Clinical Conversations

This is the first in a new series of monthly clinical updates for Ambulance Victoria clinical staff. Director of Paramedicine A/Prof Ben Meadley and Clinical Guideline Specialist James Oswald summarise the need-to-know clinical information, all in one spot.

This month: New CPG updates, trends in our patient safety data, and new cardiac monitors.

Times stamps:

2:00 New CPG updates

4:40 Snakebite

6:30 Acute coronary syndrome and activating the cath lab

7:35 Patient safety trends

10:20  Dislocation reduction – how are we doing?

12:10 Ketone strips

13:50 Case report templates

15:05 Thunderstorm asthma

15:25 IV Fluid shortage

15:50 PANDA trial update

16:40 New cardiac monitors

17:25 Professional development opportunities

Resources

European

Safe airway

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James: ⁠⁠⁠@JamesOz1⁠⁠

Ben: ⁠@ben_meadley⁠

Linkedin

James

Ben

In this episode, James speaks with critical care paramedic, academic, and newly appointed Director of Paramedicine, Associate Professor Ben Meadley. We discuss strategic clinical leadership and the future of the profession. 

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David: ⁠⁠⁠@expensivecare⁠⁠⁠

James: ⁠⁠⁠@JamesOz1⁠⁠

Ben: ⁠@ben_meadley⁠

Part 2 of David's discussion with Associate Professor Andrew Udy on Sepsis Management.

Get in touch

⁠[email protected]⁠

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David: ⁠@expensivecare⁠

James: ⁠@JamesOz1

Resources mentioned

[PHANTASI trial] Alam N, Oskam E, Stassen PM, Exter Pv, van de Ven PM, Haak HR, et al. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. The Lancet Respiratory Medicine. 2018;6(1):40-50.

Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-96.

Seymour CW, Gesten F, Prescott HC, Friedrich ME, Iwashyna TJ, Phillips GS, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med. 2017;376(23):2235-44.

ARISE Invetigators. Goal-Directed Resuscitation for Patients with Early Septic Shock. New England Journal of Medicine. 2014;371(16):1496-506.

PRISM Investigators. Early, Goal-Directed Therapy for Septic Shock — A Patient-Level Meta-Analysis. New England Journal of Medicine. 2017;376(23):2223-34.

Australian Commission on Safety and Quality in Health Care. Sepsis Clinical Care Standard 2022 [Available from: https://www.safetyandquality.gov.au/standards/clinical-care-standards/sepsis-clinical-care-standard#:~:text=The%20Sepsis%20Clinical%20Care%20Standard,Commission%20on%2030%20June%202022.

Shapiro NI, Douglas IS, Brower RG, Brown SM, Exline MC, Ginde AA, et al. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. N Engl J Med. 2023;388(6):499-510.

Other resources

Poynter MJ, Farrugia A, Kelly E, Simpson PM. Prehospital administration of antibiotics in addition to usual care versus usual care alone for patients with suspected sepsis – a systematic review. Paramedicine. 2024;21(2):52-65.

Varney J, Motawea KR, Kandil OA, Hashim HT, Murry K, Shah J, et al. Prehospital administration of broad-spectrum antibiotics for sepsis patients: A systematic review and meta-analysis. Health Sci Rep. 2022;5(3):e582.

Sepsis is arguably the most common time critical emergency we face as paramedics. This is the first of a two part series on sepsis with Professor Andrew Udy. Andrew is Head of Research at The Alfred ICU, and Deputy Director, Australian and New Zealand Intensive Care Research Centre. He was involved in the development of the recently released Ambulance Victoria Sepsis and Infection guideline. In this episode, Ambulance Victoria Medical Director A/Prof David Anderson and Andrew discuss the assessment and diagnosis of sepsis.

Get in touch

⁠⁠[email protected]⁠⁠

X / Twitter

David: ⁠⁠@expensivecare⁠⁠

James: ⁠⁠@JamesOz1⁠

Further resources

NICE. Sepsis: recognition, diagnosis and early management 2017. Available from: https://www.nice.org.uk/guidance/ng51.

Royal Children's Hospital. Sepsis – assessment and management 2020. Available from: https://www.rch.org.au/clinicalguide/guideline_index/SEPSIS_assessment_and_management/.

