BackgroundHigh blood pressure (BP) during acute stroke is associated with poorer stroke outcome. Trials of treatments to lower BP have not resulted in improved outcome, but this may be because treatment commenced too late. Emergency medical service staff (paramedics) are uniquely placed to administer early treatment; however, experience of prehospital randomised controlled trials (RCTs) is very limited.MethodsWe conducted a pilot RCT to determine the feasibility of a definitive prehospital BP-lowering RCT in acute stroke. Paramedics were trained to identify, consent and deliver a first dose of lisinopril or placebo to adults with suspected stroke and hypertension while responding to the emergency call. Further treatment continued in hospital. Study eligibility, recruitment rate, completeness of receipt of study medication and clinical data (eg, BP) were collected to inform the design of a definitive RCT.ResultsIn 14 months, 14 participants (median age=73 years, median National Institute of Health Stroke Scale=4) were recruited and received the prehospital dose of medication. Median time from stroke onset (as assessed by paramedic) to treatment was 70 min. Four participants completed 7 days of study treatment. Of ambulance transported suspected stroke patients, 1% were both study eligible and attended by a PIL-FAST paramedic.ConclusionsIt is possible to conduct a paramedic initiated double-blind RCT of a treatment for acute stroke. However, to perform a definitive RCT in a reasonable timescale, a large number of trained paramedics across several ambulance services would be needed to recruit the number of patients likely to be required.Clinical trial registrationhttp://www.clinicaltrials.gov. Unique identifier: NCT01066572.

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Objective:Lactateisasignificantmarkerofcriticalillnessandmortalityinsepsis andtraumapatients.Thepurposeofthisstudyistoevaluatepoint-of-care lactatetestingbyparamedicsinaUKambulanceservice. Methods: Selectedenhancedcareparamedicsweretrainedtousethelactate meterinpatientswithsuspectedsepsisandpatientswhotriggerthemajor traumabypassprotocol.Feedbackwascollectedonthepracticalitiesofusing themeterandthepotentialimpactonthediagnosisofsepsis. Results:Datawerecollectedon114patients,96%hadsuspectedsepsis (n=109)and4%(n=5)werepatientswhohadsustainedtrauma.The participantsfoundthattheabilitytotakelactatereadingswasusefuland increasedtheirconfidenceintheirclinicaldecisionmaking. Conclusions:Point-of-carelactatemeasurementisfeasibleinpre-hospitalcare andappearstosupportparamedicsintheirdecisionmaking.

Background: Lactate has been identified as a useful marker of shock. Lactate can be measured in the pre-hospital environment rapidly and accurately. Method: A comprehensive literature search was conducted using a targeted search strategy. Additional literature was located through reference list searching and prior awareness by the authors. This identified a number of papers which were appraised for relevance. This appraisal identified 29 papers which were included in the review. Conclusion: Lactate has been shown to be measurable in the pre-hospital environment and to be prognostic of mortality. Lactate measurement needs to be linked to specific treatment algorithms with improved outcomes for patients in order to justify inclusion in pre-hospital practice.