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Biomedical subjects

M Woollard

Publications and source records attributed to M Woollard.

16 recordsLinked to original sources
PubMed2006

Needle vs surgical cricothyroidotomy: a short cut to effective ventilation.

Cricothyroidotomy can be performed using three techniques. This literature review seeks to determine which is more appropriate for use in prehospital can't intubate/can't ventilate scenarios where laryngeal mask airways prove ineffective. The common approach of inserting a 14-gauge cannula and using low-pressure ventilation via intermittent occlusion of an opening in oxygen tubing (15 l x min(-1) flow) results in ineffective ventilation within 60 s or less, depending on the degree of airway obstruction. In the absence of a high degree of upper airway obstruction, ventilation can be effective if the cannula is attached to a high pressure (45 psi) jet ventilator, but such devices are rare in UK prehospital practice. A self-inflating bag used with a cuffed tube inserted through a horizontal scalpel incision provides sustained adequate ventilation, has a relatively low complication rate compared to needle cricothyroidotomy and is a skill that can be easily taught to paramedics, nurses and doctors.

Airway Obstruction↗
PubMed2005

Limited benefits of ambulance telemetry in delivering early thrombolysis: a randomised controlled trial.

OBJECTIVES: To evaluate the potential of a continuous telemetry system linking rural ambulances to a coronary care unit to reduce call to thrombolysis times. METHODS: This prospective randomised controlled trial recruited patients using the 999 ambulance service in a rural area of the UK with signs or symptoms of coronary heart disease. Subjects were assigned to receive either standard paramedic treatment or transmission of 12 lead ECG, blood pressure, pulse oximetry, and relevant medical history to a general hospital coronary care unit. Cardiology senior house officers then determined each patient's suitability for pre-hospital thrombolysis time, and transmitted this decision back to the ambulance. This was documented as the potential thrombolysis, although no thrombolytic agents were administered by paramedics. The between groups difference in time to potential thrombolysis (intervention group) and actual thrombolysis (controls) was compared. The proportion of intervention group subjects ultimately receiving thrombolysis in hospital was compared with that recommended for pre-hospital thrombolysis. RESULTS: The potential reduction in call to treatment time for telemetry patients recommended for pre-hospital thrombolysis was 55 minutes (p = 0.022). Following hospital admission,21/213 of the telemetry patients were thrombolysed (10%, 95% confidence interval (CI) 6% to 15%). Of these patients, 3/21 received a recommendation for thrombolysis in the ambulance (14%, 95% CI 3.1% to 36.3%). The sensitivity and specificity of the telemetry system in detecting patients requiring thrombolysis was 13.6 and 99.5% respectively. Errors were made in the pre-hospital treatment recommendations for two patients. CONCLUSIONS: Continuous telemetry systems may significantly reduce call to treatment times for patients recommended for pre-hospital thrombolysis in a rural setting. However, this benefit must be balanced against the very small proportion of eligible patients identified as suitable for pre-hospital thrombolysis. This limitation may be due to communications problems, the criteria used to identify eligible patients, or the seniority of physicians tasked with making treatment decisions.

Aged↗
PubMed2005

Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.

OBJECTIVE: To investigate whether 10% dextrose given in 5 g (50 ml) aliquots is more effective than 50% dextrose given in 5 g (10 ml) aliquots in the treatment of out of hospital hypoglycaemia. DESIGN: Randomised controlled trial. SETTING: Out of hospital patients attended by paramedics from a large UK ambulance service. PARTICIPANTS: 51 unresponsive adult patients with blood glucose levels < or = 4 mmol/l. INTERVENTION: 5 g (50 ml) intravenous aliquots of 10% dextrose or 5 g (10 ml) intravenous aliquots of 50% dextrose to a maximum dose of 25 g. MAIN OUTCOME MEASURES: To compare for each dextrose concentration the time to achieve a Glasgow Coma Scale (GCS) score of 15, and the dose required to obtain a blood glucose level of > or = 4.5 mmol/l. RESULTS: There were no statistically significant differences between the groups with regard to age or sex, median pretreatment GCS, pretreatment blood glucose level, or proportion of patients with insulin dependent diabetes. Following treatment, there were no statistically significant differences in median time to recovery (8 minutes), median post-treatment GCS, or number of subjects experiencing a further hypoglycaemic episode within 24 hours (four per group). The median total dose of dextrose administered was significantly less with the 10% concentration (10% = 10 g, 50% = 25 g, p < 0.001) and median post-treatment blood sugar levels were also significantly lower (10% = 6.2 mmol/l and 50% = 9.4 mmol/l, p = 0.003). There were no reports of extravasation injuries in either group. CONCLUSIONS: Dextrose 10% delivered in 5 g (50 ml) aliquots is administered in smaller doses than dextrose 50% delivered in 5 g/10 ml aliquots, resulting in lower post-treatment blood glucose levels. We therefore recommend it as the intravenous treatment of choice for adult hypoglycaemia.

