Pre-Hospital Emergency Care (PHEC) PDF

MPHEC: Pre-Hospital Emergency Care (PHEC) refers to the management of patients outside of a Medical Treatment Facility (MTF). Abdominal, loin and Scrotal Pain: ▪ Low threshold for transport to hospital/MTF, especially in the elderly. ▪ Assume that everyone >50 with abdominal pain has an...

MPHEC: Pre-Hospital Emergency Care (PHEC) refers to the management of patients outside of a Medical Treatment Facility (MTF). Abdominal, loin and Scrotal Pain: ▪ Low threshold for transport to hospital/MTF, especially in the elderly. ▪ Assume that everyone >50 with abdominal pain has an aneurysm and that every woman of child-bearing age with abdominal pain has an ectopic pregnancy until DEFINITIVELY proven otherwise. ▪ Support deranged physiology enroute to hospital. ▪ If able, consider giving antibiotics if significant intra-abdominal infection is suspected - Ceftolozane/tazobactam, Amoxicillin. ▪ Many relatively benign causes (biliary colic, gastroenteritis) can be extremely painful and mimic more severe pathology. Consider causes by: Etiology and/or Location of pain Etiology: Surgical Etiology Gynecological Medical Aetiology Etiology Aortic aneurysm and Ectopic pregnancy Myocardial Infarction (Heart dissection May present with Attack): Blockage of blood flow non-specific to the heart muscle, causing May present with symptoms, e.g. tissue damage. abdominal pain, back pain syncope, urinary Chest pain/pressure, shortness or renal colic-like pain. symptoms, of breath, sweating, nausea, and diarrhoea or pain radiating to the arm or jaw. shoulder tip pain without a 'missed period'. Bowel ischemia (Condition Placental Diabetic Ketoacidosis (DKA): A where blood flow to the abruption, serious complication of diabetes, intestines is reduced or where high blood sugar leads to completely blocked, leading Heavy vaginal the buildup of ketones in the to tissue damage due to a bleeding and other blood. lack of oxygen and pregnancy nutrients) complications Excessive thirst, frequent (e.g. mesenteric infraction urination, fruity breath odor, (Mesentry is the tissue nausea, vomiting, abdominal supplies blood to the pain, and confusion. intestines is obsutrctured often due to a clot) or volvulus (when a loop of the intestine twists around itself, causing a blockage and cutting off blood supply, potentially leading to bowel ischaemia) Typically presents with pain out of proportion to the clinical signs in older patients. Peritonitis (inflammation of Ovarian Torsion: Lower Lobe Pneumonia: the peritoneum, the thin Ovary twist around Infection affecting the lower part layer of tissue that lines the the ligaments that of the lungs. inside of the abdomen and support it, cutting off covers most abdominal its blood supply. Cough, fever, shortness of organs- caused by infection, breath, chest pain, and crackles injury, bacteria) heard in the lower lungs.  Presents with Caused by free bowel sudden, severe contents/acid/blood. pelvic pain, nausea, vomiting, and possible abdominal tenderness, requiring emergency surgical intervention. Acute bowel obstruction Mittelschmerz Sickle Cell Crisis: A painful (is a sudden and complete Pain due to episode in patients with sickle cell or partial blockage of the ovulation. disease due to blockage of blood intestines, preventing the vessels by abnormally shaped normal passage of food, Benign preovulatory red blood cells. fluids, and gas through the lower abdominal Sudden severe pain (especially digestive tract) pain that occurs in bones, chest, or abdomen), midcycle (between fever, swelling, and difficulty Pain, total days 7 and 24) in breathing. constipation(including women flatus) and vomiting with distended abdomen. Testicular torsion Hypercalcemia: Abnormally high levels of calcium in the blood. Pain may be referred to the abdomen. Nausea, vomiting, constipation, confusion, fatigue, and frequent urination. Urinary obstruction Abdominal Migraine: Recurrent episodes of abdominal An enlarged bladder can be pain, primarily in children, often missed if not percussed. linked to migraine. Severe, dull abdominal pain, nausea, vomiting, and pallor, often without headache. Abscesses (subphrenic, Gastritis: Inflammation of the pelvic or psoas abscess - stomach lining. Psoas abscess is a rare but Upper abdominal pain, nausea, serious infection that occurs vomiting, bloating, and in the psoas muscle, which indigestion. runs from the lower spine through the pelvis to the femur)  Pain and fever but may have few localising signs. Inflammatory Bowel Disease (IBD): Chronic inflammation of the digestive tract, including Crohn's disease and ulcerative colitis. Abdominal pain, diarrhea (often bloody), weight loss, and fatigue. Irritable Bowel Syndrome (IBS): A functional gastrointestinal disorder causing chronic abdominal discomfort and altered bowel habits. Abdominal pain, bloating, diarrhea, constipation, or alternating both. Risk stratify either by age and likely pathology, or abnormal vital signs, then treat pain and abnormal vital signs before transferring to an appropriate destination. - Can’t diagnose all problems pre-hospital often will need a CT scan. Military: Non-trauma Abdo pain is non-life-threatening and managed at R1 Whereas rarer surgical emergencies may need prolonged transfer to R2. Location: Right subcostal: Epigastric: Left subcostal: Right flank and groin: Central Abdomen: Left flank and loin: Right Iliac Fossa: Lower abdomen: Left Iliac Fossa: Location, nature and severity of pain: The pattern of pain may change over time - e.g. early appendicitis, mesenteric ischemia or bowel strangulation may begin as colicky pain (intermittent cramp like pain) and then become constant as the condition progresses; pain may localize as the parietal peritoneum becomes involved. The location of pain is not always a direct indicator of the cause. In some instances the pain can be experienced as referred in pain in a different area of the body. Pain and area radiated to: Onset of pain: Very sudden onset of pain suggests rupture or torsion of an organ (e.g., ruptured aneurysm, ectopic pregnancy, torsion of testis or ovary). Systemic symptoms: Fever, night sweats, weight loss Vomiting: May be due to severe pain (e.g., testicular torsion) gastroenteritis or obstruction Bleeding: Upper GI (hematemesis or melaena) or lower GI (rectal bleed) Vaginal bleeding or discharge: Consider gynaecological/obstetric causes. Past medical history: Note any similar episodes, note previous illness or surgery, note Medication/allergies/last meal Critical Abdominal Diagnoses in Military Personnel Appendicitis: Often dull lower abdominal pain which might be colicky in nature progressing to sharp, constant right iliac fossa pain, tenderness and local peritonitis. Suspect any person with significant abdominal pain with focal tenderness in RIF. Ectopic pregnancy: Suspect in any woman of child-bearing age with abdominal pain, especially if abnormal vital signs (evidence of shock) or PV bleeding. Typical time of presentation is 4-8 weeks into a pregnancy (only one missed period if regular). Ectopic pregnancy can be fatal. Peritonitis: Peritonitis is inflammation in your peritoneum, the tissue that lines the inside of your abdominal cavity. It's usually caused by an infection, and sometimes by irritating bodily fluids. Always suggests significant pathology although the early signs can be subtle and non-specific (i.e. they might not be peritonitis). Loin Pain: (portion of the body below the rib cage and just above the pelvis) ▪ Consider Abdominal Aortic Aneurysm (AAA) in anyone >50. ▪ Renal stones are relatively common however first presentation of renal stones in the elderly or in children is uncommon. ▪ Pyelonephritis (Pyelonephritis is a kidney infection that's usually caused by a bacterial infection) and urinary infections are more common in women ▪ Back pain is very common in all age groups. Signs and Symptoms:  ▪ Pyrexia – Pyelonephritis or abscess ▪ Hypotension – Ruptured abdominal aortic aneurysm ▪ Respiratory system examination- Basal pneumonia ▪ Abdominal examination – Several abdominal conditions can radiate to the back including pancreatitis ▪ Back examination Ruptured Abdominal Aortic Aneurysm: An abdominal aortic aneurysm (AAA) is a swelling in the aorta, the artery that carries blood from the heart to the tummy (abdomen). Transfer as an emergency to surgical Centre. Check which hospital with ambulance control as often a regional vascular on-call. Typically seen older patients, risk factors same as ischemic heart disease, typically present with flank/back pain and collapse, pain in stomach and back and pulsing feeling in tummy. Patients are often aware they have an aneurysm after screening. Renal Colic: ( Kidney stone) Renal or ureteric colic generally describes an acute and severe loin pain caused when a urinary stone moves from the kidney or obstructs the flow of urine May require role 3 capabilities such as CT scanning to determine if a stone is obstructing the kidneys. Confirmed renal colic will inevitably lead to aeromed home. ▪ Pain is sudden in onset, very severe and the patient is often writhing around. ▪ Pain may radiate to the groin and anteriorly. ▪ Often there is tenderness over the renal angle. ▪ Renal colic is rather more constant and persistent than biliary colic (temporary blockage due to gallstrones). ▪ Ask about blood in the urine - There is gross or microscopic haematuria in 85% (in the other 15% absence of gross or microscopic haematuria does not exclude renal colic). ▪ A stone that is moving may be more painful than one that is static. ▪ There should be no hypotension and opiate analgesia is likely to be required. Pyelonephritis: Pyelonephritis is a kidney infection that's usually caused by a bacterial infection. Can rapidly progress to severe sepsis and is not uncommon in younger (especially female) patients. Loin pain with features of sepsis needs urgent antibiotics and fluids and transfer to a medical treatment facility. ▪ The patients with pyelonephritis is ill, often with a very high temperature and rigors. ▪ There may be symptoms of urinary tract infection and vomiting. ▪ Pain, in contrast to renal colic, is often a constant dull ache. ▪ If signs and symptoms of systemic sepsis, consider early antibiotics and intravenous fluids. Testicular Torsion: Requires a low threshold of suspicion and immediate referral. Manage pain en route and take to nearest surgical facility. Is an emergency ▪ Difficult to exclude on clinical