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West London NHS Trust Page 1 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
Guideline: M20g Managing Acute Medical Presentations
Guideline Relates to Primary Policy: P15 Physical Healthcare
Version: M20g/03 Date Approved: 1st October 2018
Ratification Group: Clinical Governance Group
Governance Group: Medicines Management, Optimisation & Safety
Title of Author: Chief Pharmacist and Physical Health Nurse Practitioner
Responsible Director: Medical Director
Date issued: 16th October 2018
Review date: August 2019
Target audience: All clinical staff
Disclosure Status B: Can be disclosed to patients and public
West London NHS Trust Page 2 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
M20g – Managing Acute Medical Presentations Version Control Sheet
Version Date Title of Author Status Comment
M20g/01 27th August 2014
Chief Pharmacist and Physical Health Nurse Practitioner
Approved Under consultation, ending 21.02.14
Uploaded onto
the Exchange
15.09.14
M20g/02 August 2016
Chief Pharmacist and Physical Health Nurse Practitioner
Ratified & issued 2 week consultation ending 15.07.16. Uploaded to Exchange 31/08/2016
M20g/03 October 2018
Medication Safety Officer
Ratified & issued Addition of information about naloxone. Ratified at October Clinical Governance Group
West London NHS Trust Page 3 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
Contents Page
1.0 Introduction ........................................................................................................... 4
2.0 Aim ........................................................................................................................ 4
3.0 Flowchart for Management of Hypoglycaemia and hyperglycaemia ..................... 5
3.1 Management of patients with Diabetes ................................................................. 6
3.2 Management of Hypoglycaemia ............................................................................ 6
3.3 Management of Hyperglycaemia .......................................................................... 7
4.0 Flowchart for Management of Acute Asthma Attack ............................................. 9
4.1 Management of acute asthma attack .................................................................. 10
5.0 Flowchart for Management of Anaphylaxis ......................................................... 11
5.1 Management of Anaphylaxis ............................................................................... 12
6.0 Flowchart for Management of Suspected Benzodiazepine Overdose ................. 14
6.1 Management of Suspected Benzodiazepine Overdose ...................................... 15
7.0 Opioid Overdose ................................................................................................. 15
8.0 Flowchart for Management of Seizures............................................................... 18
8.1 Management of Seizures .................................................................................... 19
9.0 Flowchart for Management of Acute Cardiac Chest Pain.................................... 21
9.1 Management of Acute Cardiac Chest Pain ......................................................... 22
10.0 Management of Medicines .................................................................................. 23
11.0 Training ............................................................................................................... 23
12.0 Glossary / Acronyms ........................................................................................... 24
13.0 References .......................................................................................................... 24
14.0 Appendices ......................................................................................................... 24
Appendix 1 - Second Line Emergency Medicines Poster ............................................. 24
Appendix 2 – Naloxone Alert………………………………………………………………...24
West London NHS Trust Page 4 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
1.0 Introduction
1.1 Primary Policy 1.2 This guideline should be used in conjunction with P15 Physical Healthcare
Policy, B4 Basic Life support, M2 Medicines Policy, and the NMS poster.
1.3 Service users with mental health problems have a higher rate of physical health co-morbidity than the general population including diabetes, respiratory disease and cardiovascular disease all which could present acutely.
1.4 This guidance is intended to provide advice on how to manage common acute presentations of medical conditions in the inpatient setting.
1.5 The common acute medical presentations covered by this guidance are those outlined in the Medicines Policy (M2):
Hypoglycaemia
Hyperglycaemia
Acute asthma attacks
Anaphylaxis
Benzodiazepine Overdose
Seizures
Acute cardiac chest pain 1.6 Each inpatient clinical area will have stock medication to manage these acute
medical situations. These will be referred to as Second Line Emergency Medicines and kept in a RED TRAY in the stock medication cupboard (see section 7).
1.7 For outpatients who present with an acute medical problem that needs
immediate attention an ambulance should be called. 1.8 Medicines required for acute medical presentations may not always be
prescribed. If not prescribed they must only be given by a doctor or under a PGD by suitably trained staff.
