A review of emergency equipment carried and procedures performedby UK front line paramedics

Keith Roberts a,*, K.P. Allison b, K.M Porter b

a Heartlands Hospital, Birmingham, UKb Selly Oak Hospital, Birmingham, UK

Received 19 January 2003; received in revised form 31 March 2003; accepted 4 April 2003

Resuscitation 58 (2003) 153�/158

www.elsevier.com/locate/resuscitation

Abstract

Objectives: To assess which items of resuscitation equipment are carried on United Kingdom (UK) front line ambulances and

what procedures paramedics are able to perform. To compare these findings with those of a previous survey in 1997. Method: Postal

survey to the chief executives of all the UK ambulance services and direct comparison with the data from 1997. Results:

Nasopharyngeal airway usage (NPA) has increased (21�/55%) and the laryngeal mask airway (LMA) (from 10 to 26%). No services

employ the Combitube. 94% of services use a Hudson type trauma mask (increase of 17%). One service no longer allows its

paramedics to deliver 12�/15 l of oxygen. 68% of trust paramedics can perform needle thoracocentesis (increase of 35%). No

paramedics perform chest drain insertion. All services have 14G intravenous cannulae available and 45% carry the intraosseous

needle (increase of 30%). No services employ the MAST suit. There is an increase by 29% in the use of crystalloids and a decrease in

the use of colloids of 22%. 23% of fluid resuscitation protocols are based upon the principles of hypotensive resuscitation. Spinal

boards and extrication devices are used by 97% of services. The use of inflatable splints has decreased (38�/23%). There has been a

minor increase in the use of traction splints to 74% of services. The use of Entonox is universal. Nalbuphine (Nubain) is the most

widely used opiod. The use of morphine/diamorphine has doubled to 10% with a further 26% to introduce their use. 29% of services

have equipped some vehicles with automatic external defibrillators. Conclusions: The equipment available to UK paramedics and

procedures that they may perform continues to expand. There are still variations in the basic management of airway, breathing and

circulation care and only some services are keeping up to date with current medical thinking, for example the increasing use of

crystalloids and hypotensive resuscitation. It remains to be seen whether the widespread use of Nalbuphine as a first line analgesic

may decrease as the use of natural strong opiates becomes more widespread.

# 2003 Elsevier Ireland Ltd. All rights reserved.

Keywords: JRCALC; Paramedic; Training

Resumo

Objectivo : Avaliar que componentes do equipamento de reanimacao existem nas ambulancias da linha da frente no Reino Unido

e que procedimentos sao os paramedicos capazes de fazer. Comparar este estudo com o que foi feito em 1997. Metodo: Inquerito a

todos os chefes executivos de todas as ambulancias do Reino Unido, por via postal, comparando-o com os dados de 1997.

Resultados: O uso de via aerea naso-farıngea aumentou de 21 para 55% e de mascara larıngea de 10 para 26%. Nenhum dos servicos

usa combitube. 94% usam uma mascara de trauma tipo Hudson (aumento de 17%). Um dos servicos ja nao autoriza que os seus

paramedicos administrem 12-15L de oxigenio. 68% dos paramedicos treinado sao capazes de fazer toracocentese com agulha

(aumentou 35%). Nenhum dos paramedicos introduz drenos pleurais. Todos os servicos tem agulhas de G14 e tem agulhas

intraosseas (aumentou 30%). Nenhum dos servicos usa os fatos MAST. Aumentou o uso de cristaloides em 29% e uma diminuicao

do uso de coloides em 22%. 23% dos protocolos de administracao de fluidos baseiam-se na reanimacao por hipotensao. Os planos

duros e os coletes de extraccao sao utilizados por 97% dos servicos. O uso de colchoes insuflaveis diminuiu de 38 para 23%. Houve

um ligeiro aumento de planos de traccao em 74% dos servicos. O uso de Etonox e universal. O opioide mais usado e a nalbufina. O

* Corresponding author. Present address: 48 Broom Lane, Dickens Heath, Solihull B90 1SJ, UK. Tel./fax: �/44-7801-65-8505.

E-mail address: dr_keith@hotmail.com (K. Roberts).

