ECP Clinical Practice Guidelines PDF

Extended Care Paramedic Clinical Practice Guidelines Uncontrolled document exported 31.10.2024  CPG ECP 1.1 St John New Zealand ECP Delegated Scope of Practice...

Extended Care Paramedic Clinical Practice Guidelines Uncontrolled document exported 31.10.2024  CPG ECP 1.1 St John New Zealand ECP Delegated Scope of Practice Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz The ECP delegated scope of practice encompasses all skills and medicines described for the Paramedic delegated scope of practice in the EAS CPGs, and the additional skills and medicines outlined in the table in this guideline. Skill ECP Amlodipine PO ✔ Amoxicillin PO ✔ Amoxicillin/clavulanic acid PO ✔ Articaine 4% / adrenaline 1:100,000 SC (dental block) ✔ Aspirin PO (headache) ✔ Azithromycin PO ✔ Benzathine benzylpenicillin IM ✔ Bisacodyl suppository PR ✔ Boostrix tetanus booster vaccine IM ✔ Budesonide / formoterol (Symbicort 200/6) DPI ✔ Cefalexin PO ✔ Ceftriaxone IV and IM (urinary catheter placement, STI) ✔ Chloramphenicol 1% ointment ✔ Codeine PO ✔ Continuous subcutaneous infusion (CSCI) start ✔ Docusate sodium and sennoside B PO ✔ Doxycycline PO ✔ Droperidol IV, IM and SC (end of life care, headache, hyperemesis) ✔ Fingernail removal ✔ Flucloxacillin PO ✔ Hydrocortisone 1% cream ✔ Hyoscine butylbromide IV, IM or SC ✔ Clinical Practice Guidelines ECP Delegated Scope of Practice CPG ECP 1.1 Page 1 of 4  CPG ECP 1.1 St John New Zealand ECP Delegated Scope of Practice Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Incision and/or aspiration of abscesses ✔ Ingrown toenail management ✔ Ibuprofen PO ✔ Levonorgestrel PO ✔ Levomepromazine IV, IM and SC ✔ Lignocaine 1% / adrenaline 1:100,000 SC ✔ Lignocaine 2% gel ✔ Lignocaine 4% / fluorescein 0.25% eye drops ✔ Lignocaine 5% / phenylephrine 0.5% spray IN ✔ Local anaesthesia (edge infiltration, field block, dental block) ✔ Loperamide PO ✔ Loratadine PO (rash with prominent itch) ✔ Macrogol PO ✔ Manual disimpaction of faeces ✔ Metoclopramide IV and PO ✔ Metoprolol CR PO ✔ Metronidazole PO ✔ Miconazole 2% / hydrocortisone 1% cream ✔ Microlax enema PR ✔ Midazolam IV, IM and SC (palliative and end of life care, COPD, muscle spasm in non-traumatic ✔ lumbar back pain) Morphine IV, IM, and SC (palliative and end of life care) ✔ Nasal packing for epistaxis (anterior and posterior) ✔ Nitrofurantoin MR PO ✔ NGT placement ✔ Ondansetron PO ✔ Clinical Practice Guidelines ECP Delegated Scope of Practice CPG ECP 1.1 Page 2 of 4  CPG ECP 1.1 St John New Zealand ECP Delegated Scope of Practice Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Oral rehydration formula PO ✔ Oxycodone CR PO ✔ Paracetamol IV ✔ Parecoxib IV and IM ✔ PEG management ✔ Phosphate enema (Fleet enema) PR ✔ Prednisone PO ✔ Prednisolone PO ✔ Pregabalin PO ✔ Prochlorperazine PO and IM ✔ Radial head subluxation reduction in a child ✔ Rectal prolapse reduction ✔ Regional anaesthesia (fascia iliaca block, ankle/foot block) ✔ Ropivacaine 0.75% SC ✔ Roxithromycin PO ✔ Salbutamol MDI ✔ SC line placement ✔ Silver nitrate cautery (epistaxis) ✔ Sofradex ear drops topical ✔ SPC management ✔ Subungual haematoma trephination ✔ Tranexamic acid 10% topical ✔ Trimethoprim/sulfamethoxazole PO ✔ Ultraproct ointment topical ✔ Urinary catheter placement (in adults) ✔ Clinical Practice Guidelines ECP Delegated Scope of Practice CPG ECP 1.1 Page 3 of 4  CPG ECP 1.1 St John New Zealand ECP Delegated Scope of Practice Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Valaciclovir PO ✔ Wound closure with glue ✔ Wound closure with staples ✔ Wound closure with sutures ✔ More Information Version history Update: Multiple changes. 25/06/2024, Version 1.0.4.4 Clinical Practice Guidelines ECP Delegated Scope of Practice CPG ECP 1.1 Page 4 of 4  CPG ECP 1.2 St John New Zealand General Principles Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Using the ECP CPGs in conjunction with the EAS CPGs These ECP CPGs are an addendum to the Emergency Ambulance Sector Clinical Procedures and Guidelines (EAS CPGs). These ECP CPGs are intended to guide assessment, management and referral of patients suitable for treatment in the community. Where a clinical presentation features in both the EAS CPGs and the ECP CPGs, the relevant ECP CPG will describe: The cohort of patients and clinical presentation the CPG applies to, and How the ECP CPG supersedes guidance described within the EAS CPGs, and How the EAS CPGs and ECP CPGs should be used in conjunction with one another. The transport/referral criteria in the ECP CPGs supersede the flag tables in the EAS CPGs for the same clinical presentation. For example, the transient loss of consciousness transport/referral criteria in the ECP CPGs supersedes the syncope flag table in the EAS CPGs. Use clinical judgement to apply the transport/referral criteria in the ECP CPGs to supersede the EAS CPGs in a way that benefits the patient without adding undue clinical risk. Community management of patients is typically best achieved by referring the patient back to their usual primary care provider. This is sometimes referred to as "closing the loop'. Use local pathways whenever possible. Calling the Clinical Desk The Clinical Desk is the primary avenue for ECPs seeking clinical advice. Personnel should adhere to the principles outlined in the EAS CPGs when seeking advice via the Clinical Desk. Formalised alternative avenues have been introduced in some areas where ECPs are able to obtain clinical advice from personnel other than via the Clinical Desk (for example, the on call primary care provider for that area). These avenues should be used whenever feasible. Experience in primary care will vary between personnel on the Clinical Desk. Where feasible, advice should be sought via the Clinical Desk and if a resolution cannot be found (for example, discussion with another on-duty ECP), the situation must be escalated to the on call doctor. Clinical Practice Guidelines General Principles CPG ECP 1.2 Page 1 of 2  CPG ECP 1.2 St John New Zealand General Principles Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Providing treatment that differs from that authorised in these CPGs Use this guideline in conjunction with the relevant EAS CPG guideline. ECPs work in a variety of environments outside traditional ambulance service settings including: Primary care. Event medicine. Remote clinical environments (for example, the oil and gas industry). Prolonged care situations (for example, during search and rescue operations or supporting disaster response and recovery). These CPGs are designed to provide a basis for good clinical practice but are not prescriptive. Under certain circumstances it may be appropriate for ECPs to administer medications and/or provide treatments which fall outside of the recommendations described in these CPGs. If administering medications and/or providing treatments that fall outside recommendations described in these CPGs, then: The administration of medication and/or treatment must be clearly in the patient’s best interests, and The clinical justification for administration of the medication and/or treatment must be clearly documented in the ePRF or appropriate clinical record, and The case must be sent for clinical audit. Adoption of these CPGs other than Hato Hone St John or Wellington Free Ambulance These CPGs must be formally endorsed as standing orders if adopted by employers other than Hato Hone St John or Wellington Free Ambulance. Additional medicines or interventions not described by these CPGs must be covered by additional standing orders issued by the employer’s clinical governance personnel. Clinical Practice Guidelines General Principles CPG ECP 1.2 Page 2 of 2  Crew Resource Management