A review of emergency equipment carried and procedures

PREHOSPITAL CARE

A review of emergen cy equipment carried and

procedures performed by UK front line paramedics

on paediatric patients

K Roberts, F Jewkes, H Whalley, D Hopkins, K Porter

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See end of article for

authors’ affiliations

.......................

Correspondence to:

Dr K Roberts, 77 Three

Acres Lane, Dickens

Heath, Solihull,

Birmingham B90 1NZ, UK;

[email protected]

Accepted for publication

10 May 2005

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Emerg Med J 2005;22:572–576. doi: 10.1136/emj.2004.022533

Objectives: In 1997 a review of paramedic practice upon adult patients in the UK found many

inconsistencies and deficiencies in basic care. A follow up review in 2002 identified widespread

improvement in provision of equipment and skills to provide basic and advanced life support.

Paediatric care was not assessed in either review. The authors conducted this study to identify current

standards of care in paediatric paramedic practice and areas of potential improvement.

Method: A questionnaire designed to determine what equipment and skills were available to paramedics

for the management of common or serious paediatric emergencies was sent to chief executives of the 32

NHS Ambulance Trusts in England and Wales.

Results: The trend of expanding and standardising practice among adult patients has not extended to

paediatric practice despite national guidelines from the Joint Royal Colleges Ambulance Liaison

Committee (JRCALC). Furthermore there are some serious failings in the provision of care and skills. Many

Trusts have not adopted JRCALC guidelines for the management of life threatening paediatric emergencies

such as asthma, meningitis, and fluid replacement in hypovolaemia.

Conclusions: Ambulance Trusts not meeting standards set out in the JRCALC guidelines must address their

areas of deficiency. Failure to do so endangers children’s lives and leaves Trusts open to criticism.

nited Kingdom NHS ambulance services aim to

maintain life and alleviate patient morbidity until

definitive care can be delivered in a hospital facility.

Simple techniques and equipment are usually all that are

required in order to achieve this, using the well rehearsed

mantra of airway, breathing, and circulation. This is

particularly true for children as the vast majority of paediatric

deaths are due to hypoxia or hypovolaemic shock.

A study in 1997

reviewing variations in equipment carried

on UK front line ambulances concluded that basic levels of

ambulance equipment were adequate but that some essential

equipment was missing from the majority of Ambulance

Trusts. Such equipment included nasopharyngeal airways

(NPAs), Hudson type oxygen masks, traction splints, long

boards, and vacuum splints. It was also suggested that UK

paramedics should be able to perform needle cricothyroidot-

omy and needle thoracocentesis. The study was repeated in

2002,

four months following the introduction of the Joint

Royal Colleges Ambulance Liaison Committee (JRCALC)

guidelines, and found that the equipment available to UK

paramedics and procedures that they may perform had

expanded. Variation in practice between Trusts had decreased

while the number of interventions had increased.

Furthermore some Trusts demonstrated that they were

keeping up to date with current medical thinking—for

example, hypotensive resuscitation.

The current survey aimed to assess national practice upon

paediatric patients and identify if the standardisation of

equipment and skills by the ambulance services seen among

adult patients is occurring in paediatric practice. The survey

was commissioned on behalf of the research and develop-

ment committee of the Faculty of Pre-Hospital Care at the

Royal College of Surgeons in Edinburgh and follows the

introduction of a new degree course for ambulance para-

medics and the advent of paramedic protocols by JRCALC.

METHOD

In July 2003, a year and a half after publication of the second

edition of JRCALC guidelines, each chief executive of the 32

NHS Ambulance Trusts in England and Wales was sent a

postal questionnaire. No reminders were sent.

The questionnaire was designed to determine what

equipment and skills were available to paramedics for the

management of common or serious paediatric emergencies

including basic and advanced life support. Questions were

structured to follow the standard paradigm of the ‘‘primary

survey’’—airway, breathing, and circulation with haemor-

rhage control. Specific questions relating to extrication

equipment, spinal immobilisation, analgesia, and specific

paediatric emergencies were included.

