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Emerg Med J. 2007 September; 24(9): 671.
PMCID: PMC2464644

From the Prehospital Literature

Pre‐hospital providers have little opportunity to use even basic paediatric critical‐care skills

[filled triangle] Richard J, Osmond MH, Nesbitt L, et al. Management and outcomes of pediatric patients transported by emergency medical services in a Canadian prehospital system. Can J Emerg Med 2006;8:6–12.

This Canadian prospective cohort study explored the types of interventions given to children by pre‐hospital emergency medical services (EMS). It recruited a contiguous group of 1377 children under 16 years of age (mean 8.2 years) attended by EMS during a 6 month period. The most common presenting conditions were trauma (44.9%), seizure (11.8%) and respiratory distress (8.8%). The study showed that, despite EMS providers having a major role in treating these conditions, lifesaving interventions, particularly airway management skills, were rarely used. These included intravenous drug administration (1.4%), bag valve mask ventilation (0.3%) and endotracheal intubation (0.1%). This may be explained by the high rate of patients (28%) not transported and a low rate of urgent transports (7%) for admission to hospital. However, it demonstrates that EMS providers have very little opportunity to maintain their paediatric skills. The study found most pre‐hospital practitioners would not have the opportunity to ventilate a single child in one year. This has important implications for pre‐hospital education. While initial training programmes include paediatric modules, this study shows it is important such training to be ongoing, perhaps by giving EMS providers the chance to maintain practical and theoretical skills via “hands on” experience in hospital placements.

Sarah Christopher, British Paramedic Association Research and Audit Committee

Endotracheal intubation: are we responding to the evidence?

[filled triangle] Wirtz DD, Ortiz C, Newman DH, et al. Unrecognized misplacement of endotracheal tubes by ground prehospital providers. Prehosp Emerg Care 2007;11:213–8.

[filled triangle] Cudnik MT, Newgard CD, Wang H, et al. Endotracheal intubation increases out‐of‐hospital time in trauma patients. Prehosp Emerg Care 2007;11:224–9.

[filled triangle] Thomas JB, Abo BN, Henry E, et al. Paramedic perceptions of challenges in out‐of‐hospital endotracheal intubation. Prehosp Emerg Care 2007;11:219–23.

Wirtz and colleagues conducted a prospective study to evaluate endotracheal intubation (ETI) placement by EMS personnel in 132 consecutive patients, as determined by a physician immediately on admission. The rate of misplaced ET tubes was 12/132 (9%, 95% confidence interval (CI) 5.3% to 15.2% (11 oesophageal and 1 hypopharyngeal)), similar to many previous investigations, and intubation of the right bronchus occurred in 20/132 (15%, 95% CI 10.0% to 22.3%).

In the same journal, another study describes a retrospective cohort analysis of 8707 trauma patients. Longer on‐scene times (adjusted for confounding factors) were reported for the 570 patients intubated in the pre‐hospital setting, either following rapid sequence induction (+10.7 min, 95% CI 7.7 to 13.8 min) or standard endotracheal intubation (+5.2 min, 95% CI 2.2 to 8.1 min). While the authors do not present direct evidence of an adverse effect on patient outcome, it is widely accepted that short on‐scene times are associated with reductions in mortality from multisystem trauma.

A third paper explores the perceptions of 14 paramedics and six EMS medical directors about ETI. Surprisingly, despite agreeing that there were problems with paramedic ETI, all felt that this skill should continue to be used. Factors that impacted on the quality of ETI were given as paramedic education, skills acquisition and maintenance, the structure of emergency services, the role of the medical director, and workforce culture and professionalism. Paramedics and physicians differed as to whether rapid sequence induction was an appropriate paramedic skill.

Although all of these papers are based on data from EMS systems in the USA (as is the majority of research on the subject of prehospital intubation), their findings have implications for UK practice. There are currently no robust data available on intubation success and failure rates of UK paramedics, or indeed of other pre‐hospital practitioners of ETI. Such data are urgently needed, both to determine if we face similar issues to those found in the USA (despite differences in training, equipment, and patient populations) and to develop a strategy in response to any problems identified. This might mean changing how prehospital practitioners are trained in intubation, restricting the number of practitioners utilising this skill out‐of‐hospital, or abandoning this intervention in favour of others with a greater success rate. If it is deemed appropriate to adopt the latter approach, robust evidence will be essential to determine which airway devices offer a more effective alternative to pre‐hospital ETI.

Malcolm Woollard, British Paramedic Association Research and Audit Committee

Thrombolysis or primary PCI: the debate continues

[filled triangle] Widimsky P, Bikova D, Penicka M, et al, on behalf of the PRAGUE Study Group Investigators. Long term outcomes of patients with acute myocardial infarction presenting to hospitals without cardiac catheterization laboratory and randomized to immediate thrombolysis or interhospital transport for primary percutaneous coronary intervention. Five years' follow up of the PRAGUE‐2 trial. Eur Heart J 2007;28:679–84.

This paper from the Czech Republic, which has a nationwide primary percutaneous coronary intervention (PCI) strategy, reports on a 5 year follow‐up of patients in the PRAGUE trial. Patients with ST elevation myocardial infarction (STEMI) were randomised to receive either immediate “on site” thrombolysis in hospital, or transferred up to 120 km for primary PCI. It reports that PCI patients had better outcomes (measured as a composite of death from any cause, reinfarction, stroke or revascularisation over 5 years) than those given thrombolysis, suggesting that it is safe—and probably better—for patients to travel some distance for PCI rather than be given thrombolysis in hospital. Mortality in patients randomised within 3 h of onset was the same whichever treatment strategy was employed. The study findings may not be wholly applicable to current UK practice since patients in the thrombolysis group received streptokinase (used less often in the UK) and were treated in‐hospital rather than out‐of‐hospital. Typical times to thrombolysis may also be shorter in the UK. However, this study sends a powerful message about the benefits of primary PCI, and should reassure clinicians anxious about the value of transporting STEMI patients some distance for primary PCI as it becomes more widely available in the UK.

Tom Quinn, British Paramedic Association Research and Audit Committee

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