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CQMClinicalQualitymatters

NOV 16: THE GENERALLY UNWELL PATIENT

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Welcome to the latest issue of Clinical Quality Matters, which is back after a short break!

This edition focuses on a common call for us as an ambulance service - the generally unwell patient. This group can create a real challenge for us; some presentations can be relatively nondescript, and these patients require really detailed history taking, functional enquiry, and assessment.

But there are a number of causes for this ‘generally unwell’ patient group, which cover a vast range of body systems, conditions, and illnesses. Some can be considered minor, while others like palpitations can be more serious (linked to undiagnosed atrial fibrillation for example).

Our role goes so much wider than identifying immediate treatment and making time based decisions; instead we have to look at signposting individuals to help and guidance, and the management of new onset presentation(s). This is now a fundamental part of our role in health promotion and keeping people healthy, although not something we probably thought of when we joined the ambulance service. More and more primary care presentations are being manged through the 999 system, and in part, is a reflection of the change in use of urgent and emergency care.

The range of articles are designed to support your wider knowledge and practice development. Take time to consider and reflect on the jobs you have attended; the one thing I’d ask is for you to think about signposting patients to maintain their health - not manage their illness.

Enjoy the issue,

Marcus

Signposting to maintain healthA welcome from Marcus Bailey, Consultant Paramedic

GENERALLY UNWELL PATIENTS

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Postural hypotensionDr Tom Davis, Deputy Medical Director

The body needs to maintain blood pressure to ensure adequate perfusion of organs, particularly when an organ’s

functional demands increase. This relies on the integrity of the heart and blood vessels, maintenance of intravascular volume and various circulating and local vasoactive agents.

Blood pressure is regulated in part by baroreceptors. Age-related changes in the baroreflex mechanisms can precipitate postural hypotension, and the baroreflex-mediated heart rate response to both hypotensive and hypertensive stimuli can become impaired.

Blood pressure (BP) is a variable and can only be considered normal and abnormal in the context of the patient in question.

Hypotension is a BP that is much lower than usual, and can cause symptoms like dizziness or light-headedness. It is often defined as systolic blood pressure less than 90mm Hg, or diastolic less than 60mm Hg, but a systolic below 100mm Hg may be more appropriate if the patient normally has hypertension.

Orthostatic (postural) hypotensionDefined as a drop in BP (usually >20/10 mm Hg) within three minutes of standing, the

normal pooling of the blood in the lower limbs is not correctly regulated by the cardiovascular system on moving to a vertical position.

Although it may seem to be a relatively harmless phenomenon, patients’ safety and quality of life can be seriously affected. An understanding of the causes, together with appropriate nursing management, is essential.

It’s very common, especially in the elderly due to a number of underlying problems with BP control. The baroreflex mechanisms that

control heart rate and vascular resistance

decline with age, and they

are particularly prone to postural hypotension; it affects up to 30% of adults over 65 and is even higher in certain patient groups (for example,

those with Parkinson’s Disease). It particularly affects people on prolonged bedrest and those aged over 74. But, it’s not confined to the older population, and is more common in those who have additional risk factors.

Amongst other things, it can be caused by:

• hypovolaemia

• diabetes

• peripheral neuropathy

• Parkinson’s disease

• anaemia

• adrenal insufficiency.

There are also a number of drugs that can cause postural hypotension.

The majority of patients with orthostatic hypotension are asymptomatic or have a few non-specific symptoms. Common symptoms include dizziness, light-headedness, blurred vision, weakness, fatigue, nausea, palpitations and headache. Less common symptoms include syncope, dyspnoea, chest pain, and neck and shoulder pain.

One of the most common complaints older patients present with is a history of falls. Other symptoms include confusion and continence problems.

Any medical patient, especially an older person, with an underlying condition and/or on medications should be considered at risk of postural hypotension once an acute problem has been ruled out.

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The National Institute for Health and Clinical Excellence (NICE) publishes a range of guidance from clinical through to technical,

including therapeutic (such as medicines). As part of the publications it is a requirement for each provider organisation, like EEAST, to

consider the relevance and impact.

When we assess a guideline we consider, across all the services we deliver, if there is a need to take some action. A large proportion

of the technical guidelines are not relevant for the services and treatments that we provide.

The Institute provides a template for assessment and this is considered through the Trust clinical development and effectiveness

group. We then consider the existing guidelines we may already have, and work out the most appropriate approach and any elements we

should implement or adopt. Not all the guidance is able to be directly used within the ambulance service, and we have to assess the primary

care element of the patients we manage.

The aim of any review is to look at the practice and service we deliver, including whether there is a need to introduce, remind or modify practice or guidelines. The reviews are undertaken by the clinical team and relevant others across the Trust. We use a range

of methods in order to make this happen from bulletins to the professional update programme.

Want to know more? Visit the NICE website at www.nice.org.uk.

How we use NICE guidelines

Marcus Bailey, Consultant Paramedic


Acute hypotensionIn the acute form, hypotension can be a serious clinical feature that may cause renal, cerebral and myocardial hypoxic damage. Postural hypotension should only be considered once these causes have been excluded by the history and baseline examinations.

It is often associated with the different forms of shock including:

• septic: gram-negative septicaemia

• cardiogenic: following MI

• hypovolaemia: blood loss (haemorrhage), plasma loss (burns), dehydration (diarrhoea and/or vomiting), pooling of unavailable fluids (e.g., pancreatitis)

• anaphylactic: type I IgE-mediated hypersensitivity reaction

• neurogenic: caused by trauma to the spine, or as an adverse effect of an epidural anaesthetic. Also, it can result from pain or fear via reflex vagal stimulation.

Other causes include:

• vasodilatation from antihypertensive drugs or heat exposure

• drugs, such as narcotic analgesics, alcohol, some antidepressants and anxiolytics

• cardiac dysfunction, e.g. arrhythmia, MI, aortic regurgitation, tamponade

• pulmonary embolism

• autonomic nervous system failure

• micturition syncope.

InvestigationsIf you suspect postural hypotension, then pre-hospital investigations should include a sitting

and standing BP reading, an ECG and a BM, in addition to other baseline observations.

