UK Ambulance Service Clinical Practice Guidelines

UK Ambulance Service Clinical Practice Guidelines (2006) Editors: Dr Joanne D Fisher, Dr Simon N Brown and Professor Matthew W Cooke

Issued October 2006

ISBN 1 84690 060 3

Contents

PART 2 – ADULT GUIDELINES

Foreword Disclaimer Copyright Acknowledgements Update analysis Glossary of terms

Section 1: Cardiac Arrest and Arrhythmias Guidelines

Consent Patient confidentiality

Adult basic life support (BLS) Adult advanced life support (ALS) Adult foreign body airway obstruction Cardiac rhythm disturbance Implantable cardioverter defibrillators (ICDs) Recognition of life extinct by Ambulance Clinicians (ROLE) Traumatic cardiac arrest

Section 2: Pain Management Guidelines

Section 2: Medical Emergencies in Adults

Management of pain in adults Management of pain in children

Medical emergencies in adults – overview Abdominal pain Decreased level of consciousness Dyspnoea Headache Mental disorder Non-traumatic chest pain / discomfort

PART 1: GENERAL GUIDELINES Section 1: Ethical Issues

Section 3: Drug Protocols Drug introduction Drug codes Adrenaline (Epinephrine) Amiodarone Aspirin Atropine Benzylpenicillin (Penicillin g) Chlorphenamine (Chlorpheniramine, Piriton) Dextrose 40% gel Diazepam (as Diazemuls and Stesolid) Entonox/Nitronox Furosemide (Frusemide, Lasix) Glucagon (GlucaGen) Glucose 10% Glyceryl Trinitrate (GTN and Suscard) Hydrocortisone Ibuprofen Ipratropium Bromide (Atrovent) Lidocaine (Lignocaine) Metoclopramide (Maxolon) Morphine Sulphate Morphine Sulphate Oral Solution Naloxone Hydrochloride (Narcan) Oxygen Paracetamol solution or oral suspension (Calpol) Salbutamol (Ventolin) Sodium chloride 0.9% Sodium lactate, compound (Ringers lactate / Hartmann's solution) Syntometrine Tetracaine (AMETOP) Thrombolytics (Reteplase, Tenecteplase)

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Section 3: Specific Treatment Options Acute coronary syndrome Anaphylaxis / allergic reactions in adults Asthma in adults Chemical, biological, radiological & nuclear incidents (CBRN) Chronic obstructive pulmonary disease (COPD) Convulsions in adults Gastrointestinal bleeds (GI bleeds) Glycaemic emergencies in adults Heat exhaustion and heat stroke Hyperventilation syndrome Hypothermia Meningococcal septicaemia Overdose and poisoning in adults Pulmonary embolism Pulmonary oedema Sickle cell crisis Stroke / Transient Ischaemic Attack (TIA)

Section 4: Trauma Emergencies Trauma emergencies in adults – overview Abdominal trauma Burns and scalds in adults Electrocution Head trauma The immersion incident Limb trauma Neck and back trauma Thoracic trauma Trauma in pregnancy

October 2006

Contents

Pain Guidelines

Medical Emergencies in Adults

Drugs

Specific Treatment Options

PART 3 – PAEDIATRIC GUIDELINES Section 1: Emergencies in Children Medical emergencies in children – overview Trauma emergencies in children – overview Anaphylaxis and allergic reactions in children Asthma in children Burns and scalds in children Convulsions in children Dealing with the Death of a Child (Including Sudden Unexpected Death in Infancy (SUDI) Glycaemic emergencies in children Overdose and poisoning in children Child basic life support (BLS) Child advanced life support (ALS) Child foreign body airway obstruction Newborn life support Page for age charts (resuscitation and other emergencies in children)

PART 4 – METHODOLOGY Guideline development methodology

October 2006

Paediatric Guidelines Methodology

Safeguarding children Sexual assault Suspected abuse of vulnerable adults and recognition of abuse

Trauma Emergencies

Section 6: Treatment and Management of Assault and Abuse

Treatment & Management of Assault Obstetrics & Gynaecological Emergencies

Ethical Issues

Birth imminent (normal delivery and delivery complications) Effects of pregnancy on maternal resuscitation Haemorrhage during pregnancy (including miscarriage and ectopic pregnancy) Pregnancy induced hypertension (including eclampsia) Vaginal bleeding: gynaecological causes (including abortion)

