Clinical Update: JRCALC Update Bundle 9

In October 2022 JRCALC released their updated bundle 9 of the National Clinical Guidelines for Ambulance Services. 

The information is available via the Trust Clinical app. This clinical update provides an overview of the changes made. Further details are available in the app. The Trust is implementing all the changes in the bundle and clinicians should ensure they have read the updates and their practice amended to take on board these evidenced based changes.

Three New guidelines

Three new guidelines have been included:

• Low back pain. This includes assessment, management, red flags, guidance for community management where appropriate along with medications options.
• Human factors
• CBRN and hazardous materials. This includes use of the CRES tool and safety information.

Medicines updates

The following drugs have had updates:

• Adrenaline 1:10000, use in ROSC. Use of adrenaline boluses from a prefilled syringe rather than dilution as previously required.

EEAST will align to the new dosages of 50-100mcg i.e., 0.5-1ml of 1:10000 adrenaline (no dilution is required). The requirement to call clinical advice line is removed but it still available if required. The previous EEAST specific clinical guideline should be disregarded.

• Dexamethasone, Removal of modified Taussig score as this is no longer NICE recommend. Dexamethasone should now be administered in all cases of croup (unless contraindicated) regardless of severity.
• Ondansetron, use of repeat doses where required. Therefore, up to 8mg in total may be administered
• Nitrous Oxide and thoracic trauma, clarification on the contra indications.
• Ipratropium Bromide updated guidance.
• Glucagon, not to be used in babies at birth any longer.
• Additionally (not included in bundle 9) the TXA indication of “Haemorrhage due to disorders of obstetric origin e.g, antepartum haemorrhage, suspected placental abruption” has been removed. This is following expert advice and guidance to JRCALC. The postpartum Haemorrhage indication remains. The Trust PGD has been updated to reflect this and is available on the app.

Major Complex and High-Risk guideline

This has a revision by NARU (National Ambulance Resilience Unit) and now includes the SORT role.

Police Incapacitants guideline

Included now updates on Taser management and incapacitant sprays.

Domestic Abuse, Safeguarding in adults and children and Mental Capacity Act guidelines

All of these have been updated with recent changes in the law.

Care of the Newborn

This guideline has been extensively reviewed in light of the BAPM guidance. Details are in the recently published Trust Clinical Instruction 110.

Please see the link below:

https://ntk.eastamb.nhs.uk/news/changes-to-management-and-care-of-the-extremely-premature-infant.htm

Resuscitation

The guideline has been updated following the Resuscitation Council guidance changes in BLS/ALS and Paediatric Life Support updates.

Additional guidance has now been given on the use of devices like the LUCAS and the use of Ultrasound where qualified SP/AP Critical Care are on scene. The HOT principle is also included. A new emphasis on shaving the chest prior to attaching the electrodes when you may need to defibrillate so as to ensure the maximum contact and also to reduce the risk are arcing.

Guidance has also been given on assisting a clinician that can intubate and a further reminder of the need to ensure Waveform capnography is used when a patient has an Igel or ET tube inserted.

Termination of Resuscitation and Verification of death in adults and children.

There is changes and updates to advance care planning guidance.

Following a review of the evidence the time interval of the cessation of resuscitation has increased from 20 to 30 minutes. The evidence suggests that there are excessive survivors being seen in the 20-to-30-minute period, This now is to be followed except in pregnancy, drug overdose, hypothermia, where this is the cause of the arrest, and those under 18 years of age. In these cases, these patients should be transported to hospital.

Updated guidance on the recognition of rigor mortis has been provided.

Return of Spontaneous Circulation guideline

This guideline now states the target blood pressure should be 100mmHg through using IV fluids or adrenaline 1:10000. It also considers that children with bradycardia should have hypoxia excluded as the cause.

Foreign Body Airway Obstruction

The guideline now also includes guidance on those with a DNACPR in place but who may choke and how these should be managed.

Emergency Tracheostomy and Laryngectomy Prehospital management

New algorithms have been included.

Further details are available in the Clinical app or on the JRCALC website.

Published 4th November 2022