JRCALC Clinical Guideline Updates

JRCALC Clinical Updates

Publication date: March 2024

In the March 2024 JRCALC Clinical Guidelines Update, guidance for Dyspnoea and Altered Level of Consciousness has been fully updated and revised in line with NICE guidance. Sexual Assault has been revised and simplified, with more emphasis on accessing Sexual Assault Referral Centres (SARCs) and not leaving the patient alone with the perpetrator.

The Chemical Biological Radiological Nuclear (CBRN) Incidents guideline has also undergone a full review, led by NARU.

Other key updates include:

  • Skin tone wording updates
  • Advanced Life Support
  • Naloxone
  • Asthma in Adults and Children

>> Watch the March 2024 video summaries from JRCALC / Class Publishing here <<

JRCALC Clinical Updates

Publication date: January 2024

In the January 2024 JRCALC Clinical Guidelines Update, Haemorrhage during Pregnancy has been removed and replaced with three new standalone guidelines for bleeding in pregnancy (up to 20 weeks; after 20 weeks and post-partum haemorrhage). Major, Complex and High Risk Incidents has been updated by NARU on behalf of JRCALC. Finally, medicine updates include a full review of Syntometrine and Misoprostol.

Other key updates include:

  • Pulmonary Embolism 
  • Cardiac Rhythm Disturbance 
  • Implantable Cardioverter Defibrillator 
  • GTN and heart failure
  • Hypothermia and cardiac arrest drugs 

>> Watch the Jan 2024 video summaries from JRCALC / Class Publishing here <<


JRCALC Clinical Updates

Publication date: September 2023

>> Watch the Sept 2023 video summaries from JRCALC / Class Publishing here <<

New JRCALC Guidelines/medicines:




A completely new guideline. This guideline must be considered in conjunction with the Acute Behavioural Disturbance (ABD) and Agitated Patients guidelines. Delirium is often not recognised and is associated with poor outcomes. Details the numerous causes and suggests the need to consider delirium early in the assessment of the patient.

Includes the 4AT Screening tool for delirium. Includes guidance on which patients may need admission or if a community referral is appropriate.

Updates, Corrections, and Additional Guidance to Existing JRCALC Guidelines (Sept 2023)

Guideline/medicine: Update:

Glycaemic emergencies in adults and children


A full review and update. Includes more information and images about devices such as insulin pumps. Now includes guidance on pre-hospital ketone testing which should be performed when indicated and where ketone meters are available.  New section on diabetes mental health and diabulimia.


Alcohol-use disorders A new paragraph is included on alcoholic ketoacidosis which can occur when a person who is alcohol dependent or has had a prolonged alcohol binge, abruptly stops drinking and at the same time stops eating.


Limb trauma


A full review and update. Includes new guidance and images on fracture reduction and management of patella dislocation. More detail on hip fractures.


Heat related illnesses A full review and update. New table of medications predisposing to heat related illness.


Steroid-dependent patients The guidance is updated to place more emphasis on administering hydrocortisone for trauma as well as medical conditions, due to the physiological stress on the body for steroid dependent patients. This follows a coroner’s inquest where a patient died as a result of an acute adrenal crisis, caused by Addison’s disease and precipitated by the trauma of a fall and fractured hip.  Insufficient administration of steroid medication by medical professionals was found to be a contributory factor in this patient’s death.


Hydrocortisone Amended dosage for children ages 6 and 9 months to be in line with BNF, and wording amended to emphasise that it is indicated for trauma.
Breech birth A revised standalone guideline for the management of breech birth with a new algorithm. This has been informed by evidence where it is available and learning from adverse incidents and coroners inquests. Includes guidance on practical procedures and manoeuvres to deliver a breech baby, with images, photos and links to short video clips. Includes specific guidance on when to leave scene immediately, details around when birth is imminent or not imminent, maternal positioning (semi recumbent and all fours positions), timings and when to perform manoeuvres if needed.


COPD Small amendment in assessment and management of COPD to state that a 12 lead is to be performed ‘if indicated’.