Cardiac Arrest & Arrhythmias

Section 5: Obstetric and Gynaecological Emergencies

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Dr Thomas Clarke

The modernisation of the UK ambulance services heralds a new model for healthcare delivery with a much wider remit that has seen a shift away from the traditional role of simply transferring patients to further care. Today, the dedicated staff of the UK ambulance services work together, from the outset, to provide high quality, immediate, up-to-date, professional clinical care on which best patient outcome depends. Such care is reliant on clinical knowledge and expertise, and the Joint Royal Colleges Ambulance Liaison Committee Clinical Practice Guidelines are designed to support staff both during training and in the field.

“Up-to-date, professional clinical care for best patient outcome”

Dr Thomas Clarke Chairman Joint Royal Colleges Ambulance Liaison Committee Dr Simon Brown

“Important new changes”

Professor Matthew Cooke

The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Practice Guidelines set the standard of care for ambulance practice in the UK. It is vitally important, given the rapidly changing nature of healthcare delivery in the ambulance service, that such changes are reflected in these guidelines. Importantly, the 2006 edition sees the introduction of a paediatric section, recognising that the management of children is frequently different from that of adults. In addition, the new guidance for cardiopulmonary resuscitation is incorporated, including the management of patients fitted with an implantable cardioverter defibrillator. Some sections included in previous editions have been removed, as they are now adequately covered in training manuals. The multidisciplinary approach to the development of these guidelines not only enhances ownership but provides a ‘powerhouse’ of experience and expertise which feeds directly into the guidelines. JRCALC is indebted to those who were responsible for previous editions and those who have produced guidelines, or have allowed their work to be directly reproduced, for this current edition.

“Powerhouse of experience and expertise”

Dr Simon Brown Chairman, JRCALC Clinical Practice Guidelines Committee

Professor Matthew Cooke Project Director, University of Warwick

To the UK ambulance service’s best resource…its staff

Foreword

October 2006

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Foreword

Foreword

Disclaimer

The Joint Royal Colleges Ambulance Liaison Committee has made every effort to ensure that the information, tables, drawings and diagrams contained in Clinical Practice Guidelines issued July 2006 is accurate at the time of publication. However, the JRCALC guidance is advisory and has been developed to assist healthcare professionals, together with patients, to make decisions about the management of the patient’s health, including treatments. It is intended to support the decisionmaking process and is not a substitute for sound clinical judgement. Guidelines cannot always contain all the information necessary for determining appropriate care and cannot address all individual situations; therefore individuals using these guidelines must ensure they have the appropriate knowledge and skills to enable appropriate interpretation. The committee does not guarantee, and accepts no legal liability of whatever nature arising from or connected to, the accuracy, reliability, currency or completeness of the content of these guidelines.

Disclaimer

Users of the guidelines must always be aware that such innovations or alterations after the date of publication may not be incorporated in the content. As part of its commitment to defining national standards, the committee will periodically issue updates to the content and users should ensure they are using the most up-to-date version of the guidelines; http://www.jrcalc.org.uk Although some modification of the guidelines may be required by individual ambulance services, and approved by relevant local clinical committees, to ensure they respond to the health requirements of the local community, the majority of the guidance is universally applicable to NHS ambulance services. Modification of the guidelines may also occur when undertaking research sanctioned by a research ethics committee. Whilst these guidelines cover the full range of paramedic treatments available across the UK they will also provide a valuable tool for ambulance technicians and other pre-hospital care providers. Many of the assessment skills and general principles will remain the same. Those not qualified to Paramedic level must practise only within their level of training and competence.

Disclaimer

October 2006

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Copyright

COPYRIGHT Anyone wishing to reproduce the UK Ambulance Service Clinical Practice Guidelines 2006, either in whole or in part, in printed form, electronically or any other medium, and regardless of purpose, must consult with and gain the permission of: The Chief Executive Ambulance Service Association 7th Floor Capital Tower 91 Waterloo Road LONDON SE1 8XP Telephone +44 (0)20 7928 9620

TYPESETTING AND PUBLISHING Typesetting by DL Graphics Ltd, London; printed by Page Bros Ltd, Norwich designed and published by IHCD (part of Edexcel, a Pearson Company) on behalf of the Joint Royal Colleges Ambulance Liaison Committee and the Ambulance Service Association.