grounds; may mimic epididymo-orchitis (a condition that involves inflammation, swelling, and pain of the epididymis and/or testicles). ▪ Common in teenagers; rarer >30 years of age. ▪ Sudden or gradual onset; may have had previous self-limiting pain episodes. ▪ Painful; usually severe pain, which may radiate to the abdomen - always examine the testicles in younger males with severe abdominal pain. ▪ Cremasteric reflex is almost always absent. The cremasteric reflex is a superficial (i.e. close to the skin's surface) reflex observed in human males. This reflex is elicited by lightly stroking or poking the superior and medial (inner) part of the thigh - regardless of the direction of stroke. The normal response is an immediate contraction of the cremaster muscle that pulls up the testis ipsilaterally (on the same side of the body). ▪ Testis is often elevated or lying transversely. Strangulated Hernia: Hernias are not uncommon in military personnel and may develop over the course of a deployment, often without the individual being aware of the problem or dismissing the pain as a groin strain. A strangulated hernia occurs when the hernia (A hernia occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall) contents are ischemic due to a compromised blood supply. This phenomenon occurs most commonly when there is a small opening in the musculature and a significant quantity of contents within the hernia itself. Painful, swelling in scrotum or abdominal wall that cannot be got above, irreducible, may have peritonitis. Bold common in military personnel: ▪ Appendicitis ▪ Ectopic pregnancy ▪ Ruptured aortic aneurysm ▪ Peritonitis ▪ Pyelonephritis ▪ Testicular torsion ▪ Bowel obstruction ▪ Renal colic Cardiac monitoring and rhythm recognition: Monitoring leads: ▪ 3-lead system approximates to I, II, III ▪ Color coded ▪ Remove hair ▪ Apply over bone ▪ Lead setting (II) on ECG ▪ Set gain to appropriate level Defib paddles: ▪ Suitable for "quick look"  ▪ Movement artefact ▪ Risk of spurious asystole ▪ Most defibrillators no longer have paddles Adhesive monitoring electrodes: ▪ "Hands-free" monitoring and defibrillation ▪ Remember to set to "pads" on defibrillator ▪ Pacing will require both pads and 3 lead connected ▪ Synchronized DC shocks only required pads to be connected ▪ Automated External Defibrillators (AEDs) may provide a readable rhythm strip or may simply provide an interpretation of the rhythm ECG: Records rhythm, rate and electrical activity of the heart. P Wave: Caused by atrial depolarization (atria contract) initiated by the SA Node. ▪ Normal Rhythm: A normal P wave indicates healthy atrial depolarization and proper function of the SA node. ▪ Abnormalities: Abnormalities in the P wave or atrial depolarization can indicate conditions such as atrial enlargement, atrial fibrillation, or other arrhythmias. PR: Atrial depolarization is complete. It represents the time it takes for electrical impulses to travel from the atria through the atrioventricular (AV) node and into the ventricles. It is measured from the beginning of the P wave (the start of atrial depolarization) to the beginning of the QRS complex (the start of ventricular depolarization). Normal Range: The normal duration of the PR interval is typically between 120 to 200 milliseconds (0.12 to 0.20 seconds). This indicates normal conduction through the AV node. ▪ Short PR Interval: A PR interval shorter than 120 milliseconds may suggest conditions such as: Wolff-Parkinson-White (WPW) syndrome: An accessory pathway that allows for faster conduction. Lown-Ganong-Levine (LGL) syndrome: Another type of pre-excitation syndrome. ▪ Prolonged PR Interval: A PR interval longer than 200 milliseconds indicates delayed conduction through the AV node, which can be seen in: First-degree AV block: A consistent prolongation of the PR interval.  Second-degree AV block: Some impulses are dropped, leading to intermittent prolongation. Third-degree AV block: Complete dissociation between atrial and ventricular activity. QRS: Caused by ventricular depolarization which is the electrical activation of the ventricles leading to their contraction. It is measured from the beginning of the Q wave to the end of the S wave and typically reflects the time it takes for the electrical impulse to spread through the ventricles (80 to 100 milliseconds (0.08 to 0.10 seconds). ▪ Normal QRS Complex: A normal QRS interval indicates proper conduction of electrical impulses through the ventricles, usually through the normal conduction pathway (His-Purkinje system). ▪ Wide QRS Complex: A QRS interval longer than 100 milliseconds may indicate: Bundle Branch Block: A delay in conduction in one of the bundle branches. Ventricular Hypertrophy: Enlargement of the ventricular muscle. Myocardial Infarction: Areas of dead heart muscle can alter conduction. Electrolyte Imbalance: Such as hyperkalemia or hypocalcemia. Ventricular Rhythm: Such as ventricular tachycardia. ▪ Narrow QRS Complex: A QRS interval shorter than 80 milliseconds may suggest: Supraventricular Rhythms: Such as atrial fibrillation with rapid ventricular response. Pre-excitation Syndromes: Such as Wolff-Parkinson-White (WPW) syndrome. The ST interval represents the period between the end of ventricular depolarization and the beginning of ventricular repolarization (process by which the ventricles of the heart recover from depolarization after contraction). It is measured from the end of the S wave to the beginning of the T wave. ▪ The normal duration of the ST segment is typically 0.08 to 0.12 seconds (80 to 120 milliseconds). However, the duration may vary slightly depending on the heart rate. ▪ Normal ST Segment: A normal ST segment is typically flat (isoelectric – on the line) and indicates that the ventricles are in a resting state before repolarization. ▪ Elevated ST Segment: An elevated ST segment may indicate: a. ST-Elevation Myocardial Infarction (STEMI): This is a critical condition where there is an acute blockage of blood flow to the heart muscle, causing damage. b. Pericarditis: Inflammation of the pericardium can cause ST segment elevation. c. Early Repolarization: Commonly seen in young athletes, it can sometimes be mistaken for pathology. ▪ Depressed ST Segment: A depressed ST segment may suggest: a. Ischemia: Insufficient blood flow to the heart muscle, often seen during episodes of angina. b. Myocardial Infarction: Ischemia associated with a prior infarction. c. Electrolyte Imbalances: Such as hypokalemia. T wave: represents the repolarization of the ventricles, the process by which the heart's lower chambers return to their resting state after contraction. ▪ Duration: The T wave duration is generally less than 0.2 seconds (200 milliseconds). ▪ Amplitude: The height can vary, but it is generally smaller than that of the QRS complex. Abnormal T Waves: Changes in the morphology of the T wave can indicate various cardiac conditions: ▪ Inverted T Waves (Upside down): Often suggest myocardial ischemia, especially if they occur in the leads corresponding to the affected area of the heart.  ▪ Peaked T Waves (tall): Commonly associated with hyperkalemia (elevated potassium levels), indicating potential cardiac instability. ▪ Flattened T Waves: May indicate hypokalemia (low potassium levels) or other electrolyte imbalances. ▪ T Wave Changes in Other Conditions: Ventricular Hypertrophy: May cause tall, peaked T waves. Pericarditis: May lead to widespread ST elevation and altered T wave morphology. Myocardial Infarction: The T wave may become flattened or inverted as ischemia develops. Cardiac Arrest Rhythms: VF Bizarre irregular waveform No recognizable QRS complexes Random frequency and amplitude Uncoordinated electrical activity Coarse/Fine based on amplitude Exclude artefact – movement / electrical interference  Pulseless Ventricular Monomorphic VT: Tachycardia: Monomorphic ventricular tachycardia is an irregular heart rhythm where part of your heart beats too fast. Broad Complex rhythm Rapid rate Constant QRS morphology Polymorphic VT: Torsade de pointes Asystole Absent ventricular (QRS) Activity Atrial Activity (P Wave) may persist Rarely a straight-line trace Consider fine VF Non-Shockable PEA Clinical features of cardiac arrest Bizarre complexes hard to interpret Often slow or irregular when they are sometimes termed an agonal rhythm Non-shockable How to read a rhythm strip: Hemodynamic consequences of a rhythm will vary – Treat patient not the rhythm Normally use lead 2 1. Calculate ventricular rate (QRS) To calculate: If regular: 300 divide by number of large squares between adjacent R waves If irregular: Number of R waves within 30 large squares and multiply by 10 2. Assess is the QRS rhythm regular or irregular This may be unclear at rapid heart rates, compare R-R Intervals, irregularly irregular = AF You can mark a piece of paper with several consecutive R waves on then move along and see if it matches. See if pattern to irregularity or if it is truly irregularity Causes of regular rhythm ▪ NSR ▪ Sinus tachycardia ▪ Sinus bradycardia ▪ Supraventricular tachycardia ▪ Atrial flutter Causes of irregular rhythm ▪ Sinus arrhythmia ▪ Ectopic beats ▪ Pauses & blocks ▪ Atrial fibrillation ▪ Atrial flutter with variable block 3. Decide is the QRS width prolonged or normal: 0.12 seconds) is generally assumed to be ventricular unless proven otherwise.  Common Causes:  Ventricular Tachycardia (VT).  Ventricular Escape Rhythm.  Exceptions: Conditions like bundle branch blocks or Wolff-Parkinson- White syndrome may also cause broad QRS complexes. 5. Atrial Activity and Its Relationship to Ventricular Activity 1. Consistent Fixed PR Interval: a. Indicates normal conduction from atria to ventricles. b. Each P wave is followed by a QRS complex. c. Example: Normal sinus rhythm. 2. Variable but Recognizable Pattern:  a. Shows fluctuations in conduction time. b. Can indicate conditions like Wenckebach (type I second-degree AV block) or atrial flutter with variable conduction. 