Management of postural hypotensionOnce acute causes of hypotension have been ruled out, a patient with postural hypotension may be safe to leave in their home environment.

In patients with chronic postural hypotension, the aim is to ensure appropriate mobility and function, prevent falls and provide low-risk treatment while maintaining a suitable quality of life - rather than to achieve a target BP.

Most patients will improve with simple measures and these should be tried first. Some may require referral to other health care professionals:

• The patient (and carers) should be educated about the various factors that affect blood pressure and special aspects that have to be avoided, e.g. foods, habits, positions and drugs

• Avoid triggers, e.g., high temperature environments

• Review any medication being taken

• Advise the elderly on standing slowly, dorsiflexing the feet first and even crossing the legs whilst upright

• Raising the head of the bed

• Physical counter-pressure with compression hosiery

• A morning dose of caffeine as coffee.

That said, more severely affected patients may require further interventions. These must be tailored to the individual needs of the patient, and the benefits and risks carefully considered and discussed.


www.nice.org.uk.

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The big questions: the six Cs and the ambulance serviceAllan Sunderland, Education and Training Officer

As health professionals, it is right that we adopt ethical standards, and address the challenges facing us and our patients.

The six Cs are a set of values that underpin compassion in practice, a vision and strategy for all health and care staff: care, compassion, competence, communication, courage, and commitment. It is felt by the NHS that if each of these areas is achieved, then care can be considered excellent in nature, and in its delivery. A fundamental drive in the delivery of care is recognising that NHS colleagues should be empowered to drive this change forward.

To build the six Cs into our practice we should, can, and invariably do:

• place the quality of patient care, especially patient safety, above all other aims

• engage, empower, and hear patients and carers at all times

• foster whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work

• embrace transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.

The Berwick Report (2013)

One of the problems identified from the Francis Report (2013) was one of ‘professional disengagement’. I am sure some of you reading this may reflect and feel that you come under this heading; some causes may be from the culture in our environment, and others may be closer to home. Either way, if we can embrace the six Cs in

what we do we can

build and share

good practices or improve poor practices, all whilst having the patient at the centre.

All of our professional bodies are engaging with these commitments, whether it is the Association of Ambulance Chief Executives (AACE) or the Health and Care Professions Council (HCPC); this programme is for the whole NHS, and we are part of it.

The simplest way we can start to improve ourselves and improve the patient outcome/experience, is to apply the six Cs.

CAREThis includes quality and safety. We should be ensuring that we are up to date with our clinical knowledge, and our commitment to deliver and maintain the best possible care. As we apply our care strategies, we need to always be patient centred, safe, evidence based, and document everything correctly.

We can also look at quality improvement clinical drivers like the ambulance quality indicators (AQIs) to make sure we’ve delivering the best standard of care we can to every patient. You can download a copy from East24 if you’re not familiar with them.


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http://east24/Clinical/Clinical Information/Ambulance Quality Indicators.pdf

http://east24/Clinical/Clinical Information/Ambulance Quality Indicators.pdf

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Care also encompasses us supporting individuals to take personal responsibility for their health. In other words, do we enable them, or do we perpetuate the cycle of dependency?

COMPASSIONDo we see beyond the care we provide, and look at how we deliver it? Do we listen? What do we say? How do we do it? To start looking at our compassion, we need to recognise the impact we have on others. This is why there is a drive to include the Trust User Group, who are a volunteer group of service users from across the region, in training and other areas of the Trust. Do we listen to feedback? Do we see how the patient is actually a person? We need to find balance of professional boundaries and decisions in a humanistic way, and not be afraid to care or have the conversation. Compassion is often predicated on the ability to lead with positive behaviour, positive attitudes and positive attributes – what are yours? Do you lead by example? Leadership is required from everyone, not just from a manager, as we all have responsibilities for the standard of compassionate care we deliver.

COMMITMENTHow are we with change? Some like it, some don’t, and some aren’t bothered. How accountable do you feel you are in your environment? To commit is ultimately to be accountable, so you could argue that the level of your commitment depends on your role, as a student right up to the specialist roles. There is no doubt that the further forward on your educational or professional journey you are, the more commitment is necessary, as we need to be able to deliver tangible and rigorous standards of care that are measured and evaluated.

So how easily do you evaluate yourself? Are you happy to do this, or do you feel it is someone else’s role to do so? Both are right in varying degrees; however, through commitment you can be empowered to bring changes in your own practice and share experiences. Without this continuous degree of commitment, we are at risk of failing to deliver our best care possible. We will fail to deliver improvements in ourselves and our organisation, and, if we fail to promote self-reliance in ourselves, our colleagues and our patients, how accountable are we being with our actions in improving healthcare delivery and promotion?

COMMUNICATIONOur varying roles demand a high standard of communication, and on the whole, I feel we deliver on this. We know that communication isn’t just us, but it engages our environment and all those who share it – so colleagues, managers, patients, and carers etc.

By understanding our role in the episodic relationships we have, we will very simply build networks and engage in care delivery and improvements.

COURAGEOf all the Cs, this is the one people most commonly don’t understand. This element is more related to thinking of the next ‘big thing’. Can you improve something? Do you have the ability to challenge or overcome barriers? Do you speak up when others may not? Do you bring positive influences to your environment?

Or do you reach an obstacle and let someone else do it? Think that it’s not your place or job? Let yourself be influenced by sceptics?

We all have experiences from both sides at some point, and often it is about learning and committing to move forward and not being disheartened, as deep down you want to do the right thing for the patient. It sounds easy, but often can be quite hard, especially if you are not the senior clinician and you see something being done that you think or know to be wrong.

Ultimately, we just need to tell ourselves that we are committed to quality improvement and that we can make a difference.

COMPETENCYThis is the overarching theme to the six Cs, as it isn’t sufficient for us to say I/we care, or are committed, or are compassionate etc. - we need to develop competency in each area and that takes time, practice, experience and courage. Competency is not just linked to our clinical knowledge or ability to delivery care, but in the drive to make these ‘quality improvements’ across the board.

