In adults with severe TBI, prehospital rapid sequence intubation by paramedics increases the rate of favorable neurologic outcome at 6 months compared with intubation in the hospital.

Background and Purpose-Few acute stroke patients are treated with alteplase, partly because of significant prehospital delays after symptom onset. The aim of this study was to determine among ambulance-transported stroke patients factors associated with stroke recognition and factors associated with a call for ambulance assistance within 1 hour from symptom onset. Methods-For 6 months in 2004, all ambulance-transported stroke or transient ischemic attack patients arriving from a geographically defined region in Melbourne (Australia) to 1 of 3 hospital emergency departments were assessed. Tapes of the call for ambulance assistance were analyzed and the patient and the caller were interviewed. Results-One hundred ninety-eight patients were included in the study. Stroke was reported as the problem in 44% of ambulance calls. Unprompted stroke recognition was independently associated with facial droop (Pϭ0.015) and a history of stroke or transient ischemic attack (PϽ0.001). More than half of the calls for ambulance assistance were made within 1 hour from symptom onset and only 43% of these callers spontaneously identified the problem as "stroke." Factors independently associated with a call within 1 hour were: speech problems (Pϭ0.009), caller family history of stroke (Pϭ0.017), and the patient was not alone at symptom onset (Pϭ0.018). Conclusions-Stroke was reported as the problem (unprompted) by Ͻ50% of callers. Fewer than half the calls were made within 1 hour from symptom onset. Interventions are needed to more strongly link stroke recognition to immediate action and increase the number of stroke patients eligible for acute treatment.

Background and Purpose-Few patients with acute stroke are treated with alteplase, often due to significant prehospital delays after symptom onset. The aims of this study were to: (1) identify factors associated with rapid first medical assessment in the emergency department after a call for ambulance assistance, and (2) determine the impact of ambulance practice on times from the ambulance call to first medical assessment in the emergency department. Methods-During a 6-month period in 2004, all ambulance-transported patients with stroke or transient ischemic attack arriving from a geographically defined region in Melbourne, Australia (population 383 000) to one of 3 hospital emergency departments were assessed prospectively. Ambulance records including the tape recording of the call for ambulance assistance and hospital medical records, were analyzed. Results-One hundred ninety-eight patients were included in the study. One hundred eighty-seven ambulance patient care records were complete and available for analysis. Factors associated with first medical assessment in the emergency department Ͻ60 minutes from the ambulance call and Ͻ10 minutes from hospital arrival were: Glasgow Coma Scale Ͻ13 (PϽ0.001 and Pϭ0.021) and hospital prenotification (Pϭ0.04 and PϽ0.001). Paramedic stroke recognition and hospital prenotification were associated with shorter times from the ambulance call to first medical assessment (Pϭ0.001 and PϽ0.001). Conclusions-Paramedic stroke recognition and hospital prenotification are associated with shorter prehospital times from the ambulance call to hospital arrival and in-hospital times from hospital arrival to first medical assessment. This highlights the importance of including ambulance practice in comprehensive care pathways that span the whole process of stroke care.

Background Clinical handover between paramedics and the trauma team is undertaken in a time-pressured environment. Paramedics are often required to handover complex problems to a multitude of staff. There is evidence that information loss occurs at this transition. The aims of this project were to (1) develop a minimum dataset to assist paramedics provide handover; (2) identify attributes of effective and ineffective handover; (3) determine the feasibility of advanced data transmission; and (4) identify how to best display data in trauma bays. Methods Qualitative study of paramedics and trauma team members. A thematic analysis was undertaken using grounded theory. Results Ten paramedics and 17 trauma team members were interviewed. A minimum dataset modified on an existing template was developed to include fields required by the trauma team to inform immediate treatment. Respondents stated that an effective handover was one which was delivered succinctly and in a structured manner, and contained only vital data necessary to direct immediate treatment. Advanced transmission of data to the receiving hospital was widely supported. While computers carried by paramedics were capable of exporting data to the receiving hospital, barriers such as time constraints, workflow issues and infection control issues impeded the ability to do this in the current environment. Discussion There is support for the adoption and further evaluation of a handover template. It can provide valuable structure to the face-to-face handover, and experience from other specialties suggests it can reduce information loss. Strategies to enable information to be transmitted in advance of the patients' arrival must address concerns voiced by paramedics. BACKGROUND