Adult↗
PubMed2004

Prehospital airway management in Ambulance Services in the United Kingdom.

A postal survey of the 38 Ambulance Services in the United Kingdom was undertaken to find out what equipment is provided for paramedic crews to aid tracheal intubation and to confirm tracheal placement. The response rate to our survey was 100%. Fourteen (37%) ambulance services provided neither stylet nor bougie to facilitate difficult intubation. The laryngeal mask airway was available to 15 (40%) ambulance services. Seventeen (45%) ambulance services had use of a needle cricothyroidotomy set. Twenty-nine (76%) ambulance services had no type of device other than a stethoscope to confirm tracheal tube placement. This survey showed wide variations in the equipment for airway management available to paramedic crews in the United Kingdom. We recommend provision of a standard set of airway management equipment to all paramedic crews in the United Kingdom together with introduction of appropriate training programmes.

Emergency Medical Services↗
PubMed2004

Outcome of patients identified as dead (beyond resuscitation) at the point of the emergency call.

OBJECTIVE: Currently, an emergency ambulance is dispatched to all cardiac arrest victims. This study aimed to determine the outcome of patients with a dispatch code of 09B01 ("obvious death") and considers the appropriateness of dispatching a non-emergency response. METHODS: Dispatch records, patient report forms, and hospital records were reviewed to determine patient outcome. RESULTS: Within the one year study period 141 emergency calls were coded as 09B01. Records were obtained for 59 of these cases (42%). Ambulance crews diagnosed 54 as beyond resuscitation (91.5%, 95% CI 79.5% to 96.2%). Three received resuscitation attempts (5.1%, 95% CI 1.1% to 14.2%): two were subsequently pronounced dead at scene and one on arrival at hospital. Two patients were not in cardiac arrest (3.4%, 95% CI 0.4% to 11.7%): one was a transiently unconscious assault victim, and one had a hand injury after a road accident. Three patients coded as 09B01 were transported to hospital for treatment other than confirmation of death (5.1%, 95% CI 1.1% to 14.2%). CONCLUSION: Not all patients coded 09B01 by dispatchers are assessed as "dead beyond resuscitation" by attending ambulance crews. Although poor data recovery and a small sample size limited the study, its findings suggest that it is inappropriate to allocate a non-emergency response to 09B01 (obvious death) calls.

Death↗
PubMed2004

Levels of mental health problems among UK emergency ambulance workers.

This study examined the prevalence of post-traumatic stress disorder (PTSD), depression, and anxiety in a sample of emergency ambulance personnel. Of 1029 personnel in one ambulance service mailed a questionnaire, 617 were returned. Among respondents, the overall rate of PTSD was 22%. Levels of PTSD did not differ according to grade, but men had a higher prevalence rate than women (23% compared with 15%). Nearly one in ten reported probable clinical levels of depression, 22% reported probable clinical levels of anxiety based on Hospital Anxiety and Depression Scale scores.

Adult↗
PubMed2004

Less IS less: a randomised controlled trial comparing cautious and rapid nalbuphine dosing regimens.

OBJECTIVE: This study aimed to determine which of two paramedic administered nalbuphine dosing regimens combined the greater analgesic effect with the minimum of adverse events. METHODS: Patients suffering from chest pain or trauma were randomised to receive either a rapid dosing regimen (10 mg over 30 seconds, repeated once after three minutes if pain score remained above three) or a cautious regimen (5 mg over two minutes, repeated at three minute intervals if pain score remained above three to a maximum dose of 20 mg). Data were collected on analgesic effectiveness, changes in vital signs, and patient reported side effects. RESULTS: The pain score fell by a mean of 4.29 and 3.49 in the rapid and cautious regimen groups respectively (difference = 0.79, 95% CI 0.09 to 1.5, p = 0.028). However, over half the patients in both groups continued to suffer significant pain on arrival at hospital. There were no significant changes in vital signs after nalbuphine, but there was a greater incidence of patient reported drowsiness in rapid regimen patients (42% compared with 21%, 95% CI = 6.96 to 34.12%, p = 0.003). CONCLUSION: A rapid dosing regimen of nalbuphine using 10 mg increments is more effective than and equally as safe as a cautious regimen using 5 mg increments. Further research is required to determine if a maximum dose exceeding 20 mg would result in fewer patients continuing to suffer significant pain before arrival at hospital.