We also need confidence in ourselves and those around us, which includes our


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KEEP YOUR THOUGHTS POSITIVE, BECAUSE YOUR THOUGHTS BECOME

YOUR WORDSKEEP YOUR WORDS POSITIVE,

BECAUSE YOUR WORDS BECOME

YOUR BEHAVIOURKEEP YOUR BEHAVIOUR POSITIVE,

BECAUSE YOUR BEHAVIOUR BECOMES

YOUR HABITSKEEP YOUR HABITS POSITIVE,

BECAUSE YOUR HABITS BECOME

YOUR VALUESKEEP YOUR VALUES POSITIVE,

BECAUSE YOUR VALUES BECOME

YOUR DESTINY

patients. If all of these elements can come together we can, we will, and we already do, deliver high qualities of care that is safe and focused.

For me, in the east of England, I know that we have varying degrees of ability; we have individuals at different stages of development who require, and sometimes have a demand, for different needs clinically, educationally and personally; and we have those who are capable to deliver. Often with these subjects, it is not about telling people how and where improvements need to be made, but actually saying ‘this is what we do’ and ‘this is what we do well’. But then analysing the points and saying ‘this is where I can do better and I know how to do it’, or ‘I know someone who can help me’.

At the end of each day or each week, we are all individuals involved in a wider cause where we must come together and deliver care - and deliver it to a high standard. We can continue do so by ensuring we engage with each other, reflect, and subscribe to our EEAST core values. Let’s contribute to the wider team and be a part of the Trust’s Quality Improvement.


Early warning scores

An early warning score (EWS) is a guide used by medical services to quickly determine the degree of illness of a

patient. It is based on the six cardinal vital signs: respiratory rate, oxygen saturations, temperature, systolic blood pressure, pulse rate, and level of consciousness.

With the widespread use of EWS in medical practice, recent publications provide insights to their potential use by ambulance clinicians.

Key points:

• Early warning scores in the pre-hospital setting appear to be useful in predicting clinically important outcomes

• Support tools are required to ensure correct calculation of EWS aggregate scores

• Further research is needed to identify the EWS best suited to the pre-hospital setting

• Further research is warranted before EWS are used to support conveyance decisions.

Want to read more?Leung S.C. et al (2016) Can prehospital Modified Early Warning Score identify non-trauma patients requiring life-saving intervention in the emergency department? Emergency Medicine Australasia, 28(1), 84-89

Williams, T.A. et al (2016) The ability of early warning scores (EWS) to detect critical illness by paramedics in the prehospital setting: a systematic review. Resuscitation. 102, 35-43. doi: 10.1016/j.resuscitation.2016.02.011.

Bayer, O. et al (2015) An early warning scoring system to identify septic patients in the prehospital setting: the PRESEP score. Academy of Emergency Medicine, 22(7), 868-71

Essam, N. et al (2015) Modified early warning scores (MEWS) to support ambulance clinicians’ decisions to transport or treat at home. Emergency Medical Journal, 32:e1 doi:10.1136/emermed-2015-204880.2

Hancock, C. (2015) A national quality improvement initiative for reducing harm and death from sepsis in Wales. Intensive & Critical Care Nursing, 31(2), 100-105

Silcock D.J. et al (2015) Validation of the National Early Warning Score in the prehospital setting. Resuscitation, 89, 31-5. doi: 10.1016/j.resuscitation.2014.12.029.

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Chest painThe common

complaint with numerous causes

Dave Allen, Area Clinical Lead

Chest pain is a common chief complaint by patients; if we look at last year (2015/16) alone, we had more than 64,000 emergency 999 calls for people with

chest pain.Caused by either benign or life-threatening aetiologies, it’s usually divided into cardiac and non-cardiac causes, and all can be complicated.

Chest pain itself can be triaged into traumatic and atraumatic aetiologies, or causes. The evaluation of atraumatic chest pain requires an algorithmic approach, that first excludes acute myocardial ischaemia, before working through the various aetiologies of chest pain.

The character of chest pain should be determined, as this can help differentiate between cardiac, respiratory, musculoskeletal, and other causes. The type, severity, location, and duration of pain; the presence of any radiation; and exacerbating or relieving factors, may all be helpful in pointing towards a clinical impression.

Acute coronary syndrome (ACS) encompasses unstable angina, non-ST-segment-elevation myocardial infarction (NSTEMI), and ST-segment-elevation myocardial infarction (STEMI). Now ACS affects only a few of the patients presenting with chest pain, but excluding ACS is vital because of the mortality associated with untreated myocardial infarction (MI). Acute chest pain warrants rapid clinical assessment, as underlying disease can be life-threatening.

But clinical presentation alone cannot reliably determine acute coronary syndrome (ACS). Past medical history and specific cardiac risk factors such as known cardiac disease, raised cholesterol, hypertension, smoking, and family history support a cardiac cause. Cocaine use also makes cardiac ischaemia more likely. A detailed drug history should also be taken and considered, e.g. use of NSAIDs may result in gastric aetiology).


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British Medical Journal (2016), click to view

National Institute for Health and Care Excellence (2010), click to view

UK Ambulance Services Clinical Practice Guidelines 2016

Certain characteristics of chest pain can give clues to the origin:

• Constricting pain may be due to cardiac ischaemia or oesophageal spasm

• Pain that lasts for more than 15 minutes and is dull, central, and crushing is likely to be caused by an ACS/MI

• Pain that radiates to the jaw or upper extremities suggests a cardiac cause

• Sharp pleuritic pain that catches on inspiration may originate from the pleura or pericardium and suggests pneumonia, pulmonary embolus, or pericarditis

• A sudden substernal tearing pain that radiates towards the back is the classic presentation of aortic dissection.

Precipitating and relieving factors can help distinguish between cardiac and gastrointestinal causes, like gastro-oesophageal reflux disease (GORD), peptic ulcer disease, or oesophageal spasms. Pain brought on by food, lying down, hot drinks or alcohol, and that is relieved by antacids suggests a gastrointestinal cause. Cardiac

pain however is more likely to be brought on by exercise or emotion, and is typically relieved with rest or nitrates. Abdominal pathology such as acute cholecystitis and pancreatitis may also cause pain referred to the chest. Dyspnoea, or shortness of breath, is an associated symptom in patients with cardiac ischaemia, pulmonary embolism, pneumothorax, or pneumonia. Nausea, vomiting, and sweating may be seen in patients with ACS.

