Guideline: M20g Managing Acute Medical Presentations · 1.1 Primary Policy 1.2 This guideline...

West London NHS Trust of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018

Guideline: M20g Managing Acute Medical Presentations

Guideline Relates to Primary Policy: P15 Physical Healthcare

Version: M20g/03 Date Approved: 1st October 2018

Ratification Group: Clinical Governance Group

Governance Group: Medicines Management, Optimisation & Safety

Title of Author: Chief Pharmacist and Physical Health Nurse Practitioner

Responsible Director: Medical Director

Date issued: 16th October 2018

Review date: August 2019

Target audience: All clinical staff

Disclosure Status B: Can be disclosed to patients and public


M20g – Managing Acute Medical Presentations Version Control Sheet

Version Date Title of Author Status Comment

M20g/01 27th August 2014

Chief Pharmacist and Physical Health Nurse Practitioner

Approved Under consultation, ending 21.02.14

Uploaded onto

the Exchange

15.09.14

M20g/02 August 2016

Chief Pharmacist and Physical Health Nurse Practitioner

Ratified & issued 2 week consultation ending 15.07.16. Uploaded to Exchange 31/08/2016

M20g/03 October 2018

Medication Safety Officer

Ratified & issued Addition of information about naloxone. Ratified at October Clinical Governance Group


Contents Page

1.0 Introduction ........................................................................................................... 4

2.0 Aim ........................................................................................................................ 4

3.0 Flowchart for Management of Hypoglycaemia and hyperglycaemia ..................... 5

3.1 Management of patients with Diabetes ................................................................. 6

3.2 Management of Hypoglycaemia ............................................................................ 6

3.3 Management of Hyperglycaemia .......................................................................... 7

4.0 Flowchart for Management of Acute Asthma Attack ............................................. 9

4.1 Management of acute asthma attack .................................................................. 10

5.0 Flowchart for Management of Anaphylaxis ......................................................... 11

5.1 Management of Anaphylaxis ............................................................................... 12

6.0 Flowchart for Management of Suspected Benzodiazepine Overdose ................. 14

6.1 Management of Suspected Benzodiazepine Overdose ...................................... 15

7.0 Opioid Overdose ................................................................................................. 15

8.0 Flowchart for Management of Seizures............................................................... 18

8.1 Management of Seizures .................................................................................... 19

9.0 Flowchart for Management of Acute Cardiac Chest Pain.................................... 21

9.1 Management of Acute Cardiac Chest Pain ......................................................... 22

10.0 Management of Medicines .................................................................................. 23

11.0 Training ............................................................................................................... 23

12.0 Glossary / Acronyms ........................................................................................... 24

13.0 References .......................................................................................................... 24

14.0 Appendices ......................................................................................................... 24

Appendix 1 - Second Line Emergency Medicines Poster ............................................. 24

Appendix 2 – Naloxone Alert………………………………………………………………...24


1.0 Introduction

1.1 Primary Policy 1.2 This guideline should be used in conjunction with P15 Physical Healthcare

Policy, B4 Basic Life support, M2 Medicines Policy, and the NMS poster.

1.3 Service users with mental health problems have a higher rate of physical health co-morbidity than the general population including diabetes, respiratory disease and cardiovascular disease all which could present acutely.

1.4 This guidance is intended to provide advice on how to manage common acute presentations of medical conditions in the inpatient setting.

1.5 The common acute medical presentations covered by this guidance are those outlined in the Medicines Policy (M2):

Hypoglycaemia

Hyperglycaemia

Acute asthma attacks

Anaphylaxis

Benzodiazepine Overdose

Seizures

Acute cardiac chest pain 1.6 Each inpatient clinical area will have stock medication to manage these acute

medical situations. These will be referred to as Second Line Emergency Medicines and kept in a RED TRAY in the stock medication cupboard (see section 7).

