Introduction: Intravenous cannulation is a common procedure for paramedics. Difficulty is often encountered and may result in escalation of care to an intensive care paramedic (ICP). Ultrasound-guided peripheral intravenous access (USGPIVA) is used in-hospital as an alternative approach. Historically limited to physicians, it is increasingly embraced by non-physicians, with point of care ultrasound (POCUS) devices more affordable, portable, and suited to the out of hospital environment.Objective: To explore the utility of ICP-performed USGPIVA for patients who are predicted to be difficult according to a difficult intravenous access scoring tool.Methods: This was a prospective observational pilot study of ICPs who used the adult difficult intravenous access (A-DIVA) scale to predict difficulty and perform USGPIVA using a contemporary POCUS device.Results: For the 32 patients enroled, the overall success rate was 50% of which 87% were successful on the first attempt. Mean A-DIVA score was 4.1/5, and paradoxically, success improved with A-DIVA-predicted difficulty.Conclusion: ICPs can perform USGPIVA with moderate success. The A-DIVA score could be useful for paramedics to predict difficult cannulation. Future research should focus on increasing exposure, training time and enhancing feedback to paramedics performing USGPIVA. & COPY; 2022 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.

Background Respiratory distress is a common presentation attended by paramedics. Chest auscultation has been shown to have low accuracy for diagnosing respiratory complaints, and this can lead to inaccurate patient assessment and potentially poor patient outcomes. Conversely, lung ultrasound is a relatively simple exam allowing for rapid differentiation of respiratory complaints with comparable accuracy to more advanced imaging modalities. Evidence suggests that lung ultrasound is easy to learn and apply and could be ideal for assessment of respiratory illness by paramedics. Objective This study aimed to explore the utility of out-of-hospital lung ultrasound performed by intensive care paramedics (ICP) for patients with medical causes of respiratory distress, and explore whether the use of lung ultrasound affects the ICP's clinical impression or management. Methods This was a prospective observational pilot study. After a training program, a sample of ICPs working in metropolitan and regional Victoria, Australia used ultrasound to assess adult patients with respiratory distress and/or dyspnea. ICPs used a handheld point-of-care ultrasound device to scan respiratory patients using a modified protocol, and completed a worksheet with their scan findings. The scans were then reviewed by a subject matter expert for quality and agreement. Results Ninety-five patients were enrolled over the study period. The average image quality score was 2.68/5, and 56% of scans were of interpretable quality. Interrater agreement (between the ICPs and the subject matter expert) was reported using Cohen's kappa. Moderate overall agreement (0.44) was shown, with the highest reliability reported in A-profile and B-profile (0.49 and 0.57). In 42% of cases performance of the scan affected paramedic clinical impression and/or management. Conclusion ICPs can perform lung ultrasound with moderate accuracy for some respiratory conditions, and the scans may affect clinical impression and management. Future research should focus on enhanced education, expert feedback, and clinical outcomes.

Background: The use of ultrasound in the out-of-hospital environment is increasingly feasible. The potential uses for point-of-care ultrasound (POCUS) by paramedics are many, but have historically been limited to traumatic indications. This study utilized a scoping review methodology to map the evidence for the use of POCUS by paramedics to assess respiratory distress and to gain a broader understanding of the topic. Methods: Databases Ovid MEDLINE, EMBASE, CINAHL Plus, and PUBMED were searched from January 1, 1990 through April 14, 2021. Google Scholar was searched, and reference lists of relevant papers were examined to identify additional studies. Articles were included if they reported on out-of-hospital POCUS performed by non-physicians for non-traumatic respiratory distress. Results: A total of 591 unique articles were identified, of which seven articles met the inclusion criteria. The articles reported various different scan protocols and, with one exception, suffered from low enrolments and low participation. Most articles reported that non-physician-performed ultrasound was feasible. Articles reported moderate to high levels of agreement between paramedics and expert reviewers for scan interpretation in most studies. Conclusion: Paramedics and emergency medical technicians (EMTs) have demonstrated the feasibility of lung ultrasound in the out-of-hospital environment. Further research should investigate the utility of standardized education and scanning protocols in paramedic-performed lung ultrasound for the differentiation of respiratory distress and the implications for patient outcomes.

Objective: Using physiological markers to detect patients at risk of deterioration is common. Deaths at music festivals in Australia prompted scrutiny of tools to identify critically unwell patients for transport to hospital. This study evaluated initial physiological parameters to identify patients selected for transport to hospital from a music festival. Methods: A retrospective audit of 2045 presentations at music festivals in Victoria, Australia, was performed. Presentation heart rate, systolic blood pressure, respiratory rate, oxygen saturation, temperature, and Glasgow Coma Scale were assessed using area under the receiver operating characteristic curve (AUROC) analysis, with a prespecified threshold of 0.7. Results: The only measured variable to exceed the prespecified cutpoint was initial systolic blood pressure, with an AUROC of 0.72 and optimal cutpoint of 122 mmHg. Using commonly accepted cutpoints for variables did not improve detection performance to acceptable levels, nor did using combination systems of cutpoints. Conclusions: Initial physiological variables are poor predictors of the decision to transport to hospital from music festivals. Systolic blood pressure was significant, but only at a clinically insignificant value. Decisions on which patients to transport from an event site should incorporate more information than initial physiology. Senior clinicians should lead decision-making about hospital transport from music festivals.

