved, ensuring best care to the patient who calls upon their skills.
COPD: an overview of prehospital care
Authors: Scholes Steven , Hedges Nicola
Published: May 2014

Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. It is a debilitating airways disease which presents to the ambulance service with varying severity and is characterized by airflow obstruction which is usually progressive, not fully reversible and does not change markedly over several months. It may coexist with other comorbidities such as cardiovascular disease, making diagnosis of exacerbations difficult. COPD management in the prehospital environment is focused on effective recognition and the early application of pharmacological intervention to alleviate symptoms using current Joint Royal Colleges Ambulance Liaison Committee Guidelines.
The future of air ambulance services in trauma care
Authors: Davies Douglas
Published: May 2014

This article explores the development of air ambulances from being vehicles for inter-hospital transfers to being the modern frontline resources for prehospital care. The service models currently utilised by the various air ambulance charities are explored, as is the influence each of these may have on the delivery of patient care. The organizational structure of air ambulance charities is addressed, as it also impacts upon service delivery and the governance of clinical practice. This area gives rise to an exploration of the potential for air ambulances to offer a unique platform for the development of the paramedic profession and an expanded scope of clinical practice. The article also explores the effect of wider changes within health care and how this impacts upon the services provided by air ambulances. Analysis of potential future developments based upon a number of factors is made and conclusions drawn with regard to both current and future practice development.
Postural changes to improve perfusion in acute hypovolaemia
Authors: Hodge Alison , Lord Bill
Published: May 2014

Early management of hypoperfusion in the field has included the use of patient postures that are believed to increase venous return and to subsequently increase cardiac output, resulting in an improvement in perfusion. These postures are usually a Trendelenburg (head down position with the lower body elevated approximately 30 centimetres) or a raised leg posture with the torso horizontal. Despite apparent acceptance of these postures in the management of hypotension due to hypovolaemia there is conflicting advice in paramedic textbooks regarding the use of these postures, and as such this study sought to locate and evaluate evidence relating to the efficacy of these postures in the early management of hypoperfusion. The results of the review failed to find evidence of efficacy arising from the prehospital setting. Evidence from other health settings was subsequently reviewed to synthesise recommendations for paramedic practice. No evidence of significant clinical benefit was located, and the use of these postures by paramedics to improve perfusion should be reviewed on the basis of these findings.
Managing abdominal pain in the pre-hospital setting
Authors: Kenyon Paul
Published: May 2014

Despite the ambulance services' regular exposure to abdominal pain-related emergencies, pain management seems to be a persistent chink in their armour. Notwithstanding the advancements in pre-hospital health care, this age-old problem continues to remain uncorrected. With a greater understanding of pain and analgesia, coupled with a reminder of basic training, pain management need not be the paramedic's Achilles heel.
Recording a standard 12-lead ECG: filling gaps in quality
Authors: Crawford Jacqui , Doherty Linda
Published: May 2014

In ‘Recording a standard 12-lead ECG: Filling gaps in knowledge’ (Crawford and Doherty, 2009) the authors identified an apparent decline in the quality of electrocardiograms (ECGs) recorded in the clinical setting. Several primary steps to improve electrode placement and hence patient care were highlighted. This article will address additional issues that may also contribute to the decline in ECG quality and propose ways in which practice may be further improved.
Birth: an evidence-based approach
Authors: Reed Rachel , Peetze Jamie , Barnes Margaret
Published: May 2014

Paramedics are involved in transferring women during labour and must also be able to manage births occurring outside of the hospital setting. Prehospital obstetric incidents represent a significant proportion of large cost litigation claims in the United Kingdom (Dobbie and Cooke, 2008). Therefore, it is important to have an understanding of the physiology of birth and how best to avoid unnecessary complications. Culturally, birth is perceived as a dangerous event, and birth in an unplanned setting can be a frightening experience for women and for others present. However, birth is a normal physiological process and in the absence of prior interventions, complications are uncommon (Walsh, 2007). This paper will discuss an evidence-based approach to the management of normal birth and provide recommendations for practice which will reduce the risk of complications occurring and potentially improve the experience for women.
The three faces of atelectasis
Authors: Stancil Stewart A
Published: May 2014