Adrenaline In 2021 ILCOR changed the Adrenaline dose at birth to 20mcg/kg and Resus UK followed. Our dose ranges in Page for Age now have a Birth to one month range. The change is to give 20mcg/kg for age birth to one month.


ALS in children Paediatric wording in ALS – section 3.1 of wording changed from:

ALS procedures (e.g. establishing vascular access) must not delay the transfer of the child to hospital – start and continue good-quality BLS on scene as the priority. Attempt ALS procedures en-route, if practical; oxygenation, ventilation and chest compressions remain the priority.

Changed to:

Initiate the delivery of good quality BLS on scene, prioritising oxygen delivery, ventilation and chest compressions. ALS procedures including defibrillation if indicated, airway management and establishing IV/IO access to deliver therapies for reversal of hypovolaemia/hypoglycaemia should be considered where resources, training and skillset permit, but should not inappropriately delay transfer to definitive care.

ALS ALS double sequential defibrillation. Amended paragraph to say:

4.8 Dual Sequential Defibrillation (DSD)

JRCALC does not support use of dual sequential defibrillation. DSD involves the use of two separate manual defibrillators, delivering shocks at the same time or in rapid succession. Usually the pads from the second defibrillator are placed in an antero-posterior position to deliver a current at a different angle to the antero-lateral pads. A recent study has shown that when used for defibrillation of refractory VF, DSD is no more effective than when compared to antero-posterior pad orientation alone; the latter already being a technique recommended for defibrillation of refractory VF. Additionally, DSD is not recommended practice and it is not licensed or recommended by the defibrillator manufacturers as there is a documented risk of damage to the defibrillators.

For cases of VF where conventional antero-lateral pad position has failed to successfully defibrillate, check that the pads are correctly positioned before considering changing to antero-posterior pad positioning (a fresh set of pads is not necessary).

The reference is: https://costr.ilcor.org/document/double-sequential-defibrillation-strategy-for-cardiac-arrest-with-refractory-shockable-rhythm-als-tf-sr


JRCALC Clinical Guideline Updates 2/2023

Publication date: May 2023

Summary of changes:





Mental Health Presentations A completely revised guideline. New information around mental health services provision and treatment for mental ill health. Details on the mental health act, conveyance and provisions (Sections) and equality in mental health. Guidance on taking a comprehensive history, assessing risk, mental state examination (MSE) and physical assessment. Management guidance: therapeutic, de-escalation, shared decision making, safety planning, communication and decisions around conveyance. Guidance on self-harm, suicide, dementia, pregnancy and eating disorders.


Updates, Corrections, and Additional Guidance to Existing JRCALC Guidelines:

Guideline/medicine Update
IV fluid therapy-adults and children


This guidance has been moved from the medicines section to the general guidance section.
Advanced life support and page for age-OP airways sizes and cuffed ET tube sizes. In ALS, Table 2.3 – Airway Sizes by Type will be amended to also show international standards organisation (ISO) sizes for oropharyngeal airways and cuffed ET tube sizes for children. This will also be changed in the page for age sections.
Headache In ‘Headache’ Table 3.62 Assessment and Management, bullet point removed:  ‘Avoid morphine due to potential side effects, which could worsen the patient’s condition and/or hinder further assessment.’
Overdose and poisoning – specific substance management: Button batteries.


New guidance around considering use of honey:

Consider the administration of honey in children over the age of 12 months provided it is immediately available, the child is able to swallow and it is less than 12 hours since ingestion. Dose: 10 mL (2 teaspoons) every 10 minutes for up to 6 doses. DO NOT DELAY HOSPITAL TRANSFER

Reference: https://onlinelibrary.wiley.com/doi/abs/10.1002/lary.27312


Trauma Emergencies in Adults – Overview A consistency change has been made. Pelvic binders – clarity added on entrapped patients for pelvic binders to be applied when this can safely be done with minimal handling. This will often be after extrication.
Care of the Newborn and Birth Imminent: Normal Birth and Birth Complications


A consistency change has been made, regarding cutting the cord.


Unless there are concerns about mother or baby, the cord should remain intact until it has gone white (or for at least 60 seconds). It can then be clamped and cut approximately 5 cm from the umbilicus.