Adult↗
PubMed2003

Paramedic accuracy in using a decision support algorithm when recognising adult death: a prospective cohort study.

BACKGROUND: Prolonged advanced life support for cardiac arrest victims who present with non-shockable arrhythmias in an out of hospital setting is associated with extremely poor survival rates. This and the risks associated with rapid ambulance transport to hospital have resulted in the development of decision support algorithms, enabling paramedics to recognise when adult death has occurred. The aim of the study was to assess the accuracy with which paramedics used such an algorithm. METHOD: This prospective 16 month cohort study evaluated 188 events of recognition of adult death (ROAD) by paramedics in the period from November 1999 to February 2001. RESULTS: Of 188 ROAD applications, errors were made in 13 cases (6.9%, 95% CI 3.7 to 11.5. Additionally, there was one adverse clinical incident associated with a case in which ROAD was applied (0.5%, 95% CI 0.01 to 2.9%). ECG strips were unavailable for eight cases, although ambulance records indicated a rhythm of asystole for each of these. Assuming this diagnosis was correct, ROAD was used 174 times without errors (93%, 95% CI 88 to 96%). Assuming that it was not, the ROAD protocol was applied without errors in 166 cases (88.3%, 95% CI 82.8 to 92.5%). None of the errors made appeared to be attributable to poor clinical decision making, compromised treatment, or changed patient outcome. The mean on-scene time for ambulance crews using the ROAD policy was 60 minutes. CONCLUSION: Paramedics can accurately apply a decision support algorithm when recognising adult death. It could be argued that the attendance of a medical practitioner to confirm death is therefore an inappropriate use of such personnel and may result in unnecessarily protracted on-scene times for ambulance crews. Further research is required to confirm this, and to determine the proportion of patients suitable for recognition of adult death who are actually identified as such by paramedics.

Adult↗
PubMed2002

Hitting them where it hurts? Low dose nalbuphine therapy.

OBJECTIVE: To determine if low dose nalbuphine provides an adequate reduction in pain with minimal side effects. METHODS: Prospective cohort of 115 patients given nalbuphine by paramedics in Wales and the English borders. OUTCOME MEASURES: (1) Mean total dose of nalbuphine administered, change in pain score, time to adequate pain relief (score below four), and change in respiratory rate and systolic blood pressure; (2) proportion of patients continuing to suffer moderate to severe pain on arrival at hospital; (3) incidence of adverse events. RESULTS: Full data were obtained for all patients. The mean total dose of nalbuphine administered was 6.09 mg (range 2.5 to 12.5 mg). This was significantly higher in trauma than ischaemic chest pain patients (7.03 versus 5.13 mg). The mean reduction in pain score was -3.97 (95% CI -4.38 to -3.57, p<0.001). The mean time to adequate pain relief (where this was achieved) was 15.7 minutes (95% CI 13.4 to 17.9 minutes). On arrival at hospital 60% of patients (n=69, 95% CI 50.9 to 68.5%) still met ambulance criteria for analgesia (70.7% of trauma patients and 49.1% with ischaemic chest pain). Systolic blood pressure fell by a mean of -3.67 (95% CI -6.76 to -0.58, p=0.02) and respiratory rate increased by a mean of 1.63 (95% CI 1.08 to 2.17, p<0.001). Two patients complained of nausea (1.74%, 95% CI 0.5 to 6.0%). No other adverse events were reported. CONCLUSION: Low dose nalbuphine results in few adverse events, but offers poor pain control for a high proportion of patients.

Analgesics, Opioid↗
PubMed2001

Randomised controlled trials of staged teaching for basic life support: 2. Comparison of CPR performance and skill retention using either staged instruction or conventional training.