2.0 Aim
2.1 The aim of this guideline is to provide clinical staff with guidance on the
management of common acute medical presentations that may occur in the mental health setting.
West London NHS Trust Page 5 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
3.0 Flowchart for Management of Hypoglycaemia and hyperglycaemia
a. Ensure patients hands are washed with soap
and water prior to test
b. Ensure that Glucometer has been calibrated
that day/week (according to local procedure)
c. If not : calibrate prior to using
BM 4.0-7 mmol/l Normal reading Pre-meal BM ≤8.5
mmol/l
BM < 4 BM ≥ 20
Repeat BM
after washing and drying hands thoroughly
Was food or sugary drink ingested recently /less than 2 hours ago?
NO
YES
Repeat BM in one hour (act on each fresh BM reading from the start of the flow chart)
Check for urinary ketones
Ketones
3+++?
Check blood ketones (monitor available from: Broadmoor Site Manager 4495 or emergency drugs cupboard via unit co-ordinator)
NO
Call doctor and give any prescribed insulin. Repeat BM one hour after giving prescribed insulin(act on each fresh BM reading from the start of the flow
chart)
YES
0.6-1.5 mmol/l Alert doctor. Doctor to seek advice from Physical Health Department
and/or Local Acute Hospital
>1.5 mmol/l RISK OF DIABETIC KETOACIDOSIS Alert doctor.
Doctor to seek urgent medical advice from the Physical Health Department and/or Local Acute Hospital
< 0.6mmol/l Normal range
Is patient alert enough
to eat and drink safely?
NO YES Provide high sugar food/drink (dextrose tablets/fruit juice) followed by high carbohydrate food (biscuits/sandwich). Where there are possible delays acquiring food/drink also give prescribed glucose gel (rub into gums and inside cheeks)
Check blood sugar after 15-20 minutes (act
on each fresh BM reading from the start of the flow chart)
Ensure Basic Life Support Monitor vital signs/NEWS Give prescribed Glucagon Recheck BM after 15 mins if still <4 and/or drowsy/unconscious Call 2222 request ambulance for drowsy/unconscious hypoglycaemic patient
All other BM will be monitored in liaison with the Physical Health Department Ensure diabetic medication is taken Provide healthy lifestyle advice P
Repeat BM
BM ≤ 4 BM ≥ 20
West London NHS Trust Page 6 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
3.1 Management of patients with diabetes
All patients with diabetes should as a minimum have the following:
A care plan outlining their management of diabetes
PRN medication to manage hypoglycaemia o Glucose gel o Glucagon IM
PRN medication to manage hyperglycaemia o Insulin Actrapid
3.2 Management of Hypoglycaemia
3.2.1 The symptoms of hypoglycaemia usually begin when the blood glucose level
drops to 3 - 4 mmol per litre. 3.2.2 Symptoms may vary from person to person and it is important to be aware of the
early warning signs so that they can be treated. 3.2.3 Presenting Signs and Symptoms
feeling hungry
sweating
dizziness
tiredness (fatigue)
blurred vision
trembling or shakiness
going pale
fast pulse or palpitations
tingling lips
irritability
difficulty concentrating
confusion
disorderly or irrational behaviour, which may be mistaken for drunkenness
3.2.4 If hypoglycaemia is not treated promptly blood glucose levels may drop low
enough to cause drowsiness and loss of consciousness. 3.2.5 Immediate treatment for hypoglycaemia
Patient is still alert and able to follow instructions and swallow without risk of choking: If patient is still alert and able to swallow: Provide high sugar food/drink (dextrose tablets/fruit juice) followed by high carbohydrate food (biscuits/sandwich). Where there are possible delays acquiring food/drink also give prescribed glucose gel (rub into gums and inside cheeks) Check blood sugar after 15-20 minutes (act on each fresh BM reading from the start of the flowchart)
West London NHS Trust Page 7 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
Avoid fatty foods and drinks such as chocolate and milk, because they don't usually contain as much sugar and may cause the sugar to be absorbed more slowly. It may take 10-15 minutes before they feel better. Check BM after 15-20 minutes if below 4mmol/L continue to treat as hypoglycaemic.