0300-9572/03/$ - see front matter # 2003 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/S0300-9572(03)00150-3

uso de morfina / diamorfina duplicou para 10% com mais 26% a promoverem a sua introducao. 29% dos servicos tem viaturas

equipadas com desfibrilhadores automaticos externos. Conclusoes: o equipamento disponıvel para uso pelos paramedicos e os

procedimentos de que estes sao capazes, no Reino Unido, continua em expansao. Ainda ha variacoes na forma de lidar com a via

aerea, ventilacao e circulacao e so alguns dos servicos se mantem actualizados com referencia ao pensamento medico corrente, como

por exemplo o uso crescente de cristaloides em detrimento dos coloides. Esta por ver se o uso de Nalburfina como analgesico de

primeira linha se mantera a medida que uso de analgesicos mais potentes se generalizar.

# 2003 Elsevier Ireland Ltd. All rights reserved.

Palabras clave: JRCALC; Paramedicos; Treino

Resumen

Objetivos : Para evaluar que items del equipo de resucitacion son llevados en la primera lınea de ambulancias del Reino Unido

(UK) y que procedimientos son capaces de realizar los paramedicos. Comparar estos hallazgos con aquellos de una encuesta previa

de 1997. Metodo : Encuesta postal a los ejecutivos jefes de todos los servicios de ambulancias del UK y la comparacion directa de los

resultados con los de 1997. Resultados : El uso de la canula nasofarıngea (NPA) ha aumentado (21�/55%) y la mascara laringea

(LMA) (de 10 a 26%). Ningun servicio utiliza el Combitubo. 94% de los servicios usan mascara de tipo Hudson (aumento de 17%).

Un servicio ya no permite a sus paramedicos entregar 12-15 lt de oxıgeno. 68% de los paramedicos de hospital pueden realizar

toracocentesis con aguja (aumento de 35%). No hay paramedicos que realicen insercion de drenajes toracicos. Todos los servicios

disponen de canulas 14G y 45% lleva agujas intraoseas (aumento de 30%). No hay servicios que usen el pantalon antishock. Hay un

aumento en 29% en el uso de cristaloides y una disminucion en el uso de coloides de 22%, un 23% de los protocolos de resucitacion

con fluidos estan basados en los principios de resucitacion hipotensiva. El 97% de los servicios usan tablas espinales y dispositivos de

extricacion. El uso de ferulas inflables ha disminuido (38�/23%). Ha habido un aumento menor en el uso de ferulas de traccion hasta

en 74% de los servicios. El uso de Entonos es universal. La Nalbuphina (Nubain) es el opioide mas ampliamente usado. El uso de la

morfina/diamorfina se ha duplicado a 10% con un posterior 26% para introducir su uso. El 29% de los servicios han equipado

algunos vehıculos con desfibriladores automaticos externos. Conclusiones : El equipamiento disponible para los paramedicos y los

procedimientos que pueden realizar siguen en expansion. Aun hay variaciones en el manejo basico de la vıa aerea, cuidados de

ventilacion y circulacion y solo algunos servicios se mantienen al dıa con el pensamiento medico actual, por ejemplo el uso creciente

de cristaloides y resucitacion hipotensiva. Falta todavıa ver si acaso el uso extensivo de Nalbufina como analgesico de primera lınea

puede disminuir el uso de opiaceos naturales mas fuertes sean ampliamente utilizados

# 2003 Elsevier Ireland Ltd. All rights reserved.

K. Roberts et al. / Resuscitation 58 (2003) 153�/158154

Palabras clave: JRCALC; Paramedico; Entrenamiento

1. Introduction

Optimal pre-hospital care by the United Kingdom

(UK) statutory ambulance services aims to maintain life

and alleviate patient morbidity, until definitive care can

be delivered in a hospital facility. Simple techniques and

equipment are all that are required in order to achieve

this, using the well-rehearsed mantra of airway, breath-

ing and circulation. In 1997 in an article published in

Pre-hospital Immediate Care [1], it was concluded that

basic levels of ambulance equipment were adequate, but

that nasopharyngeal airways (NPA), Hudson type

oxygen masks, traction splints, long boards and vacuum

splints should be more available. It was also suggested

that UK paramedics should be able to perform needle

cricothyroidotomy and needle thoracocentesis.

This survey aimed to assess the progress made

towards the standardisation of equipment and skills by

the ambulance services over the last 4 years. The survey

was commissioned on behalf of the research and

development committee of the Faculty of Pre-Hospital

Care at the Royal College of Surgeons in Edinburgh and

was timed to coincide with the introduction of a new

degree course for ambulance paramedics and the advent

of new paramedic protocols by the Joint Royal Colleges

and Ambulance Liaison Committee (JRCALC) in the

UK.