3. No Relationship – Atrioventricular Dissociation: a. Indicates complete disconnect between atrial and ventricular activity. b. P waves occur independently of QRS complexes. c. Example: Complete heart block (third-degree AV block). Broad Complex Tachycardia Assumed Ventricular Origin: Broad complex tachycardia (QRS duration > 0.12 seconds) is generally assumed to be ventricular unless proven otherwise. o Common Causes: ▪ Ventricular Tachycardia (VT). ▪ Ventricular Escape Rhythm. o Exceptions: Conditions like bundle branch blocks or Wolff-Parkinson- White syndrome may also cause broad QRS complexes. Heart block: Types of Heart Block First Degree Heart Block: a. Characterized by a constant, abnormally prolonged PR interval between the P wave and the QRS complex. b. Indicates delayed conduction through the AV node, but every atrial impulse is conducted to the ventricles. Second Degree Heart Block:  c. Mobitz Type I (Wenckebach): i. PR interval gradually increases until a QRS complex is dropped. ii. This pattern repeats in cycles. d. Mobitz Type II: i. Consistently missed QRS complexes without a progressive increase in the PR interval. ii. More serious than Type I, can progress to complete heart block. Third Degree Heart Block (Complete Heart Block): e. Total electrical dissociation between the atria and ventricles. f. Atria and ventricles beat independently, resulting in a lack of correlation between P waves and QRS complexes. Initial Actions in PHEC Cardiac Arrest The initial actions during a Prehospital Emergency Care (PHEC) cardiac arrest can be organized as follows: 1. High-Quality Chest Compressions (Right Side): a. Ensure compressions are performed with minimal interruption. b. Maintain adequate rate (100-120 compressions per minute) and depth (at least 2 inches for adults). 2. Monitoring/Defibrillation (Left Side): a. Continuously monitor the patient’s rhythm.  b. Administer defibrillation if indicated, especially for shockable rhythms (e.g., ventricular fibrillation, pulseless ventricular tachycardia). 3. Airway Management (Head): a. Establish and maintain a clear airway. b. Consider using adjuncts such as bag-mask ventilation or advanced airway devices as needed. 4. IV Access/Drugs (Right Side): a. Establish intravenous access to administer medications as per protocol. b. Administer drugs like epinephrine and amiodarone, depending on the rhythm and clinical guidelines. Movement Considerations In most cases, casualties should not be moved until return of spontaneous circulation (ROSC) is achieved. Exceptions: o Pediatrics: Special considerations for moving children based on specific protocols. o Tactical Situation: If the scene is unsafe, movement may be necessary. o Persistent VF/PVT: Cases that do not respond to defibrillation may require transport to an advanced care facility. o Special protocols may apply to hypothermic patients, including potential adjustments in resuscitation efforts. Additional help in UK PHEC: Prolonged Cardiac Arrests In certain circumstances, cardiac arrest may be prolonged, and specific considerations should be made to optimize outcomes. Early activation of critical care teams is advisable in these cases. The following situations are likely to result in prolonged resuscitation efforts: 1. Post-Thrombosis for Pulmonary Embolism: a. Patients may require extended resuscitation efforts due to the complex nature of the condition and potential for successful intervention. 2. Pregnancy: a. Cardiac arrest in pregnant patients may necessitate specialized protocols (e.g., left uterine displacement) and consideration of maternal and fetal outcomes. 3. Pediatrics: a. Pediatric patients may have different resuscitation needs and potential for recovery, requiring specialized pediatric protocols and expertise. 4. Hypothermia: a. Hypothermic patients can exhibit prolonged cardiac arrest due to a slowed metabolic rate; careful resuscitation efforts should continue until rewarming is achieved. 5. Post-Poisoning: a. Cardiac arrest resulting from poisoning may require prolonged resuscitation, especially if the toxin is reversible or if antidotes are available. 6. Healthy Young Patients: a. Young, healthy individuals may have a better chance of recovery; resuscitation efforts should be continued longer than in older or more comorbid populations. Asthma: Cardiac arrest in asthma patients often occurs after a period of hypoxemia linked to several critical factors: 1. Severe Bronchospasm and Mucous Plugging: a. Airway obstruction can lead to hypoxia, increasing the risk of cardiac arrest. 2. Cardiac Arrhythmias: a. Arrhythmias may arise due to hypoxia, stimulant drugs, or electrolyte abnormalities, contributing to cardiac arrest. 3. Hyperinflation: a. Air trapping and breath stacking due to hyperinflation can further compromise ventilation and oxygenation. 4. Tension Pneumothorax: a. This condition can occur in asthma patients and is a life-threatening emergency that needs prompt recognition and intervention. Ventilation Challenges Increased Airway Resistance: Ventilation may be difficult due to bronchospasm and increased resistance; therefore, gastric inflation should be avoided to reduce the risk of aspiration and further complicate ventilation. Management Strategies ▪ Early Intubation: Intubate the trachea early to secure the airway and facilitate effective ventilation. ▪ Recommended Respiratory Rate: Maintain a respiratory rate of 10 breaths per minute during ventilation to optimize gas exchange without over-inflating the lungs. ▪ Dynamic Hyperinflation Management: o If dynamic hyperinflation is suspected during CPR, consider: ▪ Compression of the Chest Wall: This can help reduce intrathoracic pressure. ▪ Disconnection of the Tracheal Tube: This may relieve gas trapping, improving ventilation. Tension Pneumothorax Considerations ▪ Difficult Diagnosis: Tension pneumothorax can be challenging to diagnose in asthma patients. Consider the possibility of bilateral tension pneumothoraxes, especially if there is significant respiratory distress or hemodynamic instability. Drowning: ▪ Most common in males 20-30. ▪ Drowning is defined as a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium. A person is prevented from breathing air. ▪ Hypovolaemia after prolonged immersion can cause cardiovascular collapse/arrest on removal from water - especially if person is upright. ▪ Keep person in horizontal position during and after retrieval. ▪ Give 5 initial ventilations ▪ If no response - start chest compressions in ratio of 30-2 ▪ Give high-flow oxygen ▪ Give rapid IV fluid to correct hypovolemia ▪ Consider modified approach if hypothermic Hypothermia: Hypothermia exists when body core temperature is below 35 degrees, with severe being 30 degrees Celsius. ▪ Intervals between drug dosages should be doubled - adrenaline 6-10mins.  ▪ If VF persists after 3 shocks, delay further attempts until core temp >30 degrees. ▪ Mechanical CPR device recommended. ▪ Blizzard heat packs recommended. Paeds: ▪ All would need be taken to hospital if resuscitation commenced. ▪ Temptation to scoop and run, but establish BLS first including a functional airway (iGel is preferred option). ▪ ALS interventions can be attempted enroute. ▪ Straight to IO advisable. ▪ Consider critical care team and pre-alert hospital early. ▪ Be aware that child protection reports are inevitable for those who have visited the scene. Pregnancy: ▪ Initially resuscitate as per ALS. ▪ Hand position may need to be higher. ▪ Manual displacement of uterus (easier) or left lateral tilt during CPR. ▪ IV/IO access above the level of the diaphragm. ▪ Peri-mortem C Section within 5 mins if >20/40 gestation and possible (critical care team). ▪ Early transport to ED at hospital with obstetric cover after 4 minutes of ALS. PE: ▪ A potential reversible cause if thrombolysis delivered by specialist teams (4Hs/4Ts). ▪ Suggested by history (immobility, recent surgery, oral contraceptive pill, young patient). ▪ Also suggested by signs of DVT, collapse with SOB and chest pain. ▪ Manage as per ALS. ▪ Critical care teams can deliver thrombolysis and mechanical CPR devices to scene. Alteplase (tPA): Tissue plasminogen activator. ▪ Tenecteplase (TNK-tPA): A more modern, weight-based thrombolytic. ▪ If this is used, then CPR should continue for up to one hour and mechanical CPR devices are often employed to assist with this. Traumatic Cardiac Arrest: Traumatic Cardiac Arrest has high mortality, but when ROSC is achieved, neurological outcome in survivors appears to be better than in other causes. Causes of cardiac arrest include - traumatic brain injury, hypovolemia, hypoxia, direct injury to organs or major vessels, tension pneumothorax, cardiac tamponade. Damage control resuscitation is required and is time critical. Other: ▪ Hanging - ALS ▪ Electrocution - ALS + fluids ▪ Persistent VF/pulseless VT - transport with ongoing ALS to hospital with PCI capability. ▪ Post-cardiac surgery - ALS and consider emergency thoracotomy (critical care team).  ▪ Poisoning: ALS and consider Naloxone if opiates. Critical Care team or transport to ED. Post ROSC Care and ACS: 24% of Cardiac arrest get ROSC and reached admission to hospital. Only 8/5% Survive past 30 days. Post cardiac Arrest Syndrome: Caused by whole-body ischemia (Less than normal blood flow) followed by reperfusion. It has a high mortality rate in patients who initially achieve ROSC after cardiac arrest. 4 components of post-cardiac arrest syndrome: ▪ Post-cardiac arrest brain injury ▪ Post-Cardiac arrest myocardial dysfunction ▪ Systemic ischemia/reperfusion response ▪ The pathological process that caused the cardiac arrest. Pre-Hospital Post ROSC Management: Do everything possible to prevent pre-arrest. Support physiology Treat reversible causes Transport to appropriate destination Consider the following: Critical care resources: Post-ROSC PHEA for agitated patients, blood products, additional drugs, ultrasound, surgical capability (relief of tamponade), mechanical CPR. POST ROSC: Examples of vasopressors and inotropes include: ▪ Vasopressors: These drugs increase vascular tone and blood pressure by constricting blood vessels: o Phenylephrine: Causes peripheral vasoconstriction and increases arterial pressure o Norepinephrine: A vasoconstrictive sympathomimetic that raises blood pressure o Epinephrine: A vasoconstrictive sympathomimetic that raises blood pressure o Vasopressin: A vasopressor drug o Terlipressin: A vasopressor drug  ▪ Inotropes: These drugs increase myocardial contractility, which can affect heart rate, blood pressure, and other factors: o Dobutamine: A synthetic catecholamine that increases cardiac output o Levosimendan: A calcium sensitizer that increases contractility without increasing cAMP levels o Milrinone: An inotrope o Enoximone: An inotrope Diagnosis: Reversible Pathology and their management: 1. STEMI (ST-Elevation Myocardial Infarction): a. Management: i. Thrombolysis: Administer thrombolytic agents to dissolve the clot. ii. PCI (Percutaneous Coronary Intervention): Perform angioplasty and stenting to restore blood flow. 2. Massive Pulmonary Embolism: a. Management: i. Thrombolysis: Use thrombolytic therapy to dissolve the embolus and restore pulmonary blood flow. 3. Hypovolemia: a. Management: i. Fluid/Blood Resuscitation: Administer IV fluids and/or blood products to restore circulating volume. 