1.7 For outpatients who present with an acute medical problem that needs

immediate attention an ambulance should be called. 1.8 Medicines required for acute medical presentations may not always be

prescribed. If not prescribed they must only be given by a doctor or under a PGD by suitably trained staff.

2.0 Aim

2.1 The aim of this guideline is to provide clinical staff with guidance on the

management of common acute medical presentations that may occur in the mental health setting.


3.0 Flowchart for Management of Hypoglycaemia and hyperglycaemia

a. Ensure patients hands are washed with soap

and water prior to test

b. Ensure that Glucometer has been calibrated

that day/week (according to local procedure)

c. If not : calibrate prior to using

BM 4.0-7 mmol/l Normal reading Pre-meal BM ≤8.5

mmol/l

BM < 4 BM ≥ 20

Repeat BM

after washing and drying hands thoroughly

Was food or sugary drink ingested recently /less than 2 hours ago?

NO

YES

Repeat BM in one hour (act on each fresh BM reading from the start of the flow chart)

Check for urinary ketones

Ketones

3+++?

Check blood ketones (monitor available from: Broadmoor Site Manager 4495 or emergency drugs cupboard via unit co-ordinator)

NO

Call doctor and give any prescribed insulin. Repeat BM one hour after giving prescribed insulin(act on each fresh BM reading from the start of the flow

chart)

YES

0.6-1.5 mmol/l Alert doctor. Doctor to seek advice from Physical Health Department

and/or Local Acute Hospital

>1.5 mmol/l RISK OF DIABETIC KETOACIDOSIS Alert doctor.

Doctor to seek urgent medical advice from the Physical Health Department and/or Local Acute Hospital

< 0.6mmol/l Normal range

Is patient alert enough

to eat and drink safely?

NO YES Provide high sugar food/drink (dextrose tablets/fruit juice) followed by high carbohydrate food (biscuits/sandwich). Where there are possible delays acquiring food/drink also give prescribed glucose gel (rub into gums and inside cheeks)

Check blood sugar after 15-20 minutes (act

on each fresh BM reading from the start of the flow chart)

Ensure Basic Life Support Monitor vital signs/NEWS Give prescribed Glucagon Recheck BM after 15 mins if still <4 and/or drowsy/unconscious Call 2222 request ambulance for drowsy/unconscious hypoglycaemic patient

All other BM will be monitored in liaison with the Physical Health Department Ensure diabetic medication is taken Provide healthy lifestyle advice P

Repeat BM

BM ≤ 4 BM ≥ 20


3.1 Management of patients with diabetes

All patients with diabetes should as a minimum have the following:

A care plan outlining their management of diabetes

PRN medication to manage hypoglycaemia o Glucose gel o Glucagon IM

PRN medication to manage hyperglycaemia o Insulin Actrapid

3.2 Management of Hypoglycaemia

3.2.1 The symptoms of hypoglycaemia usually begin when the blood glucose level

drops to 3 - 4 mmol per litre. 3.2.2 Symptoms may vary from person to person and it is important to be aware of the

early warning signs so that they can be treated. 3.2.3 Presenting Signs and Symptoms

feeling hungry

sweating

dizziness

tiredness (fatigue)

blurred vision

trembling or shakiness

going pale

fast pulse or palpitations

tingling lips

irritability

difficulty concentrating

confusion

disorderly or irrational behaviour, which may be mistaken for drunkenness

3.2.4 If hypoglycaemia is not treated promptly blood glucose levels may drop low

enough to cause drowsiness and loss of consciousness. 3.2.5 Immediate treatment for hypoglycaemia

Patient is still alert and able to follow instructions and swallow without risk of choking: If patient is still alert and able to swallow: Provide high sugar food/drink (dextrose tablets/fruit juice) followed by high carbohydrate food (biscuits/sandwich). Where there are possible delays acquiring food/drink also give prescribed glucose gel (rub into gums and inside cheeks) Check blood sugar after 15-20 minutes (act on each fresh BM reading from the start of the flowchart)

http://www.nhs.uk/conditions/Double-vision/Pages/Introduction.aspx


Avoid fatty foods and drinks such as chocolate and milk, because they don't usually contain as much sugar and may cause the sugar to be absorbed more slowly. It may take 10-15 minutes before they feel better. Check BM after 15-20 minutes if below 4mmol/L continue to treat as hypoglycaemic.

