Associate Professor Jason Bendall

Study objective: Traumatic injury causes a significant number of deaths due to bleeding. Tranexamic acid (TXA), an antifibrinolytic agent, can reduce bleeding in traumatic injuries and potentially enhance outcomes. Previous reviews suggested potential TXA benefits but did not consider the latest trials. Methods: A systematic review and bias-adjusted meta-analysis were performed to assess TXA's effectiveness in emergency traumatic injury settings by pooling estimates from randomized controlled trials. Researchers searched Medline, Embase, and Cochrane Central for randomized controlled trials comparing TXA's effects to a placebo in emergency trauma cases. The primary endpoint was 1-month mortality. The methodological quality of the trials underwent assessment using the MASTER scale, and the meta-analysis applied the quality-effects method to adjust for methodological quality. Results: Seven randomized controlled trials met the set criteria. This meta-analysis indicated an 11% decrease in the death risk at 1 month after TXA use (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.84 to 0.95) with a number needed to treat of 61 to avoid 1 additional death. The meta-analysis also revealed reduced 24-hour mortality (OR 0.76, 95% CI 0.65 to 0.88) for TXA. No compelling evidence of increased vascular occlusive events emerged (OR 0.96, 95% CI 0.73 to 1.27). Subgroup analyses highlighted TXA's effectiveness in general trauma versus traumatic brain injury and survival advantages when administered out-of-hospital versus inhospital. Conclusions: This synthesis demonstrates that TXA use for trauma in emergencies leads to a reduction in 1-month mortality, with no significant evidence of problematic vascular occlusive events. Administering TXA in the out-of-hospital setting is associated with reduced mortality compared to inhospital administration, and less mortality with TXA in systemic trauma is noted compared with traumatic brain injury specifically.

Introduction: Prehospital trauma systems are designed to ensure optimal survival from critical injuries by triaging and transporting such patients to the most appropriate hospital in a timely manner. Objectives: We sought to evaluate whether prehospital time and location (metropolitan versus non-metropolitan) were associated with 30-day mortality in a cohort of patients transported by road ambulance using a trauma transport protocol. Methods: Data linkage analysis of routinely collected ambulance and hospital data across all public hospitals in New South Wales (NSW). The data linkage cohort included adult patients (age = 16years) transported by NSW Ambulance, where a T1 Major Trauma Transport Protocol was documented by paramedic crews and transported by road to a public hospital emergency department in NSW for two years between January 2019 and December 2020. The outcomes of interest were prehospital times (response time, scene time and transport time) and 30-day mortality due to injury. Results: 9012 cases were identified who were transported to an emergency department with T1 protocol indication. Median prehospital transport times were longer in non-metropolitan road transports [n = 3,071, 98 min (71¿126)] compared to metropolitan transports [n = 5,941, 65 min (53¿80), p < 0.001]. There was no significant difference in 30-day mortality between the two groups (1.24% vs 1.65%, p = 0.13). In the subgroup of patients with abnormal vital signs, the only predictors of mortality were increasing age, presence of severe injury (OR 24.87, 95%CI 11.02, 56.15, p < 0.001), and arrival at a non-trauma facility (OR 3.01, 95%CI 1.26, 7.20, p < 0.05). Increasing transport times were not found to increase the odds of 30-day mortality. Discussion: In the context of an inclusive trauma system and an established prehospital major trauma protocol, increasing prehospital transport times and scene location were not associated with increased mortality.

Background: Advanced airway interventions, including endotracheal intubation (ETI) and supraglottic airway devices (iGel®), are used for airway management. Advanced airway proficiency is critical to maintain patient safety. Airway registries are commonly used quality assurance tools that can drive system-level improvement. This study analyses the first two years of data from a new prehospital airway registry. Methods: This is a retrospective review of the first two years of an airway registry for Intensive Care Paramedics in New South Wales Ambulance spanning 8 August 2020 to 8 August 2022. Changes in airway management effectiveness were examined as a time series and analysis proceeded regression using Newey¿West standard errors. Additionally, a machine learning algorithm (generalised boosted model) was used to predict successful ETI. Results: There were 872 unique advanced airway episodes suitable for analysis. Of 705 patients that had received ETI, 655 were successful resulting in an overall success rate of 92.9%. Intubation was achieved on the first attempt in 573 out of 705 (81.3%) patients. Supraglottic airway insertion was successful in 193 of 222 patients (86.9%). The first-pass success for the iGel® supraglottic device was 183 of 222 (82.4%). Considerable increases in ETI and iGel® first-pass success were observed over time. A machine learning analysis demonstrated that factors predicting success for endotracheal intubation included airway-grade, patient age, the use of video laryngoscopy, patient weight and the use of external laryngeal manipulation/bi-manual laryngoscopy. Conclusions: This prehospital airway registry analysis demonstrates increasing advanced airway success over the first two years of registry implementation. These increases may be explained in part by the reflective feedback and awareness of airway management that results from the registry, training and the increased use of video laryngoscopy.

