Updates

Delirium

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.

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.

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.

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

GUIDELINE

UPDATE

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

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.

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

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.

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.

Congenital long QT syndrome added as a contraindication.

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

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

Principles of joint working diagram updated, inclusion of SORT,

removal of diagram of gunshot entry and exit wounds.

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

New flowchart for assessing mental capacity included with information around

causative nexus.

Prehospital management of the baby born at extreme preterm gestation.

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

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.

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.

New wording added:

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

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.

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.

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.

Revised management algorithms.