3.2.6 Deteriorating alertness and unable to swallow (risk of choking)

If a person is very drowsy and unable to follow instruction or becomes unconscious because of severe hypoglycaemia: Ensure Basic Life Support and start NEWs monitoring Call 2222 request ambulance for drowsy/unconscious hypoglycaemic patient Give prescribed Glucagon Monitor vital signs Never try to put food or drink into the mouth of someone who is very drowsy or unconscious, as their airway will be compromised and/or they will be at risk of choking.

3.3 Management of Hyperglycaemia

3.3.1 The symptoms of hyperglycaemia usually begin when the blood glucose level

raises to ≥ 20mmol per litre

3.3.2 Symptoms may vary from person to person and it is important to be aware of the early warning signs so that they can be treated.

3.3.3 Presenting Signs and Symptoms

blurry vision

difficulty concentrating

frequent urination

headaches

high blood glucose

high levels of sugar in the urine

increased fatigue

increased thirst

weight loss

3.3.4 Hyperglycaemia can lead to ketoacidosis which can be life-threatening, symptoms of ketoacidosis include:

nausea and vomiting

stomach ache

smell of ketones on breath (likened to smell of pear drops)

tiredness, confusion and feeling unsteady

difficulty breathing

Diabetic ketoacidosis is unlikely in type 2 diabetes.


3.3.5 Immediate treatment for hyperglycaemia

Ensure patient’s hands are washed and dried and repeat BM reading. If the patient has ingested food or sugary drink recently /less than 2 hours ago repeat BMs in one hour. If the patient has not ingested food or sugary drink in the last 2 hours check for urinary ketones. If ketones are <3 – call medic and give any prescribed insulin, repeat BMs after 1 hour and re-assess as above. If ketones are ≥ 3 +++ Blood ketones must be checked. Contact the Site Manager or Unit co-ordinator for access to the monitor. If blood ketones < 0.6mmol/l this is within the normal range - call medic and give any prescribed insulin, repeat BMs after 1 hour and re-assess as above. If blood ketones 0.6-1.5 mmol/l - Alert medic. Doctor to seek advice from Physical Health Department (forensics) and/or local acute hospital. If blood ketones >1.5 mmol/l - Alert medic. Doctor to seek urgent advice from Physical Health Department (forensics) and/or local acute hospital.


4.0 Flowchart for management of acute asthma attack

ACUTE ASTHMA SYMPTOMS

Known asthmatic- Difficulty with breathing/

Severe wheezing/

Very rapid breathing

The patient is unable to say a few words at a time/unable to speak

Nebulise 5mg Salbutamol Using nebuliser mask and 5 litres Oxygen

Or 2 puffs Salbutamol Inhaler using a spacer

and encouraging 5-6 breaths

Monitor vital signs including: Oxygen saturations

Provide additional Oxygen

With an non-rebreathe mask as required

IMPROVEMENT (NEWS score <5 no

single parameter of 3) Monitor using NEWS

chart Give salbutamol as

prescribed

Call for help

Fast bleep Duty Dr

NO IMPROVEMENT 2222 ambulance

required

Repeat Salbutamol Every 2 minutes


4.1 Management of acute asthma attack

4.1.1 Presenting Signs and Symptoms, in a person known to suffer from asthma

Difficulty breathing, shortness of breath, severe wheezing or very rapid breathing

A silent chest in the face of significant shortness of breath

Coughing that won't stop

Visible use of accessory muscles to breath –shoulders/chest

Chest pain or pressure

Unable to say more than a few words at a time /unable to speak at all

Feelings of anxiety or panic

Pale, sweaty face

Blue lips or fingernails Worsening symptoms despite use of inhaled bronchodilator medication

4.1.2 Without immediate asthma treatment, asthma attack symptoms can worsen and become life threatening.

4.1.3 Immediate treatment for asthma attack:

Step 1: Nebulise 5mg Salbutamol nebule administered via a nebuliser mask driven with oxygen at a flow rate of 5L. In those who are known to have chronic obstructive pulmonary disease (COPD) an air driven nebulise machine should be used. If this is not available then administer 2 puffs of salbutamol inhaler via a spacer, achieving 5-6 breaths.

