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Emerg Med J. 2007 June; 24(6): 439.
PMCID: PMC2658292

From the Prehospital Literature

Ipratropium bromide: a bit of a wheeze?

[filled triangle] Davis DP, Wiesner C, Chan TC, et al. The efficacy of nebulized albuterol/ipratropium bromide versus albuterol alone in the prehospital treatment of suspected reactive airways disease. Prehosp Emerg Care 2005;9:386–90.

Administration of ipratropium bromide has become standard care in UK prehospital practice for acute severe or life‐threatening asthma. This retrospective “before and after” USA study examined prehospital and emergency department records 6 months before and after the introduction of prehospital ipratropium. No statistically significant differences were observed between pre‐nebuliser and post‐nebuliser values for the salbutamol (n = 192) and the salbutamol with ipratropium bromide (n = 179) groups for heart rate (p = 0.474), blood pressure (p = 0.523), respiratory rate (p = 0.055), arterial oxygen saturation (p = 0.581) and clinical improvement rates (p = 0.944). Also, no significant differences were observed for those admitted from emergency departments (p = 0.596) and those being discharged (p = 0.713). Although these results suggest that there was no benefit in combining salbutamol and ipratropium, the study has severe limitations. Patients were not randomly allocated to treatment groups, and the limited sample size risked a type II error. Other outcome variables, such as changes in peak flow rate, may have provided more sensitive measures. Further, more than one‐third (133/371) of patients in the study were diagnosed in the emergency department with something other than reversible airway disease. This study highlights the need for good‐quality research regarding the management of asthma in the prehospital environment.

Tom Archer, London Ambulance Service

The eyes have it: does dispatch triage category match actual patient condition at scene?

[filled triangle] Feldman MJ, Verbeek R, Lyons DG, et al. Comparison of the Medical Priority Dispatch System to an out‐of‐hospital patient acuity score. Acad Emerg Med 2006;13:954–60.

This study compared the Advanced Medical Priority Assessment System (AMPDS) dispatch priority and on‐scene Canadian Triage and Acuity Scale for 102 582 emergency ambulance calls. The overall ability of the AMPDS to identify people with high‐acuity illness (sensitivity) was 68.2% (95% CI 67.8% to 68.5%), and without high‐acuity illness (specificity) was 66.2% (95% CI 65.7% to 66.7%). The positive predictive value indicated an 80.3% probability that a patient would have a high‐acuity illness if the AMPDS awarded a high dispatch priority. The negative predictive value indicated a 50.7% probability that patients would not have a high‐acuity illness if awarded a low AMPDS priority. There was wide variation between protocols, but the AMPDS identified all cases of breathing problems (sensitivity of 100.0%, 95% CI 99.9% to 100.0%), and there was a 92.6% probability that if the AMPDS identified a patient as being in cardiac arrest, this would be the case (95% CI for positive predictive value = 90.3% to 94.3%). Half of the 32 AMPDS protocols performed no better than chance for high acuity, suggesting room for improvement, and the protocol with the poorest performance was, perhaps unsurprisingly, that for unknown problems. But let it not be forgotten that assessment using caller information alone is tough compared with eyeballing the patient.

Janette Turner, British Paramedic Association Research and Audit Committee

Blowing off too much steam?

[filled triangle] O'Neill JF, Deakin CD. Do we hyperventilate cardiac arrest patients? Resuscitation 2007;73:82–5.

Hyperventilation of a patient during cardiac arrest has been clearly linked with adverse haemodynamic effects and decreased cerebral perfusion, which have been shown to translate into increased mortality. This study measured respiratory variables in patients who were intubated and manually ventilated using 100% oxygen, and showed that in this small sample, hyperventilation occurred frequently.

Current recommendations suggest that optimum ventilation is achieved with a rate of 10 breaths per minute with a volume of 10 ml/kg. In this study, 75% of patients were ventilated at a rate that was at least double that considered to be optimal. Although the tidal volume was no greater than the recommended level, this indicates that the delivered minute volume would be considerably larger than appropriate. Although this study examined ventilation as performed by senior emergency department doctors and not prehospital practitioners, it would be worth reviewing current practice to ensure that the optimum minute ventilation volumes are provided.

Pete Gregory, British Paramedic Association Research and Audit Committee

Managing the bitten hand that feeds

[filled triangle] Morgan M, Palmer J. Dog bites. BMJ 2007;334:413–17.

This paper by a team of microbiologists discusses appropriate treatment plans for patients who have experienced dog bites. It reinforces the existing rationale of not suturing bite wounds, indicating that doing so increases the risk of infection. It also identifies co‐amoxiclav as the drug of choice for infection‐prone wounds. The article cautions against the use of erythromycin and flucloxacillin as stand‐alone antibiotics in such cases because of their ineffectiveness in pasteurella infections. All prehospital practitioners should ensure that their current wound management practice meets up‐to‐date guidelines.

Mike Bjarkoy, British Paramedic Association Research and Audit Committee

Not just a snotty nose

[filled triangle] Ah‐See KW, Evans AS. Sinusitis and its management. BMJ 2007;334:358–61.

A wide range of antibiotics is available to unscheduled care practitioners as part of the treatment options for a number of conditions including acute sinusitis. This article highlights the importance of identifying signs and symptoms of orbital or intracranial sepses, both of which have significant mortality and morbidity and require emergency referral for imaging to confirm diagnosis and subsequent treatment. It also identifies those sinusitis conditions in which antibiotics are not necessarily helpful and where the drug of choice should be a simple analgesic.

Mike Bjarkoy, British Paramedic Association Research and Audit Committee


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