Physical examination can further narrow down the differential. Abnormalities revealed in the cardiac examination include abnormalities in pulse or heart sounds (e.g., new onset of aortic stenosis or worsening of existing murmur), hypo- or hyper-tension, and signs of heart failure. Crepitations revealed by auscultation in one or both bases suggest pneumonia or heart failure. Reduced breath sounds on one side can be caused by a pneumothorax, or focally due to a collapsed lobe. Tenderness on palpation over the area of chest pain usually indicates a musculoskeletal cause, such as costochondritis. However, many patients with MI also have chest wall pain on

presentation. A gastrointestinal origin of chest pain is associated with a normal cardiac and respiratory examination, unless there is existing but stable comorbidity. An abnormal abdominal examination (tenderness, rebound, guarding) makes a gastrointestinal aetiology more likely.

When an ACS is suspected, start management immediately and take a resting 12-lead ECG. Take the ECG as soon as possible, but do not delay transfer to hospital. If an ACS is not suspected, consider other causes of the chest pain as described above, some of which may be life-threatening.

Follow the PPCI pathway for people with a resting 12-lead ECG showing regional ST-segment elevation, or presumed new left bundle branch block (LBBB) consistent with an acute STEMI, until a firm diagnosis is made and continue to monitor.

For people with a resting 12-lead ECG showing regional ST-segment depression or deep T wave inversion suggestive

of a NSTEMI or unstable angina, treat, and again, do not delay transport to the emergency department. Even in the absence of ST-segment changes, have an increased suspicion of an ACS if there are other changes in the resting 12-lead ECG, specifically Q waves and T wave change. Do not exclude an ACS when people have a normal resting 12-lead ECG. If clinical assessment and a resting 12-lead ECG make a diagnosis of ACS less likely, consider other acute conditions. But remember to first consider those that are life-threatening, like pulmonary embolism, aortic dissection or pneumonia.

So, all in all, we know chest pain is a common complaint but one that has numerous possible causes. Because of that, we should always have a high index of suspicion around these patients; if the chest pain is unexplained, then more often than not your patient should be conveyed to hospital for further assessment and blood tests. But remember, a systematic approach as outlined above, supplemented with vital signs and an ECG will aid in your diagnosis, risk stratification and treatment options.

http://bestpractice.bmj.com/best-practice/monograph/301/overview/summary.html

https://www.nice.org.uk/guidance/cg95/chapter/1-guidance

https://www.nice.org.uk/guidance/cg95/chapter/1-guidance

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Serious incident case study:alcohol withdrawal

Emma De-CarteretPatient Safety and Risk Lead

The Trust received a call to a woman in her 30s who was experiencing chest pains and difficulty in breathing. From the information provided by the caller, it was coded as a Red 2.

Once on scene, the crew carried out an initial assessment and concluded that the patient was suffering alcohol withdrawal symptoms, identifying:

• the patient was an alcoholic, had been abstaining from alcohol without support, and was on the fifth day of detoxification

• that prior to this detox, she had been drinking approximately a litre of vodka per day

• she had recently been admitted to hospital with hematemesis (vomiting blood), but had been discharged with no specific treatment

• she reported a feeling of general weakness; sweating, nausea, vomiting and chest pains

• heart rate 110 beats per minute

• respiratory rate 22 breaths per minute

• blood pressure of 105/63

• blood sugar of 9.6 mmol/L

• temperature of 35.2OC

• a GCS of 14/15.

The crew considered these observations against the patient’s history of alcohol dependency and the presentation of alcohol withdrawal, and concluded that she was not suffering from septic shock. They advised the patient that conveyance to A&E was not the appropriate next step, and instead the patient was referred to her GP within 24-hours. The crew believed that, with a GP referral, the patient would be able to obtain appropriate medication and support for her alcohol withdrawal.

Two calls were made to the GP surgery; the crew were initially told that there were no appointments for that day, but eventually arranged for the GP to call back and ‘take a handover of observations and assessment’.

Following an extensive discussion with the GP, they made an appointment for the patient

later that day, at 2pm. On speaking to the patient and her friends, she said she was happy to go to the appointment, and the crew strongly advised that she should attend - as detoxing after such a long addiction time should be supported.

Following this the receptionist had contacted the specialist treatment and recovery service (STARS) for guidance regarding the patient; the advice was that the patient should start drinking a moderate amount again, and attend the clinic before 4pm for an assessment so that a ‘plan of support and assistance’ could be established. The clinic required up to date blood tests, and the receptionist booked a further appointment at the GP surgery to facilitate this.

Just after 8pm the same day, another 999 call was made for the patient. The call was made by a friend, who stated that the patient was unconscious and not breathing. The patient had deteriorated prior to her GP appointment and so had not been able to attend; on arrival it was identified the patient was in cardiac arrest. More than 40 minutes of advanced life support was provided, but was unsuccessful, and the patient very sadly died.


A serious incident, or SI, requiring investigation is one that resulted in avoidable death, serious harm or near misses. They can also be declared when there is

a serious information governance breach, abuse and when there is a loss of confidence in the service. Incidents are investigated, with the aim of identifying learning to repeat the same thing happening again. Here we take a look at a serious incident case study.

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This month our clinical conundrum comes from Research Paramedic Larissa Prothero. Answer in the next issue!

It is after lunchtime on a week day and you are attending a 57-year-old man who is unwell with breathing

problems. You find the patient walking clumsily around his bedroom, looking generally unwell and in pain. His

breathing is audible as you approach the bedroom and he is not able to communicate with you properly.

The patient’s wife has told you he has diabetes and has a ‘tummy bug’ for almost two weeks. He has been vomiting

and had diarrhoea. She tells you it all started after they went out for dinner, and she doesn’t understand it

because all she has had recently is a cold.