in CPG ECP 1.3 St John New Zealand ECP Practice Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Crew resource management (CRM) as described in the EAS CPGs is focused on optimising the performance of a team, and often in an emergent situation (for example, a resuscitation). The environment in which ECPs operate requires an adaptation of CRM principles because: ECPs are more likely to be working alone, and ECPs are likely to be working in an environment where time is less constrained, and Key stakeholders are often not physically present at the scene. Ways in which the principles of CRM can be applied to, and adapted for, the ECP environment are outlined using the same paragraph headings as the relevant guideline in the EAS CPGs: Call for help. Consider early in the assessment process if the patient is best managed using the ECP or EAS model of care. Establish a team leader. Make an early decision about whether advice will be sought from another health provider and followed (for example, a hospice team or a lead maternity carer), or whether the assessment and management process will be determined solely by the ECP. Communicate effectively. Thorough and effective communication between ECP, patient, the patient’s family/caregivers, and relevant health professionals is of utmost importance. Ensure the patient and their family/caregiver clearly understand the outcome of assessment and the transport/referral plan. Ensure the patient’s usual primary care provider has been informed of any transport/referral plan, especially if the plan relies on further action from the provider. Ensure that any investigations with results pending have clearly communicated plans for follow up. Utilise resources appropriately. Accessing a limited service or supplying a course of medication requires good stewardship. Care must be taken to ensure that limited resources are being used appropriately and that medications are not being supplied if they unnecessarily raise the risk of antibiotic resistance or drug dependence. Step back and reassess. Because ECP practice is often complex, pausing to step back and reassess any management and treatment/referral decisions before they are finalised is important. Take time to ask questions such as ‘have I obtained all the information I need to make safe and appropriate decisions for diagnosis, treatment and referral?’ and ‘is this the best thing to do for the patient?’ Clinical Practice Guidelines Crew Resource Management in ECP Practice CPG ECP 1.3 Page 1 of 1  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Introduction This guideline outlines the approach ECPs should take to clinical assessment and broadly follows the medical model. In addition to the minimum requirements for patient assessment described in the EAS CPGs, ECPs should conduct more in-depth patient assessment where clinically indicated, providing the patient consents and suitable equipment and/or facilities are available. Consider using the Te Whare Tapa Whā framework to support patient assessment as this framework recognises that health is more than physical problems. Te Whare Tapa Whā encompasses: Taha Tinana (Physical health). Taha Wairua (Spiritual health). Taha Whānau (Family health). Taha Hinengaro (Mental health). Individual guidelines in these ECP CPGs describe further assessment required for specific patient presentations. POCT is described in the POCT guideline in these CPGs. These CPGs describe sending samples (for example, wound swabs or urine) for laboratory testing: Follow this guidance if a local pathway exists. Consider referral to a provider who can request laboratory testing if a local pathway does not exist. History Take a history using the ‘four frames’ approach: Presenting complaint. Past medical history. Social and family history. Ideas, concerns and expectations. Presenting complaint: Ask the patient what their main complaint is, and why they have sought healthcare today. Establish the history of their presenting complaint. Establish which body systems may be involved. Conduct a review of the relevant systems. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 1 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Identify pertinent negatives, particularly those related to transport and referral criteria relevant to the complaint. Past medical history: Ask the patient about any existing medical conditions and recent operations/procedures. Ask the patient what medications they are prescribed, and whether they are taking any health supplements or herbal remedies. Ask if the patient is taking their medication as it is prescribed. Ask the patient about any allergies or adverse effects from medications. Access relevant electronic health records where available, with patient consent. Social and family history: Limit family medical history to first-degree relatives as family history beyond this group is usually less relevant to the presenting complaint. Establish how well the patient can mobilise, and whether any mobility aids are required. If they are elderly, ask if they have fallen in the past year. Establish whether the house is suitable for the patient and their capacity. Establish how well supported the patient is. This includes friends and whānau, specific home help such as district nurse services or cleaning. Establish the impact of the patient’s medical conditions on their ability to undertake ADLs (for example, eating, cooking, cleaning, shopping, bathing and toileting). Ask the patient if they smoke and if so, how many per day. Provide a brief intervention if indicated. Ask the patient if they drink alcohol, and if so, how much. Ask about other harmful substance use if this is appropriate. Screen for potential malignancy, frailty, and IPV where indicated. See the relevant guideline for further detail. Ideas, concerns, and expectations: Ensure a good understanding of the patient’s main concerns and what their expectations are. Ask the patient whether they have any further information to share. Ask the patient whether they have any questions. Ask the patient specifically what they want to happen. The aim is to understand the patient’s expectations of the outcome of the individual clinical interaction. Principles of examination To understand ‘normal’ within the context of clinical examination, it is important to have a wide base knowledge of ‘normal’ as a frame of reference. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 2 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Tailor the examination to the presenting complaint: Not every patient requires a head to toe, multi-system examination. The examination must be appropriate to the patient’s complaint and detailed enough to form a diagnosis and safely manage the patient. Not every component of a systems assessment may be necessary. All patients must undergo a general examination. Most aspects of a general examination can be conducted during the initial introduction and while an initial set of vital signs is being obtained. This can include observations of the patient’s cognition and general appearance (for example, perfusion status, weight, and the presence of any gross abnormalities). Specific consent must be obtained, and a chaperone present (where possible) before performing an assessment of an intimate or sensitive nature. Cardiovascular system assessment Assess perfusion status and level of cardiovascular compromise. Feel for a radial pulse and note the rate, strength and regularity. Visually inspect the patient, focusing on: Evidence of thoracic surgery. Scars, bruising or wounds. The presence of jugular vein distension. The presence of peripheral oedema. Signs of bleeding, external and internal. Palpate the chest if chest pain or discomfort is present and feel for any abnormalities and/or a change in pain during palpation. Auscultate heart sounds: Locate the apex beat. Note whether heart sounds are clear and if there are additional heart sounds. Do not attempt to diagnose specific murmurs but it is important to document the presence of additional heart sounds. Acquire a 12 lead ECG. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 3 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Dehydration assessment Categorise dehydration as mild, moderate or severe using the dehydration assessment table. There is no one factor that can be used to determine dehydration status. Multiple factors must be taken into account, noting that in most patients there will be a mixture of factors. History features relevant to dehydration assessment include: Frequency and volume of fluid intake and urine output. Frequency and volume of vomiting and/or diarrhoea. Recent illness, particularly infection. Exposure to hot environments. Increased exercise. Symptoms of dehydration include: Dizziness on standing. Dry mouth. Headache. Recent loss of weight, if it can be calculated, is the most accurate indication of dehydration. Measure loss of weight between time of assessment and last recorded weight when well. Abnormal observations, for example tachycardia, hypotension and/or tachypnoea may indicate dehydration. Severe dehydration may be associated with signs of shock. Clinical features of dehydration include dry mucous membranes and decreased skin turgor. Ketones on capillary blood analysis or urinalysis are associated with dehydration. Dehydration assessment table None to mild Moderate Severe Weight loss None < 5% ≥ 5% Fluid intake Normal Reduced Very reduced Vomiting and diarrhoea None Some Frequent Observations Normal Some abnormalities Significantly abnormal Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 4 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Other symptoms None Some Many Mucous membranes Slightly dry Dry Very dry Skin turgor Normal Decreased Very decreased Urine output Normal Reduced Profoundly reduced or anuric Ketones (mmol/litre) None ≤ 1.5 > 1.5 Respiratory system assessment Visually inspect the chest, focusing on: Work of breathing. Effectiveness of breathing. Chest wall expansion and movement. Evidence of thoracic surgery. Scars, bruising or wounds. Palpate the chest, focusing on: Chest wall expansion and movement. Abnormalities such as tenderness, crepitus, or subcutaneous air. Percuss the chest, focusing on whether the percussion note is resonant (normal), dull, or hyperresonant. Auscultate the chest: See the recommended sites for chest percussion and auscultation in the diagram below. Listen for equal air entry and the presence of abnormal lung sounds, for example, wheeze or crackles. Interpretation of lung percussion and auscultation findings: Dullness to percussion suggests fluid or lung consolidation. Dullness to percussion and crackles suggests pneumonia. Dullness to percussion and reduced lung sounds suggests a possible effusion. Hyperresonance suggests an absence of normal lung tissue below the area of hyperresonance, for example, pneumothorax. Consider referral for a chest x-ray if the lung exam is abnormal. The urgency of referral is guided by the overall clinical picture. Obtain a PEFR if indicated. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 5 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Obtain a sputum sample for MCS if indicated (see the relevant guidelines). Perform a 1-minute sit-to-stand test for patients with borderline respiratory function: The 1-minute sit to stand test is useful to identify relatively occult respiratory compromise in patients with apparently mild respiratory illness. To perform the 1-minute sit to stand test: Place a standard kitchen chair against a wall for balance and to prevent sliding. Position the patient seated on the chair with feet placed flat on the floor. Measure SpO2. Have the patient repeatedly stand then sit at their own pace, for one minute. Measure SpO2 after one minute. A fall in SpO2 of > 4% suggests occult respiratory compromise. Integrate this finding in the context of the wider clinical picture to guide referral decisions. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 6 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Recommended sites for chest percussion and auscultation Abdominal assessment Visually inspect the abdomen, focusing on: Evidence of abdominal surgery (see the common abdominal surgical scars diagram). The presence and likely cause of swelling (could be due to fat, fluid, foetus, faeces or flatus). Localised protrusion (suggesting hernia). Bruising, erythema or rashes. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 7 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Common abdominal surgical scars Auscultate the abdomen. Document the presence or absence of bowel sounds, but do not specify whether they are normal or abnormal as this is very subjective. Palpate the abdomen: Palpate the abdominal segments in a logical manner (including the flanks), aiming to palpate the painful regions last. It is unusual to feel individual organs during abdominal palpation. It should feel uniformly soft. In a thin patient, hard masses may be palpated in the left lower quadrant and this is usually faecal matter in the sigmoid colon but should still be documented. Pulsation of the aorta may also be found in a thin person above the umbilicus. Localised rigidity is a sign of localised pathology, and generalised rigidity is a sign of generalised pathology. Guarding is relatively subjective and seldom useful. Do not test for rebound tenderness. Percuss the abdomen: Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 8 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Percussion of the abdomen in the presence of peritoneal irritation is painful and should only be performed once in each quadrant if abdominal pain and tenderness are present. Consider performing the hop test for children if appendicitis is suspected. Consider the need for urinalysis. Perform a pregnancy test in all females between 12 and 60 who have abdominal pain and consider a pregnancy test in other presentations. A rectal examination may be appropriate depending on the presenting complaint but requires explicit permission and the presence of an independent chaperone (where feasible). All patients with upper abdominal (epigastric) pain must have a 12 lead ECG, noting that a normal ECG does not rule out myocardial ischaemia. Urinalysis Dipstick urinalysis testing Test mid-stream, clean catch, fresh urine samples only. Do not test urine from: Samples previously collected by the patient. Catheter bags. Nappies. To test urine from a catheterised patient, use one of the following procedures: Disconnect the drainage bag and tube from the catheter, clean the catheter end with an alcohol wipe and collect urine direct from the catheter end, or Clean the catheter needle access port with an alcohol wipe then aspirate via the access port. Do not test grossly discoloured urine (for example, macroscopic haematuria) as this may prevent accurate reading of the chemical reagent colour changes. Consider using the pregnancy test kit dropper to place a few drops of urine on each test square if only a tiny volume of urine can be collected. Urinalysis interpretation table GLU KET SG BLO pH PRO NIT LEU Interpretation Clinical suspicion of UTI Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 9 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Any inc Any inc Any inc UTI Positive NEG NEG NEG UTI > trace + - ++++ NEG ++ - +++ Unclear NEG + - ++++ NEG ++ - +++ Unclear > trace + - ++++ NEG NEG Unclear > trace NEG NEG ++ - +++ No UTI NEG