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Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 197 In Australia, methoxyflurane has been in use as an analgesic for over three decades with more than five million uses4 and with no serious reported adverse effects Since 1971, the Therapeutic Goods Administration’s database of AE notifications lists 14 reported cases possibly related to methoxyflurane, with one case each of suspected hepatic and renal failure – both of which occurred in the same patient at the same time 11. On close scrutiny, all the cases had other risk factors which were also potential causes of the adverse events. No deaths occurred as a result of the AE. In the STOP! study10 at least one treatment emergent adverse event was experienced by 50% of patients. The most common were headache and dizziness. Events requiring withdrawal from the trial were very low at 1.3%, which was lower than the placebo group! All such reactions were found to be mild and transient and in line with anticipated pharmacological action10 Considering the question of nephrotoxicity, what is the real risk, based on evidence for renal toxicity at analgesic and anaesthetic doses of Penthrox? ‘Minimum alveolar concentration’ is defined as the minimum concentration of an inhaled anaesthetic agent in the alveoli of the lungs which will prevent a response (movement) to a standard surgical stimulus (an incision) in 50% of patients. Typical values are listed below for methoxyflurane and other common volatile anaesthetic agents: • Methoxyflurane MAC = 0.16% (very potent) • Isoflurane 1.17% • Sevoflurane 1.8% • Desflurane 6.6% The lower the number the more ‘potent’ the agent. However other properties of the agent may greatly delay the rate of rise in the alveoli as it is inhaled and this may result in a slow onset, which may be misinterpreted as the agent being relatively ‘weak’. MAC Hours are used to quantify the dose or summative exposure to any inhaled anaesthetic agent. It is simply calculated by multiplying the concentration of agent (based on multiples of the MAC value) by the time in hours. For example: • 1 MAC for 1 Hour is equivalent to 1 MAC hour • 2 MAC for 30 minutes (1/2 an hour) is equivalent to 1 MAC hour and finally • 1.5 MAC for 30 minutes (0.5 hrs) is equivalent to 0.75 MAC hours. This value allows us to define key levels of exposure that may produce various properties of any particular agent, such as toxicity. Methoxyflurane the analgesic safety and adverse reactions Chapter 10: Pain Management

198 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The graph below was adapted from Dayan, 2015 which demonstrates the effects of increasing MAC hours of exposure to methoxyflurane for both anaesthetic and analgesic doses. If we consider the anaesthetic column first, we can see that for a typical anaesthetic dose (2-2.25 MAC hours) the exposure would often exceed what has been defined as the safe upper limit of methoxyflurane (2 MAC hours) that ensures no serious adverse effects. Once the level of exposure exceeds 2.5 MAC hours we can then usually biochemically detect signs of nephrotoxicity and above 5 MAC hours the nephrotoxicity will be clinically manifested and may result in long term damage. In contrast, if we look at the levels of exposure associated with analgesia, a single 3 ml dose is equivalent to 0.3 MAC hours and is more than six times lower than the safe upper limit and significantly below the typical anaesthetic doses which have led to renal problems in the past. Even with a second dose, giving an exposure of 0.6 MAC hours, we are still more than three times below the safe upper limit for methoxyflurane and as such there is a good safety margin built into the dose and protocol for methoxyflurane analgesia5 Based on work such as this to summarise the current approved dosing with methoxyflurane: 3ml dose (equivalent to 0.3 MAC hrs) which can be repeated to a maximum of 6 mls as a single treatment episode. Staying below 2 MAC hrs minimises the risk of clinical or biochemical evidence of renal insult. The total exposure in a week must not exceed 15 mls (five bottles). This would represent a total of 1.5 MAC hrs At present the safe frequency of repeated doses has not been defined. Penthrox should not be administered on consecutive days. As mentioned earlier, the nephrotoxicity after methoxyflurane anaesthesia was dose dependent and largely resulted from the inorganic fluoride metabolites. At the highest levels of exposure (>5 MAC hours) the clinical features of high output renal failure can develop, with large volumes of dilute urine and loss of the normal concentrating response to vasopressin. The biochemical and histological damage is largely focused in the proximal tubules and this picture is typical of fluoride toxicity. The risk of nephrotoxicity is primarily dose related and can be minimised by administering Penthrox (methoxyflurane) in accordance with the dosing guidelines in the SPC which we have just discussed. It should not be used in patients with clinically significant renal impairment or those taking drugs with a nephrotoxic effect, e.g. tetracycline. In view of the high fluoride content in sevoflurane and previous concerns about its potential to cause nephrotoxicity, questions have been asked about the risks of using sevoflurane after methoxyflurane analgesia. There are no specific cases or problems identified in Australia. However, there is a theoretical risk therefore the MHRA recommend that the use of sevoflurane is avoided after methoxyflurane administration. As such, we must ensure that anaesthetists are made aware that the patient has had methoxyflurane. analgesia. Methoxyflurane the analgesic safety and adverse reactions Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 199 HEPATOTOXICITY Effects on the liver have been very rarely reported at analgesic levels and have all been self-limiting. The exact aetiology is unclear but the incidence does increase with repeated exposure and is one of the adverse effects of volatile fluorinated hydrocarbons. Possible mechanisms include: • Immune mediated response • Direct toxic effects of metabolites • Host idiosyncrasy To minimise the risks of hepatotoxicity, firstly we avoid using methoxyflurane in patients with known liver disease or at risk of liver dysfunction and in patients with a history of liver impairment following exposure to other fluorinated