Paramedic clinical practice guideline development in Australia and New Zealand: A qualitative descriptive analysis.

BACKGROUND: This collaborative study by The Australasian College of Paramedicine's Clinical Practice Guidelines (CPG) Working Group aimed to examine CPG development practices in Australian and New Zealand ambulance services. METHODS: Employing a qualitative descriptive design, the research utilised thematic analysis to extract insights from interviews with eleven experts actively involved in CPG development. The study embraced a nominalist and constructivist approach, recognising the intricate connection between individual experiences and the realities of CPG development in the paramedic field. RESULTS: Key findings revealed significant heterogeneity in CPG development practices, emphasising a lack of formal training and a substantial reliance on existing guidelines. The study highlighted challenges in project management flexibility, limited research capacity, and inconsistencies in external consultations and resource utilisation. CONCLUSION: The study recommends adopting project management frameworks, investing in training, and utilising evidence evaluation methodologies like GRADE. It emphasises the need for multidisciplinary teams and formal expertise in evidence synthesis, advocating for targeted training programs. Funding challenges highlight the importance of dedicated budgets and collaborative efforts for resource allocation. Knowledge translation and implementation issues underscore the significance of training programs for evidence evaluation and knowledge translation in overcoming these challenges.

Prevalence of secondary insults and outcomes of patients with traumatic brain injury intubated in the prehospital setting: a retrospective cohort study.

BACKGROUND: Prehospital neuroprotective strategies aim to prevent secondary insults (SIs) in traumatic brain injury (TBI). This includes haemodynamic optimisation in addition to oxygenation and ventilation targets achieved through rapid sequence intubation (RSI).The primary aim was to report the incidence and prevalence of SIs (prolonged hypotension, prolonged hypoxia and hyperventilation) and outcomes of patients with TBI who were intubated in the prehospital setting. METHODS: A retrospective cohort study of adult patients with TBI who underwent RSI by a metropolitan road-based service in South-East Queensland, Australia between 1 January 2017 and 31 December 2020. Patients were divided into two cohorts based on the presence or absence of any SI sustained. Prolonged SIs were defined as occurring for ≥5 min. The association between SIs and mortality was examined in multivariable logistic regression and reported with adjusted ORs (aORs) and 95% CIs. RESULTS: 277 patients were included for analysis. Median 'Head' Abbreviated Injury Scale and Injury Severity Score were 4 (IQR: 3-5) and 26 (IQR: 17-34), respectively. Most episodes of prolonged hypotension and prolonged hypoxia were detected with the first patient contact on scene. Overall, 28-day mortality was 26%. Patients who sustained any SI had a higher mortality than those sustaining no SI (34.9% vs 14.7%, p<0.001). Prolonged hypoxia was an independent predictor of mortality (aOR 4.86 (95% CI 1.65 to 15.61)) but not prolonged hypotension (aOR 1.45 (95% CI 0.5 to 4.25)) or an end-tidal carbon dioxide <30 mm Hg on hospital arrival (aOR 1.28 (95% CI 0.5 to 3.21)). CONCLUSION: SIs were common in the early phase of prehospital care. The association of prolonged hypoxia and mortality in TBI is potentially more significant than previously recognised, and if corrected early, may improve outcomes. There may be a greater role for bystander intervention in prevention of early hypoxic insult in TBI.

Palliative paramedicine: Comparing clinical practice through guideline quality appraisal and qualitative content analysis.