Teaching CPR in stages is a strategy designed to improve skill acquisition and retention. This method has been compared with conventional teaching in a randomised trial involving 495 volunteers. The first ('bronze') stage was simplified by omitting ventilation and giving compressions in sets of 50 with pauses to open the victim's airway; in the second ('silver') stage ventilation was introduced in a ratio of 50 compressions to five breaths, and in the third ('gold') stage, the volunteers were converted to conventional CPR. 51% of those taught by this method reattended for the second ('silver') stage compared with 25% who were taught conventional CPR and advised to return for a revision session. 38% of the staged group reattended for the third ('gold') compared with 8% for the conventional group. Modest improvement in skill acquisition has earlier been reported for the 'bronze' stage teaching, and this has been followed by better performance in some of the components tested after the subsequent stages. Comparisons after the 'gold' stage were limited by the small numbers who reattended for a third session of conventional training, but no special difficulties were noted in changing the ratio of compressions to ventilation that was necessary to convert the staged training volunteers to conventional CPR. The increased number of compressions that can be achieved by teaching 'bronze' stage CPR with no ventilation was retained, to a lesser degree, when the 'silver' ratio of 50 compressions to five breaths was compared with the conventional 15:2 ratio. Our observations suggest that during the first critical 8 min of a resuscitation attempt, 58% more compressions might be delivered by using the 50:5 ratio - an increase that is likely to result in a significant augmentation of blood flow with important clinical implications. More comparative information will become available when the results of unannounced home testing are analysed.

Adult↗
PubMed2001

Public access defibrillation: a shocking idea?

Currently, survival from out-of-hospital cardiac arrest in the United Kingdom is poor. Ambulance response standards require that an ambulance reach 75 per cent of cardiac arrests within 8 min. But a short time to defibrillation from the onset of collapse is a key predictor of outcome from out-of-hospital cardiac arrest. The Department of Health has recently implemented a lay responder defibrillation programme, with the aim of shortening this time interval for victims in public places. This initiative utilizes automated external defibrillators (AEDs), which provide written and recorded voice prompts to minimize training requirements and errors in use. Lay responder AED programmes with very short response times have reported survival to discharge rates of up to 53 per cent for patients presenting in ventricular fibrillation (VF). This compares well with the results of a meta-analysis that reported a survival rate of only 6.4 per cent for traditional defibrillator-equipped ambulance systems. The annual incidence of out-of-hospital cardiac arrest in England is 123 per 100,000 population. Approximately half of these present in VF, and could benefit from an AED programme. But only 16 per cent of cardiac arrests occur in a public place. It has been calculated that there are approximately 5,000 instances of VF in public places each year in England. If half of these patients can be reached and administered a first shock within 4 min of their collapse, an additional 400 victims may survive each year. Given the current investment by the DoH of 2 million pounds, this suggests a cost per life saved of approximately 505 pounds over a 10 year period.

Community Participation↗
PubMed2001

Pre-hospital aspirin for suspected myocardial infarction and acute coronary syndromes: a headache for paramedics?

OBJECTIVE: To ascertain the frequency with which paramedics follow protocols for the administration of aspirin to patients to whom an ambulance is called for chest pain associated with suspected ischaemic heart disease. METHODS: Ambulance services in England and Wales who had conducted a recent aspirin administration audit were identified through the National Clinical Effectiveness Programme for the Ambulance Service Association. Data were requested from each of these services with a 100% return rate. RESULTS: Nine services out of a total of 35 had collected appropriate data. The proportion of patients who were given aspirin by a paramedic varied from 11% to 74%. The range of proportions of patients receiving pre-hospital aspirin increased after adding those patients who had already received aspirin from an alternative health provider, to 19% to 78%. It is estimated that at least 15% to 74% of patients who should have been given aspirin by the various ambulance services did not receive it. The proportion of patients for whom aspirin was judged to be inappropriate ranged from 4% to 35%. The reason for these widely varying and generally poor levels of compliance is not known. However, the range of indications and contraindications to the administration of aspirin varied considerably by ambulance service. This also made the comparison of data from different sources difficult. CONCLUSIONS: Aspirin has been shown to be beneficial after a myocardial infarction and for other acute coronary syndromes. However, variances in the proportion of patients with suspected ischaemic heart disease given aspirin in different ambulance services indicates the need for a re-emphasis on the importance of this treatment. A standard protocol for all UK ambulance services should be devised that minimises the number of contraindications to aspirin and otherwise requires its administration to all patients with acute coronary syndromes or suspected myocardial infarction. Regular, standardised audits of compliance should also be conducted and their results widely disseminated.

Acute Disease↗
PubMed1979

Comparison of effects on cerebral blood flow of rapid reduction in systemic arterial pressure by diazoxide and labetalol in hypertensive patients: preliminary findings.

1 Diazoxide 300 mg and labetalol 150 mg were each injected intravenously on separate occasions into five patients with essentail hypertension. The reduction in BP caused by labetalol was slightly greater than that produced by diazoxide. 2 In contrast the reduction in cerebral blood flow (CBF) by labetalol was not statistically significant, whereas diazoxide gave a greater and statistically significant reduction in CBF. 3 These observations suggest that labetalol may have an advantage over diazoxide for the rapid reduction in BP.

Blood Pressure↗