A monthly summary of clinical information from the Ambulance Victoria Office of the Medical Director.

Quick summary (0:30)

Patient Safety (1:30)

Discussing the lessons from specific adverse events is challenging due to patient privacy/consent, crew psychological safety, and investigation timelines.

We need to find a way to collectively share these lessons in a safe way.

Plans for quarterly clinical forums (2025) to foster psychologically safe discussions.

Clinical Updates (4:52)

IV Cannulation for STEMI:Avoid sites near the radial artery to support PCI access.

Extrication Monitoring: Monitoring is sometimes removed during extrication, especially self-extrication. Associated with adverse events. We need to emphasise monitoring (especially ECG/pulse oximetry) during extrication.

Ectopic Pregnancy: Patient safety Assume ectopic pregnancy for women of childbearing age with abdominal pain and shock.

Cardiac Arrest:

Always prioritize high-performance CPR over antiarrhythmics.

Clarification on stacked shocks and their intended use. CWI out soon.  

ALS paramedics encouraged to consult for post-ROSC hypotension management.

Guideline Monitoring (12:36)

Success of expanded croup guidelines: increased dexamethasone use and reduced hospital transports.

Research Updates (14:20)

PANDA Trial: Comparing noradrenaline and adrenaline in cardiogenic shock.

IV vs IO Access: Preference for IV first in cardiac arrest; IO as backup.

ROSC Blood Pressure: Minimum diastolic pressure of 35mmHg linked to better outcomes.

Equipment Notices (19:20)

Normal saline shortages persist; substitute with Hartmann’s or PlasmaLite.

New ketone strips now available—use carefully.

Professional Development (20:11)

CPD resources from the Australasian College of Paramedicine and Victorian Ambulance Union.

Links to registration standards and CPD tools in the show notes.

Resources

PARAMEDIC 3Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest

Prehospital endotracheal intubation for traumatic out-of-hospital cardiac arrest and improved neurological outcomes

PANDA trial - If you want to learn more about the study or have any questions, search for PANDA on the AV intranet or contact the team at [email protected].

Pain research with Monash - Get involved:Paramedic confidence & barriers to paediatric pain management

External development opportunities

https://www.paramedicineboard.gov.au/professional-standards/faq/faq-cpd.aspx

https://paramedics.org/

Pain is one of the most common reasons people seek help from paramedics and other healthcare professionals. Do we take it seriously? Could we be doing better? James sits down with paramedicine luminary and pain researcher A/Prof Bill Lord for a three-part series on pain.

In Episode 1, we look at assessment, bias, and disparities in pain care.

In the coming months, we’ll bring you the rest of our discussion covering best practice pain relief, system issues, myths about opioids, and special circumstances in pain care.

Further resources

Acute Pain Management: Scientific Evidence: 5th Edition

Ketamine for the treatment of prehospital acute pain: a systematic review of benefit and harm

Pain relief that matters to patients: systematic review of empirical studies assessing the minimum clinically important difference in acute pain

Ambulance call triage outcomes for patients reporting pain: a retrospective cross-sectional analysis of pain score versus triage level

Chronic pain in the paramedic practice setting – a qualitative study of patients’ perspective

Influence of patient race on administration of analgesia by student paramedics

Report on Government Services 2024

Get in touch

⁠[email protected]⁠

X / Twitter

David: ⁠@expensivecare⁠

James: ⁠@JamesOz1

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
Australasian College ofParamedicine Critical Care Summit April 2025

EuropeanEMS Congress Copenhagen June 2025

Safe airwaysociety

Get in touch

X / Twitter

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. 

X / Twitter

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]⁠

X / Twitter

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?