BACKGROUND: Palliative care is an emerging scope of practice for paramedicine. The COVID-19 pandemic has highlighted the opportunity for emergency settings to deliver palliative and end-of-life care to patients wishing to avoid intensive life-sustaining treatment. However, a gap remains in understanding the scope and limitations of current ambulance services' approach to palliative and end-of-life care. AIM: To examine the quality and content of existing Australian palliative paramedicine guidelines with a sample of guidelines from comparable Anglo-American ambulance services. DESIGN: We appraised guideline quality using the AGREE II instrument and employed a collaborative qualitative approach to analyse the content of the guidelines. DATA SOURCES: Eight palliative care ambulance service clinical practice guidelines (five Australian; one New Zealand; one Canadian; one United Kingdom). RESULTS: None of the guidelines were recommended by both appraisers for use based on the outcomes of all AGREE II evaluations. Scaled individual domain percentage scores varied across the guidelines: scope and purpose (8%-92%), stakeholder involvement (14%-53%), rigour of development (0%-20%), clarity of presentation (39%-92%), applicability (2%-38%) and editorial independence (0%-38%). Six themes were developed from the content analysis: (1) audience and approach; (2) communication is key; (3) assessing and managing symptoms; (4) looking beyond pharmaceuticals; (5) seeking support; and (6) care after death. CONCLUSIONS: It is important that ambulance services' palliative and end-of-life care guidelines are evidence-based and fit for purpose. Future research should explore the experiences and perspectives of key palliative paramedicine stakeholders. Future guidelines should consider emerging evidence and be methodologically guided by AGREE II criteria.

Acute Opioid Withdrawal Following Intramuscular Administration of Naloxone 1.6 mg: A Prospective Out-Of-Hospital Series.

STUDY OBJECTIVE: Large doses of intramuscular (IM) naloxone are commonly used in out-of-hospital settings to reverse opioid toxicity; however, they are used less commonly in hospitals because of concerns about opioid withdrawal, particularly agitation. We aimed to determine the frequency of severe agitation following a single 1.6 mg IM naloxone dose. METHODS: We undertook a prospective study of adult (>15 years) patients treated by an Australian state ambulance service with 1.6 mg IM administration of naloxone for respiratory depression (respiratory rate <11 breaths/min and/or oxygen saturation <93% in room air) caused by presumed opioid poisoning. The primary outcome was the proportion of presentations with severe agitation (Sedation Assessment Tool score >1) within 1 hour of naloxone administration. Secondary outcomes were the proportion of presentations with acute opioid withdrawal (tachycardia [pulse rate >100 beats/min], hypertension [systolic >140 mm Hg], vomiting, agitation, seizure, myocardial infarction, arrhythmia, or pulmonary edema), and reversal of respiratory depression (respiratory rate >10 breaths/min and saturation >92% or Glasgow Coma Scale score 15). RESULTS: From October 2019 to July 2021, there were 197 presentations in 171 patients, with a median age of 41 years (range, 18 to 80 years); of the total patients, 119 were men (70%). The most common opioids were heroin (131 [66%]), oxycodone (14 [7%]), and morphine (11 [6%]). Severe agitation occurred in 14 (7% [95% confidence interval {CI} 4% to 12%]) presentations. Opioid withdrawal occurred in 76 presentations (39% [95% CI 32% to 46%]), most commonly in the form of tachycardia (18%), mild agitation/anxiety (18%) and hypertension (14%). Three presentations (1.5%) received chemical sedation for severe agitation within 1 hour of naloxone administration. A single 1.6 mg dose of naloxone reversed respiratory depression in 192 (97% [95% CI: 94% to 99%]) presentations. CONCLUSION: Severe agitation was uncommon following the administration of 1.6 mg IM naloxone and rarely required chemical sedation.

Hierarchical Spin-Crossover Cooperativity in Hybrid 1D Chains of FeII -1,2,4-Triazole Trimers Linked by [Au(CN)2 ]- Bridges.

Foremost, practical applications of spin-crossover (SCO) materials require control of the nature of the spin-state coupling. In existing SCO materials, there is a single, well-defined dimensionality relevant to the switching behavior. A new material, consisting of 1,2,4-triazole-based trimers coordinated into 1D chains by [Au(CN)2 ]- and spaced by anions and exchangeable guests, underwent SCO defined by elastic coupling across multiple dimensional hierarchies. Detailed structural, vibrational, and theoretical studies conclusively confirmed that intra-trimer coupling was an order of magnitude greater than the intramolecular coupling, which was an order of magnitude greater than intermolecular coupling. As such, a clear hierarchy on the nature of elastic coupling in SCO materials was ascertained for the first time, which is a necessary step for the technological development of molecular switching materials.

Epidemiology of Oxytocin Administration in Out-of-Hospital Births Attended by Paramedics.