NEG NEG NEG Clinical suspicion of AKI Risk of AKI NEG ++ ++++ Risk of AKI > trace + - ++++ Reassuring NEG NEG Low urine volume ≤ Dilute 1.005 ≥ Concentrated 1.020 Illness or dehydration Ketonuria ≥4 Pregnancy Suggests GPH + - ++++ Suggests Gestational +- diabetes ++++ Any clinical situation +- Glucosuria ++++ Any clinical situation Haematuria > trace Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 10 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Dipstick urinalysis interpretation In the context of clinical suspicion for UTI for patients without an IDC: Positive nitrite (any uniform pink colour change) is the most specific indicator of UTI on dipstick urinalysis, regardless of blood, protein and leukocyte findings. The combination of ≥ small blood and ≥ 1+ protein and ≥ 2+ leukocytes is also positive for UTI on dipstick urinalysis even if nitrite is negative. Other combinations of leukocytes, protein and blood are equivocal: they are not clearly positive for UTI without positive nitrite. The combination of all negative blood, protein, leukocytes and nitrite has close to a 100% negative predictive value for UTI: this combination effectively excludes UTI on dipstick urinalysis. In the context of clinical suspicion for UTI in patients with an IDC: Urinalysis alone becomes less useful, and diagnosis with MCS is preferred. Positive nitrite and ≥ 2+ leukocytes and clear symptoms suggest UTI. In the context of clinical suspicion for AKI: Finding ≥ 2+ protein suggests glomerular dysfunction and risk of AKI. The combination of > trace blood and ≥ 1+ protein suggests glomerular and/or tubular dysfunction and risk of AKI. The combination of negative blood and protein is reassuring, noting that blood testing (for creatinine to calculate eGFR) is the only way to conclusively determine renal function. In the context of low urine volume: Low SG ≤ 1.005 indicates dilute urine and suggests worrying renal tubular dysfunction and inability to concentrate urine. Higher SG ≥ 1.010 indicates more concentrated urine and suggests renal tubular ability to concentrate urine is retained. In the context of illness or dehydration: Positive ketones (ketonuria) of any value are a reliable sign of physiological stress and/or dehydration. Ketones ≥ 4 mmol/litre are worrying and should trigger rehydration and referral. Ketonuria can be found in other situations (for example, in otherwise well patients on keto diets) without the same clinical significance. In the context of pregnancy: Finding ≥ 1+ protein (proteinuria) should prompt concern for gestational proteinuric hypertension (pre-eclampsia). Finding ≥ 1+ glucose (glucosuria) should prompt concern for gestational diabetes. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 11 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz In other clinical situations: A single finding of trace blood should be considered as negative. A single finding of trace protein is the upper limit for normal and should prompt non-urgent retesting in primary care. Finding ≥ 1+ glucose (glucosuria) should prompt concern for diabetes. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 12 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Neurological assessment Determine the level of consciousness using the GCS. Assess mobility. Perform a brief cranial nerve assessment including: Pupil size and reactivity. Visual fields. Eye movements including the presence or absence of diplopia and nystagmus. Symmetry of facial and tongue movement. Power of facial movements. Sensation across the distribution of the trigeminal nerve (nerve roots V1, V2, and V3). The presence of gag and swallow reflexes. Ability to shrug shoulders and rotate the head from left to right. Examine the peripheral nervous system for symmetry of: Power: 0 = No muscle contraction 1 = Flicker or trace of muscle contraction 2 = Active movement with gravity eliminated 3 = Active movement against gravity 4 = Active movement against gravity and resistance 5 = Normal power. Tone (muscle resistance against the examiner moving the limb), noting: Normal tone (relaxed limb with no resistance against examiner movement). Spasticity (velocity dependent increases in tone). Cog-wheel rigidity (intermittent increases in tone). Lead pipe rigidity (uniformly increased tone). Light touch, using dermatomes. Pain. Proprioception (perception of limb and joint position) including Romberg’s test. Tendon reflexes. Assess the cerebellar system including: Gait, including tandem gait test (heel-to-toe). Substitute the heel-shin test if the patient is not mobile. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 13 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Finger nose test. Pronation/supination test for dysdiadochokinesia. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 14 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Dermatomes figure Musculoskeletal assessment Expose and assess the affected joint or limb using the “look, feel, move” approach: Look for asymmetry, scars, swelling, redness or obvious deformity. Feel for deformity, tenderness, joint effusion and skin temperature. Assess range of movement, pain on movement and joint stability. Assess both active (the patient moves the limb/joint) and passive (the ECP moves the limb/joint) movement. Compare the affected against the unaffected joint or limb. Note the exact location of the pain, for example, whether it is the joint itself or the area around the joint that is painful. Perform a neurovascular assessment. In particular: Check distal pulses and identify any distal vascular compromise. Assess distal sensation. Assess distal motor function. Assess the patient’s mobility and use of the affected joint or limb: Consider whether they are walking normally, picking things up with ease and able to seat themselves in a chair. Consider the wider clinical picture which may include chronic mobility impairment, for example wheelchair use. Perform additional special tests as described in the relevant guidelines in these CPGs. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 15 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Medical imaging (x-ray and ultrasound): Use the relevant guideline in the ECP or EAS CPGs to guide referral for an x-ray for a minor musculoskeletal injury or problem. If the presentation is not featured within the ECP or EAS CPGs: Discuss the patient with a medical or nurse practitioner to arrange referral for an x-ray or ultrasound (for example, for chest x-ray), or Follow a local pathway (for example, a deep vein thrombosis or a practitioner-initiated x-ray pathway). Specific guidance on interpreting x-ray or ultrasound images is not contained within these CPGs. All requested imaging must have a clearly documented plan for follow up of the result by the requestor. Eye assessment Assess visual acuity using a Snellen chart. Inspect the eyelids (invert the eyelid if indicated) for evidence of infection, conjunctivitis or foreign bodies. Inspect the sclera and cornea for haemorrhage, haziness, or foreign bodies. Stain the surface of the eye with fluorescein and examine under blue or black light for leaking aqueous humour, ulceration or abrasions. Inspect the anterior chamber of the eye for floaters, sediment or blood. Check pupillary reaction and the consensual light reflex. Inspect the retina for obvious abnormalities using an ophthalmoscope (if available). Obtain a swab if indicated. Ear, nose and throat assessment Ear Perform a gross assessment of hearing: Approximately 60 cm from the ear being tested, whisper a two-syllable word and ask the patient what it is. Repeat this twice more with other two-syllable words. Repeat the same test in the other ear. If the patient can repeat the word correctly two out of three times, this is considered normal. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 16 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Weber’s and Rinne’s tests are not required as personnel will not usually have access to a tuning fork. Inspect the ears for deformities, piercings or signs of infection. Inspect and palpate behind the pinnae for tenderness, swelling or skin changes. It is not possible to perform a complete assessment of the ear without an otoscope. If an otoscope is available: Pull the pinna upwards and backwards, opening the external auditory canal. Position the otoscope in the external auditory meatus. Slowly advance the otoscope under direct vision. It may be uncomfortable for the patient but should not be painful. Inspect for wax, swelling, erythema, discharge or foreign bodies. Examine the tympanic membrane, assessing: Colour. Pearly grey or pink and translucent is normal. Bulging of the membrane. Inspect for a fluid level. Perforation of the membrane. Light reflex. Absence of a light reflex suggests increased inner ear pressure. Compare both tympanic membranes to determine what is normal for the patient. Nose Inspect the nose for evidence of skin lesions. Palpate the nose for tenderness or deformity. Examine each nostril using an otoscope or pocket torch as the light source, elevating the tip of the nose to improve visualisation. Examine for any focal bleeding spots, especially at the anterior apex of the nostril (Little’s area). Inspect the nasal septum for deviation or swelling (septal haematoma in trauma). Compare one nostril with the other to establish what is normal for the patient. Throat Assess for pain associated with mouth opening or difficulty opening the mouth. Ask the patient to open their mouth and say ‘ahh’. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 17 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Inspect the structures that can be visualised, including the tonsils and oropharynx. Use a tongue depressor to enable this if required. Obtain a throat swab if indicated. Dental assessment Inspect the oral cavity and look for swelling, erythema and lymphadenopathy. Identify the location of the problem using the ISO 3950 tooth notation system. Identify the presence of any dental abscess. Inspect the gum margins for general condition and any areas of tenderness or swelling. Tooth notation system Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 18 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Wound assessment Assess: The mechanism of injury. The time elapsed since the wound was sustained. The onset, duration, location and characteristics of pain and sensory changes related to the wound. Any treatment provided so far (for example, cleaning, and foreign body removal). The degree of tissue destruction. The degree of wound contamination. The presence of a foreign body. Assess wound depth: Visualise the base of the wound. Use a non-lint depositing sterile probe. Assess for evidence of damage to any underlying structures: Muscle and tendon structures. This includes visible deficits (for example, in muscle or tendon fascia), range of motion, motor strength and stability. Bone and joint structures. Deep vascular structures (arterial or venous). Perform a neurovascular assessment. In particular: Check distal pulses and identify any distal vascular compromise. Assess distal sensation. Assess distal motor function. Assess the suitability of the wound for closure. Assess risks for delayed wound healing. There is no one factor that can be used to determine the risk of a wound failing to heal. Multiple factors must be taken into account, noting that in most patients there will be a mixture of factors: Patient risk factors for delayed healing include: Age over 75 years. Immunocompromise (for example, diabetes, steroid use, chemotherapy). Smoking or vaping (nicotine is a vasoconstrictor). Malnutrition, including alcoholism. Obesity. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 19 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Peripheral vascular disease. Unlikely to rest and elevate the wound. Wound risk factors for delayed healing include: Infection. Contamination. Large size. Multiple wounds. Pretibial location. Oedema. Crush mechanism. Deep wounds. Obtain a swab for MCS if indicated. Additionally, for chronic wounds, use the TIMES model: Tissue. Distinguish between viable tissue (epithelial or granulating) and non-viable tissue (slough or necrotic). Infection. Determine the presence of inflammation, local infection or systemic infection. Moisture (exudate). Note the type and volume of exudate. Edges/epithelial advancement. Identify any lack of new healthy tissue at wound edges or rolled edges suggesting undermining. Surrounding skin: assess for oedema, skin damage and inflammation. Lymphatic system assessment Assess the patient for signs of: Swollen lymph nodes (lymphadenopathy). Impaired lymph drainage (for example unilateral limb oedema). Inflamed lymph vessels (lymphangitis, also known as “tracking”). Development of a provisional diagnosis Development of a provisional diagnosis takes into consideration all the information obtained from the patient history, clinical examination and other investigations/point of care testing. Look for a single unifying diagnosis, as one diagnosis is more likely than two or more coexisting diagnoses. Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 20 of 21  CPG ECP 1.4 St John New Zealand Clinical Assessment Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Prior to establishing the provisional diagnosis and commencing treatment, pause and consider whether there is an alternative diagnosis that requires further investigation. More Information Version history Update: Multiple changes. 25/06/2024, Version 1.0.4.4 Clinical Practice Guidelines Clinical Assessment CPG ECP 1.4 Page 21 of 21  CPG ECP 1.5 St John New Zealand POCT (Point of Care Testing) Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Introduction wrgfwehoij Point of care testing (POCT) refers to any clinical investigations performed that do not need to be sent away for analysis or reporting. Common point of care tests in ECP practice include: Blood glucose level test. Urine pregnancy tests. Urinalysis. Peak expiratory flow rate. ECG. POCT is an adjunct to patient assessment and should not replace sound clinical judgement. Specific use of POCT is described within the relevant guidelines. For each test, consider: Test sensitivity and specificity. Pre-test probability that the patient has the disease being tested for. If the test is appropriate for the patient (value of the test to support clinical decisions). Whether the test result makes sense. Advantages of POCT Speed. The results of the test can be obtained on scene, and do not require analysis at another location. Portability. The test or testing device is compact and/or does not require complicated infrastructure to support it, enabling it to be both ‘brought to the patient’ and easily transferred to the following patient. Availability. Largely due to the portability of the test or testing device, POCT has substantially enhanced availability, and therefore can be used in a wider variety of clinical settings and made available to wider patient populations. Expanded capability. By obtaining more information about the patient through POCT, the ability for ECPs to make a wider range of management and referral decisions for patients in the community is expanded. Clinical Practice Guidelines POCT (Point of Care Testing) CPG ECP 1.5 Page 1 of 3  CPG ECP 1.5 St John New Zealand POCT (Point of Care Testing) Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Disadvantages of POCT Quality