Atelectasis, often known as collapsed lung, is a commonly encountered medical emergency. This case study identifies three different types of atelectasis and how they apply to the law of LaPlace. Different mechanisms include collapse from forces outside the lung parenchyma, a reduction in alveolar size from exudative reactions, and an increase in alveolar surface tension. All three mechanisms result in the condition of atelectasis. All three mechanisms can be illustrated as variables in LaPlace's equation. Physiological causes and treatment considerations are discussed for each type.
What are the priorities for prehospital research?
Authors: Brace Samantha , Cooke Matthew
Published: May 2014

In July 2010, the Department of Health published a document titled: ‘Building the evidence base in prehospital urgent and emergency care: a review of research evidence and priorities for future research’. This document reviews the existing research and evidence in the field of prehospital urgent and emergency care, and identifies gaps where future research would be valuable. Here, Samantha Brace, Research Fellow, Clinical Trials Unit, Warwick Medical School and Advanced Clinical Practitioner, Emergency Medicine, Heart of England NHS Foundation Trust, and Matthew Cooke, Professor of Emergency Medicine, Warwick Medical School and Heart of England NHS Foundation Trust, comment on the report in depth. Email for correspondence: m.w.cooke@warwick.ac.uk
Enhancing the leadership and management competency of paramedics
Authors: O'Meara Peter , Acker Joe , Munro Graham , Menzies Natalie , Rae John , Woollard Malcolm
Published: May 2014

Ambulance services around the world are facing significant management and leadership challenges associated with the rapid growth of call volumes; increasing adoption of sophisticated technology; a broadening scope of clinical practice; greater expectations of citizens, patients and system governors; and the ever increasing complexity of working in both the health and public safety environments. The sustainability of vibrant, healthy and high performing ambulance services depends on competent, experienced and well-educated leaders and managers.
July roundup of the EMS blogging world
Authors: Glencorse Mark
Published: May 2014

Mark Glencorse, NHS Operational Paramedic Team Leader, Former author of 999medic.com, and Co-Host and European Programme Director of ‘The Chronicles of EMS’, updates JPP on the main issues that emergency medical services (EMS) blogs are focusing on and the topics that are creating the best discussions this month.
Bacterial tonsillitis: prevalence, prediction and treatment by the ECP
Authors: Winch Spencer
Published: May 2014

Sore throat or tonsillitis is not necessarily considered a life-threatening emergency but such calls are received and attended to by the ambulance service. It is believed that this is because a face-to-face assessment is often required as the symptoms of a high temperature, headache, lethargy, vomiting and a stiff neck are far too similar to those of meningitis. With complex telephone triage now being performed by nurses and emergency care practitioners (ECP) on clinical support desks within most emergency operation centres, it is hoped that this complaint could be narrowed down and a more appropriate ECP response despatched. When presented with tonsillitis in the community, it is difficult for the practitioner to establish whether the infection is of a bacterial or viral origin. Learned behaviour would suggest that white exudates on the tonsils deem a bacterial origin and requires antibiotic treatment, but this can sometimes be a self limiting illness and antibiotic treatment is not indicated and will only assist with resistance. This article looks as the incidence of bacterial tonsillitis, tools to predict bacterial tonsilitis, and the correct antibiotic and length of course once established. It also briefly touches on the Department of Health's current consultation on paramedic prescribing rights and how a delayed prescription treatment plan cannot be achieved working under a patient group directive (PGD) when treating bacterial tonsillitis.
September roundup of the EMS blogging world
Authors: Glencorse Mark
Published: May 2014

This month it is back over the Atlantic for ‘The Happy Medic's (Happy Medic, 2010) turn to be our featured blogger. Happy Medic, aka Justin Schorr, is a San Francisco fire fighter paramedic, who I had the opportunity to go and work with for 10 days in November 2009 for our little project that ended up becoming ‘The Chronicles of EMS’ (The Chronicles of EMS, 2010).
Blended learning: conflict resolution training for ambulance first responders
Authors: Halliwell David , Ryan Elizabeth
Published: May 2014