AIM: Primary postpartum hemorrhage (PPH) is a life-threatening obstetric emergency that can be mitigated through the administration of a uterotonic to actively manage the third stage of labor. This study describes the prehospital administration of oxytocin by paramedics following attendance of out-of-hospital (OOH) births. METHODS: A retrospective analysis was undertaken of all OOH births between the 1st January 2018 and 31st December 2018 attended by the Queensland Ambulance Service. The demographic and epidemiological characteristics of patients that were administered oxytocin and the occurrence of adverse side effects were described. RESULTS: In total, 350 OOH births were included in this study with the majority involving multigravidas women (94.3%) and all but two involving singleton pregnancies. Oxytocin was administered following 222 births (63.4%), while 67 patients (19.1%) declined administration preferring a physiological third stage of labor, and in 61 cases (17.4%) oxytocin was withheld by the attending paramedic. There were no documented adverse events or side effects following administration. Oxytocin administration occurred on average 14 minutes (interquartile range 9-25) following the time of birth. The median time from oxytocin administration to placenta delivery was 10 minutes (interquartile range 5-22). CONCLUSION: Oxytocin is well accepted and safe treatment adjunct for the management of the third stage of labor in OOH births and should be considered for routine practice by other emergency medical services.

Ketamine as a rescue treatment for severe acute behavioural disturbance: A prospective prehospital study.

OBJECTIVE: Rapidly and safely managing severe acute behavioural disturbance (ABD) in the prehospital setting is important for the welfare of both patient and prehospital clinician alike. We investigated the safety and effectiveness of ketamine as rescue sedation in patients with severe ABD. METHODS: This prospective observational study investigated ketamine use by a state ambulance service as rescue sedation for patients with severe ABD who remained agitated following droperidol administration. The primary outcome was the proportion of adverse events (vomiting, hypersalivation, emergence, over-sedation, airway obstruction, laryngospasm, hypoxia, bradypnoea and intubation). Secondary outcomes included time to sedation, requirement for additional sedation and rate of successful sedation. RESULTS: There were 105 presentations (males 69/102 [69%]; median age 31 years (16-83 years). The commonest causes of ABD were illicit drug (39%) and alcohol (33%) intoxication. The median total dose of intramuscular ketamine was 200 mg (interquartile range [IQR] 150-200 mg). There were 64 adverse events in 40 (38%) patients. Four had vomiting, two had hypersalivation, two had emergence, 15 were oversedated, four had hypoxia, three had bradypnoea and 16 were intubated. Sedation was achieved in 103 (98%) patients at a median time post-ketamine of 8 min (IQR 5-13 min). Additional sedation was administered to 41 patients (nine prehospital and 37 within 1 h of arriving to hospital). In 44 (42%) patients, ketamine successfully sedated the patient with no adverse effects and no ongoing sedation requirement. CONCLUSION: The use of ketamine as rescue sedation in prehospital patients with severe ABD is effective. Adverse events are common but can be managed supportively.

The Pre-Hospital Initial Fluid Therapy Estimate in Early Nasty Burns (PHIFTEEN B, 15-B) Guideline applied to a retrospective cohort of Intensive Care Unit patients with major burns.

BACKGROUND: Appropriate fluid administration in severe burns is a cornerstone of early burns management. The American Burns Association's (ABA) recommendation is to administer 2 mL-4 mL × burnt Body Surface Area (BSA) × weight in the first 24 h with half administered in the first eight hours. Unfortunately, the calculations involved are complex and clinicians do not estimate the BSA or weight well, which can lead to errors in the amount of fluid administered. To simplify cognitive load to calculate the fluid resuscitation of early burns, the investigators derived the PHIFTEEN B (15-B) guideline. The 15-B guideline estimates the initial hourly fluid for adults ≥ 50 kg to be: 15 mL × BSA (to the nearest 10%) AIMS: To model and determine the accuracy of the 15-B calculated based on the characteristics of a retrospective cohort of patients admitted with ≥ 20% BSA to the Royal Brisbane and Women's Hospital (RBWH) Intensive Care Unit (ICU). METHODS: The 15-B formula was retrospectively calculated on the prehospital BSA estimate on patients admitted to the RBWH ICU. In addition, the 15-B guideline was modelled against a variety of weights and BSAs. The fluid volume was deemed to be clinically significant if it was greater than 250 mL/h outside the ABA's recommendations. RESULTS: The ICU cohort consisted of 107 patients (63.2% male, median age 37 years), with a median ICU estimated BSA of 40% and a median ICU weight estimation of 80 kg. In 43.9% of the cohort, the magnitude of the proportional difference between prehospital and ICU BSA estimate was greater than 25%. The 15-B formula accurately estimated the hourly fluid for all BSA (20%-100%) and weight combinations (50 kg-140 kg) in a BSA- weight matrix. When prehospital BSA estimate was utilized, 15-B guideline accurately estimated the fluid to be given within clinically significant limits for 97.2% of cases. CONCLUSIONS: The 15-B formula is a simple, easy to calculate guideline which approximates the early fluid estimates in severely burned patients despite inaccuracy in prehospital BSA estimates.