During this period the gentleman has visited his GP three times, who advised him to maintain his fluid intake and continue taking his anti-sickness and anti-diarrhoea

medications. His wife tells you that he has been trying to follow this advice, but has not really got any better. Now he is struggling to eat or drink and she is worried about

him. She tells you his ‘sugars are normally OK’.

What else would you want to know? What would you do next?

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Picture(s) designed by Freepik.com

Learning pointsSevere alcohol withdrawal is an acute condition which must be dealt with seriously; it often requires acute medical intervention in the hospital setting, particularly if a patient has initiated withdrawal without the appropriate support.

There is also NICE guidance in place relating to this patient group:

• Best practice for patients who are alcohol dependant but not admitted to hospital is: ‘to avoid a sudden reduction in alcohol intake and to provide information about how to contact local alcohol support services.’

• For people in acute alcohol withdrawal with, or who are assessed to be, at high risk of developing alcohol withdrawal seizures or delirium tremens, offer admission to hospital for medically-assisted alcohol withdrawal.

.

Click here to see the NICE guidance, or visit:

www.nice.org.uk


https://www.nice.org.uk/guidance/cg100



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Diving in at the deep end: using oxygen for decompression illnessIt might not a regular occurrence for us at EEAST, but we do get the occasional call for patients suffering from decompression illness. Here Area Clinical Lead Ash Richardson takes a look at the what, the why, and how we treat it…

People can suffer from decompression illness when there is a reduction in ambient pressure surrounding a body – essentially decompression of the body itself.

It typically afflicts underwater divers on poorly managed ascents (known more commonly as a diving ‘bend’), or aviators flying in inadequately pressurised aircraft.

It manifests in two ways: decompression sickness, where nitrogen bubbles to form in the tissues of the body; and/or arterial gas embolism, where bubbles of air or gas get into the circulatory system, which can cause blood vessel blockage.

How does it present?Patients with decompression illness are often weak, may have reduced oxygen saturations and acute chest pain. These can however be subtle in presentation, so good history taking and assessment is key to finding a possible diagnosis.

Initial early treatment necessitates the administration of high flow oxygen therapy via a non-rebreather mask. This will assist in eliminating nitrogen from the body, providing some symptomatic relief to the patient.

The national Clinical Practice Guidelines 2016 provide some contradicting information however, namely that oxygen administration is not required for: ‘acute and sub-acute neurological and muscular conditions providing muscle weakness’. In this case, there’s a clear risk of oxygen not being given to a diver presenting new onset weakness or chest pains, as part of an acute illness. Whilst clearly the

guidelines augment our clinical decision making and management strategy plans, we must take time to consider where, for example, oxygen is still very much indicated.

Common signs of a diving bend…Head: vertigo, poor balance, confusion, nausea, fatigue, unconsciousness

Chest and body: skin rash

Spine: abdominal pain, loss of bladder function, paralysis

Fingers and feet: tingling, pins and needles

Knees, elbows and shoulders: joint pain


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When responding to a burn-injured patient, standard trauma protocols across the world

include a: stop the burning process; cool; assess; and dress algorithm.

Stop the burning processSafety for both the patient and rescuer is paramount, and particular caution should be made when attending the scene of chemical and electrical burns. When it is safe to proceed, the burning process should be stopped and the patient should be removed from the burning source.

Cool the burn injuryThe gold standard for cooling is achieved with cool running water. Cooling of the burn injury should take place for 20 minutes and is effective up to three hours after the burn has occurred.

Thorough irrigation is of particular importance in chemical burns in order remove the corrosive substance from the skin. Diphoterine is commercially available and often found in places of work where chemicals are used. It is favoured for both its amphoteric and chelating properties, meaning it is equally effective for neutralising both acid and alkali burns.

Assess and dressThe size (total body surface area, or TBSA) and depth of the burn needs to be assessed. A number of recognised tools are available to aid with this assessment, including the Lund-Brower chart, the Wallace Rule of nines and the patient’s own palm size (equally approximately 1% TBSA), all of which are supported by EEAST.

Serious burn injuries are devastating events that leave patients with long-term physical and

psychological challenges that are recognised worldwide. Emergency medical services consider them as one of the most horrific and challenging

injuries they are likely to face.

BurnsChris Corbett,

Training & Education Officer


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Assessing the depth or severity of the burn injury can prove difficult in the pre-hospital setting as the burn pattern is likely to develop over several hours. To understand this process, the Jackson’s theory of thermal burns can be used. Jackson’s model concludes there are three zones within a burn-injury: the zone of coagulation, the zone of stasis and the zone of hyperemia.

The zone of coagulation is necrotic tissue characterised by clotted blood and thrombosed blood vessels that are unable to be salvaged. The zone of stasis is characterised by decreased blood flow, and it’s this zone that’s difficult to assess in a pre-hospital setting - tissue recovery may not be known for some time. The zone of hyperaemia is the outer most zone; it’s characterised by increased blood flow and reddening of the skin. Tissue viability and recovery has a good prognosis.

Many factors will influence the recovery of the zone of stasis, including wound care, the patient’s age and other existing medical conditions. Have particular regard for patients with conditions leading to poor perfusion states, such as COPD, patients with vascular insufficiencies like diabetes, any form of immunosuppression like patients undergoing cancer, and individuals with damaged skin in the form of scarring or ulcers. Be particularly vigilant if the existing damage crosses borders with a new burn injury.

For these patient groups, every burn injury should have some form of onward care package implemented - a GP or nurse review is required to ensure healing is taking place.

DressingsDressings are important to help control the patient’s pain and to keep the burnt area clean. The burnt area should be covered with plasticised polyvinylchloride, more commonly known as cling film! Strips of cling film should be applied, never wrapped, as swelling is likely to occur. Keep the patient warm by ensuring they’re in a warm environment, and/or applying blankets.

The use of cling film is clinically-evidenced to have a supportive role in burn injury management. That said, the use of cling film on ‘hot’ burn injuries should be avoided, as the cooling process needs to be achieved first.