ERRORS, OMISSIONS AND COMMENTS Considerable effort has been taken to ensure the accuracy and consistency of these guidelines. If you find an error, omission, or would like to comment then contact us using the form below or on our website at www.warwick.ac.uk/go/jrcalcguidelines.

✄ To: Dr Joanne D Fisher Warwick Medical School, The University of Warwick, Coventry, CV4 7AL.

Name: Contact details:

Copyright

Please comment in the box below

Copyright

October 2006

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Acknowledgements

Stephen

Barnard

Greater Manchester Ambulance Service NHS Trust

Neil

Barnes


Robin

Beal

Isle of Wight Ambulance Service NHS Trust

Sarah

Black

Westcountry Ambulance Services NHS Trust

Tony

Bleetman

Birmingham Heartlands and Solihull NHS Trust

Graham

Brown


Richard

Brown

University Hospitals Leicester

Simon

Brown

Royal Berkshire Ambulance Service NHS Trust

Gillian

Bryce

Westcountry Ambulance Service NHS Trust

John

Burnham

Lincolnshire Ambulance Service NHS Trust

Colin

Cessford

North East Ambulance Service NHS Trust

Kirsty

Challen

South Manchester University Hospital

Ravi

Chauhan

Warwick Emergency Care and Rehabilitation

Thomas

Clarke

Newcastle Upon Tyne Hospitals NHS Trust

David

Coates

Avon Ambulance Service NHS Trust

Michael

Colquhoun

Welsh Ambulance Services NHS Trust / Resuscitation Council (UK)

Mark

Cooke

Ambulance Service Association

Matthew

Cooke

Warwick Medical School

Andrew

Currie


Charles

Deakin

Royal College of Anaesthetists

Richard

Diment


Ben

Disney

University Hospitals Coventry and Warwickshire

Sarah

Docherty

North East Ambulance Service NHS Trust

Darren

Earley

Mersey Regional Ambulance Service NHS Trust

Jon

Ellis

East Midlands Ambulance Service NHS Trust

Chris

Evans

Welsh Ambulance Services NHS Trust

Gary

Evans


Kevin

Errington

Staffordshire Ambulance Service NHS Trust

Yaish

Firas

University Hospitals Birmingham

Joanne

Fisher


James

Gray

South Yorkshire Ambulance Service NHS Trust

Dave

Greggs

East Anglia Ambulance Service NHS Trust

Henry

Guly

Plymouth Hospitals NHS Trust

David

Haigh


Glyn

Harding


Pam

Hardy

East Midlands Ambulance Service NHS Trust

Stephen

Hines

London Ambulance Service NHS Trust

Kim

Hinshaw

Royal College of Obstetricians and Gynaecologists

Mike

Jackson


David

Janes

Sussex Ambulance Service NHS Trust

Rose

Jarvis


Fiona

Jewkes

Wiltshire Ambulance Service NHS Trust

Graham

Johnson

Leeds Teaching Hospitals NHS Trust

Acknowledgements

October 2006

Acknowledgements

The Joint Royal Colleges Ambulance Liaison Committee is indebted to the following who have contributed to the development of the UK Ambulance Service Clinical Practice Guidelines 2006.