If assessment indicates a need for immediate resuscitation of the newborn, clamp and cut the cord and move to the resuscitation area.


<C> ABCDE A consistency change has been made and throughout JRCALC there will be use of <C> ABCDE approach
Amiodarone There may be two presentations of amiodarone available to use. Both are now included:  Amiodarone Pre-Filled Syringe 300 milligrams in 10 ml and Amiodarone Ampoule 150 milligrams in 3 ml. It is important to check which presentation you are using, and to check the correct dosage table.
Diazepam emulsion Diazepam oil in water emulsion is now a discontinued medicine, so this presentation will be removed from JRCALC. Diazepam solution will remain.
Fluid therapy in children The amount of fluids for children with medical causes of hypovolaemia has changed from 20ml/kg to 10ml/kg for the initial dose which is repeated according to response. For children with heart or renal failure the initial dose is reduced to 5ml/kg and no repeat dose without seeking clinical advice.
Methoxyflurane (Penthrox) Changes made to be more in line with the manufacturers summary of product characteristics (SPC) and now includes an image of a finger over the diluter hole for stronger administration.


New contraindication: Severe adverse reaction to inhaled anaesthetic gases.

New caution:  Administration on consecutive days is not recommended.

Side effects amended:

Very common – Dizziness

Common – Coughing on initiation, drowsiness, headache, nausea

Elderly – Hypotension and bradycardia

Uncommon – see BNF / SPC link

Dosage and administration: If stronger analgesia is required, patient can cover dilutor hole on the activated carbon chamber with finger during use. (New image included)

Patients should be advised to take the lowest possible dose to achieve pain relief

Morphine and Paracetamol use for pain relief Indications for IV paracetamol amended to relief of moderate to severe pain. Updated text in IV dosage table, ‘IV paracetamol is only used when managing moderate and severe pain (use an oral preparation when managing fever with discomfort).

New indication for oral morphine: ‘Oral morphine can be used as a component of managing moderate pain’.

Initial adult dose for oral morphine (not end of life) changed from 20mg, to 10-20mg, as it is now  indicated for moderate pain.


Oxygen Additional wording for clarity has been added to Table 7.5 – High levels of supplemental oxygen for adults with critical illnesses: During the prehospital phase of care vital signs may not normalise and therefore patients with abnormal vital signs should continue to be administered high flow oxygen until hospital arrival.
Tranexamic acid (TXA) New caution added: Current evidence does not support the use of TXA for gastrointestinal haemorrhage
Page for age For clarity about drug dosages in children, the page for age ‘Birth’ has been amended to ‘Birth to one month’


JRCALC Clinical Updates – Publication date: January 2023

The first update bundle of 2023 includes a new guideline for Agitated patients. This will sit alongside the existing guidance for acute behavioural disturbance (ABD). JRCALC are also in the process of developing new guidance on delirium. Agitation can have multiple causes and the clinical management can be challenging.  The focus should be on identifying and treating, or arranging to treat the underlying cause.

In addition there are a number of updates to existing guidelines:

Acute coronary syndrome (ACS):

Full review and update of ACS. This  includes a new section on health inequalities, women and racial differences. Strengthened wording, re. need to reduce on-scene time if possible.

Clopidogrel will be removed from JRCALC as part of the ACS update. Follow local policies/guidelines for P2Y12 inhibitor antiplatelet agents (e.g. ticagrelor, prasugrel).

‘Trauma emergencies in adults-overview’ and ‘Spinal injury and spinal cord injury guidance’

Additional wording added in relation to women and TXA administration.  Additional wording added around extrication, care during entrapment, self-extrication and time on scene. These changes are  in relation to a Delphi study of rescue and clinical subject matter experts on the extrication of patients following a motor vehicle collision >> https://pubmed.ncbi.nlm.nih.gov/35725580/

Also, a study around use of TXA in major trauma has concluded that administration of TXA to patients with bleeding trauma reduces mortality to a similar extent in women and men, but women are substantially less likely to be treated with TXA and if they are treated, it is at a later stage than for men. This will  now be highlighted in the text and in the key points in ‘Trauma emergencies in adults-overview’ >> https://pubmed.ncbi.nlm.nih.gov/35597623/

A number of small changes will be made to the following medicines:

  • Aspirin
  • Buccal midazolam
  • Penthrox
  • Rectal Diazepam

Page for age: For ages at birth and one month the respiratory rate will be changed to 40-60.