Cling film should not be used on chemical burns; rather a traditional ambulance dressing soaked in NaCl should be applied after thorough irrigation (minimum 15 minutes) of the wound.

In the absence of cool running water, burn dressings like the Waterjel Technologies dressing can be used to good effect to cool the burn. These dressings should be used as a replacement for cool running water and cling film combined, and once applied

should be left in situ - the dressings are made with no active ingredients and are designed to be washed off in hospital. It is important to note that the Waterjel Technologies dressings are designed to be placed directly onto the ‘hot’ burn injury.

Pain reliefBurns of any size can be very painful and adequate pain relief should be offered in all cases. Pain relief begins with cooling the burn, and covering it plays an important role as often friction between exposed nerve endings and the air proves very painful. Finally, analgesia should be given within your scope of practice with early recognition for extended skills. This enhanced care can be sought through the critical care desk (CCD), by changing your radio handset to channel 202.

Burn shock and fluid therapyIt is a widely accepted fact that severe fluid loss is the greatest problem faced following major burn injuries, and appropriate fluid management of major burns directly improves survival rates. Despite this unchallenged statement, there is still an ongoing debate regarding the best type of fluid management for burn-injured patients within the first 24 hours.

Burn shock develops over a period of time, it is not an immediate response. Shock caused through a burn is as a result of combined processes; an inflammatory response with the release of histamine and prostaglandins causes an increase

in capillary permeability. This in turn leads to localised oedema. Toxic cell metabolites are released which cause cellular membrane dysfunction, furthering the immune response. Previously injured tissue now becomes affected and further fluid loss can be seen here. The heat itself initiates the release of inflammatory and vasoactive mediators, and these mediators are responsible for systemic vasodilation and increased trans-capillary permeability. The resulting affect is a third-space fluid shift where circulating fluid in the vascular compartment moves to the interstitial space. This is ultimately lost externally through loss of the protective skin layers.

These processes can occur within a few minutes, but the true effects will often only be seen hours after the injury. If hypotension and a clinically shocked (pale, diaphoretic) patient is observed at the scene of the incident, double check that no other fluid loss, such as bleeding, is the cause.

Fluid therapy in the long term is titrated to effect, and careful calculations are made against the patient’s weight, their age, urine output and TBSA burnt. There is however something we can do in the short-term: JRCALC recommends one litre of 0.9% sodium chloride to be given to all adult patients suffering 15%-25% TBSA with a time to hospital greater than 30 minutes, and to all patients with more than 25% TBSA. Fluid therapy should also be considered with patients experiencing burns to their face, hands, feet and genitals.


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Is it just diarrhoea and vomiting?Neil Campbell, ECP and CSD clinician

Diarrhoea and vomiting is very common, usually self-limiting and will resolve itself after a few days.

The most common causes are viral, e.g. norovirus and rotavirus in children, or bacterial as caused by food poisoning.

Most cases can be treated at home without the need to see a GP or healthcare professional; if patients have no other relevant symptoms, history or red flags they should not attend A&E as their condition is highly infectious and can easily be passed on to other patients.

Obviously assessment is much easier when you’re face to face with a patient as you can treat what you can see, but when assessing someone over the phone you have no visual clues therefore questioning, active listening and use of knowledge are essential. You must establish a clear history, ask for all signs and symptoms, and try to

visualise what the patient would look like if you were

there in front of them. The questioning should look to identify red flags and consider differential

diagnosis as the diarrhoea

and vomiting may be symptomatic of other illness or medical problems.

Ask about the patient has previous history - is the diarrhoea overflow due to constipation, does the patient have a history of bowel problems such as irritable bowel syndrome or Crohns disease? Is the patient diabetic? Diabetic neuropathy can damage the nerves of the small intestine and diabetic diarrhoea can occur. Also ask about previous/past medical, surgical and treatment regimens (such as antibiotics or chemotherapy).

Diarrhoea and vomiting is potentially more problematic in the very young and very old and can lead to severe complications, particularly dehydration. To avoid this, encourage plenty of fluids - food is less important until the episode seems to be resolving. In adults, avoid dairy products and fatty foods. Babies still being breastfed should continue as normal, babies taking milk can continue with the milk but should avoid fruit juices, and both adults and children should eat a bland diet. A normal diet can be encouraged once clear of diarrhoea for 48 hours.

If the patient has no red flags, give rehydration and diet advice; explain good hygiene practices and advise on medication for fever control, i.e. paracetamol and ibuprofen; perhaps suggest pharmacist for rehydration therapy and give worsening advice.

As previously stated, dehydration is a very serious possible side effect of diarrhoea and vomiting and can be life-threatening.

Symptoms of dehydration to look out for in both the elderly and very young:

• Passing little urine

• Dry mouth, tongue and lips

• Fewer tears when crying (in the very young)

• Sunken eyes

• General weakness

• Lethargy and irritability.

Symptoms of severe dehydration include:

• drowsiness

• cold hands and feet

• dry nappies

• fast, shallow breathing.

Other red flags:

• Very high temperature

• Neck stiffness

• Non-blanching rash

• Acute onset surgical abdomen.

Any red flags would suggest a medical emergency and the patient should be transported to hospital with pre-alert given. If no red flags are present advise rehydration, diet, good hygiene practices and monitor.

If the patient is stable but you feel a doctor should see patient, then refer to a GP or the out-of-hours service. If leaving a patient at

home, even if you have made a referral to a GP, always give parents and carers worsening advise; tell them what red flags to look for and to seek medical care immediately should any red flags occur - either call back on 999 or, if safe to do so, make their own way to hospital.

Most diarrhoea and vomiting in very small children is caused by rotavirus, but since September 2013 a vaccine has been available, given as drops (by mouth) and is normally given between two to three months old.

Other complications of diarrhoea and vomiting, although rare, can lead to other medical conditions. These are known as reactive complications they can affect other parts of the body and manifest as: joint inflammation and arthritis; skin inflammation; eye inflammation such as conjunctivitis and blepharitis; and it can also spread to the meninges.

Children can also develop Haemolytic Uraemic Syndrome; it is very rare and potentially very serious and is caused by certain types of E-Coli infection. It can lead to anaemia, low platelet count and kidney failure, but if recognised and treated quickly most children will recover well.