RESULTS

Twenty two (69%) Trusts replied to the survey. The results,

including comparison with adult practice in 2002 where

appropriate (indicated as ‘‘adult % of Trusts’’), are presented

in tables 1 to 5.

In tables and text ‘‘Trusts (%)’’ refers to the percentage of

Trusts who responded to the questionnaire and not the total

number of UK NHS Ambulance Trusts.

Airway

Table 1 shows the equipment and procedures available to the

paramedic for airway control. One Trust cannot provide high

flow Oxygen (12–15 l/min) because they do not carry

paediatric non re-breather masks with a reservoir bag. All

trusts carry oropharyngeal airways. Only 27% of Trusts

permit the cutting of endotracheal tubes for use as

nasopharyngeal airways. Intubation is permitted by all trusts,

Abbreviations: JRCALC, Joint Royal Colleges Ambulance Liaison

Committee; LMA, laryngeal mask airway; NPA, nasopharyngeal

airways; OPA, oropharyngeal airway.

572

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however practice varies widely. 36% of Trusts do not carry

straight blades (which are preferred for intubating very

young children) and two do not carry uncuffed endotracheal

tubes (preferred before puberty as the pressure of the cuff can

damage the airway in these children). Six Trusts do not

permit intubation of under one year olds, one Trust under

five year olds, and one Trust under six year olds. Three Trusts

(14%) permit the use of the laryngeal mask airway in

children and three have capnography widely available.

Needle cricothyroidotomy is permitted by 60% of Trusts.

Breathing

Table 2 shows that 73% of Trusts allow their paramedics to

perform needle thoracocentesis in children, comparable to

adult practice (68%). Three Trusts do not permit or have the

equipment for pulse oximetry. Twenty one (95%) Trusts carry

peak flow meters. None carry spacer devices for the

inhalation of commonly used asthma medications.

Circulation

Table 3 shows the equipment available for the treatment of

shock. All trusts carry intravenous cannulae and all permit the

use of large bore, size 14 gauge cannulae. Eighty two per cent

carry intraosseous needles and 23% permit placement of

cannulae in the external jugular vein. Twenty one (95%)

Trusts employ JRCALC guidelines for the resuscitation of

patients suffering haemorrhagic shock with 20 ml/kg being

given as a first bolus. Eleven Trusts follow guidelines allowing a

second bolus. Practice varies in the remaining Trusts from no

further fluid to unlimited boluses. The use of crystalloids in

paediatric and adult practice is comparable (Hartmans solution,

64% (this study) and 68% (adult study 2002); normal saline,

77% (this study) and 71% (adult study 2002)) whereas the

availability of colloids continues to decrease (Gelofusine, 18%

(this study) v 39% (adult study 2002) and 54% (adult study

1997); Haemaccel, 9% (this study) v 29% (adult study 2002) and

72% (adult study 1997)). Eighteen Trusts have a protocol for

fluid replacement of paediatric burn victims; however, the

protocols vary widely (see table 3). Sixty eight per cent of Trusts

carry cling film or Waterjel (Water-Jel Technologies, Carlstadt,

New Jersey, USA) for topical application to prevent dehydration

of burnt tissue, further fluid loss, and pain relief.

Disability, and spinal and limb immobilisation

The use of AVPU as a tool to assess conscious level is

universal. Fourteen Trusts also employ the use of the

paediatric Glasgow Coma Scale.

All Trusts returning the questionnaire carry long spinal

boards and 9% paediatric scoop stretchers. The use of traction

splints (namely Donway, Sagar, or Thomas) is permitted by

half of the Trusts (compared with 74% of adult practice).

Every Trust uses either box or vacuum splints (or both) for

immobilisation of long bone fractures. Extrication devices

such as the Telford and Kendrick devices are widely available

(87%). These can also be used as a method of paediatric

spinal immobilisation.