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Acknowledgements

Sue

Acknowledgements

Jones

St George’s Healthcare NHS Trust

Carl

Keeble

East Midlands Ambulance Service

Yvette

LaFlamme-Williams


Robin

Lawrenson

Scottish Ambulance Service NHS Trust

Bill

Lord

Monash University, Melbourne, Australia

Andrew

Marsden

Medical Director Scottish Ambulance Service

Jeremy

Mayhew

Kent Ambulance Service NHS Trust

Janet

McComb

Newcastle Upon Tyne Hospitals NHS Trust

Iain

McNeil

Royal College of General Practitioners

Ken

Morgan

Merseyside Ambulance Service NHS Trust

Fionna

Moore


Steve

Mortley

East Anglian Ambulance Service NHS Trust

Adrian

Noon


Matthew

O’Meara

Warwick Emergency Care and Rehabilitation

Bill

O’Neil


Rose Ann

O’Shea

Hinchingbrooke NHS Trust

Keith

Porter

University Hospitals Birmingham

Tom

Quinn

Staffordshire Ambulance Service/Coventry University

Iain

Robertson-Steel

West Midlands Ambulance Service NHS Trust

Julian

Sandell

University College Hospital London

Tina

Sajjanhar

Lewisham Hospital NHS Trust

John

Scott

East Anglian Ambulance Service NHS Trust

Dougie

Shepard

Scottish Ambulance Service

Mike

Smyth

Hereford and Worcester Ambulance Service NHS Trust

Richard

Steyn

Birmingham Heartlands and Solihull NHS Trust

Richard

Taffler


Duncan

Thomas


Andy

Thurgood

West Midlands CARE Team

Ian

Todd


Dominic

Tolley

Coventry & Warwickshire Ambulance Service NHS Trust

Eddie

Tunn


Paul

Underwood

Avon Ambulance Service NHS Trust

Anton

van Dellen

Staffordshire Ambulance Service NHS Trust

Darren

Walter


Michael

Ward

Oxfordshire Ambulance Service NHS Trust

Jim

Wardrope

South Yorkshire Ambulance Service NHS Trust

Andy

Weal

Gloucestershire Ambulance Service NHS Trust

Mark

Whitbread


Richard

Whitfield


David

Wilmot

Wiltshire Ambulance Service NHS Trust

Richard

Williams

Royal College of Psychiatrists

John

Wood

Avon Ambulance NHS Trust

Malcolm

Woollard

Faculty of Pre-hospital Care Research Unit, James Cook University Hospital

Matthew

Wyse

Coventry & Warwickshire Ambulance Service NHS Trust

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October 2006

Acknowledgements

Acknowledgements

Peak Flow Charts used with permission from Clement Clarke International. The Foundation for the Study of Infant Deaths. Meningitis Research Foundation. The ICD image with permission from Medmovie.com. The committee would also like to thank the following for allowing the reproduction of their guidance to be published in the UK Ambulance Service Clinical Practice Guidelines 2006.

Michael Colquhoun

Recognition of Life Extinct by Ambulance Personnel

Andrew Marsden Michael Ward Simon Brown

Implantable Cardioverter Defibrillator

Thomas Clarke Michael Colquhoun Mark Cooke Sue Jones Janet McComb Steven Bland

Chemical, Biological, Radiological and Nuclear Incidents Sort Algorithm

Iain McNeil

Chemical, Biological, Radiological and Nuclear Incidents (Special Agent) Triage Algorithm

Graham Brown

JRCALC Drug Codes – July 2006

Iain Robertson-Steel Resuscitation Council (UK) Howard Swanton

Resuscitation Algorithms Thrombolytics Protocol

Tom Quinn Mark Cooke Sue Dodd David Smith Fionna Moore Mark Whitbread Liam Penny Tom Evans Michael Langman

Acknowledgements

October 2006

Page 3 of 3

Acknowledgements

The Wong-Baker FACES Pain Rating Scale used with permission from Mosby.

Update Analysis – Report of the Key Changes

Significant revisions have been made to the 2006-2008 edition of the clinical practice guidelines. Some sections have been removed as these are now adequately covered in training manuals, and other important areas of clinical practice have been included. Importantly, the paediatric section has been expanded recognising that the management of children is frequently different from that of adults. The Resuscitation Council’s (UK) latest guidance for cardiopulmonary resuscitation (CPR) is incorporated, including a new guideline for the management of patients fitted with an implantable cardioverter defibrillator. All drug protocols now have administration tables including: age, dose, concentration, and volume. Drug dosages are no longer detailed within the guidelines and clinicians are referred to the specific drug protocol(s). In addition, standardised terminology relating to the administration of oxygen and fluid has been included. Each guideline also includes a list of the key points. This report indicates where key changes have been made, and is a signpost to changes within the guidelines but is not a substitute for reading and assimilating the new guidance.