4. Hypothermia: a. Management: i. Rewarming: Use active warming techniques (e.g., blankets, heating devices) to raise the patient’s core temperature.  5. Hypoglycemia: a. Management: i. Glucose Administration: Administer oral glucose or IV dextrose to raise blood sugar levels. 6. Hyperkalemia: a. Management: i. Calcium Administration: Administer calcium gluconate or calcium chloride to stabilize cardiac membranes and protect against arrhythmias. 7. Cardiac Tamponade: a. Management: i. Drainage: Perform pericardiocentesis or surgical drainage to relieve pressure on the heart. 8. Tension Pneumothorax: a. Management: i. Decompression: Perform needle decompression (e.g., using a large-bore cannula) to relieve intrathoracic pressure. ii. Higher risk if asthma 9. Poisoning: a. Management: i. Antidote Administration: Administer specific antidotes based on the type of poison (e.g., naloxone for opioid overdose, activated charcoal for certain ingestions, Sodium Bicarbonate with tri-cyclic antidepressants) Ischemic Heart Disease: Appropriate recognition and treatment may prevent arrest. Post-arrest patients will benefit from transfer to specialist centres with PCI, device implantation and specialist rhythm management. Refractory VF should be transported to a PCI capable facility with CPR ongoing (critical care team can assist with additional drugs and mechanical CPR). Adults who are unconscious after cardiac arrest caused by suspected acute STEMI are not excluded from having coronary angiography (with follow-on primary percutaneous coronary intervention (PCI) if indicated). Differential Diagnosis in Chest Pain that can cause arrest: 1. Acute Coronary Syndrome (ACS) ACS, including heart attacks, blocks blood flow to the heart, causing ischemia. This can trigger arrhythmias (like ventricular fibrillation) or heart failure, leading to cardiac arrest. 2. Pulmonary Embolism (PE) A large blood clot in the lungs strains the right heart, causing right heart failure, severe hypoxemia, and obstructive shock. This can lead to arrhythmias and cardiac arrest. 3. Aortic Dissection A tear in the aorta can lead to rupture, cardiac tamponade, or blockage of coronary arteries. These result in internal bleeding, obstructive shock, or arrhythmias, causing cardiac arrest. Acute Coronary Syndromes (ACS) Is a term that encompasses a range of conditions associated with sudden reduced blood flow to the heart muscle, primarily due to the rupture of atherosclerotic plaques and the formation of blood clots in the coronary arteries 1. ST-Segment Elevation Myocardial Infarction (STEMI) Diagnosis: o ST Segment Elevation: Identified on a 12-lead ECG. o New-Onset Left Bundle Branch Block (LBBB): May also indicate STEMI. Management: o Administer ACS medications (e.g., antiplatelets, anticoagulants, nitrates).4 Antiplatelet reducing the risk of clot formation. Aspirin: Irreversibly inhibits cyclooxygenase-1 (COX-1), decreasing thromboxane A2 production. P2Y12 Inhibitors: Clopidogrel (Plavix): Blocks the P2Y12 receptor on platelets, preventing aggregation. Prasugrel (Effient): Similar to clopidogrel but with a more potent effect on platelets.  Anticoagulants: prevent blood clots from forming or growing larger by interfering with clotting factors. Unfractionated Heparin (UFH): Activates antithrombin, inhibiting thrombin and Factor Xa. Low Molecular Weight Heparins (LMWH): Enoxaparin (Lovenox): Inhibits Factor Xa more selectively. Direct Oral Anticoagulants (DOACs): Rivaroxaban (Xarelto) and Apixaban (Eliquis): Direct Factor Xa inhibitors. Nitrates: These drugs dilate blood vessels, reducing the heart's oxygen demand and alleviating chest pain. Nitroglycerin: Available in sublingual, oral, or IV forms for rapid relief of chest pain. Isosorbide Dinitrate: Longer-acting oral nitrate for ongoing angina management. Time-Critical Transfer: Transport to a facility with PPCI (Primary Percutaneous Coronary Intervention) capability. PPCI: A procedure to open the blocked coronary artery. Consider thrombolysis if PPCI is not available in a timely manner. 2. Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) Diagnosis: o Clinical history consistent with ACS. o ECG Findings: May show non-ST elevation ischemic changes or be normal. Management: o Administer ACS medications (e.g., antiplatelets, anticoagulants). o Time-Critical Transfer: Transfer to a facility for further evaluation and management. 3. Unstable Angina (UA) Diagnosis: o Cardiac chest pain occurring at rest or with minimal exertion. o ECG Findings: May show transient changes or be normal. Management: o Administer ACS medications (e.g., antiplatelets, nitrates).  o Time-Critical Transfer: Transfer for further assessment and management. Clinical History in ACS: ▪ Characteristics: o Location: Pain typically occurs in the chest, often radiating to the arms (especially the left arm), back, neck, jaw, or epigastric area. o Duration: Usually lasts longer than 15 minutes; may be persistent or intermittent. o Nature: Described as pressure, squeezing, tightness, or a burning sensation. ▪ Associated Symptoms: o Nausea and vomiting. o Diaphoresis (excessive sweating). o Dyspnea (shortness of breath). o Palpitations or irregular heartbeats. o Hemodynamic instability: Possible signs include hypotension, tachycardia, or altered mental status. Atypical Presentations ▪ Certain populations may present atypically with ACS symptoms, which can complicate diagnosis: ▪ Women: o It is more likely to report atypical symptoms such as fatigue, shortness of breath, nausea, and abdominal pain rather than classic chest pain. ▪ Diabetics: o May experience silent ischemia or atypical symptoms due to neuropathy, leading to diminished pain perception. ▪ Older Patients: o Often present with vague symptoms like confusion, weakness, or fatigue instead of classic angina, making it challenging to recognize ACS. Pre-Hospital Management of Acute Coronary Syndrome (ACS): MONA MONA is an acronym that represents the key components of pre-hospital management for patients experiencing acute coronary syndrome (ACS). Drugs 1. Morphine: a. Dosage: Administer 2.5–10 mg IV. Every 5-15 minutes. b. Repeat: Can repeat to a total of 20 mg if needed for pain relief. c. Indication: Provides analgesia and may help reduce myocardial oxygen demand. 2. Oxygen: a. Target: Titrate oxygen to maintain SaO2 > 94%. b. Supplemental Oxygen: Administer if SaO2 is below 94%. c. Considerations: For patients with known or suspected COPD, aim for an SaO2 of 88-92% to avoid the risk of hypercapnic respiratory failure. 3. Nitrates (Glyceryl Tri-Nitrate, GTN): a. Administration: Available as a spray or tablet. b. Dosage: Repeat every 5–10 minutes if chest pain persists and blood pressure is >90 mmHg systolic. c. Cautions: Do not administer if the patient has low blood pressure, as this can worsen right-sided heart function and compromise preload. 4. Antiplatelet Medication: a. Aspirin: Administer 300 mg PO for immediate antiplatelet effect. b. Clopidogrel: i. 300 mg PO as an adjunct to thrombolysis.  ii. 600 mg PO as an adjunct to PPCI (Primary Percutaneous Coronary Intervention). Discharge at Scene Pathway: The discharge at scene pathway is akin to military protocols for transferring patients, specifically to a Role 1 facility, while avoiding higher-level care facilities (Role 2 or 3). Spinal Injury Considerations Hospital Transfer: All patients suspected of having a spinal injury should be transported to the hospital. NEXUS Criteria The NEXUS (National Emergency X-Radiography Utilisation Study) criteria help determine whether trauma patients require cervical spine imaging. Patients who do not require imaging must meet all the following criteria: 1. Alert and stable: The patient is conscious and hemodynamically stable. 2. No focal neurologic deficit: Absence of weakness, numbness, or other neurological signs. 3. No altered level of consciousness: The patient is fully aware and oriented. 4. Not intoxicated: The patient does not have a significant level of alcohol or drug intoxication. 5. No midline spinal tenderness: No tenderness along the spine when palpated. 6. No distracting injury: No other injuries that may distract from a potential spinal injury. JRCALC Modifications The JRCALC (Joint Royal Colleges Ambulance Liaison Committee) guidelines modify NEXUS to include an additional criterion:  Patient complaint of spinal pain: If the patient reports pain in the spinal region, imaging is indicated. Canadian C-Spine Rule Recommendation: The Canadian C-spine rule is favored by the National Institute of Clinical Excellence (NICE) for assessing the need for cervical spine imaging. Sensitivity: It has shown over 99% sensitivity in detecting significant cervical spine injuries during initial in-hospital studies. Concerns About Fractures: If there are any concerns regarding potential thoracic or lumbar fractures, immobilization is essential. JRCALC Recommendations Full Immobilization: o Collar and Blocks: The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) recommends full immobilization, including the use of a cervical collar and spinal blocks, when there is suspicion of thoracic or lumbar injury. Self Extrication in Cervical Injuries: o For patients with suspected cervical injuries who are alert and have no distracting injuries, they may self-extricate from vehicles if possible. This should be done before lying down on a trolley for immobilization. Head Injury Management Criteria for Referral to Hospital: Patients with head injuries should be referred to a hospital if any of the following criteria are met: Medical History Previous Brain Surgery: History of prior surgeries on the brain. Bleeding or Clotting Disorders: Any history indicating issues with blood coagulation. Type of Injury High-Energy Head Injury: Involvement of significant force or trauma.  