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From the prehospital literature
  1. Malcolm Woollard, Edited by

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    The 12-lead ECG is a fundamental component of patient assessment for a range of presentations and is almost universally available across a variety of healthcare settings. In prehospital care, 12-lead ECG equipment has become standard in ambulance services and is recommended in international guidelines for cardiac care.1

    Despite this, there is evidence that the prehospital ECG (PHECG) is underutilised. In the USA, for example, less than 10% of patients with acute ST segment elevation myocardial infarction have a PHECG, according to the National Registry of Myocardial Infarction, a rate that has not substantially improved in the past decade.2 Experience from the UK, although not yet published, suggests much higher use, with approximately three-quarters of patients with ST segment elevation myocardial infarction who were under emergency medical services care having a PHECG recorded.

    The American Heart Association have published a scientific statement setting out the available evidence, alongside practice recommendations and possible questions for future research. This covers the perceived benefits of PHECG, skill and competence in acquisition, interpretation and communication of ECG findings by emergency medical services staff, organisational and system issues and possible barriers to implementation.

    A key practice recommendation is that the PHECG should take priority over other components of care such as oxygen and opiate administration, facilitating early decision-making about possible reperfusion options including alerting a percutaneous coronary intervention centre.


    1. Van de Werf F, Bax J, Betriu A, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J 2008;29:2909–45.

    2. Curtis JP, Portnay EL, Wang Y, et al. The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000–2002: findings from the National Registry of Myocardial Infarction-4. J Am Coll Cardiol 2006;47:1544–52.

    Tom Quinn, College of Paramedics Research and Audit Committee

    Ting HH, Krumholz HM, Bradley EH, . Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome: a scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology. Circulation 2008;118:1066–79.


    There has long been debate over the efficacy of intravenous drugs in cardiac arrest. This observational, prospective study set out to investigate whether the introduction of a single dose of 1 mg intravenous epinephrine improved outcomes from prehospital cardiac arrest in an emergency medical service that did not previously use this drug. Outcomes examined included survival to discharge, survival to hospital admission, return of spontaneous circulation and functional status on discharge. Although the authors state that they were unable to establish a survival benefit with the introduction of intravenous epinephrine to this emergency medical service, many unmeasured confounders were not accounted for. The study examined the effect of only a single dose of epinephrine until after arrival at hospital and no other drugs such as amiodarone or lignocaine were given. It was admitted that there was a relatively low success rate of intravenous drug delivery and variations in post-resuscitation care were not accounted for. This study highlights the importance of designing prehospital studies that are methodologically robust, if questions about the efficacy of interventions such as medical devices or drugs are to be answered definitively. Adequately powered randomised controlled trials may be difficult to conduct in this setting but are not impossible and remain the gold standard.

    Sarah Christopher, College of Paramedics Research and Audit Committee

    Eng Hock Ong M, Hoe Tan E, Suan Peng Ng S, . Survival outcomes with the introduction of intravenous epinephrine in the management of out-of-hospital cardiac arrest. Ann Emerg Med 2007;50:635–42.


    This retrospective observational study compared the accuracy of the recognition of stroke by paramedics using the Cincinnati prehospital stroke scale (CSS) in the prehospital setting with that of emergency medical dispatchers using the medical priority dispatch systems when processing emergency telephone calls. From 477 patients assessed as having a stroke by paramedics using the CSS, 193 had a final discharge of stroke (sensitivity 44%, positive predictive value 40%). From the 882 patients with a dispatch determinant of stroke from the medical priority dispatch systems, 367 had a final discharge of stroke (sensitivity 83%, positive predictive value 42%). These findings are surprising given that other studies have shown paramedics to have a higher sensitivity using the CSS. However, there are potentially more confounding variables with paramedic practice, such as training and clinical level, when compared with dispatchers using a computer programme that follows a strict algorithm.

    This study highlights the need for paramedics to identify correctly a higher proportion of those patients who are having a stroke. If the sensitivity reported in this study is typical, currently more than half of the patients who could benefit from direct admission to a specialist stroke centre will instead be admitted to an emergency department, potentially delaying time-critical treatment.

    Tom Archer, London Ambulance Service

    Ramanujum P, Guluma KZ, Castillo EM, . Accuracy of stroke recognition by emergency medical dispatchers and paramedics – San Diego experience. Prehosp Emerg Care 2008;12:307–13.


    It was recognised nearly a decade ago that the majority of UK ambulance professionals retired early as a result of ill health, and that in those who managed to stay in post until the statutory age of 65 years the average post-retirement life expectancy was 3 years. The risk factors behind these alarming statistics were not, however, subject to further exploration. This review from the USA may shed some light on the underlying aetiology; however, indicating that approximately three-quarters of US emergency responders (fire, police and ambulance) have hypertension or “prehypertension” and that this interacts with the strenuous nature of their jobs and other personal risk factors to increase the likelihood of cardiovascular events. The authors note that the majority of such incidents occur in those workers whose blood pressure lies in a range for which physicians tend not to prescribe medication (140–146 mm Hg systolic/88–92 mm Hg diastolic). Patients in the UK with a blood pressure consistently measuring over 140/90 mm Hg but under 160/100 mm Hg typically only receive medication in the presence of other cardiac risk factors, but the authors of this review suggest employment as an emergency service worker should be factored in as an additional risk factor for patients with “mild” hypertension.

    Kales SN, Tsismenakis AJ, Zhang C, . Blood pressure in firefighters, police officers, and other emergency responders. Am J Hypertens 2009;22:11–20.