Further resources tab:  New resources will be added as links:

The JRCALC committee would like to record their appreciation to all who have contributed to these updates and to the continued development of JRCLAC Clinical Guidelines.


Bundle No. 9 – Publication date: October 2022


New JRCALC Guidelines

Guideline Update
Low Back Pain (Non-Traumatic) Guidance on the assessment and management of this common presentation. Includes differential diagnosis, red flags, serious pathologies for hospital conveyance and guidance on those patients that may be suitable for community management or referral to primary care, pharmacological and non-pharmacological pain management, advise on simple exercises and safety netting.
Human Factors This new guideline will be placed in the General Guidance section. A short section on human factors will remain in ‘Out-of-Hospital Cardiac Arrest: Overview’.
Chemical Biological Radiological Nuclear (CBRN) including Hazardous Materials New guidance to go in the ‘Special Situations’ section. Includes Safety Triggers for Emergency Personnel (STEP) 1-2-3 Plus, CRESS tool (consciousness, respiration, eyes, secretion, skin), specific agents:  nerve agents, cyanide, opiates, atropine toxicity, corrosive substances, Individual Chemical Exposure (ICE), ionising radiation and decontamination, illicit drugs labs.




Updates, Corrections, and Additional Guidance to Existing JRCALC Guidelines

Guideline/medicine Update
Adrenaline 1 in 10,000 Indications and dosages now included for ROSC, as per ROSC guidance.

Although 250 – 500ml of IV (or IO) fluid may support the circulation, it may take several minutes to administer. If hypotension is present during or after this fluid administration, provide additional circulatory support using careful administration of an adrenaline bolus, repeated as required, every 3-5 mins to maintain the systolic BP > 100 mmHg.

Initial dose:  50 mcg (0.05 mg) IV/IO. (0.5 ml from a 1:10,000 pre-filled 10 ml adrenaline syringe).

Subsequent doses: 50-100 mcg (0.05-0.10 mg). (0.5 – 1.0 ml from a 1:10,000 pre-filled 10 ml adrenaline syringe).

Follow each adrenaline bolus with a flush of 20 ml 0.9% N.saline.

Glucagon Dosages amended to ‘N/A’ for birth – at birth babies do not have any stores of glycogen so glucagon does not work.
Ondansetron Repeat doses added.

Congenital long QT syndrome added as a contraindication.

Prednisolone Glaucoma, recent MI and breastfeeding moved from contraindications to cautions.
DuoDote® Drug guideline removed, now incorporated into the new CBRN guidance.
Nitrous oxide and thoracic trauma New wording added:

Do not give nitrous oxide for patients with chest injuries and a clinically suspected pneumothorax.

Ipatroprium bromide New indication added: ‘Expiratory wheezing’.
Respiratory illness in children-Croup and Dexamethasone Removal of modified Taussig croup score as not advised by NICE.

Dexamethasone is now indicated for children with croup; regardless of whether it is mild, moderate, or severe.

Major, Complex and High-Risk Incidents Reviewed and updated by NARU.

Principles of joint working diagram updated, inclusion of SORT,

removal of diagram of gunshot entry and exit wounds.

Police Incapacitants Reviewed and updated by NARU. Updated guidance on Conducted Energy Devices (Tasers) and for their assessment, management and removal,

updated assessment and management of irritant/incapacitant sprays, attenuating energy projectiles and batons.

Domestic Abuse Revised and updated with current legislation.
Safeguarding Children Revised and updated with current legislation.
Safeguarding adults Revised and updated with current legislation.
Mental Capacity Act 2005 (England and Wales) Revised and updated with current legislation.

New flowchart for assessing mental capacity included with information around

causative nexus.