Objectives: Video laryngoscopy (VL) is increasingly used as an alternative to direct laryngoscopy (DL) to improve airway visualisation and endotracheal intubation (ETI) success. Intensive Care Paramedics in New South Wales Ambulance, Australia started using VL in 2020, and recorded success in a new advanced airway registry. We used this registry to compare VL to DL. Methods: The present study was a retrospective analysis of out-of-hospital data for ETI by specialist paramedics using an airway registry. We calculated overall and first-pass success for VL versus DL, and compared success using a ¿2 test. Results: The DL overall success was 61 out of 78 (78.2%) and VL was 233 out of 246 (94.7%); difference of 16.5% (P < 0.001). First-pass for DL was successful for 49 out of 78 (62.8%) and for VL in 195 out of 246 (79.3%); difference of 16.5% (P¿=¿0.003). There were five (1.6%) patients where both VL and DL were used and in all instances, DL was used first. Conclusions: This analysis of a new airway registry used by specialist paramedics in New South Wales shows a substantial increase in overall and first-pass intubation success with the use of VL when compared to DL.

Aim: To conduct a systematic review of the use of the recovery position in adults and children with non-traumatic decreased levels of responsiveness changes outcomes in comparison with other positioning strategies. Methods: We searched Medline (Ovid), Embase, Cochrane Library, CINAHL, medRxiv and Google Scholar from inception to 15 March 2021 for studies involving adults and children in an out-of-hospital, first aid setting who had reduced levels of responsiveness of non-traumatic aetiology but did not require resuscitative interventions. We used the ROBINS-I tool to assess risk of bias and GRADE methodology to determine the certainty of evidence. Results: Of 17,947 citations retrieved, three prospective observational studies and four case series were included. The prone and semi-recumbent positions were associated with a decreased rate of suspected aspiration pneumonia in acute poisoning. Use of the recovery position in paediatric patients with decreased levels of responsiveness was associated with a deceased admission rate and the prone position was the position most commonly associated with sudden unexpected death in epilepsy. High risk of bias, imprecision and indirectness of evidence limited our ability to perform pooled analyses. Conclusion: We identified a limited number of observational studies and case series comparing outcomes following use of the recovery position with outcomes when other patient positions were used. There was limited evidence to support or revise existing first aid guidance; however, greater emphasis on the initial assessment of responsiveness and need for CPR, as well as the detection and management of patient deterioration of a person identified with decreased responsiveness, is recommended.

Background: Cooling thermal burns with running water is a recommended first aid intervention. However, guidance on the ideal duration of cooling remains controversial and inconsistent across organisations. Aim: To perform a systematic review of the evidence for the question; Among adults and children with thermal burn, does active cooling using running water as an immediate first aid intervention for 20 min or more, compared with active cooling using running water for any other duration, change the outcomes of burn size, burn depth, pain, adverse outcome (hypothermia) or complications? Method: We searched Medline, Embase, Cochrane Database of Systematic Reviews and used ROBINS-I to assess for risk of bias. We used Grading of Recommendations, Assessment, Development and Evaluation methodology for determining the certainty of evidence. We included all studies that compared the selected outcomes of the duration of cooling of thermal burns with water in all patient ages. (PROSPERO registration number: CRD42021180665). From 560 screened references, we included four observational studies. In these studies, 48% of burns were cooled for 20 min or more. We found no benefit for a duration of 20 min or more of cooling when compared with less than 20 min of cooling for the outcomes of size and depth of burn, re-epithelialization, or skin grafting. The evidence is of very low certainty owing to limitations in study design, risk of bias and indirectness. Conclusion: The optimal duration of cooling for thermal burns remains unknown and future prospective research is indicated to better define this treatment recommendation.

Unlike practitioners of formal diagnostic sonography, point-of-care ultrasound users must often acquire basic ultrasound skills in far shorter time frames, with less time dedicated to obtaining mastery; therefore, they often rely on conceptual models to achieve this. There is currently no introductory model which point-of-care ultrasound users might adopt to describe the cognitive processes involved in acquiring a basic ultrasound image, and in learning point-of-care ultrasonography. We propose the ¿sonographic OODA loop¿ in reference to Boyd¿s observe¿orient¿decide¿act (OODA) decision loop, as a model which can be used initially by ultrasound-naive clinicians to understand the cognitive and motor processes that occur when they acquire ultrasound images, and hopefully achieve greater insight into their early practice.