Inada-Kim M. NEWS2 and improving outcomes from sepsis. Clin Med (Lond). 2022;22(6):514-7.

Lisa S, Shammi R, Steve G. Comparison of qSOFA and Hospital Early Warning Scores for prognosis in suspected sepsis in emergency department patients: a systematic review. Emergency Medicine Journal. 2022;39(4):284.

Mellhammar L, Linder A, Tverring J, Christensson B, Boyd JH, Sendi P, et al. NEWS2 is Superior to qSOFA in Detecting Sepsis with Organ Dysfunction in the Emergency Department. J Clin Med. 2019;8(8).

Oduncu AF, Kıyan GS, Yalçınlı S. Comparison of qSOFA, SIRS, and NEWS scoring systems for diagnosis, mortality, and morbidity of sepsis in emergency department. Am J Emerg Med. 2021;48:54-9.

Patel R, Nugawela MD, Edwards HB, Richards A, Le Roux H, Pullyblank A, et al. Can early warning scores identify deteriorating patients in pre-hospital settings? A systematic review. Resuscitation. 2018;132:101-11.

Steve G, Laura S, Ben T, Olivia H, Khurram I, Susan C, et al. Prehospital early warning scores for adults with suspected sepsis: retrospective diagnostic cohort study. Emergency Medicine Journal. 2023;40(11):768.

Verity Frances T, Melanie M, Graham H, Andy S, Aroha B, Tony S, et al. Predictive value of the New Zealand Early Warning Score for early mortality in low-acuity patients discharged at scene by paramedics: an observational study. BMJ Open. 2022;12(7):e058462.

Wang C, Xu R, Zeng Y, Zhao Y, Hu X. A comparison of qSOFA, SIRS and NEWS in predicting the accuracy of mortality in patients with suspected sepsis: A meta-analysis. PLoS ONE. 2022;17:e0266755.

In Australia, penetrating truncal trauma is rare and the care of these patients involves a quite different mindset than we're used to. This is a cohort where our stay-and-play approach can do harm. James and David discuss the evidence relating to penetrating trauma and practical recommendations for your practice.

Further resources

Over view of major traumatic injury in Australia–Implications for trauma system design

The evil of good is better: Making the case for basic life support transport for penetrating trauma victims in an urban environment

Association of Police Transport With Survival Among Patients With Penetrating Trauma in Philadelphia, Pennsylvania - PubMed (nih.gov) 

The effect of transport mode on mortality following isolated penetrating torso Trauma - PubMed

Every minute counts: The impact of pre-hospital response time and scene time on mortality of penetrating trauma patients

Get in touch

[email protected]

X / Twitter

David: @expensivecare

James: @JamesOz1

Clinical practice varies between the different state ambulance services in Australia. Yet we all claim to be evidence-based. So why is this, how big of a problem is it and what should we do about it? Are national guidelines the answer? James speaks with paramedic and PhD candidate Matt Wilkinson-Stokes to find out, while David shares his perspective on national guidelines.

Further resources

Matt's presentation on the differences between state ambulance service guidelines

Comparisons of clinical guidelines between states

Other papers mentioned:

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2243-y

Get in touch

[email protected]

X / Twitter

David: @expensivecare

James: @JamesOz1

For over a decade after a large study showed a mortality benefit, this drug remained controversial. David and James look at the TXA saga.

Clinical conversations is back. But where have we been, what have we been doing and what do we have planned for the future?

We’re all familiar with the concept of STEMI. But the definition is built around a single ECG sign – not the underlying problem itself. Is that the best way to do it? Should we be thinking about this in a totally different way? Is Occlusive Myocardial Infarction (OMI) the new STEMI?

OMI Manifesto

Amal Mattu on YouTube

Subtle STEMI iOS app

The Ancient Scholar

Capnography plays a crucial role in the treatment of a range of life-threatening conditions. Its central role following intubation is undeniable and it's also an important part of our approach to cardiac arrest and sedated patients of all kinds. Yet it is not always as straightforward as it might seem. In this episode, David and James speak with Matt Humar (intensive care paramedic, acting patient safety review lead at Ambulance Victoria, and secretary of the safe airway society) about matters capnographic.