Monitor vital Signs. Record the vital signs on a Trust approved NEWS chart. Additional oxygen may be provided with a non-rebreathe mask at a flow rate of 15L. Alongside oxygen administration pulse oximetry must be performed.

4.1.4 Step 2: If no improvement call the emergency services on ex 2222 and repeat the administration of salbutamol every two minutes.


5.0 Flowchart for management of anaphylaxis

Administer Adrenaline 1 in 1,000 by I.M. injection. Dose 0.5mls (500 micrograms) 1:1000 solution.

If using the pre-filled syringe 0.5ml should be

expelled from the syringe prior to administration.

NO IMPROVEMENT

After 5 minutes

IMPROVEMENT (NEWS score <5 no single parameter of 3) Monitor using NEWS chart

Further assessment required as a secondary reaction may develop when adrenaline has worn off. Antihistamines and

steroids may need to be prescribed. Patient requires referral to specialist allergy services

ANAPHYLAXIS

Administer high flow oxygen via a non-rebreathe mask Lay patient flat with legs raised (unless respiratory distress increased) Administer basic life support Monitor vital signs – NEWS score Be prepared to give CPR if necessary

Call 2222 ambulance required

Rash, swelling, itching

Shortness of breath/chest tightness

Cramps, nausea/vomiting, diarrhoea

Drop in BP, dizziness and/or loss of consciousness ANAPHYLAXIS MAY OCCUR with or without the presence of a known allergen


5.1 Management of Anaphylaxis 5.1.1 Anaphylaxis is a severe life threatening allergic reaction which may occur where

a patient comes into contact with a known or unknown allergen. It could also take place following administration of a medication (e.g. flu vaccine, antibiotic). Prescription charts must have all allergies documented and allergies should be checked with the patient prior to administering the first dose of a new medication. An allergy can occur at any time, even following years of uneventful contact.

5.1.2 Presenting Signs and Symptoms include some or all of the following:

airway is compromised, narrowing of airways which can result in difficulty in breathing, swallowing or speaking and airway obstruction. Patient may be wheezy.

swelling of tongue, patient feels aware of tongue, tongue may tingle.

generalised flushing (redness) of the skin, or marked pallor indicates that the patient is about/has collapsed

a red raised itchy skin rash/nettle rash (hives) anywhere on the body

a sense of impending doom like something terrible is going to happen

swelling of throat, mouth, lips, eyes, hands and or feet

feeling like there is a lump inside the throat

strange metallic taste in the mouth

alterations in heart rate

abdominal pain, nausea and vomiting

sudden feeling of weakness, dizziness or feeling faint (drop in blood pressure)

collapse and unconsciousness

5.1.3 Immediate treatment for anaphylaxis

In cases of suspected anaphylaxis medical help must be summoned urgently Step 1 – Airway is compromised, lay patient flat and elevate feet, give oxygen, administer basic life support, monitor vital signs and call emergency services on ex 2222 and ask for an ambulance. Step 2 - Administer Adrenaline 1 in 1,000 by I.M. injection. Dose 0.5mls (500 micrograms) 1:1000 solution. If using the pre-filled syringe 0.5ml should be expelled from the syringe prior to administration. A rapid improvement in symptoms should occur once the adrenaline has been administered. If no improvement is observed after five minutes then a second dose of adrenaline should be given. Patients will need further assessment as they may develop a secondary reaction when adrenaline has worn off. Antihistamines and steroids may need to be prescribed. Where available Chlorphenamine maleate 10 - 20 mgs and Hydrocortisone 100-500 mgs may be given IM or slowly IV by a physician if considered necessary (this may need to be administered by ambulance staff or the acute hospital).