Complex Skull Fracture: Any suspicion of complex fractures of the skull. Penetrating Injury: Evidence of objects penetrating the skull. Consciousness Level: Unconsciousness or lack of full consciousness following the injury. Symptoms Following Injury New Focal Neurological Deficits: Any loss of function or ability related to specific body areas. Seizures: Any seizure activity since the time of injury. Persistent Headache: Continuous headache that began after the injury. Amnesia: Inability to recall events before or after the injury. Vomiting Episodes: Any occurrences of vomiting since the injury. Irritability or Altered Behavior: Notable changes in mood or behavior. Other Considerations Anticoagulant or Antiplatelet Treatment: Current use of anticoagulants or antiplatelet medications (excluding aspirin). Drug or Alcohol Intoxication: Current impairment due to substance use. Safeguarding Concerns: Issues related to the patient’s safety or welfare. Professional Staff Concerns: Any concerns raised by healthcare professionals regarding the patient's condition. Focal Neurological Deficit Definition: Focal neurological deficits are problems restricted to specific areas or functions, which may include: Difficulties with understanding, speaking, reading, or writing. Decreased sensation or altered sensation in specific body parts. Loss of balance or coordination. General weakness in limbs or other areas. Visual changes, such as blurred or double vision. Abnormal reflexes or issues with walking. High-Energy Head Injury Characteristics: High-energy head injuries are typically associated with significant trauma and can lead to a range of neurological deficits similar to those outlined above. Limb Injuries: Clinical Rules for Discharge Clinical Rules: The Ottawa Ankle and Knee Rules help determine the need for imaging and facilitate appropriate discharge pathways, such as to minor injury units. Ottawa Ankle Rules The Ottawa Ankle Rules are designed to rule out clinically significant foot and ankle fractures and reduce unnecessary X-ray imaging. The criteria include: X-ray is required if any of the following are present: o Bone tenderness at any of the following locations: ▪ Posterior edge or tip of the lateral malleolus (outer ankle bone). ▪ Posterior edge or tip of the medial malleolus (inner ankle bone). o Inability to bear weight both immediately after the injury and during the examination (i.e., cannot take four steps). Ottawa Knee Rules The Ottawa Knee Rules help determine the necessity of X-ray imaging for knee injuries. X-rays are indicated if any of the following criteria are met: Age: Patient is 55 years or older. Tenderness: o Tenderness at the head of the fibula. o Isolated tenderness of the patella (kneecap). Inability to flex the knee: o Patient cannot flex the knee greater than 90 degrees. Inability to bear weight: o Inability to bear weight both immediately after the injury and during the examination (i.e., cannot take four steps). Drowning: Submersion and Immersion Drowning is defined as a process that results in primary respiratory impairment due to submersion in a liquid medium.  Submersion: Occurs when the head goes below the liquid. Immersion: The body enters the liquid while the head remains above it, although water may still be aspirated or ingested. Key Facts Many drowning incidents happen within a few meters of safety, often involving victims who are otherwise healthy and physically capable. Proposed mechanisms for drowning include: o Cold Shock o Exhaustion ("swim failure") o Hypothermia Cold Shock Cold Shock encompasses both respiratory and cardiovascular effects that can lead to rapid incapacitation upon sudden immersion in cold water (typically below 15°C). Respiratory Effects Rapid, Uncontrollable Breathing: This can lead to water aspiration. Hyperventilation: May result in muscle weakness and incapacitation. Cardiovascular Effects Sympathetic Nervous System Response: The "fight or flight" response can elevate heart rate and blood pressure. Potential Complications: This can precipitate:  o Cardiac arrhythmias o Myocardial ischemia o Cerebrovascular accidents (strokes) Timing: Cold shock is most critical in the first 3 minutes of immersion, after which the effects of cold fatigue may begin to manifest, potentially leading to hypothermia. Mammalian Diving Response (MDR) The Mammalian Diving Response is triggered when the face or oropharynx is exposed to cold water. This response involves: Slowing of the Heart Rate: Driven by the parasympathetic nervous system. Autonomic Conflict: Simultaneous activation of the sympathetic and parasympathetic nervous systems can lead to fatal arrhythmias, even in healthy individuals. Exhaustion and Hypothermia Swim Failure: ▪ Prior to hypothermia, conditions like shivering and muscle stiffness can impair swimming ability, often termed "swim failure." This is particularly evident in individuals with significant skin exposure to cold water. Why Drowning Can Be Fatal Hypoxia: ▪ The primary clinical concern in drowning incidents is hypoxia. ▪ Aspiration of Fluid: Water entering the lungs leads to respiratory impairment. If severe or prolonged, this can result in cardiac arrest. ▪ Early Intervention: Rapid action to alleviate hypoxia is crucial for improving survival chances. Freshwater vs. Saltwater Drowning ▪ Freshwater Drowning: o Destroys lung surfactant. o Causes rapid fluid movement into circulation, leading to hemodilution and alveolar collapse. ▪ Saltwater Drowning: o Draws water into the lungs, causing greater alveolar fluid accumulation and cardiovascular collapse. o Has a lesser effect on surfactant compared to freshwater. Note: Treatment approaches are the same for both types of drowning. Complications of Submersion and Immersion 1. Hypothermia: a. Considered in all cases, as it can mimic death signs. b. Protective effects can occur (e.g., reduced oxygen consumption with lower core temperatures), particularly in children.  c. Milder hypothermia may provoke cardiac arrhythmias upon rewarming. 2. Injuries: a. Always assess for head and spinal injuries, especially in cases involving diving into shallow water. b. Injuries may be either a consequence of the drowning event or a contributing factor. 3. Post-Immersion Circulatory Collapse: a. Victims often float vertically in water, leading to increased pressure on the legs. b. Vasoconstriction from cold water results in hypovolemia due to increased urinary output. c. Upon rescue, loss of pressure combined with warming can lead to life-threatening cardiovascular collapse. d. Recommendation: Keep the patient flat during rescue to mitigate risks. 4. Respiratory Complications: a. Potential outcomes include respiratory distress, pulmonary edema, and infection. b. Recognize that respiratory function may deteriorate in the hours following a near-drowning incident, potentially leading to ARDS or pneumonia. c. Treatment: Administer high-flow oxygen and address bronchospasm with nebulized salbutamol. Prognosis Immersed Victims: Generally, have a better prognosis compared to submerged victims. Scene Management Considerations Resuscitation Guidelines: o Submersion for 90 minutes: Resuscitation is warranted if the water temperature is below 6°C or if a child is involved. o Good Outcomes: Occasionally observed in small children after prolonged submersion, especially in cold water. Clinical Management of Drowning Victims Assess A-E (Airway, Breathing, Circulation): Airway Management Clear Airway: Ensure the airway is clear and free from obstruction.  Suction Ready: Maintain suction at hand due to the high risk of regurgitation. Ventilation Importance: Adequate ventilation and oxygenation are crucial for restoring cardiac activity. Assisted Ventilation: Consider assisted ventilation if: o SPO2 < 90% o Respiratory rate (RR) < 12 or > 30 o Inadequate lung expansion based on the patient's consciousness level. Challenges: Ventilation may be difficult due to reduced lung compliance if water has been inhaled. Even with large volumes of water, the lungs can still be ventilated. Cardiac Arrest Protocol Inflation Breaths: If the patient is in cardiac arrest, administer 5 inflation breaths before commencing CPR. Oxygen Administration Oxygen for All: Administer oxygen to all patients initially, as SPO2 readings may be inaccurate due to cold peripheries. Compression-only CPR is inadequate without oxygen. Monitoring Cardiac Arrhythmias: Monitor closely, as hypothermia can lead to very slow or undetectable heart rates. ECG: Perform a 12-lead ECG to assess cardiac function. CPR Compressions: Begin compressions when on a firm surface and appropriate for age. Response: Bradycardia often improves with better ventilation and oxygenation. Be aware that hypothermia may cause cardiac dysrhythmias. Concomitant Injuries Neck and Back Injuries: Always consider and treat any potential neck or back injuries. Warming Warm Slowly: Avoid rapid rewarming unless the patient is in cardiac arrest. IV Fluids Fluid Consideration: Consider administering IV fluids if available, as prolonged immersion may lead to hypovolemia. Do not hypotensive-resuscitate drowning victims; follow fluid guidelines for management. Positioning Keep Flat: Maintain the patient in a flat position to avoid postural drainage. Note that 80% will aspirate water into the stomach, and tilting the patient can move water back into the pharynx, further compromising the airway. Observations Asymptomatic Cases: Consider observing all asymptomatic near-drowning cases for at least 6 hours. Symptomatic Patients: Admit all symptomatic patients for further evaluation and management. Capnography in pre-hospital emergency care: The end-result of cellular respiration is the waste gas Carbon Dioxide (CO2). This is transferred in the bloodstream from the site of cellular respiration (the mitochondria) to the lungs. In the lungs, CO2 diffuses into the alveoli down a concentration gradient. Ventilation of the lungs results in CO2 being expelled into the atmosphere. ETCO2: ETCO2 may be recorded either through monitoring attached to airway devices (such as endotracheal tubes and iGels), or through nasal prongs for spontaneously breathing patients. Monitors record ETCO2 either simply as a number or as a constant waveform which gives us much more information. The number is referred to as capnometry, the graph is referred to as waveform capnography. Normal Values of CO₂ in Respiration Inspired Air: o CO₂ Level: 0.04 kPa (0.3 mmHg) Alveolar Air: o CO₂ Level: 5.3 kPa (40 mmHg) Expired Air: o CO₂ Level: 3.6 kPa (27 mmHg) ETCO₂ Readings in Different Conditions Nasal Specs: o Reading: 3.6 kPa  Intubated Patients: o Reading: 4.5 kPa to 5.5 kPa Criteria for Sustained ETCO₂ Monitoring To record a sustained ETCO₂, a patient must have: An Airway (intubated or otherwise