Introduction: Non-physician performed point-of-care ultrasound (POCUS) is emerging as a diagnostic adjunct with the potential to enhance current practice. The scope of POCUS utility is broad and well-established in-hospital, yet limited research has occurred in the out-of-hospital environment. Many physician-based studies expound the value of POCUS in the acute setting as a therapeutic and diagnostic tool. This study utilized a scoping review methodology to map the literature pertaining to non-physician use of POCUS to improve success of peripheral intravenous access (PIVA), especially in patients predicted to be difficult to cannulate. Methods: Ovid MEDLINE, CINAHL Plus, EMBASE, and PubMed were searched from January 1, 1990 through April 15, 2021. A thorough search of the grey literature and reference lists of relevant articles was also performed to identify additional studies. Articles were included if they examined non-physician utilization of ultrasound-guided PIVA (USGPIVA) for patients anticipated to be difficult to cannulate. Results: A total of 158 articles were identified. A total of 16 articles met the inclusion criteria. The majority of participants had varied experience with ultrasound, making accurate comparison difficult. Training and education were non-standardized, as was the approach to determining difficult intravenous access (DIVA). Despite this, the majority of the studies demonstrated high first attempt and overall success rates for PIVA performed by non-physicians. Conclusion: Non-physician USGPIVA appears to be a superior method for PIVA when difficulty is anticipated. Additional benefits include reduced requirement for central venous catheter (CVC) or intraosseous (IO) needle placement. Paramedics, nurses, and emergency department (ED) technicians are able to achieve competence in this skill with relatively little training. Further research is required to explore the utility of this practice in the out-of-hospital environment.

INTRODUCTION:Triage at mass gatherings in Australia is commonly performed by staff members with first aid training. There have been no evaluations of the performance of first aid staff with respect to diagnostic accuracy or identification of presentations requiring ambulance transport to hospital.HYPOTHESIS:It was hypothesized that triage decisions by first aid staff would be considered correct in at least 61% of presentations.METHODS:A retrospective audit of 1,048 presentations to a single supplier of event health care services in Australia was conducted. The presentations were assessed based on the first measured set of physiological parameters, and the primary triage decision was classified as "expected" if the primary and secondary triage classifications were the same or "not expected" if they differed. The performance of the two triage systems was compared using area under the receiver operating characteristic curve (AUROC) analysis.RESULTS:The expected decision was made by first aid staff in 674 (71%) of presentations. Under-triage occurred in 131 (14%) presentations and over-triage in 142 (15%) presentations. The primary triage strategy had an AUROC of 0.7644, while the secondary triage strategy had an AUROC of 0.6280, which was significantly different (P = .0199).CONCLUSION:The results support the continued use of first aid trained staff members in triage roles at Australian mass gatherings. Triage tools should be simple, and the addition of physiological variables to improve the sensitivity of triage tools is not recommended because such an approach does not improve the discriminatory capacity of the tools.

Introduction: Serotonin and sympathomimetic toxicity (SST) after ingestion of amphetamine-based drugs can lead to severe morbidity and death. There have been evaluations of the safety and efficacy of on-site treatment protocols for SST at music festivals. Problem: The study aimed to examine the safety and efficacy of treating patients with SST on-site at a music festival using a protocol adapted from hospital-based treatment of SST. Methods: The study is an audit of presentations with SST over a one-year period. The primary outcome was need for ambulance transport to hospital. The threshold for safety was prospectively defined as less than 10% of patients requiring ambulance transport to hospital. The protocol suggested patients be treated with a combination of benzodiazepines; cold intravenous (IV) fluid; specific therapies (cyproheptadine, chlorpromazine, and clonidine); rapid sequence intubation; and cooling with ice, misted water, and convection techniques. Results: One patient of 13 (7.7%) patients with mild or moderate SST required ambulance transport to hospital. Two of seven further patients with severe SST required transport to hospital. Conclusions: On-site treatment may be a safe, efficacious, and efficient alternative to urgent transport to hospital for patients with mild and moderate SST. The keys to success of the protocol tested included inclusive and clear education of staff at all levels of the organization, robust referral pathways to senior clinical staff, and the rapid delivery of therapies aimed at rapidly lowering body temperature. Further collaborative research is required to define the optimal approach to patients with SST at music festivals.