Medication and analgesia

All Trusts surveyed use entonox. The availability of nalbu-

phine continues (77%) and no Trust, in accordance with

version 2 of the JRCALC guidelines, permits the use of

morphine. Simple analgesics (paracetamol or oral non-

steroidal anti-inflammatory drugs) are employed by half of

Table 1 Airway management

Equipment carried or

procedure performed Trusts (n) Trusts (%)

Adult % of

Trusts

Oropharyngeal airway 22 100 100

Nasopharyngeal airway* 62755

Intubation 22 100 100

Neonatal straight

endotracheal blade

14 64 –

Uncuffed endotracheal

tube

20 91 –

Laryngeal mask airway 3 14 26

Capnography 3 14 –

Hudson type mask 21 95 94

Oxygen 12–15 l/min 21 95 96

Needle cricothyroidotomy 13 60 35

*In young children this necessitates cutting an endotracheal tube for use

as an NPA.

Eight Trusts do not permit intubation of younger children. The age limits

are: under 1 year old (six Trusts), under 5 year old (one Trust), under

6 year old (one Trust).

Table 2 Paediatric breathing and ventilation

management

Equipment carried or

procedure performed Trusts (n) Trusts (%) Adult % of Trusts

Needle thoracocentesis 16 73 68

Pulse oximetry 19 86 95

Peak flow meter 21 95 –

Spacer device 0 0 –

Table 3 Paediatric circulation, haemorrhage control,

and burn management

Equipment carried or

procedure performed Trusts (n) Trusts (%) Adult % of Trusts

Circulation management

Intravenous cannula 22 100 100

Large bore (14G) 22 100 100

External jugular vein 5 23 –

Intraosseous needles 18 82 –

Intravenous fluids

JRCALC protocol* 21 95 –

Hartman’s solution 14 64 68

Normal saline 17 77 71

Gelofusine 4 18 39

Haemaccel 2 9 29

Burn management

Cling film or Waterjel 15 68 –

Fluid replacement 18 81 –

Protocol

*JRCALC protocol = 20 ml/kg bolus.

15 JRCALC version 2 protocol [20 ml/kg bolus] (15 Trusts): nil if

,5 years old and 500 ml if .5 years old (two Trusts); if systolic BP

,90 mmHg or transfer time .1 hour (one Trust).

Table 4 Disability, and spinal and limb immobilisation

Equipment carried or

procedure performed Trusts (n) Trusts (%) Adult % of Trusts

AVPU 22 100 –

Paediatric GCS 14 64 –

Adult GCS 18 82 –

Spinal board 22 100 97

Paediatric scoop 2 9 –

Traction splint 11 50 74

Box splint 21 95 97

Inflatable splint 4 18 23

Vacuum splint 13 59 77

Extrication device

(TED or KED)

19 87 97

GCS, Glasgow Coma Scale.

UK front line paramedics and paediatric patients 573

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the Trusts. Every Trust permits the use of nebulised

salbutamol in the treatment of asthma although none carries

salbutamol inhalers. The protocols for the volumes of

nebulised salbutamol vary widely (number of Trusts that

adopt each protocol is given in parentheses): no maximum

unless side effects become a problem (JRCALC guidline)

(nine); 5 mg max (two); ,1 year old 2.5 mg, .1 year old no

max (three); nil to ,1 year olds and various other doses for

.1 year olds (five); 2.5 mg as required (one); 5 mg ,5 year

old, 10 mg .5 year old (one); and no protocol (three).

Hydrocortisone can be given by four Trusts (18%) for the

treatment of asthma.

One Trust does not allow the use of adrenaline (epinephrine)

in anaphylaxis whereas two (9%) permit chlorphenamine (not

recommended in version 2 but is now in version 3 of the

guidelines) and seven (32%) hydrocortisone.