secured) Be Ventilating (spontaneously or with assistance) Have Functional Circulation (spontaneous circulation or during CPR) Uses of ETCO₂ Monitoring Confirm Tracheal Placement: Essential for verifying correct placement of the endotracheal tube during intubation. Confirm Ventilation: Allows for monitoring and recording the rate of ventilation. Measure Circulatory Adequacy: Particularly important during cardiac arrest scenarios. Important Considerations Intubation Protocol: If ETCO₂ monitoring is unavailable, intubation should not be performed. ETCO₂ Trace During CPR: There should always be an ETCO₂ trace during CPR when a tracheal tube is in place, even if the readings are low. Absence of ETCO₂: A lack of ETCO₂ suggests potential esophageal intubation or equipment failure. Waveforms: Types of waveform: Normal, Hyperventilation (falling CO2 level, higher rate), Hypoventilation (increasing CO2 level, lower rate), Lower airway obstruction (sloping plateau, 'sharks fin'), Oesophageal intubation (rapidly falling CO2, abnormal waveform). Normal Waveform: Features: o Expiratory Upstroke: The initial rise in CO₂ during expiration. o Expiratory Plateau: A flat phase where CO₂ remains steady. o D = ETCO₂ Value: The peak value during expiration. o D-E = Inspiration Begins: Transition point indicating the start of inhalation. Hyperventilation: Characteristics: o Rapid respiratory rate. o ETCO₂ Level: Rapidly falling, indicating decreased CO₂ in exhaled air. Hypoventilation: Characteristics:  o Slower respiratory rate. o ETCO₂ Level: Increasing due to insufficient ventilation. Lower Airway Obstruction: Characteristics: o Waveform Shape: Sloping plateau or “shark fin” appearance. o Indicates a prolonged expiratory phase due to obstruction. Oesophageal Intubation: Characteristics: o Waveform: Rapid decline in ETCO₂ over several ventilations. o Indicates potential oesophageal placement of the tube, which requires urgent removal or confirmation of cardiac arrest. Causes of Oesophageal Intubation Possible Causes: o Missed intubation attempt. o A normal capnogram is the best indicator of proper ET tube placement. o When the ET tube is in the esophagus, little to no CO₂ will be detected in the exhaled air. Reading Waveforms: CO₂ Levels and Their Implications Reasons for Higher Than Expected CO₂ Levels: 1. Hypoventilation: a. Effect: Reduced respiratory rate leads to CO₂ accumulation in the body. 2. Increased CO₂ Production: a. Causes: Conditions that elevate metabolic activity (e.g., fever, sepsis). 3. Reduced CO₂ Excretion: a. Conditions: i. COPD (chronic obstructive pulmonary disease) where ventilation is impaired. 4. Medications:  a. Examples: Administration of sodium bicarbonate, which can increase blood CO₂ levels. Reasons for Lower Than Expected CO₂ Levels: 1. Hyperventilation: a. Effect: Increased respiratory rate causes excessive CO₂ removal (blowing off CO₂). 2. Reduced Cellular Respiration: a. Considerations: i. Evaluate if the heart is functioning normally. ii. Assess if oxygen is adequately delivered to tissues. 3. Cardiac Arrest: a. Implication: Poor quality CPR may not effectively circulate blood, impacting CO₂ levels. Important Note: Total Absence of ETCO₂: o Urgent consideration should be given to: ▪ Misplaced endotracheal tube in intubated patients. ▪ Possible equipment failure, necessitating immediate troubleshooting. ETCO₂ Devices 1. Easi-Cap: a. Function: Provides a color change in the presence of CO₂. 2. EMMA:  a. Function: Delivers continuous CO₂ measurements. b. Features: Capable of displaying a graph, depending on the model. 3. Monitor: a. Type: Waveform capnography monitor (e.g., Tempus Pro). b. Function: Offers real-time monitoring of ETCO₂ levels with graphical representation. Causes increased ETCO2 Causes decreased ETCO2 Respiratory Respiratory insufficency Alveolar Hyperventilation Respiratory depression Bronchospasm Obstructive pulmonary Mucous Plugging disease Partial airway obstruction Effective bronchodilator ETT in hyopharynx therapy Pulmonary embolus Decreased minute Increased minute ventilation ventilation Circulatory Increased CO with constant Cardiac arrest ventilation Embolism Sudden hypovolemia Sudden hypotension Decreased CO Metabolism Pain Analgesia / sedation Hyperthermia Hypothermia Malignant Hyperthermia Shivering Equipment Defective exhalation valve Leak in airway system Exhaused Co2 absorber Iatrogenic NAHCO2 infusion Torniquet release Intoxication and poisoning: Intoxication: A transient condition that follows the administration of a psychoactive substance and results in disturbances in the level of consciousness, cognition, perception, judgement, affect, or behavior, or other psychophysiological functions and responses. Intoxication: Intoxication is highly dependent on the type and dose of drug and is influenced by an individual's level of tolerance and other factors. Frequently, a drug is taken in order to achieve a desired degree of intoxication. Acute intoxication: Acute intoxication is the term in ICD-11 (WHO 2019) for intoxication of clinical significance. Complications may include trauma, inhalation of vomitus, delirium, coma and convulsions, depending on the substance and method of administration. Assessment of alcohol intoxication: Local policies determine treatment protocol. A blood sugar should be obtained for anyone who appears intoxicated. Poison: Any substance that interferes with normal bodily functions after it is swallowed, inhaled, injected, or absorbed. The branch of medicine that deals with the detection and treatment of poisons is known as toxicology. Types of Poisons and Their Effects: 1. Metabolic Interference: a. Example: Cyanide b. Effect: Disrupts cellular respiration. 2. Organ Damage: a. Examples: Heavy metals (e.g., lead, mercury) and paracetamol. b. Effect: Can lead to liver or kidney damage. 3. CNS Depression: a. Examples: Diazepam, heroin. b. Effect: May cause coma and respiratory/circulatory failure. 4. Respiratory and Circulatory Impact: a. Example: Carbon monoxide. b. Effect: Affects oxygen transport and can lead to hypoxia. 5. Corrosive Agents: a. Examples: Bleach, acids. b. Effect: Cause tissue damage on contact. Diagnosis and Management of Poisoning Diagnostic Approach: Identification Challenges: It is often difficult to positively identify the specific poison. Clinical Examination: o Use the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure) along with a glucose check. o Essential for assessing the severity of poisoning. Toxidromes: o Many poisons produce distinct symptoms, known as toxidromes, which assist in identification. Management: Supportive Treatment: o Most treatments are supportive, even in intensive care settings. Specific Antidotes: o Some poisons have specific antidotes (e.g., naloxone for opioid overdose). Classification of Poisoning 1. Unintentional or Accidental Poisoning Common Demographics: o Most frequently seen in children under five. o Common substances: tablets, household chemicals, and certain plants. Older Children and Adults: o May accidentally ingest chemicals from bottles with unclear labeling. Statistics: o Responsible for approximately 1000 deaths annually in the UK. o 50% of these deaths are attributed to opiate/opioid poisoning. Body Packers:  o Drug smugglers who conceal drugs wrapped in condoms or latex within the body (e.g., in the bowel, rectum, or vagina). o Risk of fatal poisoning occurs if the package leaks. Clinical Note: o Always consider opiate/opioid poisoning if the relevant toxidrome is present. 2. Deliberative Poisoning Prevalence: o Accounts for one-third of all acute poisoning cases. o Typically involves intentional overdoses or substance abuse. Common Substances: o Paracetamol (Acetaminophen): accounts for 50% of all intentional self- poisoning cases. o Other common substances include non-steroidal anti-inflammatory drugs (NSAIDs) and antidepressants. 3. Non-Accidental Poisoning Fabricated or Induced Illnesses: o Rare cases where a parent deliberately poisons a child. o Always consider child protection protocols in suspected cases. Homicidal Poisoning: o Also rare; may involve either acute or chronic poisoning with various chemicals. Assessment and Management of Poisoning Resus-RSI-DEAD Protocol 1. RESUS: Resuscitation a. Airway: Ensure the airway is clear and patent. b. Breathing: Assess breathing; provide support if needed. c. Circulation: Evaluate circulatory status; perform CPR if necessary. 2. Detect and Correct: a. Hypoglycaemia: Check blood sugar levels and treat as necessary.  b. Seizures: Monitor for seizures; provide appropriate management. c. Hyper/Hypothermia: Assess and manage body temperature abnormalities. d. Emergency Antidote Administration: Administer specific antidotes if indicated. 3. Risk Assessment: a. Drug: Identify the substance involved. b. Dose: Determine the amount taken. c. Time Since Ingestion: Establish how long ago the substance was ingested. d. Clinical Features and Course: Observe and document symptoms and their progression. e. Patient Factors: Consider age, weight, pre-existing conditions, and other individual factors. Note: If the patient is alert, they may provide information about the substance taken. Look for discarded packets and bottles to gather additional data. Check for dispensed dates on prescriptions, which can help assess if the medication was recently acquired. 4. UK TOXBASE: a. Most commonly used online database for poison management. b. Contact the National Poisons Information Service (NPIS) via the ambulance service clinical hub in the UK for further advice. 5. Supportive Care and Monitoring: a. Morbidity and mortality often arise from the effects of poisons on the respiratory, cardiovascular, and central nervous systems. Supportive treatment can range from IV fluids to intensive care unit (ICU) admission, depending on the severity. 6. Investigations: a. Screening: Perform a 12-lead ECG on all unconscious patients, as many overdoses can cause significant ECG changes (e.g., bradycardia, tachycardia, QRS prolongation, heart block, QT prolongation). b. Paracetamol: Specific testing for paracetamol levels if suspected. 