2. Method

In June 2001 each of the chief executives of the 31

ambulance services in the UK were sent a postal

questionnaire. The questions were designed to determine

the equipment carried on front line ambulances for the

management of all types of emergencies in children and

adults including basic and advanced life support. The

questionnaire was structured to follow the standard

paradigm of the ‘primary survey’*/airway,

breathing and circulation with haemorrhage control.

It also included specific questions relating to

extrication equipment, spinal immobilisation, analgesia

and paramedic skills. The questions were designed to

highlight points of interest identified from the 1997

survey.

3. Results

Every ambulance service replied to the survey. The

results, with comparison to the 1997 results, arepresented in Tables 1�/5.

3.1. Airway

Table 1 shows the equipment and procedures avail-able to the paramedic for airway control. All services

carry oropharyngeal airways and encouragingly there

has been an increase in the use or availability of the

NPA (34�/55%), laryngeal mask airway LMA (10�/26%)

and needle cricothyroidotomy (15�/38%). A further four

(13%) trusts are to introduce the NPA or LMA and two

(6%) are evaluating the LMA with the aim of introdu-

cing it. The use of a Hudson type oxygen mask hasincreased from 77 to 94%. One service no longer allows

its paramedics to dispense oxygen at 12�/15 l/min,

previously all did. There is no explanation offered for

this.

3.2. Breathing

Table 2 shows an increase of 35% in the number of

services who allow their paramedics to perform needle

thoracocentesis to 68% (21). No services allow para-

medics to perform tube thoracostomy. Pulse oximetry is

still used by the vast majority of services (95%).

3.3. Circulation

Table 3 shows the equipment available for the

treatment of shock. All services carry intravenous

cannulae and all 29 questionnaires indicated the avail-ability of large bore, size 14 gauge cannulae. There has

been a 3-fold increase in the availability of the intraoss-

eous needle from 15 to 45%. A further 6% of services

aim to introduce it.

The use of crystalloids has increased (Hartmans*/by

12�/68% and Normal saline*/by 17�/71%). Colloid

usage / availability has decreased (GelofusineTM*/

down 15�/39% and HaemaccelTM*/down 43�/29%).

Hypotensive resuscitation principles (the maintenance

of a radial pulse and a systolic blood pressure �/90mmHg) have been adopted by 23% of services. 58% of

services have protocols for the maximum volume of

fluid (crystalloid, colloid or both) allowed for infusion.

Fourteen (46%) set this maximum value at 2 l, one (3%)

at 1 l, one at 1.5 l, one at 2.5 l and one at 3 l.

3.4. Extrication, immobilisation and splintage

97% of ambulance services carry long spinal boards,

an increase of 7%. There has been a slight decrease in the

availability of extrication devices. The use of the

inflatable splint has decreased by 15�/23%. There has

been a 2% increase in the use of traction splints to 74%.The use of vacuum splints has increased 13�/77% whilst

there has been no change in the use of box splints with

97% of services using them.

3.5. Analgesia

Table 5 shows that there has been little change in the

use of Entonox, jTramadol and nalbuphine (Nubain).

All ambulance trusts still use Entonox. Nalbuphine

remains the most popular parenteral analgesic. The

use of powerful opiates has doubled to 10%. A further

eight (26%) services report that morphine is to be

introduced shortly. One further service is evaluatingthe role of morphine as a front line analgesic.

4. Discussion

The treatment role of the paramedic is constantly

expanding in terms of the procedures that they are able

to perform and the equipment needed to carry out these

tasks. This study aimed to identify this change by means

of review and comparison of their practice over a 4-year

period. The original paper identified several areas of

Table 1

Airway management

Equipment carried

1997 % 2001 % Change%

Oropharyngeal airway 39 100 31 100 0

Nasopharyngeal airway 8 21 17 55 �/ 34

Tracheal tube 39 100 31 100 0

LMA 4 10 8 26 �/ 16

Combitube 1 3 0 0 ¡/ 3

Needle cricothyroidotomy 6 15 11 35 �/ 20

Oxygen 12�/15 l/min 39 100 30 96 ¡/ 4

Hudson type mask 30 77 29 94 �/ 17

K. Roberts et al. / Resuscitation 58 (2003) 153�/158 155

inconsistency throughout the country such as the use of

airway adjuncts, needle decompression, traction splin-

tage and analgesia. It was felt that the use of inflatable

splints was inappropriate in view of research demon-

strating ischaemic complications [2,3].