All Trusts carry diazepam for rectal administration and 17

(77%) permit the use of intravenous diazepam. Version 3 of

the guidelines permits intravenous or rectal routes for the

administration of diazepam.

Benzylpenicillin is carried by 17 (77%) Trusts for the use in

cases of suspected meningitis; four of these permit its use

when there is no non-blanching purpuric rash.

Four Trusts permit the use of nebulised adrenaline in croup.

None carries nebulised budesonide or oral dexamethasone.

One Trust does not routinely check finger tip blood sugar

levels but all carry glucagon. Intravenous glucose is carried by

17 Trusts (77%) and oral by 12 (55%).

DISCUSSION

This review demonstrates that paediatric care by UK

paramedics is limited by resource and skill availability and

on occasion accepted standards are seriously lacking, as

assessed by comparison with national guidelines. It is not

clear why the observed improvement in adult practice has not

extended to paediatric practice.

Hypoxia is the commonest mechanism of death in children

and the equipment required to maintain an airway is

minimal, inexpensive, and easy to use. Standards of

paediatric airway care are varied and on occasion inadequate.

Every Trust returning a questionnaire approved the use of

OPAs and allowed intubation in children but few encouraged

the use of nasopharyngeal airways. In cases where an OPA is

contraindicated, the NPA is a simple, safe, and potentially

lifesaving alternative. Although smallest commercially avail-

able NPAs have a 5 mm internal diameter, many Trusts

(73%) are not using either these preformed tubes or making

their own by cutting an appropriately measured endotracheal

tube to size. This observation is not confined to paediatric

practice.

In 2002 only 55% of Trusts carried NPAs for adult

use. A suspected base of skull fracture is a widely taught

contraindication for NPA placement and it is possible that

fear of this complication has limited the use of the NPA.

However the evidence for this complication is based upon a

single case report

and has recently been contested on the

grounds that the clinical indicators of a basal skull fracture

can be difficult to interpret, especially outside of the well lit

hospital environment and that teaching should focus on

correct placement of the NPA (parallel to the nasal floor) and

the advantages of this piece of equipment rather than the

often quoted but once cited complication.

The value of prehospital intubation of children is dubious,

with a large, well conducted study demonstrating no benefit

over efficient bag valve mask ventilation.

Nevertheless,

paramedics should be able to place an endotracheal tube in

a child of any age, in case of a difficult airway or special

circumstances making bag valve mask ventilation less

desirable—such as very long transit times or when there is

a high risk of aspiration such as drowning. This skill is

infrequently performed and therefore it is essential that all

appropriate equipment should be available to make life as

easy as possible. Age discrimination is unacceptable.

Endotracheal intubation 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 paramedics. Procedures need to be in place to

recognise this complication.

One such procedure is the use of

end tidal CO

monitoring, which is recommended in the

JRCALC guidelines, and available in only three Trusts.

While the laryngeal mask airway (LMA) is widely used in

hospital paediatric practice, its use in prehospital care has not

been established and expert bodies do not yet recommend its

use in children. It may prove to provide a valuable

mechanism of airway maintenance, as it is undoubtedly

easier to place than an endotracheal tube. This device does

not protect the patient from aspiration of gastric contents as

effectively as an endotracheal tube; however, the incidence of

aspiration in non-fasted patients has been vastly over-

estimated.

In addition it is relatively easy to learn how to

use and retain this skill.

Cricothyroidotomy is an emergency procedure to ‘‘buy’’

time and is simple to perform. In children it could be

lifesaving in cases of upper airway obstruction due to foreign

body or epiglottitis and is a technique that every paramedic

should be trained to perform, although skill decay is a

concern. Furthermore, assembling equipment for the task

can be cumbersome and take several minutes. The authors

recommend constructing equipment and storing it in a safe

place for use should an appropriate emergency arise.

