JRCALC Clinical Guideline Updates 2/2023
Summary of changes:
| GUIDELINE | UPDATE |
| 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 TRANSFERReference: 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 – DizzinessCommon – Coughing on initiation, drowsiness, headache, nauseaElderly – Hypotension and bradycardiaUncommon – see BNF / SPC linkDosage 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’ |