3.2.6 Deteriorating alertness and unable to swallow (risk of choking)
If a person is very drowsy and unable to follow instruction or becomes unconscious because of severe hypoglycaemia: Ensure Basic Life Support and start NEWs monitoring Call 2222 request ambulance for drowsy/unconscious hypoglycaemic patient Give prescribed Glucagon Monitor vital signs Never try to put food or drink into the mouth of someone who is very drowsy or unconscious, as their airway will be compromised and/or they will be at risk of choking.
3.3 Management of Hyperglycaemia
3.3.1 The symptoms of hyperglycaemia usually begin when the blood glucose level
raises to ≥ 20mmol per litre
3.3.2 Symptoms may vary from person to person and it is important to be aware of the early warning signs so that they can be treated.
3.3.3 Presenting Signs and Symptoms
blurry vision
difficulty concentrating
frequent urination
headaches
high blood glucose
high levels of sugar in the urine
increased fatigue
increased thirst
weight loss
3.3.4 Hyperglycaemia can lead to ketoacidosis which can be life-threatening, symptoms of ketoacidosis include:
nausea and vomiting
stomach ache
smell of ketones on breath (likened to smell of pear drops)
tiredness, confusion and feeling unsteady
difficulty breathing
Diabetic ketoacidosis is unlikely in type 2 diabetes.
West London NHS Trust Page 8 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
3.3.5 Immediate treatment for hyperglycaemia
Ensure patient’s hands are washed and dried and repeat BM reading. If the patient has ingested food or sugary drink recently /less than 2 hours ago repeat BMs in one hour. If the patient has not ingested food or sugary drink in the last 2 hours check for urinary ketones. If ketones are <3 – call medic and give any prescribed insulin, repeat BMs after 1 hour and re-assess as above. If ketones are ≥ 3 +++ Blood ketones must be checked. Contact the Site Manager or Unit co-ordinator for access to the monitor. If blood ketones < 0.6mmol/l this is within the normal range - call medic and give any prescribed insulin, repeat BMs after 1 hour and re-assess as above. If blood ketones 0.6-1.5 mmol/l - Alert medic. Doctor to seek advice from Physical Health Department (forensics) and/or local acute hospital. If blood ketones >1.5 mmol/l - Alert medic. Doctor to seek urgent advice from Physical Health Department (forensics) and/or local acute hospital.
West London NHS Trust Page 9 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
4.0 Flowchart for management of acute asthma attack
ACUTE ASTHMA SYMPTOMS
Known asthmatic- Difficulty with breathing/
Severe wheezing/
Very rapid breathing
The patient is unable to say a few words at a time/unable to speak
Nebulise 5mg Salbutamol Using nebuliser mask and 5 litres Oxygen
Or 2 puffs Salbutamol Inhaler using a spacer
and encouraging 5-6 breaths
Monitor vital signs including: Oxygen saturations
Provide additional Oxygen
With an non-rebreathe mask as required
IMPROVEMENT (NEWS score <5 no
single parameter of 3) Monitor using NEWS
chart Give salbutamol as
prescribed
Call for help
Fast bleep Duty Dr
NO IMPROVEMENT 2222 ambulance
required
Repeat Salbutamol Every 2 minutes
West London NHS Trust Page 10 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
4.1 Management of acute asthma attack
4.1.1 Presenting Signs and Symptoms, in a person known to suffer from asthma
Difficulty breathing, shortness of breath, severe wheezing or very rapid breathing
A silent chest in the face of significant shortness of breath
Coughing that won't stop
Visible use of accessory muscles to breath –shoulders/chest
Chest pain or pressure
Unable to say more than a few words at a time /unable to speak at all
Feelings of anxiety or panic
Pale, sweaty face
Blue lips or fingernails Worsening symptoms despite use of inhaled bronchodilator medication
4.1.2 Without immediate asthma treatment, asthma attack symptoms can worsen and become life threatening.
4.1.3 Immediate treatment for asthma attack:
Step 1: Nebulise 5mg Salbutamol nebule administered via a nebuliser mask driven with oxygen at a flow rate of 5L. In those who are known to have chronic obstructive pulmonary disease (COPD) an air driven nebulise machine should be used. If this is not available then administer 2 puffs of salbutamol inhaler via a spacer, achieving 5-6 breaths.