Diarrhoea and vomiting is very common, not usually serious, and self-resolving. It should clear the body in five to seven days. However, it can become very serious and life-threatening. Next time you are treating a patient with diarrhoea and vomiting, ask yourself – is it just diarrhoea and vomiting?


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How high is high?

Damo Wheddon, Area Clinical Lead

Hypertension is a leading cause of heart disease and stroke. Many people who have hypertension are seen by clinicians each year, but many remain undiagnosed—essentially ‘hiding in plain sight’ within

clinical settings.

High blood pressure, or hypertension, affects seven million of us in the UK, but because hypertension rarely has symptoms, it’s not often a topic patients discuss with their GPs. Even while following best practices and providing the highest level of care, providers can have patients who are at risk for hypertension or who remain undiagnosed.

The exact causes of high blood pressure are not entirely known, but several factors and conditions are thought to play a role in its development:

• Smoking

• Being overweight or obese

• Lack of physical activity

• Too much salt in the diet

• Too much alcohol consumption (more than one to two drinks per day)

• Stress

• Older age

• Genetics

• Family history of high blood pressure

• Chronic kidney disease

• Adrenal and thyroid disorders

• Sleep apnoea.

So what do we do when we attend a patient and discover that they have a high blood pressure? Well first of all, one high reading doesn’t qualify your patient as being hypertensive; as with any baseline observation they need to be viewed as a trend and within the clinical presentation of your patient.


A look at hypertension


Cont. page 32

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• Stage 2 hypertension: Clinic blood pressure is 160/100mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95mmHg or higher.

• Severe hypertension: Clinic systolic blood pressure is 180mmHg or higher or clinic diastolic blood pressure is 110mmHg or higher.

It’s worth remembering that in emergency situations, an elevated BP may reflect the patient’s anxiety or pain.

The pulse pressure (difference between the systolic and diastolic) gives a rough indication of the elasticity of the arterial walls and the stroke volume (SV). In patients with arteriosclerosis, the arterial walls are stiffened and the pulse pressure is increased. In cardiogenic shock or cardiac tamponade the SV is reduced as the heart cannot pump effectively, so the pulse pressure is narrowed.

If your patient is symptomatic with high blood pressure or is in hypertensive crisis

(papilloedema, visual disturbances, limb weakness or other neurological symptoms/signs) , consider transport to hospital; these patients are at high risk of stroke, heart attack, heart failure, kidney damage and aortic aneurism.

If your patient has high blood pressure that’s not in the dangerous category, directly refer to the patient’s GP or out-of-hours provider, or get further advice by calling the Clinical Advice Line (CAL) on 07753 950843.

Please don’t ignore hypertension - your findings can make a significant difference to those patients with undiagnosed high blood pressure.

• Blood pressure monitoring should also be compared on both sides and with postural changes sitting/standing (some conditions such as aneurysm or stroke may cause blood pressure to vary from the right to the left side)

• In patients with symptoms of postural hypotension (falls or postural dizziness), measure initial blood pressure with the person either supine or seated. Consider a second reading with the person having stood for at least one minute prior to measuring

• If the difference in readings between arms is more than 20mmHg, repeat the measurements

• If the difference in readings between arms remains more than 20mmHg on the second reading, measure subsequent blood pressures in the arm with the higher reading

• Undertake 12-lead ECG monitoring.

Ideally the first blood pressure recording should be done manually using a calibrated, tested and in date sphygmomanometer. This is because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation). If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery. Healthcare providers must ensure that devices for measuring blood pressure are properly validated, maintained and regularly recalibrated according to manufacturer instructions.

So, all this raises the question of - how high is high? The NICE guidelines list this definition:

• Stage 1 hypertension: Clinic blood pressure is 140/90mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85mmHg or higher


British Heart Foundation: high blood pressure

NICE guidance: diagnosing hypertension


https://www.bhf.org.uk/heart-health/risk-factors/high-blood-pressure

https://www.bhf.org.uk/heart-health/risk-factors/high-blood-pressure

https://www.nice.org.uk/guidance/cg127/chapter/1-Guidance#/diagnosing-hypertension-2

https://www.nice.org.uk/guidance/cg127/chapter/1-Guidance#/diagnosing-hypertension-2

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The most common heart arrhythmia: managing AFDan Phillips, Area Clinical Lead

As many of you will know, atrial fibrillation, or ‘AF’, is a heart condition that causes an irregular and sometime

abnormally fast heart rate.

It is the most common heart arrhythmia and affects around one million people in the UK. It can affect adults of any age, but is more common in older people, with latest figures suggesting that as many as seven in every 100 people over 65 can be affected. More common in men than women, it’s often associated with people who have a history of cardiac disease and hypertension.

Pre-hospital management for these patients is relatively straightforward. Simply put, patients presenting with a new onset and no previous history of AF need to go to hospital for further assessment, and to risk-assess and mitigate any complications that AF can cause, like stroke or cardiac damage.

That said, there are other things to consider when assessing and caring for this group of patients. First, we have to identify the problem. As with all assessments, we start with our A-E approach. The focus in most cases of AF will be to the C (circulation) assessment, although there maybe effects on A (airway) and B (breathing) if the patient is

compromised.

The first indication of AF will likely be from the patient reporting irregular palpations, or when a radial pulse is taken and it is noted to be irregular. We have to investigate further and manage any priority symptoms; if an irregular pulse is identified, then cardiac monitoring needs to start. Printing of a rhythm strip will aid in the assessment and identification of AF - when presented with a rhythm strip we should apply our six stage approach, asking is it: narrow or wide; fast or slow; regular or irregular?

Atrial fibrillation can in fact present with any of these features, apart from being regular of course. It is also sometimes seen in a wide, complex pattern where there

is aberrant conduction, but this is difficult to diagnose without expert

interpretation. Once AF is identified, our goal is to manage any symptoms associated with it and convey to hospital. If a patient has

a normal but irregular rate and no adverse signs, they should be conveyed to hospital for further assessment; it is unlikely any interventions beyond monitoring will be required.

