Safety and efficacy of paramedic treatment of regular supraventricular tachycardia: a randomised controlled trial.

INTRODUCTION: Supraventricular tachycardias (SVTs) are a common cause of acute hospital presentations. Adenosine is an effective treatment. To date, no studies have directly compared paramedic-with hospital-delivered treatment of acute SVT with adenosine. METHOD: Randomised controlled trial comparing the treatment of SVT and discharge by paramedics with conventional emergency department (ED)-based care. Patients were excluded if they had structural heart disease or contraindication to adenosine. Discharge time, follow-up management, costs and patient satisfaction were compared. RESULTS: Eighty-six patients were enrolled: 44 were randomised to paramedic-delivered adenosine (PARA) and 42 to conventional care (ED). Of the 37 patients in the PARA group given adenosine, the tachycardia was successfully terminated in 81%. There was a 98% correlation between the paramedics' ECG diagnosis and that of two electrophysiologists. No patients had any documented adverse events in either group. The discharge time was lower in the PARA group than in the ED group (125 min (range 55-9513) vs 222 min (range 72-26 153); p=0.01), and this treatment strategy was more cost-effective (£282 vs £423; p=0.01). The majority of patients preferred this management approach. Being treated and discharged by paramedics did not result in the patients being less likely to receive ongoing management of their arrhythmia and cardiology follow-up. CONCLUSIONS: Patients with SVT can effectively and safely be treated with adenosine delivered by trained paramedics. Implementation of paramedic-delivered acute SVT care has the potential to reduce healthcare costs without compromising patient care. TRIAL REGISTRATION NUMBER: NCT02216240.

Reducing time to angiography and hospital stay for patients with high-risk non-ST-elevation acute coronary syndrome: retrospective analysis of a paramedic-activated direct access pathway.

OBJECTIVE: To assess whether a novel 'direct access pathway' (DAP) for the management of high-risk non-ST-elevation acute coronary syndromes (NSTEACS) is safe, results in 'shorter time to intervention and shorter admission times'. This pathway was developed locally to enable London Ambulance Service to rapidly transfer suspected high-risk NSTEACS from the community to our regional heart attack centre for consideration of early angiography. METHODS: This is a retrospective case-control analysis of 289 patients comparing patients with high-risk NSTEACS admitted via DAP with age-matched controls from the standard pan-London high-risk ACS pathway (PLP) and the conventional pathway (CP). The primary end point of the study was time from admission to coronary angiography/intervention. Secondary end point was total length of hospital stay. RESULTS: Over a period of 43 months, 101 patients were admitted by DAP, 109 matched patients by PLP and 79 matched patients through CP. Median times from admission to coronary angiography for DAP, PLP and CP were 2.8 (1.5-9), 16.6 (6-50) and 60 (33-116) hours, respectively (p<0.001). Median length of hospital stay for DAP and PLP was similar at 3.0 (2.0-5.0) days in comparison to 5 (3-7) days for CP (p<0.001). CONCLUSIONS: DAP resulted in a significant reduction in time to angiography for patients with high-risk NSTEACS when compared to existing pathways.

Phenotypic and functional differentiation of KG-1 into dendritic-like cells.

The cell line KG-1 has been used as an in vitro model for human dendritic cell (DC) differentiation. We have investigated the response of KG-1 cells to stimulation with a number of factors known to induce differentiation and/or maturation of DCs in vitro. KG-1 cells showed no differentiation in response to LPS, CpG oligodeoxynucleotide or CD40 ligation. Culture in the presence of TNF-alpha induced some differentiation, but only treatment with PMA and ionomycin (with or without prior culture in GM-CSF and IL-4) induced morphological and phenotypic changes consistent with DC-like maturation, and even these maximally differentiated KG-1 cells showed lower levels of surface marker expression, macromolecular endocytosis, and ability to stimulate in allogeneic MLR compared with in vitro monocyte-derived DCs. Our data show that KG-1 cells differentiate in vitro into cells with DC-like functional characteristics under the influence of strong inducers of cellular activation, but lack the potency of mature DCs in key aspects of professional antigen presenting cells.