7. DEAD: a. Decontamination: i. Skin or clothing may need decontamination. ii. Activated Charcoal: Used for gastrointestinal decontamination if the patient presents within one hour of ingestion of certain poisons. The patient must be fully conscious and able to protect their airway. b. Enhanced Elimination:  i. Pre-hospital: Focus on ensuring good hydration. ii. In Medical Treatment Facility (MTF): Options include urinary alkalinization, hemodialysis, and hemofiltration for certain poisonings. c. Antidotes: i. Pre-hospital: 1. Opiates/Opioids: Naloxone 2. Cyanide: Hydroxocobalamin 3. Carbon Monoxide: High-flow oxygen 4. Nerve Agents: Combopen (atropine, pralidoxime, diazepam) 5. Tricyclic Antidepressants e.g. amitriptyline: Sodium bicarbonate ii. In MTF: 1. Beta Blockers: Glucagon 2. Paracetamol: N-Acetyl cysteine 3. Methemoglobinemia: Methylene blue 4. Digoxin: Digi-bind 5. Ethylene Glycol/Methanol: Ethanol or Fomepizole 6. Cyanide: Hydroxocobalamin, sodium thiosulfate, sodium nitrite, dicobalt edetate 8. Disposition: a. Non-intentional Exposures: May be suitable for discharge if they meet local guidelines, including: i. The substance is verified as harmless by TOXBASE or NPIS. ii. A responsible adult is present to monitor the patient. iii. The patient is advised to seek medical attention if they feel unwell. iv. The patient’s health visitor or general practitioner (GP) is informed. Overdose: Always check glucose levels in overdose. Deliberate overdoses usually involve an element of mental health or capacity issues. In general, all deliberate overdoses will need transportation to a MTF. All unintentional overdoses should have a mental health assessment. Mass Poisoning: Overview and Response Definition: Mass poisoning refers to situations where multiple individuals are affected by a toxic substance, leading to a public health emergency. Possible Sources of Mass Poisoning: 1. Industrial Accidents: a. Chemical Spills: Accidental releases of hazardous chemicals in factories or during transport can result in widespread exposure. b. Chemical Manufacturing Plants: Explosions or leaks in facilities producing toxic substances can endanger nearby communities. 2. Domestic Accidents: a. Carbon Monoxide Poisoning: Often occurs due to faulty heating systems, poorly ventilated spaces, or the use of gas appliances. Symptoms can affect multiple household members. 3. Terrorist Attacks: a. Use of Nerve Agents: Intentional release of chemical weapons, such as sarin or VX, in public spaces can lead to mass casualties. b. Biological or Chemical Warfare: Attackers may use toxins to incapacitate or kill large numbers of people. Symptoms of Early Poisoning: Symptoms may mimic common conditions, such as anxiety or flu, including: o Nausea o Vomiting o Headaches  o Dizziness o Confusion o Shortness of breath Note: The overlap in symptoms can lead to misdiagnosis or delayed treatment. Key Indicators to Suspect Mass Poisoning: Presence of 2 or more casualties with similar symptoms. Rapid onset of symptoms in a community or specific area. Exposure to a potential source, such as an industrial facility or after a specific event (e.g., public gathering, food festival). Safety and Response Measures: 1. Personal Safety: a. Do Not Put Yourself at Risk: Avoid entering areas suspected to be contaminated without proper protective equipment. 2. Call for Specialist Assistance: a. Hazardous Area Response Teams (HART): Trained teams equipped to handle hazardous materials incidents. b. Chemical, Biological, Radiological, and Nuclear (CBRN) Teams: Specialized units capable of identifying and responding to chemical or biological threats. 3. Emergency Response: a. Evacuation: If safe to do so, evacuate affected individuals to minimize further exposure. b. Decontamination: Ensure that individuals exposed to toxic substances are decontaminated to prevent secondary contamination.  c. Monitoring and Treatment: Provide medical assistance to affected individuals as soon as possible. Major Incidents and MIMMS: Any incident where the location, number, severity or type of live casualties requires extraordinary resources. These can be: ▪ Natural incidents or man-made ▪ Simple or compound ▪ Compensated or uncompensated Nato Definition: Major Medical Incident (MMI) is an incident where the number, severity, or type of live casualties, or by its location, requires extraordinary resources. An MMI is declared ‘bottom up’, with each level of command considering whether it also needs to make the same declaration. A Mass Casualty Incident (MASCAL) is an MMI which, despite the use of extraordinary measures, has or will result in an overwhelming of the available medical capability and/or capacity. Stages of a major incident: Categories of Major Incidents: Natural or man made Simple or compound: A simple incident is one where infrastructure (communication and transport) remains intact. A compound incident is one where existing infrastructure is damaged. Compensated or Uncompensated: A 'compensated incident' is defined as an incident in which casualties are dealt with by mobilising additional resources. An 'uncompensated incident' is when medical resources are unable to cope with the number of casualties, despite mobilising additional resources. Structural approach to major incident management: CSCATTT ▪ Command and control: ▪ The first vehicle on scene will become the Incident Commander until relieved ▪ Action cards are issued ▪ Tabards worn ▪ Safety: Ensure your own safety ▪ Ensure scene safety using cordons ▪ Communications: Start early communications with METHANE ▪ Use Airwave and Talk Groups ▪ Start a log ▪ Assessment: Assess the incident ▪ Use METHANE to request resources to the Ambulance Control Room Manager as soon as you can ▪ Triage: Start Primary Triage ▪ Encourage casualty self-help ▪ Establish a Casualty Clearing Station ▪ Treatment: Start treatment/stabilization as soon as the sieve is complete  ▪ Transport: Consider the capability, availability and suitability of types of transport ▪ Consider the capacity and capability of receiving units Methane: The Model Medical Command and Control Structure Bronze: On-Scene commanding, discrete sectors or areas of the incident. Silver: On-Scene commanders for the entire incident Gold: Overall offsite command, assisting in provision of resources and plan to return to normal. It is important to be familiar with the Operational-Tactical-Strategic terminology also used by emergency services which differs from the military Tactical-Operational- Strategic model: → Operational: Implement the tactical plan, command the single organization response, co-ordinates actions. → Tactical: Interprets the strategic decision, develops the tactical plan, co- ordinates activities and assests. → Strategic: Sets the strategic direction, co-ordinates responders, priorities resources. Scene layout: Ten Second Triage: (TST) For non-clinical responders ▪ Set up a Casualty Clearing Station ▪ Each Casualty is assigned a triage category ▪ They are treated as appropriate and brought to the Casualty Clearing Station in the order of their triage category as resources come available ▪ In the Casualty Clearing Station the patients are re-triaged ▪ Treatment is given as appropriate  ▪ Patients are transported to the most appropriate facility according to their triage priority and clinical requirements Medical advisors: As a Medical Advisor at a major incident, your role is crucial for coordinating the medical response, ensuring efficient casualty management, and providing technical advice to the incident command team. Breakdown of your responsibilities (provided to you on a card): 1. Wear a Tabard Why: To clearly identify yourself as the Medical Advisor in charge. This helps with visibility and ensures all responders can easily recognize your role during the incident. 2. Check Your Call Sign and Communications (Start a Log) Ensure you have the correct call sign for the incident. Confirm all your communication devices are working (e.g., radio, phone). Start an incident log documenting key decisions, times, and actions. This is important for accountability and debriefing. 3. Liaise with the Ambulance Incident Commander (Silver) Get a Briefing: Obtain a situational update from the Ambulance Incident Commander to understand the scale, type of incident, and key priorities. Work in conjunction with the Ambulance Incident Commander to coordinate the triage, treatment, and transportation of casualties. 4. Communication with Receiving Hospitals Start communication with hospitals to inform them of the nature of the incident and likely number/type of casualties. If necessary, liaise with the Strategic Medical Advisor to discuss activating the P4/T4 (Expectant) triage category for patients who are unlikely to survive despite treatment. Regularly brief the Strategic Medical Advisor on the situation, ensuring up-to- date information flow. 5. Remain at Command Location Co-locate with either the Ambulance Incident Commander or the Bronze Commander throughout the incident to facilitate coordination. Do Not attempt rescue or treatment of casualties yourself—you need to focus on the bigger picture of coordination. 6. Establish Communication Between Doctors Establish a communication system between all BASICS/HEMS doctors at the incident. Check doctors' IDs to confirm their legitimacy and qualifications. There have been instances of bogus doctors appearing at major incidents. Assign doctors to relevant areas: Bronze areas, Casualty Clearing Stations, and the body holding area. 7. Ensure Effective Flow of Casualties Work with the Casualty Clearing Officer to ensure that casualties are triaged, treated, and transported efficiently. Stay aware of the status of receiving hospital beds, so patients are sent to the appropriate facilities. Work with the Ambulance Incident Commander and Strategic Medical Advisor to explore all available options for evacuating casualties (e.g., air transport, coaches). 8. Coordinate with Specialist Hospitals If specialist care is required (e.g., for burns, pediatrics), liaise with the Ambulance Incident Commander to identify appropriate specialist hospitals and coordinate transportation. 9. Relief of Medical Staff Organize relief for medical staff as needed, ensuring there is no fatigue and that staff are rotated when appropriate. 