Monitor vital Signs. Record the vital signs on a Trust approved NEWS chart. Additional oxygen may be provided with a non-rebreathe mask at a flow rate of 15L. Alongside oxygen administration pulse oximetry must be performed.
4.1.4 Step 2: If no improvement call the emergency services on ex 2222 and repeat the administration of salbutamol every two minutes.
West London NHS Trust Page 11 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
5.0 Flowchart for management of anaphylaxis
Administer Adrenaline 1 in 1,000 by I.M. injection. Dose 0.5mls (500 micrograms) 1:1000 solution.
If using the pre-filled syringe 0.5ml should be
expelled from the syringe prior to administration.
NO IMPROVEMENT
After 5 minutes
IMPROVEMENT (NEWS score <5 no single parameter of 3) Monitor using NEWS chart
Further assessment required as a secondary reaction may develop when adrenaline has worn off. Antihistamines and
steroids may need to be prescribed. Patient requires referral to specialist allergy services
ANAPHYLAXIS
Administer high flow oxygen via a non-rebreathe mask Lay patient flat with legs raised (unless respiratory distress increased) Administer basic life support Monitor vital signs – NEWS score Be prepared to give CPR if necessary
Call 2222 ambulance required
Rash, swelling, itching
Shortness of breath/chest tightness
Cramps, nausea/vomiting, diarrhoea
Drop in BP, dizziness and/or loss of consciousness ANAPHYLAXIS MAY OCCUR with or without the presence of a known allergen
West London NHS Trust Page 12 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
5.1 Management of Anaphylaxis 5.1.1 Anaphylaxis is a severe life threatening allergic reaction which may occur where
a patient comes into contact with a known or unknown allergen. It could also take place following administration of a medication (e.g. flu vaccine, antibiotic). Prescription charts must have all allergies documented and allergies should be checked with the patient prior to administering the first dose of a new medication. An allergy can occur at any time, even following years of uneventful contact.
5.1.2 Presenting Signs and Symptoms include some or all of the following:
airway is compromised, narrowing of airways which can result in difficulty in breathing, swallowing or speaking and airway obstruction. Patient may be wheezy.
swelling of tongue, patient feels aware of tongue, tongue may tingle.
generalised flushing (redness) of the skin, or marked pallor indicates that the patient is about/has collapsed
a red raised itchy skin rash/nettle rash (hives) anywhere on the body
a sense of impending doom like something terrible is going to happen
swelling of throat, mouth, lips, eyes, hands and or feet
feeling like there is a lump inside the throat
strange metallic taste in the mouth
alterations in heart rate
abdominal pain, nausea and vomiting
sudden feeling of weakness, dizziness or feeling faint (drop in blood pressure)
collapse and unconsciousness
5.1.3 Immediate treatment for anaphylaxis
In cases of suspected anaphylaxis medical help must be summoned urgently Step 1 – Airway is compromised, lay patient flat and elevate feet, give oxygen, administer basic life support, monitor vital signs and call emergency services on ex 2222 and ask for an ambulance. Step 2 - Administer Adrenaline 1 in 1,000 by I.M. injection. Dose 0.5mls (500 micrograms) 1:1000 solution. If using the pre-filled syringe 0.5ml should be expelled from the syringe prior to administration. A rapid improvement in symptoms should occur once the adrenaline has been administered. If no improvement is observed after five minutes then a second dose of adrenaline should be given. Patients will need further assessment as they may develop a secondary reaction when adrenaline has worn off. Antihistamines and steroids may need to be prescribed. Where available Chlorphenamine maleate 10 - 20 mgs and Hydrocortisone 100-500 mgs may be given IM or slowly IV by a physician if considered necessary (this may need to be administered by ambulance staff or the acute hospital).