Needle decompression of a tension pneumothorax, a

simple and quick life saving procedure, can be performed

by 73% of paramedics. This practice must become universal:

tension pneumothorax can rapidly kill and prehospital

diagnosis and treatment undoubtedly saves lives. Pulse

oximetry provides rapid, non-invasive monitoring to assess

Table 5 Medication and analgesia

Equipment carried or

procedure performed Trusts (n) Trusts (%) Adult % of Trusts

Analgesia

Paracetamol/oral NSAID 11 50 –

Entonox 22 100 100

Nalbuphine 17 77 71

Morphine 0 0 10

Asthma

Salbutamol inhaler 0 0 –

Salbutamol nebuliser 22 100 –

Ipratroprium inh/neb 0 0 –

Hydrocortisone 4 18 –

Anaphylaxis

Adrenaline 21 95 –

Chlorpheniramine 2 9 –

Hydrocortisone 7 32 –

Epilepsy

Diazepam – IV 17 77 –

Diazepam – rectal 22 100 –

Meningitis

Benzylpenicillin 17 77 –

With no rash present 4 18 –

Croup

Nebulised adrenaline 4 18 –

Nebulised budesonide 0 0 –

Dexamethasone 0 0 –

Hypoglycaemia

Routine BM check 21 95 –

Glucose – oral 12 55 –

10% Glucose – IV 17 77 –

Glucagon 22 100 –

NSAID, non-steroidal anti-inflammatory.

Note: The previous studies reviewing adult practice did not assess

treatment of medical conditions.

574 Roberts, Jewkes, Whalley, et al

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the ability of the patient to oxygenate their blood and guide

the paramedic as to the effectiveness and need for further

airway or breathing support. It is less widely used in children

than adults (86% v 95%). The fact that it is less available to

children than adults suggests that Trusts have failed to

purchase paediatric sensors—presumably on grounds of

economy. This is unacceptable, because the main cause of

death in children is hypoxia.

All Trusts appropriately employ wide bore cannulae. Eighty

two per cent carry the intraosseous needle and 23% allow

placement of cannulae in the external jugular vein. In

shocked patients venous access can be difficult and intraoss-

eous needles offer rapid access to the vascular compartment.

All drugs and intravenous fluids can be given by this route. It

is a concern, as with NPAs, cricothyroidotomy, and chest

decompression, that a proportion of Trusts do not permit

their use. Similarly, they are easy to learn how to use,

effective, and there is little skill decay. There are complica-

tions with their use such as extravasation, osteomyelitis, or

growth plate damage and therefore teaching methods of safe

placement in order to avoid complications is essential.

The external jugular vein is a large peripheral vein that is

easily accessible. Cannulating this vein is easy to teach and

again the focus must be how to avoid complications such as

damage to pleura and other deep structures.

Circulatory support is essential in trauma care. There is

much debate and research over volume and type of fluid that

should be used in the resuscitation of adult patients in and

outside of hospital.

11–15

However children have very different

physiological and compensatory mechanisms to hypovolae-

mic shock and the authors are not aware of any significant

work investigating fluid resuscitation of children in pre-

hospital care. It is important not to overly extrapolate adult

conclusions to children who have different cardiovascular

physiology.

The increased use of crystalloids and decreased use of

colloids reveal that ambulance Trusts are adapting to the

current trend in medical practice. A recent systematic review

of randomised controlled trials comparing colloid and

crystalloid resuscitation in critically ill trauma patients found

no difference in outcome.

A further systematic review of

randomised controlled trials identified an increased relative

risk of death associated with colloid use (2.6, 95% CI 1.1 to

5.9) in a similar group of patients.

All this, however, is adult

work. If crystalloid is to be given the choice is important. The

use of a lactate containing solution (such as Hartman’s) in

massive haemorrhagic shock decreases acidosis and improves

outcome in adults.

However children metabolise lactate

poorly, particularly in ‘‘medical’’ shock where lactic acidosis

may become severe (for example, meningococcal sepsis) and

it may be that solutions without lactate, such as 0.9% sodium

chloride, are best.