Importantly, we must observe the patient to identify any signs of

compromise. It is unlikely to see compromise in patients with AF, and a normal

heart rate, although they may report palpations, light

headedness and shortness of breath. Patient in ‘fast AF’ though

may well be compromised, and may display symptoms like shock, syncope,

myocardial ischemia or even cardiac

failure. If any of these red flags are present, the patient requires rapid transport to hospital and supportive measures to maintain adequate ABCs. The use of Valsalva maneuverers can be attempted if the patient is able. Carotid sinus massage can also be considered if you are competent and confident in auscultating for carotid bruits.

If the patient is compromised then consider requesting critical care support for cardioversion; synchronised cardioversion is the first line treatment in any patient with compromised tachyarrhythmia. However, it’s important to adequately assess and balance the risk of waiting on scene for critical care or transporting to hospital if this is closer. Similarly, if the patient is showing signs of myocardial ischaemia then instigate ACS management (if the patient can tolerate this), and the same is true if there are signs of heart failure.

Ultimately these patients require further specialist management that can only be provided in hospital. Our primary goal is to facilitate this, having carried out a thorough assessment and supported and cardiorespiratory compromise.



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Wound care and closureSteve Colmer, Emergency Care Practitioner

A dictionary definition: A wound occurs when the integrity of any tissue is compromised (e.g. skin breaks, muscle tears, burns, or bone fractures). A

wound may be caused by an act, such as a gunshot, fall, or surgical procedure, by an infectious disease, or by an underlying condition.

In 2006/7, more than 18 million patients attended an A&E department in UK. Not all, but many, would have called 999 and an ambulance attendance would have occurred. Around half of these patients had relatively minor injuries or illness, and at least one million of them could have been treated at the scene of the incident, rather than going to A&E.

With the advent of the primary care specialist paramedic role, new pathways are opening allowing ambulance clinicians to enhance the patient experience by referring patients to more appropriate management and subsequent discharge.

Wound care and closure is an obvious area to examine, as many of us in the past will have taken patients with no bone injuries but relatively minor skin tears to A&E departments in the absence of alternatives.

Wound care and management is a very specialist area within healthcare and well beyond this short article, but we do have the opportunity to examine some basic principles in managing minor wounds, and the current methods of wound closure available to both paramedics and emergency care practitioners (ECPs) within the Trust.

Why clean wounds?

Exploration: In simple terms wounds that contain dirt and coagulated blood are unable to be effectively assessed.

Infection: By irrigating the wound thoroughly with saline or drinking water, large and small particles of debris are removed, reducing the risk of colonisation by harmful bacteria that can cause infection.

Cosmetic: Poorly cleaned wounds may not heal properly, become infected, and then leave the patient with unsightly scars or ‘tattooing’ with embedded dirt.


Cont. page 38

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CQM 39


Wound cleansing methods

Vigorously clean around the non-injured area of the site and the edges of the wound, which will remove any dirt that may migrate into the wound. The generally accepted technique is to wipe away from the edges of the wound using saline soaked gauze swabs - one wipe then throw it away. In the absence of saline, drinkable tap water is better than leaving a wound dirty.

Irrigate (do not wipe) the open area of the wound with a high pressure jet of saline, making sure to protect yourself and others from splashback.

Irrigation techniques may include setting up a saline infusion and connecting an IV catheter with the sharp removed. This method may also use a 20ml syringe in place of the saline infusion.

Specifically designed products such as Steripods are perfect for the task and available from stores.

Types of wound closure

Self-adhesive strips (Steri-strip)

These are perfect for the management of pre-tibial lacerations and superficial wounds. They are also very useful for minor wounds to the face (within guidelines), where sutures and glue may be inappropriate or problematic. Steri-strips are especially useful with children, as application is painless and repeated attempts may be required.

Benefits:

• Less scarring when compared to sutures

• No local anaesthetic required before application

• Minimal preparation and equipment required

• Good for paediatrics

• Easy and painless to apply and comfortable once applied

• Can be used on paper thin skin

• Significantly cheaper than glue or sutures.

Drawbacks:

• Prone to coming off when applied on mobile areas such as finger joints, elbows and knees

• Comes off easily when exposed to water and sweat

• Can only be used for superficial wounds

• Less effective around areas where there is hair.

Tissue adhesive (LiquiBand®Optima)

Tissue adhesive is an extremely versatile product that can be used on many different types of wounds. These include the usual accidental injuries caused by patients falling, but any wound that falls within the inclusion criteria should be considered.

It is particularly good for scalp lacerations in children, but it should be noted that it is not suitable for pre-tibial lacerations. Its ambient storage meaning wastage is kept to a minimum.

Benefits:

• Stronger than sutures on wounds less than 5cm in length

• Easily taught and easy to apply

• Children prefer it to sutures as it doesn’t hurt.

Drawbacks:

• Unsafe to apply to wounds near the eyes, although it can be used on eyebrows with caution

• Should not be applied to wounds that are actively bleeding, as the wound needs to be perfectly dry

• Not the best option for patients known to be in a wet environment in the next five days, although the manufacture states that the product is water resistant

• Some patients, for example children and dementia sufferers, like to pick at the glue.

Sutures (ECPs only)

Sutures are suitable when self-adhesive strips or tissue adhesive can’t be ideally used.

Benefits:

• Secure, gold standard wound closure

• Patient able to continue full range of normal daily activities.

Drawbacks:

• Moderately difficult skill to master, so is lengthy to learn and become competent compared to other forms of wound closure; skill fade can also occur should the opportunity to practice not present itself that often

• The equipment required to carry out the procedure is relatively expensive

• Sutures are considered to be a surgical technique, requiring a greater level of aseptic practice.

DoH (2007) Attendances at accident and Emergency

departments and minor injury units. NHS organisations in

England, 2006-07.

DoH (2007). Reforming Emergency Care. Minor Illness

and injury.

DoH (2005). Taking Healthcare to the Patient; Transforming NHS

Ambulance Services

Royal Madsen Encyclopaedia of Clinical Nursing Practice


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