West London NHS Trust Page 13 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
Give psychological support - anaphylaxis is an extremely frightening experience. Information to be transferred with patient • Substance causing the reaction • Dosage and time of adrenaline injections • Known medical history Report the incident on a ‘yellow card’ to the Committee on Safety of Medicines. (See M24p) Record details on an IR1 form on the exchange, and give a full account of incidents in patient electronic health records, and record allergen on prescription chart and in patient electronic record.
West London NHS Trust Page 14 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
6.0 Flowchart for management of suspected Benzodiazepine overdose
Dizziness
Confusion
Drowsiness
Blurred vision
Anxiety
Agitation
Unresponsiveness
This could lead to:
SUSPECTED BENZODIAZAPINE
OVERDOSE
Call 2222
Ambulance required
BLS
Oxygen
Record vital signs-NEWS score
Flumazenil may be given by IV injection: • By a competent person
and • If there is evidence of benzodiazepine ingestion
Respiratory Depression Resp. rate ≤ 11
West London NHS Trust Page 15 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
6.1 Management of suspected Benzodiazepine overdose
6.1.1 NICE specify that all areas that may administer Rapid Tranquillisation must hold stock of flumazenil, the benzodiazepine reverser.
6.1.2 Initial signs and symptoms usually develop within 4 hours of ingestion and may
present as
Dizziness
Confusion
Drowsiness
Blurred vision
Unresponsiveness
Anxiety
Agitation (NB these symptoms may also present in many other conditions/situations) This may proceed to
Respiratory depression (slow respiratory rate that does not provide for full expansion of the lung or provide enough oxygen to the tissues) with abnormal or decreased breath sounds. If it is not treated, it can be fatal.
6.1.3 Immediate treatment for suspected benzodiazepine overdose:
Step 1: In cases of respiratory depression with suspected benzodiazepine overdose call the emergency services on ex 2222 specifying suspected benzodiazepine overdose. Airway is compromised administer basic life support and monitor vital signs. Flumazenil is available for immediate use by a competent practitioner. It is important that there is evidence of benzodiazepine ingestion. Flumazenil should not be used as a diagnostic test in an unconscious patient. Flumazenil by intravenous injection, 300 micrograms over 15 seconds, then 100 micrograms at 60-second intervals if required; max. total dose 2 mg if drowsiness recurs 300 micrograms by intravenous injection. Use of flumazenil can be hazardous, particularly in mixed overdoses involving tricyclic antidepressants or in benzodiazepine-dependent patients.
7.0 Opioid overdose
Naloxone is a highly effective antidote for opioids and opiates and its use is potentially life-saving in many circumstances. It is used across a range of care settings where opioid and opiate use is common, and for a number of scenarios that range from management of drug misuse and dependence to the provision of palliative care. The primary aim of treatment is to reverse the toxic effects of opiates such that patients are no longer at risk of respiratory arrest, airway loss, or other opioid-related complications. The primary aim of treatment should not be to restore a normal level of consciousness, and indeed in some circumstances restoring a normal level of consciousness is entirely inappropriate. Naloxone is given most often by the intravenous or intramuscular routes.
West London NHS Trust Page 16 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
In 2014 NHSE published a patient safety alert drawing attention to the safety implications of inappropriate doses of the opioid antagonist naloxone. The alert highlighted the use of naloxone where it was not indicated or, in larger than recommended doses, can cause a rapid reversal of the physiological effects for pain control, leading to intense pain and distress and in increase in sympathetic nervous stimulation and cytokine release precipitating an acute withdrawal syndrome. Please see attached alert for more information. Fundamentally the only indication for urgent and emergency use of naloxone is respiratory depression, regardless of the reason for the exposure to opioids or opiates. A diagnosis of respiratory depression should be sought before naloxone is considered. Symptoms of respiratory depression vary. Mild or moderate symptoms may include tiredness, daytime sleepiness, shortness of breath, slow and shallow breathing. As the condition progresses and carbon dioxide level increases, the patient may develop bluish-coloured lips, fingers, or toes, seizures, confusion and headaches. Doses are injected in the deltoid region or anterolateral thigh. Where practicable, the site of injection should be varied for repeated intramuscular doses.