Newborn Life Support Revised and updated, algorithm revised in line with RCUK.
Care of the Newborn Updated and inclusion of guidance for preterm babies, in line with the British Association of Perinatal Medicine (BAPM) framework for practice:

Prehospital management of the baby born at extreme preterm gestation.

Guidance on ‘comfort care’ for babies known to be born before 22 weeks.

Out-of-Hospital Cardiac Arrest: Overview Reviewed and updated in line with RCUK.

New wording included:

Auditing and reviewing data downloads will help determine how quickly shocks are being delivered. Based on this local data, decisions can be made as to whether to recommend using AED mode for the first shock in order to minimise shock delays. Local audit data can help inform the decision making process.

Advanced Life Support Reviewed and updated in line with RCUK.

Updated guidance on mechanical chest compression devices and use of ultrasound. Other key changes include:

Addition of HOT approach; hypovolaemia, oxygenation (hypoxia) and tension pneumothorax.

Consideration of hypoglycaemia as a cause of arrest.

A precordial thump is no longer recommended for initial treatment of shockable rhythms even if a defibrillator is not immediately available.

In children where hypovolaemia is thought to be a contributory factor: give a fluid bolus of 10 ml/kg (N.saline (0.9%) or Hartmann’s solution), repeated once if indicated. Seek appropriate medical opinion if further boluses are thought to be indicated.

We suggest a starting energy of at least 150J, escalating to maximum output for refractory rhythms.

Quickly shaving the chest prior to defibrillation not only ensures better electrical contact (and therefore defibrillation success) but is likely to reduce the risk of electrical arcing between pads which may trigger a fire.

Laryngoscopy remains an important skill for visually inspecting the oropharynx in choking and should be part of ongoing competency assessments.

Staff attending the arrest will need to be trained to provide support to the clinician that is performing the intubation, such as preparing and passing the equipment

Waveform capnography should always be used when using a supraglottic device and BVM.

Once a tracheal tube is in place, continue continuous chest compressions with 10 gentle ventilations per minute. Avoid hyperventilation and high airway pressures during manual ventilation which adversely affect outcome.

Basic Life Support in Adults Reviewed and updated in line with RCUK.

New wording added:

Use of a CPR feedback device allows optimisation of BLS delivery and assessment of performance.

Basic Life Support in Children Reviewed and updated in line with RCUK.

New wording added:

Remember that pulse checks may be unreliable and are prone to errors. The detection of circulation therefore should also include other intra-arrest parameters such as ETCO2, blood pressure and SpO2.

Termination and Verification of Death in Adults Reviewed and updated in line with RCUK. New section on advance care planning included and more guidance added to clarify decisions around ARDT, lasting power of attorney and DNACPR, expected and unexpected deaths.

The decision to terminate resuscitation has been increased to 30 minutes from 20 minutes: If, following ALS interventions, the patient has been persistently and continuously asystolic for 30 minutes and all reversible causes have been identified and corrected, resuscitation may be discontinued except in cases listed below.

•         pregnancy

•         hypothermic patients (where hypothermia is the primary cause of the cardiac arrest)

•         suspected drugs overdose/poisoning

•         Infants, children and adolescents (i.e. all those < 18 yrs age)-refer to termination of resuscitation and verification of death in children

New wording has been added:

Rigor is also distinct from trismus (spasm of the muscles around the jaw) which may occur in those with a reduced level of consciousness. It is distinct from the rigidity of rigor mortis which is not isolated to jaw muscles alone.

Return of spontaneous circulation. Reviewed and updated in line with RCUK. New wording includes:

Aim for a systolic blood pressure (SBP) > 100 mmHg. Administration of fluids and adrenaline detailed. (See adrenaline above).

In the event of symptomatic bradycardia in children/infants, first ensure that hypoxia has been reversed (the commonest cause of bradycardia).

There is no evidence that cooling patients post-ROSC is of benefit, but extremes of temperature are harmful. Some patients post-ROSC will have a mild hypothermia. Ensure that patients do not become colder by using no more clothing/blankets than is necessary. Vehicle heating is only required to provide a comfortable ambient temperature.

Aim for a core temperature no higher than 37.5°C.