Give psychological support - anaphylaxis is an extremely frightening experience. Information to be transferred with patient • Substance causing the reaction • Dosage and time of adrenaline injections • Known medical history Report the incident on a ‘yellow card’ to the Committee on Safety of Medicines. (See M24p) Record details on an IR1 form on the exchange, and give a full account of incidents in patient electronic health records, and record allergen on prescription chart and in patient electronic record.


6.0 Flowchart for management of suspected Benzodiazepine overdose

Dizziness

Confusion

Drowsiness

Blurred vision

Anxiety

Agitation

Unresponsiveness

This could lead to:

SUSPECTED BENZODIAZAPINE

OVERDOSE

Call 2222

Ambulance required

BLS

Oxygen

Record vital signs-NEWS score

Flumazenil may be given by IV injection: • By a competent person

and • If there is evidence of benzodiazepine ingestion

Respiratory Depression Resp. rate ≤ 11


6.1 Management of suspected Benzodiazepine overdose

6.1.1 NICE specify that all areas that may administer Rapid Tranquillisation must hold stock of flumazenil, the benzodiazepine reverser.

6.1.2 Initial signs and symptoms usually develop within 4 hours of ingestion and may

present as

Dizziness

Confusion

Drowsiness

Blurred vision

Unresponsiveness

Anxiety

Agitation (NB these symptoms may also present in many other conditions/situations) This may proceed to

Respiratory depression (slow respiratory rate that does not provide for full expansion of the lung or provide enough oxygen to the tissues) with abnormal or decreased breath sounds. If it is not treated, it can be fatal.

6.1.3 Immediate treatment for suspected benzodiazepine overdose:

Step 1: In cases of respiratory depression with suspected benzodiazepine overdose call the emergency services on ex 2222 specifying suspected benzodiazepine overdose. Airway is compromised administer basic life support and monitor vital signs. Flumazenil is available for immediate use by a competent practitioner. It is important that there is evidence of benzodiazepine ingestion. Flumazenil should not be used as a diagnostic test in an unconscious patient. Flumazenil by intravenous injection, 300 micrograms over 15 seconds, then 100 micrograms at 60-second intervals if required; max. total dose 2 mg if drowsiness recurs 300 micrograms by intravenous injection. Use of flumazenil can be hazardous, particularly in mixed overdoses involving tricyclic antidepressants or in benzodiazepine-dependent patients.

7.0 Opioid overdose

Naloxone is a highly effective antidote for opioids and opiates and its use is potentially life-saving in many circumstances. It is used across a range of care settings where opioid and opiate use is common, and for a number of scenarios that range from management of drug misuse and dependence to the provision of palliative care. The primary aim of treatment is to reverse the toxic effects of opiates such that patients are no longer at risk of respiratory arrest, airway loss, or other opioid-related complications. The primary aim of treatment should not be to restore a normal level of consciousness, and indeed in some circumstances restoring a normal level of consciousness is entirely inappropriate. Naloxone is given most often by the intravenous or intramuscular routes.


In 2014 NHSE published a patient safety alert drawing attention to the safety implications of inappropriate doses of the opioid antagonist naloxone. The alert highlighted the use of naloxone where it was not indicated or, in larger than recommended doses, can cause a rapid reversal of the physiological effects for pain control, leading to intense pain and distress and in increase in sympathetic nervous stimulation and cytokine release precipitating an acute withdrawal syndrome. Please see attached alert for more information. Fundamentally the only indication for urgent and emergency use of naloxone is respiratory depression, regardless of the reason for the exposure to opioids or opiates. A diagnosis of respiratory depression should be sought before naloxone is considered. Symptoms of respiratory depression vary. Mild or moderate symptoms may include tiredness, daytime sleepiness, shortness of breath, slow and shallow breathing. As the condition progresses and carbon dioxide level increases, the patient may develop bluish-coloured lips, fingers, or toes, seizures, confusion and headaches. Doses are injected in the deltoid region or anterolateral thigh. Where practicable, the site of injection should be varied for repeated intramuscular doses.