Background/Aim: It is crucial to store an avulsed tooth appropriately to preserve the viability of the periodontal ligament cells prior to replantation. The aim of this systematic review was to identify the best available evidence for the effectiveness of any technique available to laypeople for storing an avulsed tooth compared with storage in milk or saliva. Methods: The following databases were searched (September 2019): Cochrane Library, MEDLINE, and Embase. Two reviewers independently considered trial eligibility, then extracted and analyzed data, and assessed the risk of bias. The certainty of the body of evidence was appraised according to the GRADE methodology. Results: Out of 4118 references, 33 studies were included and reported 23 comparisons of which 10 were synthesized in a meta-analysis. The limited evidence available favors storing an avulsed tooth in Hank's balanced salt solution (pooled SMD 2.47, 95% CI [1.59;3.34], P¿<.00001), propolis solution (pooled SMD 1.73, 95% CI [1.12;2.33], P¿<.00001), oral rehydration salts (pooled SMD 4.16, 95% CI [2.10;6.23], P¿<.0001), rice water, and cling film compared with storage in milk. The cell viability rate was significantly lower in teeth stored in saline solutions (pooled SMD -4.35, 95% CI [-7.55;-1.14], P¿=.008), tap water, buttermilk, castor oil, GC Tooth Mousse, and turmeric extract than those stored in milk. There is insufficient evidence to recommend for or against temporary storage of an avulsed tooth in saliva compared with alternative solutions. The certainty of evidence was considered low to very low due to limitations in study design, indirect study populations and outcome measures, and imprecision. Conclusion: Although milk was shown to extend the periodontal ligament cell viability before replantation compared with saline or tap water, the following media have also demonstrated efficacy at preserving the cell viability: Hank's balanced salt solution, propolis, oral rehydration salts, rice water, and cling film.

Background: Heat stroke is an emergent condition characterized by hyperthermia (>40 °C/>104 °F) and nervous system dysregulation. There are two primary etiologies: exertional which occurs during physical activity and non-exertional which occurs during extreme heat events without physical exertion. Left untreated, both may lead to significant morbidity, are considered a special circumstance for cardiac arrest, and cause of mortality. Methods: We searched Medline, Embase, CINAHL and SPORTDiscus. We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods and risk of bias assessments to determine the certainty and quality of evidence. We included randomized controlled trials, non-randomized trials, cohort studies and case series of five or more patients that evaluated adults and children with non-exertional or exertional heat stroke or exertional hyperthermia, and any cooling technique applicable to first aid and prehospital settings. Outcomes included: cooling rate, mortality, neurological dysfunction, adverse effects and hospital length of stay. Results: We included 63 studies, of which 37 were controlled studies, two were cohort studies and 24 were case series of heat stroke patients. Water immersion of adults with exertional hyperthermia [cold water (14¿17 °C/57.2¿62.6 °F), colder water (8¿12 °C/48.2¿53.6 °F) and ice water (1¿5 °C/33.8¿41 °F)] resulted in faster cooling rates when compared to passive cooling. No single water temperature range was found to be associated with a quicker core temperature reduction than another (cold, colder or ice). Conclusion: Water immersion techniques (using 1¿17 °C water) more effectively lowered core body temperatures when compared with passive cooling, in hyperthermic adults. The available evidence suggests water immersion can rapidly reduce core body temperature in settings where it is feasible.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.

Background: approximately 25% of older people who fall and receive paramedic care are not subsequently transported to an emergency department (ED). These people are at high risk of future falls, unplanned healthcare use and poor health outcomes. Objective: to evaluate the impact of a fall-risk assessment and tailored fall prevention interventions among older community-dwellers not transported to ED following a fall on subsequent falls and health service use. Design, setting, participants: Randomised controlled trial involving 221 non-transported older fallers from Sydney, Australia. Intervention: the intervention targeted identified risk factors and used existing services to implement physiotherapy, occupational therapy, geriatric assessment, optometry and medication management interventions as appropriate. The control group received individualised written fall prevention advice. Measurements: primary outcome measures were rates of falls and injurious falls. Secondary outcome measures were ambulance re-attendance, ED presentation, hospitalisation and quality of life over 12 months. Analysis was by intentionto- treat and per-protocol according to self-reported adherence using negative binominal regression and multivariate analysis. Results: ITT analysis showed no significant difference between groups in subsequent falls, injurious falls and health service use. The per-protocol analyses revealed that the intervention participants who adhered to the recommended interventions had significantly lower rates of falls compared to non-adherers (IRR: 0.53 (95% CI: 0.32-0.87)). Conclusion: a multidisciplinary intervention did not prevent falls in older people who received paramedic care but were not transported to ED. However the intervention was effective in those who adhered to the recommendations. Trial registration: the trial is registered at the Australian New Zealand Clinical Trials Registry: ACTRN 12611000503921, 13/05/2011.