Prospective study of the safety and effectiveness of droperidol in elderly patients for pre-hospital acute behavioural disturbance.

OBJECTIVE: Acute behavioural disturbance in the elderly (≥65 years) is a significant issue for emergency medical services with increasing prevalence of dementia and aging populations. We investigated the pre-hospital safety and effectiveness of droperidol in the elderly with acute behavioural disturbance. METHODS: This was a pre-hospital prospective observational 1-year study of elderly patients with acute behavioural disturbance. The primary outcome was proportion of adverse events (AEs) (airway intervention, oxygen saturation <90% and/or respiratory rate <12/min, systolic blood pressure <90 mmHg, sedation assessment tool score of -3 and dystonic reactions). Secondary outcomes included time to sedation, additional sedation, proportion with successful sedation. RESULTS: There were 149 patients (males 78 [52%], median age 78 years; 65-101 years) presenting on 162 occasions. Dementia was the commonest cause (107/164 [65%]) of acute behavioural disturbance. There were six AEs in five patients (5/162 [3%]; 95% confidence interval 1-7). Three had hypotension, one with associated hypoxia (80%); and two had respiratory AEs (respiratory rate, 10/min [no hypoxia] and hypoxia [88%] which required oxygen). Median time to sedation was 19 min (interquartile range 12-29 min). Additional sedation was given in 2/162 patients during ambulance transfer and 16/162 within an hour of hospital arrival; 24/162 (15%) failed to sedate in the ambulance; 16 subsequently settled in ED and 8/24 received additional sedation. Of 162, 123 (76%) patients successfully sedated, without AEs or additional sedation. Of 162, 114 (70%) patients received 5 mg, 46 (29%) received two doses of 5 mg and two patients (1%) received three doses. CONCLUSIONS: Droperidol appeared to be safe and effective for pre-hospital sedation of acute behavioural disturbance in elderly patients.

Insights into the epidemiology of cardiopulmonary resuscitation-induced consciousness in out-of-hospital cardiac arrest.

OBJECTIVES: To describe the characteristics and outcomes of cardiopulmonary resuscitation (CPR)-induced consciousness patients from a large database of out-of-hospital cardiac arrest (OHCA). METHODS: Included were adult patients, attended between January 2007 and December 2018 by the Queensland Ambulance Service, where resuscitation was attempted by paramedics. Manual review of records was undertaken to identify CPR-induced consciousness cases. Patients exhibiting purposeful limb/body movement during CPR, with or without displaying other signs, were considered to be CPR-induced consciousness. Characteristics and outcomes of CPR-induced consciousness patients were compared to those without CPR-induced consciousness. RESULTS: A total of 23 011 OHCA patients were included; of these, 52 (0.23%) were CPR-induced consciousness. This translates into an incidence rate of 2.3 cases per 1000 adult resuscitation attempts over 12 years. Combativeness/agitation was the most common sign of CPR-induced consciousness, described in 34.6% (18/52) of patients. CPR-induced consciousness patients had numerically higher rates of return of spontaneous circulation on hospital arrival (51.9% vs 28.6%), discharge survival (46.2% vs 15.1%) and 30-day survival (46.2% vs 14.7%), than those without CPR-induced consciousness; however, CPR-induced consciousness was not found to be an independent predictor of survival. Higher proportions of CPR-induced consciousness patients had arrest witnessed by paramedics, occurring in public places, of cardiac aetiology and initial shockable rhythm, than patients without CPR-induced consciousness. CONCLUSIONS: CPR-induced consciousness in OHCA appears to be associated with higher survival rates. Standardised guidelines on recognition and management of CPR-induced consciousness remain to be established.