Adult patients with a cardiac arrest of presumed primary cardiac aetiology should be transported directly to a hospital with 24/7 coronary angiography capability (Both STEMI and Non-STEMI patients).

Adult patients with non-traumatic OHCA should be considered for transport to a recognised centre of care for appropriate specialist treatment, according to local protocols. There is no evidence to express a preference for a policy of primarily transporting via ambulance (using bypass protocols) or one of secondary inter-hospital transfer.

Termination and Verification of Death in Children New title replacing ‘Death of a Child’ guideline. Reviewed in line with RCUK. Includes guidance for children with care plans and for expected deaths.
Foreign Body Airway Obstruction Reviewed in line with RCUK. Includes new guidance to highlight there will be occasions when a patient who has a DNACPR form may have a cardiac arrest that is considered unnatural and not in the envisaged circumstances and has a potentially reversible cause such as choking. All reversible causes should be considered. In these circumstances, resuscitation and rapid conveyance to hospital should be considered as the cause of the arrest is unrelated to their main clinical problem(s) and could be reversible.
Tracheostomy and Laryngectomy Emergency Pre-Hospital Management Reviewed in line with RCUK.

Revised management algorithms.

JRCALC Clinical Guideline Updates Bundle No. 8 – Feb 2022

NB: Each individual organisation reviews the new JRCALC guidance and decides on the local clinical and operational practice. The introduction of a new medicine or procedure may take some time to be operationalised into an organisation.



New JRCALC Guidelines/medicines

Steroid-dependent PatientsNew guideline covering assessment and management of steroid-dependent patients with emphasis on hydrocortisone administration. The existing wording in Medical Emergencies in Adults is removed as it is now superseded by this new guideline.
PrednisoloneNew JRCALC medicine.
Indications: Asthma and COPD.
MagnesiumNew JRCALC medicine.
Indications: Asthma, eclampsia, severe pre-eclampsia and torsades de points.


Updates, Corrections, and Additional Guidance to Existing JRCALC Guidelines

Medicines OverviewUpdated. Table of routes of administration deleted as this is detailed in each medicine guideline.
Trauma Emergencies in Adults,
Trauma Emergencies in Children
New guidance around assessment and management of hanging added, with reference also added to Trauma Emergencies in Children.
Asthma in Adults and ChildrenUpdated guidance to include magnesium for life threatening asthma, and prednisolone.
Maternity Care (including Obstetric Emergencies Overview)New guidance on waterbirths included in 7. Special Considerations section. Emphasis on getting a woman in labour out of the water prior to giving birth.
Medical Emergencies in Adults, Falls in Older Adults, Trauma Emergencies in Adults New wording around frailty scoring added: consider using the clinical frailty scale, as per local pathways.
A link in Further Resources to the NHS Clinical Frailty app will be added.
Glucose Gel 40%Maximum dose changed from 2 tubes to no maximum dose.
Tranexamic AcidRemoval of wording in indications. The indication for TXA in women with post-partum hemorrhage if the patient continues to bleed remains. The following text has been removed:
Obstetric Emergencies
• Life threatening bleeding due to disorders of obstetric origin (e.g. antepartum haemorrhage, suspected placental abruption).
• Women who are pregnant and/or breastfeeding should have tranexamic acid administered in life threatening haemorrhage.
Sickle Cell Disease and Pain Management in AdultsAlignment to advise oral, intramuscular, or subcutaneous administration of opioid rather than IV in sickle cell disease.
HydrocortisoneUpdated indications: COPD and pregnant women with known Addison’s Disease who are in established labour (regular painful contractions)
ChlorphenamineThe IV route is re-included as a route for anaphylaxis for alleviating distressing cutaneous symptoms, only after emergency treatment with adrenaline and the patient is stable and oral anti-histamine administration is not possible.
Buccal midazolamAddition of dosages for child aged three months and one month. The rectal 2.5mg diazepam will no longer be manufactured, and those trusts that have buccal midazolam will be able to use the dosages as detailed in JRCALC and follow local procedures for administration. Trusts that do not have buccal midazolam will need to follow local procedures for managing seizures in small children.