Recommend naloxone dosing regimen for nurses: 1. Call ambulance, then IM dose of 400micrograms initially 2. Repeat ever 2-3mins. Each dose is given in subsequent resuscitation

cycles if the patient is not breathing normally 3. Until an effect is noted, breathing is normal or the ambulance arrives or

medical assistance is available Recommended naloxone dosing regimen for doctors:

1. Call ambulance, then IV/ IM dose of 400micrograms initially 2. If no response after 1 min give 800micrograms 3. If still no response after another 1 min repeat dose of 800micrograms 4. If still not response give 2mg (4mg may be required in a seriously

poisoned patient), then review diagnosis

Further doses may be required if respiratory function deteriorates Where acute toxicity and the subsequent need for naloxone is established, in most circumstances, a higher dose regimens will be safe and efficacious in reversing the effects of overdose in drug misuse and dependence. However the need for high initial dose treatment as well as its continuation needs to be balanced against the risks of acute withdrawal syndrome and sympathetic excess. The treatment risks need to be considered against the risk of death without naloxone. The risks of giving too much naloxone include acute withdrawal from opioids. Vomiting, agitation, shivering, sweating, tremor and tachycardia may occur. Delirium and aggression are relatively common. Vomiting where it affects aspiration may be life-threatening. Acute withdrawal causing sympathetic excess with resistant pulmonary oedema and ventricular arrhythmia are potentially life-threatening. In drug misuse and dependence, life-threatening withdrawal


reactions can occur in as many as 1% of cases of naloxone administration (particularly in cases of poly-drug misuse). An effective naloxone dose can vary greatly depending on the opioid or opiate type and the amount ingested or injected. Where overdoses are particularly sizeable, huge doses of naloxone may be required. Where the overdoses are smaller, the required naloxone doses will be too. All cases of opioid toxicity should be treated by a general acute hospital regardless of the response to naloxone.


8.0 Flowchart for management of seizures

Tonic Phase (lasts seconds)

Clinical Presentation Action Required

Body stiffens Call for help

Loss of consciousness Be alert for any injury sustained during fall Patient will slump/fall Fast bleep Duty Doctor

Status Epilepticus

Call 2222 ambulance required

Give prescribed diazepam

Place high dose oxygen on patient's face

Clonic Phase TIME THIS PHASE (May last seconds to minutes to a life threatening period)


Muscles relax and contract appearing as Make environment safe for patient

Exaggerated twitching to violent shaking of extremities Maintain patient dignity

Patient will not be breathing as effectively Obtain Oxygen and diazepam PR in case it is required

Post Ictal Clinical Presentation Actions Required

Patient in deep sleep Maintain airway by placing in recovery Take and record vital signs on NEWS chart

Gradual Awakening


Probable period of Reassurance

confusion and amnesia Monitor health before gradual and safety

awareness takes place

Patient has returned to

Clonic phase with no gradual

awakening

Clonic phase

≥ 5 mins


8.1 Management of seizures

8.1.1 Seizures may occur in patients in the mental health setting for a number of

reasons including:

Epilepsy

Treatment with anti-psychotics – anti-psychotics can lower the seizure threshold making it more likely to fit. There is increased risk with Clozapine treatment especially when levels are high.

Withdrawal from alcohol or benzodiazepines

Overdose The most common type of seizure is a tonic-clonic seizure.

8.1.2 Dissociative seizures (an episode resembling an epileptic seizure but having purely psychological causes) also occur in the mental health setting and may be difficult to distinguish from real seizures.