Recommend naloxone dosing regimen for nurses: 1. Call ambulance, then IM dose of 400micrograms initially 2. Repeat ever 2-3mins. Each dose is given in subsequent resuscitation
cycles if the patient is not breathing normally 3. Until an effect is noted, breathing is normal or the ambulance arrives or
medical assistance is available Recommended naloxone dosing regimen for doctors:
1. Call ambulance, then IV/ IM dose of 400micrograms initially 2. If no response after 1 min give 800micrograms 3. If still no response after another 1 min repeat dose of 800micrograms 4. If still not response give 2mg (4mg may be required in a seriously
poisoned patient), then review diagnosis
Further doses may be required if respiratory function deteriorates Where acute toxicity and the subsequent need for naloxone is established, in most circumstances, a higher dose regimens will be safe and efficacious in reversing the effects of overdose in drug misuse and dependence. However the need for high initial dose treatment as well as its continuation needs to be balanced against the risks of acute withdrawal syndrome and sympathetic excess. The treatment risks need to be considered against the risk of death without naloxone. The risks of giving too much naloxone include acute withdrawal from opioids. Vomiting, agitation, shivering, sweating, tremor and tachycardia may occur. Delirium and aggression are relatively common. Vomiting where it affects aspiration may be life-threatening. Acute withdrawal causing sympathetic excess with resistant pulmonary oedema and ventricular arrhythmia are potentially life-threatening. In drug misuse and dependence, life-threatening withdrawal
West London NHS Trust Page 17 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
reactions can occur in as many as 1% of cases of naloxone administration (particularly in cases of poly-drug misuse). An effective naloxone dose can vary greatly depending on the opioid or opiate type and the amount ingested or injected. Where overdoses are particularly sizeable, huge doses of naloxone may be required. Where the overdoses are smaller, the required naloxone doses will be too. All cases of opioid toxicity should be treated by a general acute hospital regardless of the response to naloxone.
West London NHS Trust Page 18 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
8.0 Flowchart for management of seizures
Tonic Phase (lasts seconds)
Clinical Presentation Action Required
Body stiffens Call for help
Loss of consciousness Be alert for any injury sustained during fall Patient will slump/fall Fast bleep Duty Doctor
Status Epilepticus
Call 2222 ambulance required
Give prescribed diazepam
Place high dose oxygen on patient's face
Clonic Phase TIME THIS PHASE (May last seconds to minutes to a life threatening period)
Clinical Presentation Action Required
Muscles relax and contract appearing as Make environment safe for patient
Exaggerated twitching to violent shaking of extremities Maintain patient dignity
Patient will not be breathing as effectively Obtain Oxygen and diazepam PR in case it is required
Post Ictal Clinical Presentation Actions Required
Patient in deep sleep Maintain airway by placing in recovery Take and record vital signs on NEWS chart
Gradual Awakening
Clinical Presentation Action Required
Probable period of Reassurance
confusion and amnesia Monitor health before gradual and safety
awareness takes place
Patient has returned to
Clonic phase with no gradual
awakening
Clonic phase
≥ 5 mins
West London NHS Trust Page 19 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
8.1 Management of seizures
8.1.1 Seizures may occur in patients in the mental health setting for a number of
reasons including:
Epilepsy
Treatment with anti-psychotics – anti-psychotics can lower the seizure threshold making it more likely to fit. There is increased risk with Clozapine treatment especially when levels are high.
Withdrawal from alcohol or benzodiazepines
Overdose The most common type of seizure is a tonic-clonic seizure.
8.1.2 Dissociative seizures (an episode resembling an epileptic seizure but having purely psychological causes) also occur in the mental health setting and may be difficult to distinguish from real seizures.