Currently paramedic practice is protocol based but

this may begin to change with the advent of a paramedic

degree course [4]; this review identifies areas of potential

improvement for such trainees. In addition, the Joint

Royal College Liaison Committee has published best

evidence protocols for care, that will dictate a national

paramedic practice.

All ambulance services carry oropharyngeal airways.

The use of NPAs has nearly tripled from 21 to 55%.

Their use is invaluable in cases of head injury, oral

trauma, trismus and where the patient’s conscious level

has not decreased enough to tolerate an oral airway but

requires airway support [5,6]. Similarly the use of the

LMA has increased from 10 to 26%. It is perceived that

this device does not protect the patient from aspiration

of gastric contents as effectively as a tracheal tube. The

incidence of aspiration in patients prepared for surgical

operation, however, has been vastly overestimated [7].

The LMA provides a valuable back up if tracheal

intubation fails [8]. Training in its use is relatively easy

and the skill is well retained. Tracheal intubation itself

carries risks, the most important being unrecognised

oesophageal intubation. The risk is increased when no

anaesthetic agents are used, as is the case with UK

parmedics. Procedures need to be in place to recognise

complications [9] such as the use of end tidal CO2

monitoring. This is recommended in the JRCALC

guidelines. No services carry the Combitube. This can

also be a valuable alternative to the tracheal tube where

there is limited access to the patient. It is also easy to

insert and in the hands of paramedics success rates are

high, though not as high as for the LMA [8].

Nearly all ambulance services allow their paramedics

to deliver high flow oxygen (12�/15 l/min), previously all

services did. However, the use of a Hudson type oxygen

reservoir mask, essential to deliver such flow rates, has

increased from 77 to 94%. This is encouraging.

Previously, only one third of paramedics were able to

perform needle decompression of a tension pneu-

mothorax, a simple and quick life saving procedure.

Now over two thirds (68%) of paramedics can perform

this procedure. No services allow their paramedics to

perform chest drain insertion, which is entirely appro-

priate due to a lack of surgical training and increased

potential to do harm. There has been no change in the

Table 2

Breathing and ventilation management

Equipment carried

1997 % 2001 % Change%

Bag valve mask system 39 100 Not assessed

Needle thoracocentesis 13 33 21 68 �/ 35

Chest drains 0 0 0 0 0

Pulse oximetry 37 95 29 95 0

Table 3

Circulation and haemorrhage control

Equipment carried

1997 % 2001 % Change%

Circulation management

Intravenous cannulae 39 100 31 100 0

Intraosseous needles 6 15 14 45 �/ 30

MAST suit 0 0 0 0 0

Intravenous fluids

Hartman’s solution 22 56 20 68 �/ 13

Normal saline 21 54 22 71 �/ 17

Gelofusine 21 54 12 39 ¡/ 15

Haemaccel 28 72 9 29 ¡/ 43

Table 4

Spinal and limb immobilisation

Equipment carried

1997 % 2001 % Change%

Spine board 35 90 30 97 �/ 7

Extrication device 39 100 30 97 ¡/ 3

Box splint 38 97 30 97 0

Inflatable splint 15 38 7 23 ¡/ 15

Vacuum splint 25 64 24 77 �/ 13

Traction splint 28 72 23 74 �/ 2

Table 5

Analgesia

Drugs carried

1997 % 2001 % Change%

Entonox 39 100 31 100 0

Morphine/diamorphine 2 5 3 10 �/ 5

Tramadol 8 21 6 19 ¡/ 2

Nalbuphine (nubain) 27 69 22 71 �/ 2

K. Roberts et al. / Resuscitation 58 (2003) 153�/158156

use of pulse oximetry, which is ideal for quick non-

invasive monitoring of the oxygenation of the circula-

tion and guide the paramedic as to the need for further

airway or breathing support. The paramedic needs to beaware of several factors that affect the accuracy of this

equipment such as peripheral vascular shutdown, car-

bon monoxide poisoning and a bright light environment

[10].

It is encouraging that all services employ wide bore

cannulae and that the use of the intraosseous needle has

increased 3-fold to 45%. Circulatory support is essential

in trauma care, although there is much debate overvolumes and types of fluid that should be used in and

outside hospital [11�/15]. The increased use of crystal-

loids and reduced use of colloids reveal that ambulance

services are adapting to the current trend in medical

practice. Furthermore, 23% of services base fluid

resuscitation upon principles of hypotensive resuscita-

tion on evidence that aggressive fluid resuscitation

before surgical intervention may be detrimental[16,17]. This is a widely debated area of ongoing

research and a detailed discussion is beyond the scope

of this work. There is evidence that demonstrates no

significant effect on mortality when hypotensive resus-

citation is practised in humans [18], however this work

involved too few patients to be sufficiently powerful.