8.1.3 Presenting symptoms of a tonic-clonic seizure

Tonic Phase

body will become stiff (may last seconds)

loss of consciousness Clonic Phase

Muscles will start to contract and relax rapidly causing convulsions. These may range from exaggerated twitches of the limbs to violent shaking or vibrating of the stiffened extremities. Incontinence may occur Postictal phase.

A period of sleep and/or gradual return to consciousness. May be a degree of confusion during this time.

8.1.4 Management of seizure clonic phase

Step 1: Patient needs to be made safe from injury ensuring environment is clear of objects. Step 2: Time the clonic phase as during the clonic phase the patient will not be breathing effectively . Step 3: High dose oxygen should be provided (15L flow rate) wherever possible. Step 4: If the clonic phase has continued for 5 minutes or the patient is cycling between clonic and post-ictal sleep without returning to consciousness, then the patient is now in Status Epilepticus. Call the emergency services on ex 2222 and medication must be administered as prescribed (midazolam buccal or diazepam rectal). If the clonic phase continues 10 minutes following administration of medication a repeat dose must be given. Exception If the patient is known to experience prolonged seizures medication must be administered at the earliest opportunity as prescribed (midazolam buccal or diazepam rectal).


8.1.5 Management of seizure post-ictal phase Maintain patient in the recovery position protecting their airway. Monitor vital signs.

8.1.6 Rescue medication for seizures All patients with a diagnosis of epilepsy should have a care plan that specifies their preferred rescue medication for seizures. There are two medications available, diazepam rectal and midazolam buccal.

Diazepam rectal should be prescribed as 10mg rectal PRN repeated once after 10 minutes.

Midazolam buccal is currently only licensed for use in those aged 3months to < 18 years and in the majority of patients will be ‘off-label’. Patients will need to have capacity and consented to its use, and this must be documented.

Midazolam buccal should be prescribed as 10mg buccal* PRN repeated once after 10 minutes. *into the buccal cavity, this is the gutter between the teeth and the cheek.

Midazolam is a controlled drug and will only be supplied to wards where patients are prescribed it.

Following a first seizure if medication is required diazepam rectal should be used as the patient will not be able to consent.

8.1.7 Following first seizure

A first seizure will ALWAYS need to be referred to a neurologist for further investigation Forensic services refer to primary care services for investigations and referral for specialist advice. Local services the responsible clinician will decide if referral to a neurologist, or back to the registered GP is the most appropriate response (this will depend on date of discharge, and other physical health co-morbidities). Review current medication for possible lowering seizure threshold properties and review dose as necessary.


9.0 Flowchart for management of Acute Cardiac Chest Pain

2222 Ambulance required

Monitor vital signs – NEWS

ECG if time/appropriate to do so

Oxygen and AED kept nearby

Give GTN 400mcg spray

Repeat as required

Give 300mgs Aspirin (unless allergic)

Monitor Oxygen saturations: 94-98% 88-92% in those with COPD

Provide additional Oxygen if needed

Acute Cardiac Chest Pain

Pain in central chest and/or arms/back/jaw lasting more than 15 mins

May be accompanied by: • Nausea and vomiting

• Marked sweating

• Breathlessness

• Grey pallor • Dizziness


9.1 Management of Acute Cardiac Chest Pain

9.1.1 Acute Cardiac Chest Pain may occur in patients in the mental health setting for a

number of reasons including:

Cardiac Diagnosed Stable Angina Acute Coronary Syndromes:

Unstable angina

Myocardial Infarction – ST segment elevation (STEMI) or Non ST segment elevation (NSTEMI)

Acute pericarditis Aortic dissection Myocarditis

9.1.2 Presenting Symptoms

Symptoms that may indicate acute coronary syndrome (ACS) include:

Pain in the chest and/or other areas (e.g. the arms, back or jaw) lasting longer than 15 minutes.

Chest pain with nausea and vomiting, marked sweating and /or breathlessness, or haemodynamic instability.

New-onset chest pain or abrupt deterioration in stable angina, with recurrent pain occurring frequently with little or no exertion and often lasting longer than 15 minutes.

