SummaryPre‐hospital emergency anaesthesia with oral tracheal intubation is the technique of choice for trauma patients who cannot maintain their airway or achieve adequate ventilation. It should be carried out as soon as safely possible, and performed to the same standards as in‐hospital emergency anaesthesia. It should only be conducted within organisations with comprehensive clinical governance arrangements. Techniques should be straightforward, reproducible, as simple as possible and supported by the use of checklists. Monitoring and equipment should meet in‐hospital anaesthesia standards. Practitioners need to be competent in the provision of in‐hospital emergency anaesthesia and have supervised pre‐hospital experience before carrying out pre‐hospital emergency anaesthesia. Training programmes allowing the safe delivery of pre‐hospital emergency anaesthesia by non‐physicians do not currently exist in the UK. Where pre‐hospital emergency anaesthesia skills are not available, oxygenation and ventilation should be maintained with the use of second‐generation supraglottic airways in patients without airway reflexes, or basic airway manoeuvres and basic airway adjuncts in patients with intact airway reflexes.

Massive haemorrhage still accounts for up to 40% of mortality after traumatic injury. The importance of limiting blood loss after injury in order to prevent its associated complications has led to rapid advances in the development of dressings for haemostatic control. Driven by recent military conflicts, there is increasing evidence to support their role in the civilian prehospital care environment. This review aims to summarise the key characteristics of the haemostatic dressings currently available on the market and provide an educational review of the published literature that supports their use. Medline and Embase were searched from start to January 2012. Other sources included both manufacturer and military publications. Agents not designed for use in prehospital care or that have been removed from the market due to significant safety concerns were excluded. The dressings reviewed have differing mechanisms of action. Mineral based dressings are potent activators of the intrinsic clotting cascade resulting in clot formation. Chitosan based dressings achieve haemostasis by adhering to damaged tissues and creating a physical barrier to further bleeding. Acetylated glucosamine dressings work via a combination of platelet and clotting cascade activation, agglutination of red blood cells and local vasoconstriction. Anecdotal reports strongly support the use of haemostatic dressings when bleeding cannot be controlled using pressure dressings alone; however, current research focuses on studies conducted using animal models. There is a paucity of published clinical literature that provides an evidence base for the use of one type of haemostatic dressing over another in humans.

BackgroundPoor communication during patient handover is recognised internationally as a root cause of a significant proportion of preventable deaths. Improving the accuracy and quality of handover may reduce associated mortality and morbidity. Although the practice of handover between Ambulance and Emergency Department clinicians has received some attention over recent years there is little evidence to support handover best practice within the prehospital domain. Further research is therefore urgently required to understand the most appropriate way to deliver clinical information exchange in the pre-hospital environment. We aimed to investigate current clinical information exchange practices, perceived challenges and the preferred handover mnemonic for use during transfer of high acuity patients between ambulance clinicians and specialist prehospital teams.MethodsA national, cross-sectional questionnaire study. Participants were road based ambulance clinicians (RBAC) or active members of specialist prehospital teams (SPHT) based in Scotland.ResultsOver a three month study period there were 247 prehospital incidents involving specialist teams. One hundred ninety individuals completed the questionnaire; 61% [n = 116] RBAC and 39% [n = 74] SPHT. Median length of prehospital experience was 10 years (IQR 5–18). Overall current prehospital handover practices were perceived as being effective (Mdn 4.00; IQR 3–4 [1 = very ineffective - 5 = very effective]) although SPHT clinicians rated handover effectiveness slightly lower than RBAC’s (Mdn 3.00 vs 4.00, U = 1842.5, p = .03). ‘ATMIST’ (Age, Time of onset, Medical complaint/injury, Investigation, Signs and Treatment) was deemed the mnemonic of choice. The clinical variables perceived as essential for handover are not explicitly identified within the SBAR mnemonic. The most frequently reported method of recording and transferring information during handover was via memory (n = 112 and n = 120 respectively) and ‘interruptions’ were perceived as the most significant barrier to effective handover.ConclusionWhile, overall, current prehospital handover practice is perceived as effective this study has identified a number of areas for improvement. These include the development of a shared mental model through system standardisation, innovations to support information recording and delivery, and the clear identification at incidents of a handover lead. Mnemonics must be carefully selected to ensure they explicitly contain the perceived essential clinical variables required for prehospital handover; the mnemonic ATMIST meets these requirements. New theoretically informed, evidence-based interventions, must be developed and tested within existing systems of care to minimise information loss and risk to patients.

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Background: Remote and Rural pre-hospital care practitioners manage serious illness and injury on an unplanned basis, necessitating technical and non-technical skills (NTS). However, no behaviour rating systems currently address NTS within these settings. Informed by health psychology theory, a NTS-specific behaviour rating system was developed for use within pre-hospital care training for remote and rural practitioners.Method: The Immediate Medical Care Behaviour Rating System (IMCBRS), was informed by literature, expert advice and review and observation of an Immediate Medical Care (IMC) course. Once developed, the usability and appropriateness of the rating system was tested through observation of candidates' behaviour at IMC courses during simulated scenarios and rating their use of NTS using the IMCBRS.Results and Conclusion: Observation of training confirmed rating system items were demonstrated in 28-62% of scenarios, depending on context. The IMCBRS may thus be a useful addition to training for rural and remote practitioners. Highlights A patient safety behaviour rating system for rural/remote settings was developed.  Testing of the system suggests that its content may be appropriate and observable.  Some elements were more observable, which may affect future work using this system. BackgroundRural/remote practitioners manage serious illness and injury on an infrequent, unplanned basis. Within rural/remote settings the first person at the scene of a medical emergency is often a general practitioner (GP) or practice nurse. Compared to urban or hospital-based settings, those attending an emergency in these settings may be doing so single-handedly or with limited assistance, for considerable time within potentially harsh conditions, prior to an ambulance providing transport to definitive care. Quite often, working in such settings requires decisions to be made based on the distance to hospital and the patient's likelihood of survival. Effective pre-hospital care thus necessitates a high level of non-technical skills (NTS), such as communication and decision-making (1). The importance of NTS within these settings is evident within research which suggests the factors involved in the likelihood of surviving out of hospital cardiac arrest include a witnessed cardiac arrest, provision of bystander CPR, shockable cardiac rhythm and return of spontaneous circulation (ROSC) within the field (2). The tasks involved in this example necessitate communication skills involved in the provision of CPR (e.g. communicating planned actions to others) and decision-making skills (e.g. who should do what) about how to respond to the situation. In order for optimal care to be provided both technical (e.g. providing CPR) and non-technical (e.g. co-ordinating people at the scene of an emergency) skills need to be employed. Consequently, approaches to improving patient safety and clinical outcomes from emergency care should focus not only on clinical skills and operational and service factors, such as ensuring equipment ...

This paper reports the successful prehospital use of small uncuffed tubes in both breathing and apnoeic patients. The survival rate to hospital following a prehospital surgical airway is reasonable. There is a high incidence of spontaneous ventilation in this patient cohort. There were a number of limitations with this study, but the subject is worthy of further research.

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hest pain is the commonest reason for 999 calls and accounts for 2.5% of out of hours calls. Of patients taken to hospital about 10% will have an acute myocardial infarction (AMI). Evidence suggests that up to 7.5% of these will be missed on first presentation. There are a number of other life threatening conditions, which can present as chest pain and must not be overlooked. The objectives of this article are therefore to provide a safe and comprehensive system of dealing with this presenting complaint (box 1).