control. Maintaining the chain of quality control for POCT devices can be challenging. Validity. While most testing devices translate well to the out-of-hospital environment, it is important to be aware of how a point of care test performs in various clinical environments. Association with medical records. Most laboratory-performed test results are filed directly (or with minimal reliance on human input) into the patient’s medical record. POCT can require a more labour- intensive approach to ensure the POCT results are linked with the patient’s medical record. Cost. In some cases, the cost of each test by a POCT device compared to the cost of the same test within a laboratory is significant. This cost can be prohibitive and is a trade-off between the cost of the device and the cost saving of keeping a patient out of hospital when feasible and safe to do so. POCT validity and quality control A test is only useful and valid if its reliability can be demonstrated against a known standard. Quality control is the process by which the accuracy of the POCT result is confirmed. Each manufactured test has specific internal quality controls built into the testing device. To maintain POCT quality assurance, personnel must: Ensure they have been appropriately trained in using the POCT device, and Avoid rushing to perform the test (each step is important to ensure accuracy), and Comply with any quality control steps required. Quality control steps that may be required include: Daily machine checks. Logging results. Ensuring test strips are not expired. Ensuring the testing cartridges have been stored properly. Checking testing devices have up-to-date software and are maintained. i-STAT i-STAT blood analysers are becoming increasingly common devices for performing POCT blood tests including: Basic electrolytes. Clinical Practice Guidelines POCT (Point of Care Testing) CPG ECP 1.5 Page 2 of 3  CPG ECP 1.5 St John New Zealand POCT (Point of Care Testing) Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Renal function. Liver function. Venous or arterial blood gases. Troponins. These are not currently widely available in the New Zealand out-of-hospital environment. If i-STAT blood analysers are available, they may only be used by personnel who have been trained and authorised to do so. POCUS This guideline is for ECPs who have been credentialed for POCUS. The role of POCUS for ECPs is tightly focused on: Ruling in a specific problem for example, a pneumothorax, not to exclude a suspected problem, or Gaining peripheral IV access. POCUS findings must be interpreted within the wider clinical assessment of the patient which then guides further treatment and/or referral. Basic scans Following credentialling, ECPs may perform the following scans: Vascular access. Abscess localisation. Joint effusions. Pulmonary assessment (rule in fluid or pneumothorax). Confirmation of IUP and foetal heart. Incidental findings Manage concerning incidental findings by referring the patient to their usual primary care provider. Clinical Practice Guidelines POCT (Point of Care Testing) CPG ECP 1.5 Page 3 of 3  CPG ECP 1.6 St John New Zealand Analgesia: Acute Pain Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz This guideline is for patients with acute pain and a low risk of serious illness or injury. General principles The ECP approach to analgesia is like EAS practice but with some key differences: A focus on community management of low acuity, low risk presentations. Supply of analgesia for up to several days. An extended range of oral analgesic options. An extended range of local anaesthetic options. The ability to manage some presentations of severe pain in the community. As a result, the medicine guidelines within these ECP CPGs are subtly different from that of the EAS medicine guidelines. Personnel must be aware of the additional risks and precautions in administering more than a single dose of any given medicine. In general, personnel should follow the principle of administering the lowest effective dose to achieve the longest possible duration of analgesia. Presentations involving severe undiagnosed pain should usually be referred to an ED, with reference to the relevant EAS CPGs. Patients must be given a clear recommendation to be transported to an ED by ambulance if they are administered either: Ketamine via any route, or More than two doses of parenteral opioid. Stepwise progression of analgesia Use a multi-modal and stepwise progression of analgesia administration and supply in response to the severity of the patient’s pain. Refer to the analgesia steps table to guide treatment. Analgesia steps table Step < 14 years ≥ 14 years Paracetamol 1 Paracetamol and/or ibuprofen. or ibuprofen Clinical Practice Guidelines Analgesia: Acute Pain CPG ECP 1.6 Page 1 of 4  CPG ECP 1.6 St John New Zealand Analgesia: Acute Pain Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Paracetamol Consider adding a weak opioid. Consider high dose ibuprofen for patients aged < 65 2 and years. ibuprofen Consider replacing the weak opioid with oxycodone CR. Consider adding a single Consult or 3 parenteral dose of paracetamol or NSAID to manage more severe pain in the acute refer phase. Analgesia in the elderly The elderly are commonly prescribed multiple medications (polypharmacy) and are therefore vulnerable to medication interactions and side effects. The selection of analgesia at step two of the analgesia steps table should be guided by balancing the risk of adverse effects (for example, AKI, constipation, and GI bleeding) against tolerability issues (for example, nausea, vomiting, dizziness and sedation). Refer to the step two analgesia options in the elderly table for guidance. The elderly are particularly vulnerable to AKI from NSAIDs due to factors including: Age-related decreased renal function. Renal disease. Polypharmacy. Nephrotoxic medication use, for example: ACE inhibitors. Angiotensin receptor blockers. Diuretics. Step 2 analgesia options in the elderly table Risks Codeine Tramadol NSAID Constipation High Medium No Respiratory depression Medium Low No Acute kidney injury No No High GI bleeding No No High Cardiovascular adverse event No No Medium Clinical Practice Guidelines Analgesia: Acute Pain CPG ECP 1.6 Page 2 of 4  CPG ECP 1.6 St John New Zealand Analgesia: Acute Pain Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Serotonin syndrome No Medium* No Sedation Medium Medium No Confusion Medium Medium No Orthostatic hypotension No Medium No Seizure No Medium No Nausea and vomiting Low Medium Low Dizziness Low Medium Low * When taken in combination with antidepressants and/or triptans. NSAID treatment The risk profile of NSAIDs and COX-2 inhibitors is dependent on the: Age of the patient, and Past medical history, and Degree of polypharmacy, and Severity of pain. These risks include: GI adverse effects (for example, bleeding). Adverse cardiovascular effects relating to platelet aggregation. Patients with previous myocardial infarction are at increased risk of an adverse cardiovascular event during the first seven days of NSAID treatment. AKI. Avoid NSAIDs in: Diverticulitis (due to the risk of perforation). Gastro-oesophageal reflux disease (GORD) and dyspepsia. Renal impairment (known, suspected, or at risk of impairment). Children, especially those who are dehydrated or have a higher body mass index, are at risk of NSAID- provoked AKI in the first seven days of NSAID treatment, even at recommended doses. Avoid administering NSAIDs to children with chickenpox (Varicella zoster) infection due to the risk of invasive group A streptococcal complications and severe skin and soft tissue infections. Clinical Practice Guidelines Analgesia: Acute Pain CPG ECP 1.6 Page 3 of 