9.1.3 Assessment for possible acute coronary syndrome

Consider the history of the pain, any cardiovascular risk factors, history of ischaemic heart disease and any previous treatment, and previous investigations for chest pain

Monitor Blood pressure, pulse, temp,O2 sats, respiratory rate using NEWS

Doctor to conduct a cardiovascular examination

Take a resting 12-lead electrocardiogram (ECG) as soon as possible.

Do not exclude an acute coronary syndrome (ACS) when people have a normal resting 12-lead ECG

9.1.4 If Acute Coronary Syndrome Suspected:

administer basic life support, monitor vital signs, oxygen saturation by pulse oximetery, pain management and call emergency services on ex 2222

Stop any activity and rest. Offer pain relief as soon as possible. This may be achieved with GTN 400micrograms spray 1-2 sprays sublingual, repeated as required.

Offer people a single loading dose of 300 mg aspirin as soon as possible unless there is clear evidence that they are allergic to it.

If aspirin is given before arrival at hospital, send a written record that it has been given with the person.

http://www.patient.co.uk/search.asp?searchterm=ACUTE+PERICARDITIS&collections=PPsearch

http://www.patient.co.uk/search.asp?searchterm=SWEATING++FINDING+&collections=PPsearch


Do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to:

people with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94–98%

people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 of 88–92% until blood gas analysis is available.

Ensure defibrillator is in close vicinity to patient.

Send the ECG results to hospital before they arrive if possible. Recording and sending the ECG should not delay transfer to hospital.

9.1.5 Following acute chest pain it may be relevant to monitor cardiac enzymes 12

host post episode with a blood test if a cardiac cause is suspected.

10. Management of medicines

Hammersmith and Fulham inpatient unit medicines for the Crash team are stored in the Crash trolleys. Lakeside inpatient unit medicines for the Crash team are stored in the treatment room in a blue carry case. Second line emergency medicines for the management of acute medical presentations as follows: Adrenaline IM Diazepam PR Flumazenil IV Glucose gel Salbutamol nebules Salbutamol Inhaler Spacer Device Glyceryl Trinitrate Sublingual Spray Aspirin 300mg oral are stock on all inpatients wards and are kept in the red ‘second line emergency medicine’ tray in a locked cupboard. The cupboard should be labelled highlighting where the second line emergency medicines are kept (Appendix 1). Medicines for acute medical presentations may not always be prescribed. If not prescribed they must only be given by a doctor or under a PGD by suitably trained staff.

11. Training Each CSU should ensure that healthcare workers who may be involved in the management of acute medical presentations are aware of this guideline. This guideline will be highlighted during doctor’s induction.


12. Glossary / Acronyms AED - automated external defibrillator ACS - acute coronary syndrome BLS - Basic Life Support BM – Blood glucose Monitoring COPD – Chronic obstructive pulmonary disease ECG - Electrocardiogram GP – General Practitioner GTN – Glyceryl trinitrate IV - Intravenous IM - Intramuscular NEWS – National Early Warning Score PGD- Patient Group Directions PR – per rectum PRN – Pro Re Nata – when required

13. References https://www.medicinescomplete.com/mc/bnf/current/ https://www.nice.org.uk/guidance/CG137 https://www.nice.org.uk/guidance/ng10 https://www.nice.org.uk/guidance/CG95

14. Appendices

Appendix 1 - Second Line Emergency Medicines Poster

SECOND LINE EMERGENCY MEDICINES poster v3.0.pptx Appendix 2 – Naloxone Alert

psa-inappropriate-doses-naloxone.pdf

https://www.medicinescomplete.com/mc/bnf/current/

https://www.nice.org.uk/guidance/CG137

https://www.nice.org.uk/guidance/ng10

https://www.nice.org.uk/guidance/CG95

Guideline: M20g Managing Acute Medical Presentations · 1.1 Primary Policy 1.2 This guideline...

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