10. Provide Technical Advice Act as a technical advisor on medical matters for all services on-site, including fire, police, and ambulance. JESIP: Joint Emergency Service Interoperability Principles ▪ Initially JESIP was a two-year programmed that ran from 2012-2014 ▪ It was primarily about improving the way the Police, Fire & Rescue and Ambulance services work together ▪ What JESIP produced was much needed practical guidance to help improve multi-agency response ▪ The interoperability framework sets out a standard approach to multi-agency working The Joint Decision Model: Useful during early stages of an incident, once the situation develops past this follow a more detailed briefing tool. IIMARCH – More detailed model The IMARCH model for a medical advisor at a mass casualty incident: I – Information Gather key details: What happened, where, when, how many casualties, and what might happen next. Know the hazards, and keep updated on the situation. I – Intent Clarify goals: efficient triage, treatment, and safe transport of casualties. Ensure responder safety and aim to prevent further harm. M – Method Implement the plan: Set up triage and casualty clearing stations, coordinate transport, and ensure supplies (antidotes, equipment) are available. Use METHANE for early reporting. A – Administration Organize resources: Allocate roles, manage logistics (supplies, transport), and plan for staff rotation to avoid fatigue. R – Risk Assessment Identify risks: Protect responders from hazards (chemical, structural), ensure safe evacuation routes, and establish decontamination protocols if needed. C – Communications Set up clear communication: Maintain reliable contact between all teams, hospitals, and command. Provide regular updates on casualty numbers and conditions. H – Humanitarian Issues Respect human dignity: Treat casualties with care, offer psychological support, handle deceased respectfully, and ensure fair, non-discriminatory decisions. MACA: Military Aid to Civilian Authorities (MACA) is occasionally implemented in the UK for MMIs. Military and civilian integration: Civilian services will have primacy in running the major incident, but the military must attempt to seamlessly integrate. n a major incident response, civilian services take the lead, but the military must integrate smoothly by following these principles: Co-Locate Position together with other responders in a single, safe, and easily identifiable location to ensure collaboration and avoid confusion. Communicate Use clear, plain language and avoid jargon or abbreviations. Share information through METHANE reports when appropriate to maintain clarity. Co-ordinate Agree on the lead organization. Identify priorities, capabilities, and limitations to ensure a coordinated response, including scheduling future meetings. Jointly Understand Risk Share information among all parties to understand and manage risks. Agree on control measures to mitigate hazards. Share Situational Awareness Use METHANE reports and the Joint Decision Model to maintain a common understanding of the situation and ensure coordinated actions. Multiple casualty incidents: Consider: ▪ Treatment ▪ Transfer ▪ Destination ▪ Discharge on scene The correct order for responding to a major incident is: 1. Safety: Ensure the scene is safe before taking any action. 2. Communicate: Establish clear communication with all teams and responders. 3. Read the Scene: Assess the scene to understand the situation and risks. 4. Everyone Accounted For: Ensure all personnel and victims are identified and accounted for. 5. Assess the Casualties: Evaluate the condition of casualties and their medical needs. 6. Method of Extraction: Determine how casualties will be safely extracted. 7. Evacuation Route: Identify and secure a clear evacuation route. 8. Right Facility: Ensure casualties are taken to the appropriate medical facility. SCREAMER can only be fully applied after confirming the scene is safe. Initial Actions of a Major Incident: 1. Safety: Prioritize personal, scene, and patient safety.  2. CSCATTT: First responder focuses on command and control, not triage or treatment unless in a team of 3+. 3. Alert Authorities: Notify Police, Fire, and Ambulance services using a "Major Incident Alert/Standby" message for incidents with potential for mass casualties. 4. Establish Control Point: Set a control point at your vehicle, ensuring blue lights stay on, vehicle is parked visibly, and PPE and tabards are worn. 5. Double Crewed Ambulance: Acts as temporary medical command and liaison until more resources arrive, following JESIP principles. Triage Sieve: Once no longer a major incident consider: When a major incident is no longer in effect, consider the following: Additional Resources: What further resources may be needed? Patient Transport: Decide where patients will be sent and by what means. Alternative Transport: Can patients be moved using non-ambulance options? Multiple Patients in a DCA: Can you transport more than one patient in a double-crewed ambulance? Special Considerations: Are there non-medical reasons for sending patients to specific hospitals? On-Scene Discharge: Who can be safely discharged on the scene? Once the situation is under control, the major incident should be formally cancelled or stood down. Ensure governance tasks are completed, including event tracking, patient destinations, and command coordination. Mental Capacity and Pre-Hospital Mental Health: Capacity: The ability to understand and perform actions, including having a legal right and soundness of mind to comprehend the nature and consequences of one's acts. Lacking Capacity: A person is unable to make a decision due to an impairment or disturbance in brain function (e.g., dementia, drugs, psychosis). Mental Capacity Act (MCA) 2005: Provides the legal framework for making decisions for individuals lacking capacity. It requires compliance when making decisions for those who lack capacity at the specific time and for a specific matter. Capacity may fluctuate, be partial or temporary, and relate to one matter but not others. An assessment that a person lacks capacity to make a decision must never be based on: Their age. Their appearance (e.g. scars, features linked to Down’s syndrome, muscle spasms caused by cerebral palsy). Assumptions about their condition (e.g., physical disabilities, learning difficulties, illnesses related to age, and temporary conditions like drunkenness or unconsciousness). Any aspect of their behavior (e.g., being extroverted, withdrawn, talking to themselves, or avoiding eye contact). Mental Capacity Act 2005: The Mental Capacity Act 2005 provides a statutory framework for people who lack capacity to make decisions for themselves or who have capacity and want to prepare for a time when they may lack capacity in the future. The Act offers the legal framework for acting and making decisions on behalf of individuals who lack the mental capacity to make (not necessarily all) decisions for themselves. The Act balances an individual’s right to make decisions for themselves with their right to be protected from harm if they lack the capacity to protect themselves. The MCA codifies many common law principles, such as the doctrine of necessity and best interests, into an Act. The MCA 2005 protects human rights in the absence of capacity. It is also important to consider the Human Rights Act 1998, which protects patient liberty and self- governance. There are 16 articles in total, including the Right to Life, Right to Liberty and Security, and the Right to Private Life. Five Statutory Principles: Capacity to Consent Form: Assessment Process: 1. Initial Evaluation: The first stage is to assess whether the person has an impairment of, or a disturbance in the functioning of their mind or brain, including mental illness. 2. Decision-Making Ability: Next, determine if the impairment or disturbance means that the person is unable to make a specific decision when it needs to be made. 3. Proof of Capacity: Anyone claiming that an individual lacks capacity must provide evidence. 4. Reasonable Belief: They must demonstrate that they had a reasonable belief that the individual lacked the capacity to make a particular decision at the time it needed to be made. 5. Importance of Documentation: This is why the ‘outline your conversation’ box is crucial; it allows you to include quotes from your conversation with the patient, supporting your assessment of their capacity. Components of Capacity: ▪ Understand: All efforts made help patients understand the decision and its consequences. ▪ Retain: Short term is acceptable. ▪ Weigh: Weigh up decision. ▪ Communicate Remember that all four requirements must be met for a patient to have capacity. Best Interest Decision-Making: When Time is Limited: Act in Best Interest: If you have genuine concerns that a patient is at risk of serious harm, prioritize acting in their best interest. The law and society typically support the preservation of life. Escalate Concerns: Utilize all available resources and continue to escalate the situation as needed. Court of Protection: In non-emergency situations where there is a dispute regarding a person’s capacity, the Court of Protection can be consulted for a judgment. Factors for Best Interest Assessment: 1. Past and Present Wishes: Consider the individual's past and present wishes and feelings, along with any relevant written statements made when they had capacity. 2. Advance Directives: Take into account any advance directives the person may have established. 3. Known Beliefs and Values: Incorporate their beliefs and values into the decision-making process. 4. Religion and Culture: Respect the individual's religious and cultural background. 5. Additional Considerations: Factor in any other elements that the individual would likely consider if they were able to make decisions. When taking this action staff must ensure: They have undertaken the 2- stage capacity assessment and determined the person lacks capacity to give informed consent for the care or treatment intervention proposed. They have taken account of any advance medical directive made by the patient that they are aware of. A capacity assessment will normally be carried out if a patient disagrees with a suggested course of action. Two-Stage Capacity Assessment The first stage asks: 1. Does the person have an impairment of, or a disturbance in the functioning of, their mind or brain? a. If the answer is no: The patient should be presumed to have capacity. b. If the answer is yes: Proceed to the second part of the assessment. The second part of the assessment asks the following questions. Can they: Understand information about the decision? Retain that information? Weigh that information as part of the decision-making process?  Communicate that decision? If You Need Advice: Clinical Support Desk: Sometimes, the clinical support desk can be useful to persuade patients, acting as the voice of authority on the telephone. Police Assistance: As a last (or sometimes first) re