4  CPG ECP 1.6 St John New Zealand Analgesia: Acute Pain Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz High dose ibuprofen up to maximum of 2400 mg/day is safe and effective in adult patients with a low risk of adverse effects from NSAIDs. Consider high dose ibuprofen in situations such as gout, renal colic and arthritis. Opioids and laxatives The risk of constipation when administering opioids should be reduced where possible, particularly for elderly patients and patients already taking constipating drugs (refer to the relevant ECP CPG guideline). This could mean either: Encouraging appropriate use of the patient’s prescribed laxatives. Concurrently administering docusate sodium and sennoside B if the patient does not have prescribed laxatives. Procedural sedation Procedural sedation in an ambulance environment is reserved for facilitating procedures in immediate life or limb threatening emergencies. This threshold is not met for most ECP interventions. Contact the on call doctor via the Clinical Desk to discuss a request for procedural sedation if the circumstances are exceptional. Exceptional circumstances cannot be tightly defined but may include situations where: An ECP intervention (for example, wound closure or urinary catheter placement) is expected to be successful in enabling the patient to be managed in the community, and The intervention cannot be performed without sedating the patient, and There is urgency to perform the intervention, and There is a good reason why it is not in the patient’s best interests to be transported to an ED to have the intervention performed. If approved by the on call doctor: A CCP must be dispatched to the scene to perform sedation, and Dissociative sedation using a single agent (for example, ketamine) is the preferred approach. Polypharmacy sedation is not recommended. ECP administration of liberal analgesia, without decreasing the patient’s GCS, is not considered procedural sedation. Clinical Practice Guidelines Analgesia: Acute Pain CPG ECP 1.6 Page 4 of 4  Analgesia: Chronic or Persistent CPG ECP 1.10 St John New Zealand Pain Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz This guideline is for adults with chronic or persistent pain. Use this guideline in conjunction with the relevant EAS CPG. Move to the relevant ECP guideline for acute pain, or for pain related to palliative or end of life care. Assessment Take a history, focusing on: Features suggesting new or acute pathology. Any existing diagnosis of chronic pain. Any existing care plan or pain management plan. A detailed pain history. A social history including any carer stress. Perform a physical examination, focusing on: Excluding new or acute pathology. Identifying significantly abnormal baselines. Management Use simple non-pharmacological pain reduction strategies: Encourage exercise and movement, even during an acute episode. Consider thermotherapy for localised pain. Encourage meditation and other relaxation techniques. Encourage engagement with community and/or online support groups. Develop a clear short-term plan (in alignment with existing plans) for the next few days. Care plans: Follow the patient’s care plan/pain management plan if they have one. Follow non-ambulance service plans, provided the plan does not include ambulance service supplied parenteral opioids, ketamine or methoxyflurane. Administer, or facilitate the administration of prescribed crisis medications that have been supplied to the patient by their usual primary care provider or pain service if there is a clearly documented and clinically sensible plan. Clinical Practice Guidelines Analgesia: Chronic or Persistent Pain CPG ECP 1.10 Page 1 of 6  Analgesia: Chronic or Persistent CPG ECP 1.10 St John New Zealand Pain Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Administer 1 g paracetamol PO and 800 mg ibuprofen PO if the patient has not taken paracetamol in the last four hours or ibuprofen in the last six hours. Administer 1.25 mg droperidol IV. Supply 75 mg pregabalin PO once daily for two days then twice daily for a further five days (for a total of seven days) if the pain is neuropathic and the patient is regularly taking paracetamol. Transport/referral criteria The patient requires immediate referral to an ED via ambulance: Significantly abnormal vital signs. Life-threatening problem. The patient requires immediate referral to an ED, however alternative transport may be appropriate: Unable to exclude serious pathology. Refer the patient to their usual primary care provider within one week: Administered droperidol. Supplied pregabalin. Chronic or persistent pain and no care plan/pain management plan. Additional information Background Chronic or persistent pain is defined as an ongoing unpleasant sensory experience with no correlation to the severity of pathology. About 20% of the population live with a degree of chronic or persistent pain, and it is a common cause of presentations to primary, urgent and emergency care. Patients may experience serious acute pathology unrelated to their chronic pain, for example acute appendicitis on a background of chronic lower abdominal pain. Acute pain is usually due to the stimulation of pain receptors by noxious stimuli and is a symptom, while chronic pain is usually due to an abnormal perception of normal stimuli and is a disease in its own right. Causes of chronic or persistent pain may include: Ongoing pathology related to a chronic condition. Clinical Practice Guidelines Analgesia: Chronic or Persistent Pain CPG ECP 1.10 Page 2 of 6  Analgesia: Chronic or Persistent CPG ECP 1.10 St John New Zealand Pain Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz An acute historical precipitating event that is no longer active. No easily recognised or identifiable injury or illness (idiopathic). Opioid tolerance, dependence and addiction Tolerance is a physiological phenomenon seen with opioids where the effect of the drug decreases over time, and higher doses are needed to obtain the same effect. Tolerance is a driver for patients who are prescribed opioids for chronic pain to request increasing opioid doses. Dependence refers to a physiological response to long-term opioid use and can result in a withdrawal syndrome if: There is a sudden reduction in dose, or The opioid is abruptly stopped, or The opioid is reversed with an antagonist. Opioid withdrawal syndrome symptoms include: Agitation. Sweating. Musculoskeletal pain. Abdominal cramps. Diarrhoea. Nausea and vomiting. Seizures. Constant piloerection (goosebumps). Opioid addiction is a combination of dependence associated with drug-seeking and drug-taking behaviours. Neuropathic pain Neuropathic pain is persistent and originates from a lesion or disease affecting the central or peripheral nervous system, for example, diabetic neuropathy, radiculopathic back pain or shingles. Patients may describe burning, shooting, tingling or pins and needles pain. Do not supply both pregabalin and opioids for neuropathic pain because: Opioids are not the preferred approach for neuropathic pain, and There is an increased risk of excessive sedation from concurrent pregabalin and opioid use. Clinical Practice Guidelines Analgesia: Chronic or Persistent Pain CPG ECP 1.10 Page 3 of 6  Analgesia: Chronic or Persistent CPG ECP 1.10 St John New Zealand Pain Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Approach Utilising a supportive and empathetic approach in your words, tone and body language will result in better engagement and outcomes. Patients may have a physical and/or behavioural addiction to medications (especially opioids and benzodiazepines); it is important that these patients are treated with care and respect. Difficult patient behaviours may be