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Objective: To determine the effectiveness of intranasal (IN) naloxone compared with intramuscular (IM) naloxone for treatment of respiratory depression due to suspected opiate overdose in the prehospital setting. Design: Prospective, randomised, unblinded trial of either 2 mg naloxone injected intramuscularly or 2 mg naloxone delivered intranasally with a mucosal atomiser. Participants and setting: 155 patients (71 IM and 84 IN) requiring treatment for suspected opiate overdose and attended by paramedics of the Metropolitan Ambulance Service (MAS) and Rural Ambulance Victoria (RAV) in Victoria. Main outcome measures: Response time to regain a respiratory rate greater than 10 per minute. Secondary outcome measures were proportion of patients with respiratory rate greater than 10 per minute at 8 minutes and/or a GCS score over 11 at 8 minutes; proportion requiring rescue naloxone; rate of adverse events; proportion of the IN group for whom IN naloxone alone was sufficient treatment. Results: The IM group had more rapid response than the IN group, and were more likely to have more than 10 spontaneous respirations per minute within 8 minutes (82% v 63%; P = 0.0173). There was no statistically significant difference between the IM and IN groups for needing rescue naloxone (13% [IM group] v 26% [IN group]; P = 0.0558). There were no major adverse events. For patients treated with IN naloxone, this was sufficient to reverse opiate toxicity in 74%. Conclusion: IN naloxone is effective in treating opiate‐induced respiratory depression, but is not as effective as IM naloxone. IN delivery of naxolone could reduce the risk of needlestick injury to ambulance officers and, being relatively safe to make more widely available, could increase access to life‐saving treatment in the community.

Objective: To determine the proportion of patients in Victoria treated within the British Heart Foundation 90‐minute call‐to‐needle (CTN) time benchmark for thrombolysis of ST‐elevation myocardial infarction (STEMI), and to validate the British Heart Foundation 90‐minute benchmark with respect to mortality. Design: Cohort study. Setting: 20 hospitals and two ambulance services in the State of Victoria, Australia. Participants: 1147 patients with STEMI transported to hospital by ambulance and eligible for thrombolysis. Main outcome measures: CTN time, and in‐hospital mortality. Results: Median CTN time was 83 minutes (mean, 93.2 min; range, 29–894 min). Median door‐to‐needle (DTN) time was 37 minutes (mean, 46.5 min; range, 0–853 min). 61% of patients received thrombolysis within the 90‐minute benchmark. Patients with CTN times > 90 minutes had an increased risk of dying (relative risk, 1.8; 95% CI, 1.3–2.7). Factors associated with CTN time < 90 minutes were lower DTN time, prior notification of the receiving hospital and transport time less than 20 minutes. Conclusion: The British Heart Foundation CTN time benchmark is being met for 61% of eligible STEMI patients in Victoria. Strategies to reduce CTN time should be region‐specific, and should include attempts to reduce DTN and to enhance ambulance–hospital communication. Prehospital thrombolysis may be appropriate for some regions.

Objective: To determine the effects of rapid sequence intubation in patients with severe head injury performed by paramedics on a helicopter emergency medical service. Methods: The patient care records for patients with severe head injury who underwent rapid sequence intubation between November 1999 and February 2002 (inclusive) were examined. Data were extracted on the demographics of the patients, as well as the physiological changes before and after rapid sequence intubation. Results: There were 122 patients with severe head injury evaluated at the scene during the study period. Rapid sequence intubation was attempted in 110 patients and was successful in 107 (97%). Intubation was associated with improvements in systolic blood pressure, oxygen saturation and end‐tidal carbon dioxide levels, compared with baseline levels. Conclusion: Rapid sequence intubation in patients with severe head injury may be safely undertaken by helicopter‐based ambulance paramedics and is associated with improvements in oxygenation, ventilation and blood pressure. Further studies of this skill undertaken by road‐based paramedics are warranted.