Ethical Issues Consent

The following aspects have been added to the existing guideline, each of which has become more prominent since the initial guideline was written: • An update on recent (2004, 2005) case law and good practice criteria. • Further analysis of existing references, in particular, ‘Reference Guide to Consent for Examination’ and ‘Good Practice in Consent Implementation (DH)’.

Update Analysis

• The inclusion of a ‘definitions’ section, covering the major terms/phrases used in the guideline (valid consent, informed consent, duration of consent). • The inclusion of a paragraph outlining the ‘three tests’ for consent. • The inclusion of a paragraph explaining how to seek consent. • A complete rewrite of consent for young people. • The inclusion of a paragraph concerning consent versus duty of care versus human rights. • Inclusion of a paragraph concerning consent and research. • All other paragraphs underwent major rewriting. Patient confidentiality

The following aspects have been added to the existing guideline, each of which has become more prominent since the initial guideline was written: • Definition of ‘identifiable information’. • The relevance of the Data Protection Act (1998) to patient confidentiality. • The NHS Code of Practice on patient confidentiality. • Patient’s rights of access to their health records. • Disclosure to non-NHS partners. • Involvement of research.

Update Analysis

October 2006

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Pain Management Guidelines Pain management in adults

A new guideline for the assessment and management of pain in adults. • Sections covering pharmacological and non-pharmacological methods of pain relief. • Methods of pain scoring.

Pain management in children

A new guideline for the assessment and management of pain in children. • Sections covering pharmacological and non-pharmacological methods of pain relief. • Methods of pain scoring.

Drugs This edition sees the introduction of four new drug protocols: amiodarone, tetracaine, oral morphine sulphate solution and ibuprofen and the withdrawal of the nalbuphine hydrochloride protocol. The introduction of oral morphine sulphate solution further enhances pain management for patients and integrates care pathways between the ambulance service and other healthcare providers. The dosages and administration section has been standardised across all drug protocols, with the inclusion of administration tables. Calculations have been based on either average weight or age range, with the volume rounded (volumes 1ml rounded to 1 decimal place) and the dose calculated.

Update Analysis

A caution has been added to relevant drug protocols warning that for patients likely to require thrombolysis intramuscular administration of any drug should be avoided. A list of drug codes has been provided for INFORMATION ONLY and represents drugs that may be commonly encountered in the emergency/urgent care environment. Drug introduction

• Drug route section now merged into the drug introduction section. • Guidance on the use of abbreviations has been included.

Adrenaline

• The dose for endotracheal administration has changed from 2 milligrams to 3 milligrams. The volume increased to 30 millilitres. • Caution added – severe hypertension may occur in patients on beta-blockers and half doses of adrenaline should be administered, unless there is profound hypotension. • Caution added – half doses of adrenaline should be administered for anaphylaxis for patients taking tricyclic anti-depressants.

Amiodarone

• A new protocol for use in refractory ventricular fibrillation or pulseless ventricular tachycardia. • Amiodarone has Prescription Only Medicine exemption for use in cardiac arrest, thus, a Patient Group Directive is not required and any suitably trained paramedic can give it. • A warning is included that amiodarone must be administered into a large vein as extravisation can cause burns. • A warning is included that amiodarone must never be administered via the endotracheal route.

Aspirin

• Anticoagulants now listed as a caution rather than a contra-indication. • Clinical or ECG evidence of myocardial infarction (MI) or ischaemia has been added as an indication so patients with ‘silent MI’ receive aspirin.

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October 2006



Atropine

• In children, administration of atropine is restricted to persistent bradycardia caused by vagal stimulation from suction or intubation or for organophosphate poisoning.

Benzylpenicillin (penicillin g)

Change in the indications for administration to:

Diazepam (Diazemuls and Stesolid)

• Administration for eclampsia has been expanded to – ‘initiate treatment if fit lasts >2-3 minutes or if it is recurrent’

• ‘indicated by the presence of a non-blanching rash and signs/symptoms suggestive of meningococcal septicaemia. Some signs/symptoms may be absent and the order in which they appear may vary’.