Background: Older fallers constitute a large proportion of ambulance work, and as many as 25% are not transported to hospital following paramedic assessment. The objective of this study was to explore the decision making process used by paramedics when caring for older fallers. Methods: A qualitative study was conducted using constructivist grounded theory methodology. Purposive sampling was used to recruit paramedics to participate in semi-structured interviews and focus groups. Data analysis commenced with line-by-line coding, developing into formation of theoretical categories. Theoretical sampling was then used to clarify emerging theoretical concepts, with data collection and analysis continuing until theoretical saturation was achieved. Results: A total of 33 paramedics participated in 13 interviews and 4 focus groups. When caring for older fallers, paramedic decision making is profoundly affected by ¿role perception¿, in which the individual paramedic¿s perception of what the role of a paramedic is determines the nature of the decision making process. Transport decisions are heavily influenced by a sense of ¿personal protection¿, or their confidence in the ambulance service supporting their decisions. ¿Education and training¿ impacts on decision making capacity, and the nature of that training subliminally contributes to role perception. Role perception influences the sense of legitimacy a paramedic attaches to cases involving older fallers, impacting on patient assessment routines and the quality of subsequent decisions. Conclusions: Paramedic decision making processes when caring for older people who have fallen appear to be strongly influenced by their perception of what their role should be, and the perceived legitimacy of incidents involving older fallers as constituting ¿real¿ paramedic work.

Introduction Ambulance use in rural and remote parts of Australia has been reported anecdotally to be lower than urban areas. Experiences of paramedics in rural locations gave rise to questions of whether this phenomenon was occurring and to what degree. Methods Data from emergency department (ED) records was obtained from the Hunter New England Area Health Service from 1 July 2008 to 30 June 2009. In total, 354,909 records were obtained. These records were de-identified and analysed to determine the method of arrival to ED, specifically in high acuity patients. Results People from inner regional areas are 41.5% less likely overall and 27.7% less likely in serious health emergencies to attend EDs by ambulance compared to people in major cities. People from outer regional and remote areas are 55.1% less likely overall and 27.9% less likely in serious health emergencies to attend EDs by ambulance compared to people living in major cities. Logistic regression modelling indicated rurality was a significant factor in ambulance use in adults in areas outside major cities and in children in inner regional areas. Age was a significant predictor of ambulance demand with older people using ambulances more. Discussion This study indicates disparity between rates of ambulance use in urban and non-urban areas. The concept of unmet need should be considered as a more complex phenomenon than simply a utilisation gap and exploration of unmet need is warranted. Conclusion A clearer understanding of how rurality affects ambulance use has a number of implications for ambulance services.

Objective. To determine whether analgesic administration in the out-of-hospital setting is influenced by the gender of the patient or the gender of the paramedic. Methods. This retrospective cohort study of patient care records included adult patients (age > 15 years) with moderate to severe pain (verbal numerical rating score 4-10) treated by paramedics between January 1, 2008 and December 31, 2009. Data extracted included patient pain severity score, analgesia provided by paramedics, and gender of the treating paramedic. Data was analyzed by descriptive statistics, ¿2 test, and logistic regression. The primary outcome measures were the effect of patient and paramedic gender on analgesic administration. Results. The study population comprised 42,051 patients, median age of 57 years (38-75); 50.4% were female and 51% were administered an analgesic agent. For the outcome of receiving any analgesia, neither patient gender nor paramedic gender was predictive (p = NS). In a multivariate model for the outcome of receiving any analgesia, patient gender, paramedic gender, and the interaction between patient and paramedic gender were all nonsignificant (p = NS). For the outcome of receiving opioid analgesia (i.e., morphine or fentanyl), male patients were at greater odds of receiving an opioid (OR 1.52, 95% CI 1.29-1.79, p < 0.0001). Paramedic gender was not predictive of whether an opioid was given (p = NS). Conclusions. The gender of the paramedic did not appear to influence the odds of analgesic administration. Female patients were less likely to receive opioids. Paramedic gender does not explain this finding. © 2014 National Association of EMS Physicians.

Objectives: Asthma is an important health problem in Australia with more than 2.2. million Australians currently diagnosed with Asthma. Asthma is associated with significant mortality and frequent use of emergency medical services. The objectives of this paper were to: a) present a case study of a near-fatal episode of severe acute asthma in which the patient was administered corticosteroids by an Ambulance Service of New South Wales Extended Care Paramedic; b) review the epidemiology and pathophysiology of acute asthma as well as current pharmacotherapy in asthma management; and c) conduct a literature search and critical appraisal of existing evidence supporting the out-of-hospital administration of corticosteroids for acute asthma by paramedics.