In 2004, the NHS Counter Fraud and Security Management Service (CFSMS) were asked to provide training to raise awareness of conflict resolution techniques for all frontline NHS staff, including ambulance personnel. Specific ambulance guidance was published in 2007—this guidance sought to protect NHS workers from the perception that there was evidence of violence against health workers ( NHS CFSMS, 2007 ). South Western Ambulance Service Foundation NHS Trust (SWASFT) trained, in a classroom setting, all members of its 999 frontline, patient transport and all other patient-facing staff during 2009–2010. Following this training, concerns were raised about how the Trust was to undertake the dissemination of this training to its 900 plus volunteer community responder staff, scattered across the community in Dorset, Somerset, Devon, Cornwall, and the Isles of Scilly. The team within SWASFT began work, with a partner company, to design a blended learning solution—combining e-learning with face-to-face training in order to teach community responders the theoretical concepts of conflict resolution. This project was undertaken in partnership with Solutions Training and Advisory Ltd, a specialist conflict resolution training company. This article aims to provide a detailed overview of the approach used by SWASFT when designing a suitable training programme for its community responders. In addition, it seeks to demonstrate the value of this type of educational approach when dealing with community based support workers who, by virtue of their role, do the training in their own time and in their own homes.
Paediatric tricyclic antidepressant overdose
Authors: Levas Michael , Condra Cole
Published: May 2014

A case of paediatric tricyclic antidepressant (TCA) ingestion is discussed in this article. Ingestions, especially from TCAs, are potentially life-threatening, requiring prompt recognition and treatment. Successfully treating a TCA ingestion hinges on the recognition of both the availability of TCAs to the patient and the signs and symptoms of TCA ingestion. Unfortunately, once TCA ingestion is identified, there is variability in management by emergency medical services (EMS), leading to variability in outcomes. The diagnosis and management of TCA ingestion are reviewed in this case study, as well as barriers that prehospital care providers encounter in diagnosing and treatment.
Emergency ultrasound in the prehospital setting
Authors: Jaffer Usman , Aslam Mohammed , Jaffer Amina , Standfield Nigel , Pennell Aaron
Published: May 2014

Paramedic practice in the UK has seen some diverse and lengthy changes in the last ten years. The way that ambulance services are now involved in emergency care is very different, with more focus placed on the efficient and appropriate use of other primary and secondary care resources. The advent of closer and more formal working relationships between prehospital care physicians and paramedics will provide the opportunity to further develop the quality of care delivered by the doctor-paramedic team. It is now widely accepted that for the most seriously injured patients out of hospital, the application of physician-led skills such as prehospital anaesthesia contribute significantly to the process of the early management of trauma and improvement of outcome ( Van der Hoeven and De Koning, 1995 ). Similarly, the development of the team approach has meant that more goal–led therapies can be instituted in a timely fashion. The use of ultrasound in the prehospital environment is not new. While its role is not yet fully established ( Brooke et al. 2010 ), it is nevertheless finding its rightful place in the hands of both trained physicians and paramedics. The diversity of applications for paramedic–led ultrasound is also gaining momentum with high levels of sensitivity and specificity reported ( Heiner and McArthur, 2010 ; Tazarourte et al, 2010 ). This article addresses some of the issues regarding the use of ultrasound in prehospital care and describes some of the applications which are taught in the emergency and prehospital ultrasound course at the Imperial College, London.
Prehospital continuous positive airway pressure ventilation in ACPO: Part 1
Authors: Rees Nigel
Published: May 2014

Acute cardiogenic pulmonary oedema (ACPO) is a common medical emergency facing UK paramedics. While swift management can delay progression of ACPO, many patients spiral into deteriorating respiratory and cardiac function, leading to respiratory failure requiring endotracheal intubation (ETI). Continuous pulmonary airway pressure (CPAP) is increasingly being adopted for ACPO in the hospital setting, leading to moves to introduce it into prehospital care. This article is the first in a two part review of the literature surrounding CPAP. It presents a critique of the in–hospital studies in order to highlight implications for paramedics wishing to introduce CPAP into their practice. Methods: A comprehensive literature search of MEDLINE and CINAHL from 2000 to November 2010 was conducted using ‘CPAP’ as a subject heading combined with the sub headings: ‘Pulmonary Oedema’, ‘Pulmonary Edema’ ‘ACPO’, ‘Heart Failure’ ‘pre hospital’ and ‘Paramedic’ as key words. A second search was conducted using ‘Non invasive Ventilation’ as a subject heading along with all the subheadings above. Results: 253 papers were retrieved. These were manually scanned for relevance and eligibility, leaving 53 papers for review. In hospital studies were finally limited to 10. Application of CPAP resulted in significant improvements in physiological variables, need to ETI and relief of breathlessness. However, these benefits were not transferred into improved mortality. Maximizing medical therapy to include the use of intravenous nitrates significant improved mortality, and subsequently confounded the results of many CPAP trials. Conclusion: while application of CPAP is yet to be robustly attributed to improved survival in hospital, it may offer opportunities unique to the prehospital environment. Application of CPAP earlier in the acute phase of ACPO has the potential to improve mortality; it would offer a non–invasive means of supporting ventilation prior to ETI, and palliation of breathlessness. Prior to any such moves, consideration should be given to adherence and maximisation of current medical therapy within JRCALC, and future potential for use of intravenous nitrates.
Evaluation of the use of portfolios in paramedic practice: part 2
Authors: Armitage Ewan
Published: May 2014