Retrospective study into the delivery of telephone cardiopulmonary resuscitation to "999" callers.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is an essential part of the chain of survival, with early administration directly affecting the patient's chance of survival. Pre-arrival telephone CPR instructions provide callers who have no CPR training on how to undertake this intervention. With the emergency medical dispatcher unable to see the caller or the patient, it is possible that problems will arise, presenting barriers, that stop the caller undertaking effective CPR. OBJECTIVE: To examine how commonly barriers to telephone CPR occur and whether this affects the time it takes to perform the intervention. METHOD: A retrospective quantitative analysis was undertaken using a convenience sample of 100 emergency calls. Calls were identified in the emergency control room as cardiac arrests and confirmed by the responding paramedics as cardiac arrests. The calls were listened to, established if CPR instructions were given, if the instructions were followed, if anything hindered the instructions undertaken, and the time taken to reach key points. FINDINGS: 18 cases had bystander CPR administered. An additional 56 of cases had CPR instructions provided but "barriers" in 49% (n = 27) hindered the effectiveness of these. The median time to recognition of cardiac arrest was 40 seconds, with time to first ventilation being 4 min 10 s and time to first compression 5 min 30 s. These times were notably higher in those cases where a barrier to effective telephone CPR existed. CONCLUSIONS: Barriers to undertaking telephone CPR occurred with a high degree of frequency. These barriers affect the ability of the caller to perform rapid and effective telephone CPR.

Recognition of ST elevation by paramedics.

OBJECTIVE: To define the ability of UK paramedics to recognise ST segment elevation using a prehospital 12 lead electrocardiogram (ECG). METHODS: Analysis of the diagnostic ability of seven paramedics 12 months after a two day training course, using interpretation of a 12 lead ECG by two cardiologists as the criterion standard. Comparison of paramedic and A&E SHO diagnosis to determine accuracy, specificity, sensitivity, negative predictive value, and positive predictive value of paramedic interpretation. RESULTS: Paramedics showed a median accuracy of 0.95 (95% CI 0.88 to 0.98), a specificity of 0.91 (95% CI 0.53 to 1.0), a sensitivity of 0.97 (95% CI 0.94 to 0.99), a NPV of 0.77 (95% CI 0.62 to 0.92) and a PPV of 0.99 (95% CI 0.92 to 1.0). This was not significantly different from a group of experienced A&E SHOs. CONCLUSIONS: UK paramedics can recognise ST elevation using a 12 lead ECG. Radio transmission of an ECG may not be necessary to pre-alert the hospital.

Resuscitation training for medical students.

This paper describes the systematic training of undergraduate medical students in resuscitation skills, aimed at overcoming the well known deficiencies in the resuscitation skills of junior doctors. This training can be integrated with the medical curriculum, but takes a considerable commitment in teaching time. To give each of our 240 medical students 36 h of resuscitation training, including an advanced life support (ALS) course for all students, 2442 h of teacher's time is required each year. It is important that teaching is continued on the wards as part of the training of pre-registration house officers. The amount of teaching time required justifies the appointment of Medical School Resuscitation Officers, dedicated to teaching medical students, dental students and pre-registration house officers.

Emergency drugs in dental practice.

An increase in the life expectancy of medically compromised patients has resulted in greater numbers of these individuals within our ageing population. As dental surgeons are increasingly expected to provide care for such patients, the likelihood of a medical emergency occurring within the dental surgery may increase. This article reviews the more common emergency drugs that a dentist may have to administer in the event of a medical emergency. The indications, mode of action, method of administration and dose of each agent are discussed.

Effect of multiple dose oral ciprofloxacin on the pharmacokinetics of theophylline and indocyanine green.

Interaction between ciprofloxacin and theophylline was studied in eight male volunteers, who were randomly divided into two groups. All subjects were given intravenous theophylline and indocyanine green (ICG) on study days 0, 7 and 14. Group I subjects received ciprofloxacin 750 mg orally every 12 h on days 1-7. Group II subjects received ciprofloxacin 750 mg every 12 h on days 6-14. No significant changes in ICG clearance or half-life were noted. A significant increase in theophylline half-life and volume of distribution was observed (P less than 0.05); however, clearance was not significantly decreased (P = 0.1). A potentially clinically significant interaction was detected in three subjects whose theophylline clearance decreased by 42-113%. Until further clinical experience is gained, we advise caution when these agents are coadministered. Some adjustment in theophylline dosage may be required; therefore, these patients should have serum theophylline concentration measurements and careful clinical assessment for theophylline toxicity.