associated with a patient perception of being disbelieved about their experience of pain. Making a sincere attempt to understand the patient’s central concern will often improve the situation. Reassure the patient that there doesn't appear to be an acute issue, if this conclusion is supported by your assessment. Assessment History and examination are focused on confirming there is no evidence of new or acute pathology. Complete a focused assessment of chronic or persistent pain after excluding new or acute pathology. There is limited value using a traditional numerical pain score. Discuss what is usually effective for managing their pain. Ask about allergies, noting that excessive allergies to analgesic agents may indicate medication dependence. A social history includes asking about their carer and how well they are coping. This helps identify carer stress, noting that unrecognised or unmanaged carer stress can lead to neglect and/or abuse. Management Management goals: The principal goal in managing chronic or persistent pain is improved ability to function, not a reduction in pain score. For most patients, successful management will be non-pharmacological. Lead clinician: Seek clinical advice from a clinician directly involved in the patient’s usual care. Most patients with chronic or persistent pain will have their usual primary care provider involved in their care. Clinical Practice Guidelines Analgesia: Chronic or Persistent Pain CPG ECP 1.10 Page 4 of 6  Analgesia: Chronic or Persistent CPG ECP 1.10 St John New Zealand Pain Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz It is usually inappropriate for an ECP to become involved in the ongoing management of a patient's chronic or persistent pain. Forward the patients details to the appropriate personnel responsible for developing care plans if the patient is calling frequently and does not have a care or management plan. Care plans: Encourage the patient to follow established care plans or pain management plans. Having a clear plan is associated with reduced patient distress. Simply working with the patient to develop a simple plan (in alignment with any existing plans) for the next 1-4 days can significantly improve their ability to cope. Non-pharmacological pain reduction strategies: Encourage exercise and movement. Chronic and persistent pain is known to be helped by regular exercise of light intensity, even during an acute flare. Thermotherapy is often beneficial if the pain is localised to a relatively confined area. Some patients derive more benefit from hot and some from cold. Some patients benefit from alternating hot and cold. Thermotherapy can be applied for 20 minutes on and 20 minutes off for two hours. Meditation and other relaxation techniques are also shown to consistently offer benefits. Smartphones host useful apps which can introduce the patient to meditation, even in an acute setting, if the patient is willing to engage. Community and online support groups. Socially isolated patients who join and/or maintain engagement with local or online support groups experience distractive pain reduction benefits. Medications: Medications for persistent or chronic pain are usually only moderately effective in changing the patient's perception of their pain. The goal is to modify the patient experience of pain to the extent they are better able to function and cope with residual painful sensation. Avoid using terms like ‘painkillers’ when referring to medication for chronic or persistent pain. Analgesics effective for acute pain are generally not so useful for chronic or persistent pain in an acute setting. Opioids, ketamine and methoxyflurane do not have a role in ECP management of chronic or persistent pain. Discuss with the on call doctor prior to administration of ambulance service supplied opioids, ketamine or methoxyflurane. More Information Version history New: Guideline released. 25/06/2024, Version 1.0.4.4 Clinical Practice Guidelines Analgesia: Chronic or Persistent Pain CPG ECP 1.10 Page 5 of 6  Analgesia: Chronic or Persistent CPG ECP 1.10 St John New Zealand Pain Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz Clinical Practice Guidelines Analgesia: Chronic or Persistent Pain CPG ECP 1.10 Page 6 of 6  CPG ECP 1.7 St John New Zealand Palliative and End of Life Care Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz This guideline is for adults receiving palliative and/or end of life care and should be used in conjunction with the relevant EAS CPG. Consult with the patient’s palliative care team or on call doctor if the patient is a child. Involve the primary care provider and/or hospice team responsible for managing the patient in all decisions relating to the patient’s care when possible. Manage the patient using the principles outlined in this guideline if unable to contact the primary care provider and/or hospice team responsible for managing the patient. The goal of palliative care is to support quality of life, manage symptoms and enable the patient to live in a way that is important to them. The goal of end of life care is to provide adequate symptom relief without intentionally hastening the patient’s death. Assessment Take a history and perform a physical examination, focusing on: How well symptoms are managed. Features contained in the Recognising dying table. Features contained in the Suitability for community management (safe place to die) table. The patient’s wishes and goals of care. Total daily dose of opioids. Identify potentially reversible palliative care emergencies including: Superior vena cava obstruction. Metastatic spinal cord compression. Malignant hypercalcaemia. Opioid toxicity. Management Pain Administer an opioid for pain. Morphine is preferred over fentanyl due to the longer duration of action, however, fentanyl may be used if severe renal failure is a feature or if it is the only opioid available. Clinical Practice Guidelines Palliative and End of Life Care CPG ECP 1.7 Page 1 of 12  CPG ECP 1.7 St John New Zealand Palliative and End of Life Care Uncontrolled document exported 31.10.2024 View online at cpg.stjohn.org.nz The breakthrough dose of opioid is typically one sixth of the total dose of opioid the patient has received in the previous 24 hours. Patients that are already taking opioids may need higher doses than anticipated to achieve symptom control. There is no total maximum dose. Consider administration of 1 g paracetamol IV, which can be useful for breakthrough pain, even for patients who are on very high doses of opioids. Administer hyoscine butylbromide 20 mg SC for abdominal colic. Repeat at four-hour intervals, and change to one-hour intervals, if necessary, to a maximum of 80 mg per day. Nausea and/or vomiting Administer 0.625-1.25 mg droperidol IV or SC (up to a maximum of 5 mg over 30 minutes) to manage breakthrough nausea or vomiting. If nausea is not well controlled with droperidol consider administering an additional antiemetic providing the additional antiemetic has not already been administered to the patient as part of their care plan: 10 mg metoclopramide IV or SC, or 6.25-12.5 mg levomepromazine IV or SC, or 4-8 mg ondansetron IV. Consider placing a large bore NGT if nausea and vomiting is intractable (is otherwise unable to be managed). Agitation Administer midazolam to manage breakthrough symptoms of agitation: 5 mg midazolam SC, or 1-2 mg midazolam IV. Repeat dosing as required to gain control of symptoms. Administer 12.5 mg levomepromazine SC if midazolam does not rapidly manage agitation. Repeat the levomepromazine dose hourly until control is achieved. Dyspnoea Administer midazolam to manage breakthrough symptoms of dyspnoea: 5 mg midazolam SC, or Clinical Practice Guidelines Palliativ