Although the arguments continue over what fluid type is

best it is accepted that warm fluid must be given to avoid

secondary coagulopathy.

This is particularly important in

children as their body surface to volume ratio predisposes

them to hypothermia.

A further trend adopted by prehospital practitioners in

adult practice is ‘‘hypotensive resuscitation’’. This describes

limited fluid replacement to achieve vital organ perfusion

while accepting a lower than normal blood pressure in an

attempt to control further blood loss. A detailed discussion is

beyond the remit of this paper and can be found elsewhere.

However, during haemorrhage, children maintain their blood

pressure very well before rapid cardiovascular collapse and

death. The hypotensive state that can be identified and then

maintained by limited fluid replacement in adults is not easy

to identify in children. The JRCALC (version 3) guidelines

therefore recommend up to two 20 ml/kg fluid boluses

aiming to normalise pulse and capillary refill time.

Fluid resuscitation outside of hospital can increase on-

scene time and the total volumes of fluid infused are low

because of short scene and transit times.

18 19

The temptation

to cannulate on-scene and infuse fluids should be deferred in

non-entrapped patients until the ambulance is en route to

definitive care. If the patient is trapped and greater

circulatory support is required prehospital then medical

advice should be sought from prehospital doctors or hospital

based medical personnel.

A minimum standard of care is the ability to splint

fractures and immobilise the spine. This is achieved

universally. Some trusts carry specific paediatric scoop

stretchers or spinal boards; however the majority use adult

long spinal boards—presumably using blankets to stabilise

smaller children on the board.

Lower limb traction splints, such as Donway, Sagar, or

Thomas, can be used by 50% of Trusts on paediatric patients.

This is 24% less than adult practice. Low limb fractures,

especially of the femur, cause moderate blood loss if the

fracture is closed and massive haemorrhage if open. Traction

splintage decreases the volume of blood loss and also the

incidence of fat embolism and pain. The use of the Thomas

splint in the First World War contributed to a decreased

mortality from 80% to 8% in open fractures of the femur.

is appreciated that their application takes several minutes,

but in cases of long on-scene or transport times their use can

be life saving and certainly decreases morbidity and pain.

Four Trusts still use inflatable splints despite concerns over

microvascular compromise.

21 22

Now that box or vacuum

splints are available this equipment should be abandoned.

Extrication devices such as the Telford Extrication Device

(TED) and Kendrich Extrication Device (KED) can be very

useful in the extrication of trapped patients from motor

vehicle accidents. In children they have a further use—their

design enables spinal immobilisation and a means of

transport.

A long term criticism of the ambulance service has been

the inadequate provision of analgesia.

In adult practice this

seems to be addressed,

however the paediatric patient has

until recently been exempt. At the time of the study

paramedics were not permitted to give paediatric patients

morphine. However, in 2003, the Medicines and Health care

products Regulatory Agency (MHRA) approved its use.

Version 3 (March 2004) of the JRCALC guidelines include

advice on the use of morphine in children and this must be

encouraged because of the distress and physiological stress

that pain causes children. When doses are calculated for the

patient’s age the response to intravenous morphine is

predictable and safe.

With the paramedic role continuing to expand and the

introduction of a paramedic degree course, there is scope to

consider the use of other forms of anaesthesia. One suitable

example would be the use of local anaesthetic to anaesthetise

the femoral nerve in fractures of the femur. This aids pain

relief, splintage, and transportation of the patient. Another

would be the use of ketamine to aid extrication of patients

with fractured limbs trapped in road traffic accidents.

Furthermore younger children do not appear to experience

unpleasant emergence phenomena, which can be a problem

with its use in adults.

Every Trust carries salbutamol for nebulised administra-

tion, however the doses given to patients vary greatly and

three Trusts do not allow administration to under one year

olds. Once more discrimination on the basis of age is

unacceptable. At the time of the study ipratroprium was

not permitted, this has been changed in version 3 of the

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guidelines. Salbutamol is less effective in under one year olds

whereas ipratropium can be particularly effective.