• A note has been added – ‘the earlier the drug is given the more likely the patient is to respond’.

Entonox

• Labour pains have been added to the list of indications because entonox is the appropriate analgesia for administration during transfer to further care.

Glucagon (GlucaGen)

• The blood glucose level at which intervention is indicated has been increased to 4mmol/l.

Glucose 10%

• The blood glucose level at which intervention is indicated has been increased to 4mmol/l.

Glucose Gel

• Name changed from hypostop to glucose gel. • Guidance provided on the dose required.

Glyceryl Trinitrate (GTN and Suscard)

• A note has been added to indicate that a tablet could be removed if side effects such as hypotension occurred. • Contra-indication added – unconscious patients.

Hydrocortisone

• Change in the indications for administration to include Addisonian Crisis. • Guidance has been included on dosage and information for patients with Addisonian Crisis. • Adults – hydrocortisone ‘100mg intravenous (IV) (OR IM when IV access is impossible)-given by SLOW IV administration’. • Children – 1 month to 11 years, administer the dosages as per anaphylaxis and asthma table. • A note has been added to indicate that it is better to administer hydrocortisone if there is any doubt about previous steroid status. • Caution added – ‘in a patient likely to require thrombolysis, intramuscular administration of any drug should be avoided’. • The side effect of a burning and itching sensation in the groin is only when hydrocortisone sodium phosphate is administered too quickly. • Addition of Solucortef to the presentation section.

Ibuprofen

• New protocol for the relief of mild to moderate pain and/or high temperature and pain and inflammation of soft tissue injuries.


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Update Analysis

• Caution added – ‘in a patient likely to require thrombolysis, intramuscular administration of any drug should be avoided’.


Lidocaine (lignocaine)

• Contra-indication added ‘where amiodarone has already been administered’. • Removal of the ET route of administration for children. • Lidocaine as a local anaesthetic was removed as an action and information about its administration was added to the ‘additional information section’.

Metoclopramide (Maxolon)

• Routine prophylactic administration prior to opiate analgesia no longer required. • Caution added – in a patient likely to require thrombolysis, intramuscular administration of any drug should be avoided. • Caution added – avoid in cases of drug overdose.

Morphine sulphate

• The caution section emphasises that morphine should not to be used ‘routinely’ for labour pains. • Paediatric dose of 0.1mg/kg can be repeated at 5-10 minute intervals titrated against pain relief to a maximum of 0.2mg/kg. Note added regarding the peak effect of each dose which may not occur until 10-20 minutes after administration. • It is also stressed that the appropriate dose of naloxone must be known before morphine has been administered so that it could be given if required.

Update Analysis

• Monoamine oxidase inhibitors and acute alcohol intoxication is now included as a caution and not a contra-indication, stressing that morphine should not be administered until the patient’s drug information card has been checked. Morphine sulphate oral solution

• A new protocol for administration of morphine in cases of severe pain.

Nalbuphine hydrochloride (Nubain)

• This protocol has been removed from the 2006-2008 edition because the manufacturers withdrew this product for commercial reasons. Morphine is the recommended alternative.

Naloxone hydrochloride (Narcan)

• This protocol now extends to ambulance technicians, with the appropriate education/training. Administration will be by the IM route to a patient in an emergency situation.

Sodium chloride 0.9%

• Caution is advised for the administration of fluids in the prehospital environment.

Sodium lactate, compound (Ringers lactate/Hartmann’s solution)

• Caution is advised for the administration of fluids in the prehospital environment.

Tetracaine (AMETOP)

• A new protocol for the application of tetracaine, where venepuncture may be required, in the non-urgent situation or anticipated venepuncture for children and needle phobic patients.

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• New table relating to the administration of fluid volumes for medical (20ml/kg) and trauma (5ml/kg) emergencies in children.

• New table relating to the administration of fluid volumes for medical (20ml/kg) and trauma (5ml/kg) emergencies in children.

October 2006



Thrombolytics (reteplase, tenecteplase)

• Removal of Streptokinase. • Details referring to permissions for the administration of heparin, the mechanism of action and the legal aspects and response from JRCALC have been removed from this guideline. • The initial dose of heparin has been increased to 5,000U (except for patients