This second of a two-part evaluation on the use of portfolios in paramedic practice, focuses on what constitutes evidence of a paramedic's competence and ultimate fitness to practice. A variety of evaluation models are identified to help in this process and this is developed further with reference to some educational theories. In the final part of the evaluation, the author proposes a number of recommendations concerning the use of portfolios within the paramedic profession and draws on the issues identified in the first part of the evaluation to summarize the current position of paramedic portfolios.
Using patient experiences of emergency and unscheduled care for quality improvement
Authors: Brady Mike
Published: May 2014

Paramedics like, all health care professionals are required to support and justify their actions through evidence based practice. A concept that for many years now has focused on clinical and randomised control trials to produce its sole evidence base. This article explores the growing recognition in recent decades among all healthcare professions not just paramedicine, that the collection and analysis of the experiences of service users, family, friends and carers cannot only justify practitioner actions, but improve the quality of emergency and unscheduled care services.
Acute multiligament injured or dislocated knee: field assessment and management
Authors: Ghatan Andrew , Merritt Andrew , Wahl Christopher
Published: May 2014

Knee dislocation is a serious but uncommon injury that can result in significant trauma to the ligaments, nerves, and blood vessels of the leg. With a high rate of spontaneous reduction and signs of injury that are often subtle in the acute stage, knee dislocation can be missed if not specifically sought through meticulous and thorough history-taking and physical examination. Targeted visual inspection, neurologic and vascular examination, and palpation of the limb are all instrumental in the identification of a potential multiligament knee injury or dislocated knee. The association of significant vascular injury with knee dislocation puts the injury victim at risk of limb loss if the injury is not identified and treated in a timely fashion. By identifying the injury, reducing and splinting as appropriate, and communicating awareness of the injury to hospital-based caregivers, the paramedic has a unique opportunity to direct the course of treatment that the patient receives.
Transient asystole: aetiology and treatment by paramedics
Authors: Hayes Jane
Published: May 2014

Transient asystole is seen relatively rarely by paramedics. It is often mistaken for syncope or seizures, which means that paramedics may miss an opportunity to help with a swift diagnosis and therefore help reduce morbidity and mortality ( Deakin et al, 2010 ). This article explores the aetiology of transient asystole along with its pathophysiology and analyses how some prescription drugs may contribute to the onset of transient asystole. It will look at treatment options that are available to paramedics including atropine, and establish if this is the optimal treatment for the condition.
Pre-hospital improvised bronchodilator therapy of a patient on bi-level positive airway pressure therapy
Authors: Haley Anthony , Forbes Anthony
Published: May 2014

Patients suffering acute breathlessness is a common emergency situation, many patients with airways disease require bronchodilator therapy with (3-agonists. To assist the management of these cases paramedics use guidelines drawn up by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). They provide guidance on the management of most situations paramedics are likely to encounter. However, there will be occasions when paramedics are called to deal with a situation which is outside of their experience and the JRCALC guidelines do not provide the appropriate guidance required to fully inform clinical decision making. In the UK telephone support from a physician skilled in the specific discipline they require is generally not available, so paramedics have become skilled at improvising. This case study describes such an improvisation, in the management of acute breathlessness in a patient who is on home bi-level positive airway pressure (BiPAP) therapy.
Making the transition to high quality CPR: implications for paramedic practice
Authors: Aljerian Nawfal A. , Verbeek Richard , Cheskes Sheldon
Published: May 2014

Out of hospital cardiac arrest remains a leading cause of mortality. Well known components of good quality cardiopulmonary resuscitation (CPR) include proper chest compression rate and depth, and allowing full chest recoil. Recently, new metrics have been developed that will lead the transition from good to high quality CPR. These include hands-off time, peri-shock pause and chest compression fraction. This article discusses new findings that show how these new metrics are associated with improved survival from out of hospital cardiac arrest and how they can be implemented by paramedics performing cardiac arrest resuscitation using current and evolving defibrillator technology.