This study has identified many areas of deficiency;

however, there are infrequent but encouraging examples of

Trusts permitting more advanced practice than basic guide-

lines recommend. Regarding the treatment of asthma, four

Trusts permit the use of hydrocortisone (not discussed in

JRCALC guidelines). Another, and more contentious, exam-

ple is the administration of intravenous benzylpenicillin in

cases of suspected meningitis. Currently the majority of

Trusts (76%) adopt JRCALC guidelines and permit this when

a patient’s history is in keeping with meningitis and the

patient has a non-blanching purpuric rash. Antibiotic therapy

is more effective given earlier in the disease, before rash

formation, and four Trusts permit the administration of

benzylpenicillin when there is no rash but the history is

suggestive of meningitis. Presumably this is by a locally

arranged patient group directive, a legal arrangement

permitting non-doctors to prescribe in certain circumstances.

This attitude of widening the paramedics scope to improve

patient care and to expand practice has to be encouraged,

although there are concerns over the diagnostic abilities of

paramedics and thus inappropriate administration of ben-

zylpenicillin with potential serious adverse reaction. We

would advise Trusts to support their paramedics with

additional, specific training when establishing such patient

group directives. Audit of this practice is essential along with

dissemination of results with other Trusts.

The management of anaphylaxis varies widely. One Trust

does not even allow the administration of intramuscular

adrenaline whereas two permit chlorpheniramine and seven

hydrocortisone. At the time of the study, chlorpheniramine

was not endorsed by the JRCALC guidelines but has been in

the current version. Although hydrocortisone and chlorphen-

amine have a delayed onset of action, their administration

before hospitalisation is desirable if transfer is not delayed by

the process.

CONCLUSION

The trend of expanding and standardising practice among

adult patients has largely not extended to paediatric practice,

despite national guidelines being in place for over 18 months.

Basic standards of care are widely achieved. Such practice

includes the use of high flow oxygen combined with suitable

oxygen masks, simple airway adjuncts including the ability of

modify endotracheal tubes for the use as NPAs, the ability to

gain IV access and give fluid, spinal immobilisation, and

fracture management. However it is not adequate that such

basic care is widely practiced—universal practice must be

achieved. Furthermore age discrimination is not acceptable.

Ambulance Trusts not meeting standards set out in the

JRCALC guidelines must address their areas of deficiency.

Failure to do so endangers children’s lives and leaves Trusts

open to criticism. We recommend universal ability to provide

or perform:

high flow oxygen

NPAs for any age of patient

intubation equipment (including straight blades) for all

ages

cricothyroidotomy

chest decompression

pulse oximetry

intraosseous access

low limb traction splints

morphine administration.

The management of common medical and traumatic

emergencies is not universal and we recommend that

Trusts streamline protocols and base them upon the

JRCALC guidelines. Such cases include fluid replacement in

trauma and burns and the management of asthma, anaphy-

laxis, and suspected meningitis. We also recommend wider

use of the LMA and capnography.

Paramedics are under increasing pressure to perform a

wider spectrum of skills and further existing standards of

care. In this environment skill decay is a real problem,

especially with infrequently performed but potentially life

saving procedures. Paramedics must be fully supported to

avoid this problem. Methods include Trusts developing

regular in-house training sessions and the establishment of

external training and review.

Authors’ affiliations

.....................

K Roberts, Walsall Manor Hospital, West Midlands, Warwickshire and

Northamptonshire Air Ambulance, UK

F Jewkes, Wiltshire Ambulance Service, UK

H Whalley, SHO Surgery, Heartlands Hospital, Birmingham, UK

D Hopkins, Warwickshire and Northamptonshire Air Ambulance, UK

K Porter, Selly Oak Hospital, Birmingham, UK

Competing interests: none declared

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