One single large intramuscular dose of naloxone is effective and safe in suspected heroin poisoning.

OBJECTIVE: Naloxone is an established antidote for the treatment of heroin poisoning; however, dosing regimens vary widely, with a current trend towards small titrated intravenous dosing. This study aims to characterise naloxone use in the treatment of patients presenting with suspected heroin poisoning. METHODS: This was a retrospective review of poisoned patients presenting to a clinical toxicology unit in Brisbane from January 2015 to December 2017. Patient demographics, clinical effects, naloxone dosing, observation periods and complications were extracted from the patient's medical records. RESULTS: There were 117 presentations accounted for by 108 patients. Prehospital naloxone was provided to 57 (49%) patients, 46 of which received a standardised 1.6 mg i.m. dose. The remaining 60 (51%) patients received their first naloxone in hospital, with 58 (97%) receiving this by titrated i.v. doses. A subsequent naloxone infusion was required significantly more often in those treated with i.v. titrated naloxone compared to i.m. dose (27/69 [39%] vs 5/48 [10%], P = 0.0006). The need for parenteral sedation to manage acute behavioural disturbance following naloxone provision was rare (3/117 [3%]). CONCLUSIONS: In this retrospective observational study, a single large i.m. dose of naloxone reversed the toxicity of suspected heroin overdose in the majority of patients. In addition, patients were less likely to require repeated intermittent doses or naloxone infusion than those treated solely with i.v. naloxone. Further comparison in a prospective study is warranted to validate these observations in confirmed heroin overdose. Requirement for sedation secondary to acute behavioural disturbance was rare regardless of the route.

A Prospective Study of the Safety and Effectiveness of Droperidol in Children for Prehospital Acute Behavioral Disturbance.

Study objective: Although uncommon, children (<16 years) with acute behavioral disturbance are a significant issue for emergency medical service providers. In this study, we aimed to investigate the safety and effectiveness of droperidol in children with prehospital acute behavioral disturbance. Methods: This was a prospective observational study over 1 year investigating the use of droperidol (0.1-0.2 mg/kg) for children (< 16 years) with acute behavioral disturbance. Inclusion criteria for acute behavioral disturbance were defined by a sedation assessment tool score of ≥2 determined by the attending paramedic. The primary outcome was the proportion of adverse effects (need for airway intervention, oxygen saturation <90% and/or respiratory rate <12, systolic blood pressure <90 mmHg, sedation assessment tool score of -3 and dystonic reactions). Secondary outcomes included time to sedation (sedation assessment tool score decreased by 2 or more, or a score of zero), requirement for additional sedation, failure to sedate and proportion of sedation success defined as the number of patients successfully sedated who did not suffer any adverse events or receive additional sedation. Results: There were 96 patients (males 51 [53%], median age 14 years [range 7-15 years]) who presented on 102 occasions over the one year study period. Self-harm and/or harm to others was the commonest (74/105 [70%]) cause of acute behavioral disturbance followed by alcohol (16/105 [15%]). There were 9 adverse events in 8 patients (8/102 [8%]; 95% confidence intervals [CI]: 3-13%) Five patients had hypotension, all asymptomatic and only one required treatment; 2 dystonic reactions managed with benztropine and one patient with respiratory depression. Median time to sedation was 14 min (interquartile range (IQR): 10-20 min; range: 3-85 min). There was no requirement for prehospital additional sedation (0/102 [0%]; 95% CI: 0-4%) and additional sedation in the first hour of arrival to hospital was required by 4 patients (4/102 [4%]; 95% CI: 1-10%). Overall successful sedation was achieved in 89 (87%) patients. Conclusions: The use of droperidol in children for acute behavioral disturbance in the prehospital setting is both safe and effective.

A Prospective Before and After Study of Droperidol for Prehospital Acute Behavioral Disturbance.