8.1.3 Presenting symptoms of a tonic-clonic seizure
Tonic Phase
body will become stiff (may last seconds)
loss of consciousness Clonic Phase
Muscles will start to contract and relax rapidly causing convulsions. These may range from exaggerated twitches of the limbs to violent shaking or vibrating of the stiffened extremities. Incontinence may occur Postictal phase.
A period of sleep and/or gradual return to consciousness. May be a degree of confusion during this time.
8.1.4 Management of seizure clonic phase
Step 1: Patient needs to be made safe from injury ensuring environment is clear of objects. Step 2: Time the clonic phase as during the clonic phase the patient will not be breathing effectively . Step 3: High dose oxygen should be provided (15L flow rate) wherever possible. Step 4: If the clonic phase has continued for 5 minutes or the patient is cycling between clonic and post-ictal sleep without returning to consciousness, then the patient is now in Status Epilepticus. Call the emergency services on ex 2222 and medication must be administered as prescribed (midazolam buccal or diazepam rectal). If the clonic phase continues 10 minutes following administration of medication a repeat dose must be given. Exception If the patient is known to experience prolonged seizures medication must be administered at the earliest opportunity as prescribed (midazolam buccal or diazepam rectal).
West London NHS Trust Page 20 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
8.1.5 Management of seizure post-ictal phase Maintain patient in the recovery position protecting their airway. Monitor vital signs.
8.1.6 Rescue medication for seizures All patients with a diagnosis of epilepsy should have a care plan that specifies their preferred rescue medication for seizures. There are two medications available, diazepam rectal and midazolam buccal.
Diazepam rectal should be prescribed as 10mg rectal PRN repeated once after 10 minutes.
Midazolam buccal is currently only licensed for use in those aged 3months to < 18 years and in the majority of patients will be ‘off-label’. Patients will need to have capacity and consented to its use, and this must be documented.
Midazolam buccal should be prescribed as 10mg buccal* PRN repeated once after 10 minutes. *into the buccal cavity, this is the gutter between the teeth and the cheek.
Midazolam is a controlled drug and will only be supplied to wards where patients are prescribed it.
Following a first seizure if medication is required diazepam rectal should be used as the patient will not be able to consent.
8.1.7 Following first seizure
A first seizure will ALWAYS need to be referred to a neurologist for further investigation Forensic services refer to primary care services for investigations and referral for specialist advice. Local services the responsible clinician will decide if referral to a neurologist, or back to the registered GP is the most appropriate response (this will depend on date of discharge, and other physical health co-morbidities). Review current medication for possible lowering seizure threshold properties and review dose as necessary.
West London NHS Trust Page 21 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
9.0 Flowchart for management of Acute Cardiac Chest Pain
2222 Ambulance required
Monitor vital signs – NEWS
ECG if time/appropriate to do so
Oxygen and AED kept nearby
Give GTN 400mcg spray
Repeat as required
Give 300mgs Aspirin (unless allergic)
Monitor Oxygen saturations: 94-98% 88-92% in those with COPD
Provide additional Oxygen if needed
Acute Cardiac Chest Pain
Pain in central chest and/or arms/back/jaw lasting more than 15 mins
May be accompanied by: • Nausea and vomiting
• Marked sweating
• Breathlessness
• Grey pallor • Dizziness
West London NHS Trust Page 22 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
9.1 Management of Acute Cardiac Chest Pain
9.1.1 Acute Cardiac Chest Pain may occur in patients in the mental health setting for a
number of reasons including:
Cardiac Diagnosed Stable Angina Acute Coronary Syndromes:
Unstable angina
Myocardial Infarction – ST segment elevation (STEMI) or Non ST segment elevation (NSTEMI)
Acute pericarditis Aortic dissection Myocarditis
9.1.2 Presenting Symptoms
Symptoms that may indicate acute coronary syndrome (ACS) include:
Pain in the chest and/or other areas (e.g. the arms, back or jaw) lasting longer than 15 minutes.
Chest pain with nausea and vomiting, marked sweating and /or breathlessness, or haemodynamic instability.