Numerous animal models [19�/26] have demonstrated

clearly increased haemorrhage when a normal systolicblood pressure is used as a target for resuscitation

compared with a lower blood pressure. Most of this

work demonstrated an improved survival [19�/23,25,26].

The hypothesis accounting for this is that increased

bleeding occurs due to raised arterial and venous

pressure and dilution of clotting factors by the infusion

of intravenous fluids. Furthermore a hypothermic

coagulopathy can occur when subjects are given intra-venous fluids at temperatures lower than the physiolo-

gical norm.

There is a group of patients in whom hypotensive

resuscitation must be avoided. There is clear evidence

that a low systolic pressure increases mortality from

secondary head injury due to decreased cerebral perfu-

sion pressure [27].

Fluid resuscitation outside hospital can increase on-scene time and the total volumes of fluid infused are low

due to short scene and transit times [28,29].

From the available evidence we advocate hypotensive

resuscitation to all trauma patients without evidence or

suspicion of head injury. Hypotensive resuscitation is

advocated by the Faculty of Pre-hospital Care of the

Royal College of Surgeons of Edinburgh and the

JRCALC. A compromise is necessary in patients withhead injury to limit secondary brain injury. However, in

non-compressible non-controllable internal haemor-

rhage controlled hypotension may be the only way of

getting the patient to hospital alive. Paramedic training

must focus on understanding the principles of hypoten-

sive resuscitation and learning to recognise patients who

have a head injury. The temptation to establish intra-

venous access on-scene and infuse fluids should bedeferred in non entrapped patients until the ambulance

is en-route to definitive care. If the patient is trapped

and circulatory support is required at the scene then

medical advice should be sought from pre-hospital

doctors or hospital based medical personnel.

There has been little change in extrication and

splintage equipment. It is pleasing to find an almost

universal use of the long spinal board, an increase of 7�/

97%. We are also pleased to report a decreased use of

inflatable splints following concerns of microvascular

compromise. This has most probably resulted in the

increase in the application of vacuum splints. There has

been only a 2% increase in the use of traction splints

such as the SagarTM splint. These are simple pieces of

equipment but decrease blood loss and pain. The use of

the Thomas splint in the First World War contributed tothe decreased mortality from 80 to 8% in open fractures

of the femur [30]. It is appreciated that their application

takes several minutes but in cases of long on scene or

transport times their use could be life saving.

A long-term criticism of the ambulance service has

been the provision of analgesia. This seems to be being

addressed. The use of morphine has doubled. Whilst this

amounts to only 10% a further 26% are to introduce itsuse. It is hoped that this trend continues. JRCALC

guidelines suggest the introduction of morphine in

patients with chest pain, so it is to be hoped that it is

only a matter of time before opiate analgesia can be used

across a wide range of conditions by the ambulance

services. Nerve blocks can be very effective in semi-

regional anaesthesia, especially in fractures of the femur.

Their use, combined with traction splintage, could be avaluable skill available to the new paramedic graduates.

5. Conclusion

This paper reports a survey of the equipment carried

by and the procedures available to all 31 of the UKsambulance services in 2001 and compares this data with

previous data from 1997. The changes are encouraging

although seem slow to happen. The use of a best

evidence base and application of current medical trends

indicates that ambulance services are adapting to

current medical thinking. On the basis of our findings

we would recommend the following:

. Universal use of the Hudson type trauma mask and

high flow oxygen.. Universal use of the simple NPA.

. Increased availability of the LMA for use where

tracheal intubation has failed.

K. Roberts et al. / Resuscitation 58 (2003) 153�/158 157

. Use of end tidal CO2 monitoring to identify correct

placement of tracheal tubes.

. Universal ability to perform needle cricothyroidot-

omy.. Universal ability to perform needle thoracocentesis.

. Widespread replacement of fluid in trauma patients

with no evidence of head injury based upon hypo-

tensive resuscitation.

. Increased use of traction splints and universal use of

the long spinal board.

. Universal use of titrated opiate analgesia.

There are no conflicts of interest to declare.

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