STUDY OBJECTIVE: Acute behavioral disturbance is a common problem for emergency medical services. We aimed to investigate the safety and effectiveness of droperidol compared to midazolam in the prehospital setting. METHODS: This was a prospective before and after study comparing droperidol to midazolam for prehospital acute behavioral disturbance, when the state ambulance service changed medications. The primary outcome was the proportion of adverse effects (airway intervention, oxygen saturation < 90%, respiratory rate < 12, systolic blood pressure < 90 mmHg, sedation assessment tool score -3 and dystonic reactions) in patients receiving sedation. Secondary outcomes included time to sedation, requirement for additional sedation, staff and patient injuries, and prehospital time. RESULTS: There were 141 patients administered midazolam and 149 patients administered droperidol in the study. Alcohol was the most common cause of acute behavioral disturbance. Fewer patient adverse events occurred with droperidol (11/149) compared to midazolam (33/141) (7% vs. 23%; absolute difference 16%; 95% confidence interval [CI]: 8% to 24%; p = 0.0001). Median time to sedation was 22 min (interquartile range [IQR]:18 to 35 min) for droperidol compared to 30 min (IQR:20 to 45 min) for midazolam. Additional prehospital sedation was required in 6/149 (4%) droperidol patients and 20/141 (14%) midazolam patients, and 11 (7%) droperidol and 59 (42%) midazolam patients required further sedation in the emergency department. There were no differences in patient or staff injuries, or prehospital time. CONCLUSIONS: The use of droperidol for acute behavioral disturbance in the prehospital setting is associated with fewer adverse events, a shorter time to sedation, and fewer requirements for additional sedation.

Characteristics and outcomes of patients administered blood in the prehospital environment by a road based trauma response team.

OBJECTIVE: To describe the characteristics, clinical interventions and the outcomes of patients administered packed red blood cells (pRBCs) by a metropolitan, road based, doctor-paramedic trauma response team (TRT). METHODS: A retrospective cohort study examining 18 months of historical data collated by the Queensland Ambulance Service TRT, the Pathology Queensland Central Transfusion Laboratory, the Royal Brisbane and Women's Hospital and the Princess Alexandra Hospital Trauma Services was undertaken. RESULTS: Over an 18-month period (1 January 2011 to 30 June 2012), 71 trauma patients were administered pRBCs by the TRT. Seven patients (9.9%) died on scene and 39 of the 64 patients (60.9%) transported to hospital survived to hospital discharge. 57 (89.1%) of the transported patients had an Injury Severity Score (ISS) > 15, with a mean ISS, Revised Trauma Score (RTS) and Trauma-Injury Severity Score of 32.11, 4.70 and 0.57, respectively. No patients with an RTS < 2 survived to hospital discharge. 53 patients (82.8%) received additional pRBCs in hospital with 17 patients (26.6%) requiring greater than 10 units pRBCs in the first 24 h. 47 patients (73.4%) required surgical or interventional radiological procedures in the first 24 h. CONCLUSIONS: There is a potential role for prehospital pRBC transfusions in an integrated civilian trauma system. The RTS calculated using the initial set of observations may be a useful tool in determining in which patients the administration of prehospital pRBC transfusions would be futile.

The feasibility of civilian prehospital trauma teams carrying and administering packed red blood cells.

OBJECTIVE: To evaluate the feasibility, limitations and costs involved in providing prehospital trauma teams with packed red blood cells (pRBCs) for use in the prehospital setting. METHODS: A retrospective cohort study, examining 18 months of historical data collated by the Queensland Ambulance Service Trauma Response Team (TRT) and the Pathology Queensland Central Transfusion Laboratory was undertaken. RESULTS: Over an 18-month period (1 January 2011-30 June 2012), of 500 pRBC units provided to the TRT, 130 (26%) were administered to patients in the prehospital environment. Of the non-transfused units, 97.8% were returned to a hospital blood bank and were available for reissue. No instances of equipment failure directly contributed to wastage of pRBCs. The cost of providing pRBCs for prehospital use was $A551 (£361) for each unit transfused. CONCLUSIONS: It is feasible and practical to provide prehospital trauma teams with pRBCs for use in the field. Use of pRBCs in the prehospital setting is associated with similar rates of pRBC wastage to that reported in emergency departments.