New-onset chest pain or abrupt deterioration in stable angina, with recurrent pain occurring frequently with little or no exertion and often lasting longer than 15 minutes.
9.1.3 Assessment for possible acute coronary syndrome
Consider the history of the pain, any cardiovascular risk factors, history of ischaemic heart disease and any previous treatment, and previous investigations for chest pain
Monitor Blood pressure, pulse, temp,O2 sats, respiratory rate using NEWS
Doctor to conduct a cardiovascular examination
Take a resting 12-lead electrocardiogram (ECG) as soon as possible.
Do not exclude an acute coronary syndrome (ACS) when people have a normal resting 12-lead ECG
9.1.4 If Acute Coronary Syndrome Suspected:
administer basic life support, monitor vital signs, oxygen saturation by pulse oximetery, pain management and call emergency services on ex 2222
Stop any activity and rest. Offer pain relief as soon as possible. This may be achieved with GTN 400micrograms spray 1-2 sprays sublingual, repeated as required.
Offer people a single loading dose of 300 mg aspirin as soon as possible unless there is clear evidence that they are allergic to it.
If aspirin is given before arrival at hospital, send a written record that it has been given with the person.
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Do not routinely administer oxygen, but monitor oxygen saturation using pulse oximetry as soon as possible, ideally before hospital admission. Only offer supplemental oxygen to:
people with oxygen saturation (SpO2) of less than 94% who are not at risk of hypercapnic respiratory failure, aiming for SpO2 of 94–98%
people with chronic obstructive pulmonary disease who are at risk of hypercapnic respiratory failure, to achieve a target SpO2 of 88–92% until blood gas analysis is available.
Ensure defibrillator is in close vicinity to patient.
Send the ECG results to hospital before they arrive if possible. Recording and sending the ECG should not delay transfer to hospital.
9.1.5 Following acute chest pain it may be relevant to monitor cardiac enzymes 12
host post episode with a blood test if a cardiac cause is suspected.
10. Management of medicines
Hammersmith and Fulham inpatient unit medicines for the Crash team are stored in the Crash trolleys. Lakeside inpatient unit medicines for the Crash team are stored in the treatment room in a blue carry case. Second line emergency medicines for the management of acute medical presentations as follows: Adrenaline IM Diazepam PR Flumazenil IV Glucose gel Salbutamol nebules Salbutamol Inhaler Spacer Device Glyceryl Trinitrate Sublingual Spray Aspirin 300mg oral are stock on all inpatients wards and are kept in the red ‘second line emergency medicine’ tray in a locked cupboard. The cupboard should be labelled highlighting where the second line emergency medicines are kept (Appendix 1). Medicines for acute medical presentations may not always be prescribed. If not prescribed they must only be given by a doctor or under a PGD by suitably trained staff.
11. Training Each CSU should ensure that healthcare workers who may be involved in the management of acute medical presentations are aware of this guideline. This guideline will be highlighted during doctor’s induction.
West London NHS Trust Page 24 of 24 Guidance M20g First Date of Issue: Sept 2014 This is current version M20g/03 October 2018
12. Glossary / Acronyms AED - automated external defibrillator ACS - acute coronary syndrome BLS - Basic Life Support BM – Blood glucose Monitoring COPD – Chronic obstructive pulmonary disease ECG - Electrocardiogram GP – General Practitioner GTN – Glyceryl trinitrate IV - Intravenous IM - Intramuscular NEWS – National Early Warning Score PGD- Patient Group Directions PR – per rectum PRN – Pro Re Nata – when required
13. References https://www.medicinescomplete.com/mc/bnf/current/ https://www.nice.org.uk/guidance/CG137 https://www.nice.org.uk/guidance/ng10 https://www.nice.org.uk/guidance/CG95
14. Appendices
Appendix 1 - Second Line Emergency Medicines Poster
SECOND LINE EMERGENCY MEDICINES poster v3.0.pptx Appendix 2 – Naloxone Alert
psa-inappropriate-doses-naloxone.pdf
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