| 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 aroundcausative 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 equipmentWaveform 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 childrenNew 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. |