anaesthetics. Secondly, we limit the dosage in a single administration to no more than 6ml, as we do want to minimise the risk of renal complications. Cautious clinical judgement should be used when administering Penthrox more frequently than once every three months. We also recommend use of the lowest effective dose and do not simply use 6mls on every patient as this may not be required in all cases. One question that remains unresolved is the safe frequency of repeated doses. This has not been the subject of any specific research owing to the potential risks at very high doses. A posology has been defined by the MHRA as no more than 15ml per week and administration on consecutive days in not recommended. A safe frequency of use has not been established. Penthrox has been historically used for trauma patients and a patient does not usually present multiple times in a short time period with a new trauma. DRUG INTERACTIONS If we now consider how methoxyflurane interacts with other drugs and medications, at analgesic doses of 3-6mls, no drug interactions have been reported. Previous case reports have involved the anaesthetic use of methoxyflurane at typically 10 times higher doses of 40-60mls. Effects that are entirely understandable are the increased CNS depressant effects of methoxyflurane when administered in conjunction with other depressants such as opioids, sedatives, general anaesthetics, phenothiazines, muscle relaxants, antihistamines and alcohol. The simple solution to this issue is to state that any patient with a reduced level of consciousness is not suitable for methoxyflurane analgesia. Patients receiving methoxyflurane for analgesia should always be observed for any significant reduction in level of consciousness. An additional safety factor is the self-administration aspect, as if the conscious level does fall, the patient will start to lose the ability to use the device and the effects will most likely wear off. Enzyme inducers include alcohol or isoniazid for CYP 2E1 & phenobarbital or rifampicin for CYP 2A6. As these may increase the potential toxicity of methoxyflurane, we must avoid concomitant use. Methoxyflurane the analgesic safety and adverse reactions Chapter 10: Pain Management

200 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com OCCUPATIONAL EXPOSURE A recent occupation exposure study has determined that a conservative safe maximum exposure limit for a working day (8 hrs) is 15 ppm. This is at least 50 times greater than the observed exposure to healthcare professionals administering Penthrox. It is important to note that methoxyflurane has a very potent smell which can be detected as low as 0.1-0.2 ppm. Healthcare professionals will often be able to smell methoxyflurane but the exposure they are getting is extremely low. Historically, levels higher than this have been detected higher than this in obstetric units until scavenging was adopted, and one case of occupational exposure adverse effects was identified in an anaesthetic nurse who developed myasthenic-like symptoms with weakness and ptosis. These symptoms were later reproduced with further exposure, but fully resolved spontaneously. She was later diagnosed as a sub-clinical myasthenic which had been unmasked rather than caused by methoxyflurane. In Europe, the Penthrox inhaler is supplied with an Activated Charcoal (AC) chamber so that all exhaled air that enters the Inhaler will pass via a one way valve through this absorbing chamber, deactivating the vapour. These are not routinely used in Australasian ambulances. The AC chamber will adsorb any methoxyflurane that remains on a patient’s breath. The AC chamber has been shown to result in near zero levels of methoxyflurane in the exhaled air that has passed through the AC chamber. Always ensure that the patient both inhales and exhales through the inhaler while they are using Penthrox. Methoxyflurane has caused cardiovascular and respiratory depression at anaesthetic dose. Hypotension and respiratory effects (e.g. coughing) were common adverse events in clinical trials. The risk of coughing can be reduced, ensuring that initially the patient takes gentle breaths through the inhaler. Risk may be higher in older patients with hypotension and bradycardia. A recent study of patients treated by an Australian ambulance service found that in 117 patients aged over 75 years their mean baseline systolic BP dropped ~8 points on average, from approx. 145 to 137. Patients of all age groups were included in this study. However, the largest change in systolic BP was in the older patient groups. Little effect was evident in patients aged 18 – 50 years. Only administer to patients who do not have clinically evident CV instability or respiratory depression. Use caution when administering methoxyflurane in elderly patients due to a potential reduction in blood pressure. Methoxyflurane the analgesic safety and adverse reactions Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 201 Malignant hyperthermia is a rare genetic disorder which results in a potentially lethal rapid rise in temperature. It is usually triggered by an anaesthetic, including methoxyflurane. To minimise the risk of malignant hyperthermia, always ask patients if they have malignant hyperthermia or if they know whether any family members have it. If they are at risk of malignant hyperthermia, do not administer methoxyflurane. As methoxyflurane can have CNS effects, such as sedation, euphoria and as change in mood, it has some abuse potential. As it is a prescription-only medicine which is administered only in single doses under the supervision of a healthcare professional, the main risk group for abuse is healthcare professionals. The risk of abuse can be minimised by storing methoxyflurane appropriately in a locked cabinet and not leaving it on open shelves. It should also be disposed of responsibly after use. In summary, methoxyflurane analgesia is well tolerated with few serious adverse effects at the recommended analgesic doses. ADVERSE EVENTS Presented below are the nature and incidence of reported side effects with Penthrox use for analgesia. Methoxyflurane the analgesic safety and adverse reactions MedDRA System Organ Class Common >1/100 to <1/10 Uncommon >1/1,000 to <1/100 Nervous system disorders Amnesia Anxiety Depression Dizziness Dysarthria Dysgeusia (altered taste) Euphoria Headache Sensory neuropathy Somnolence Paraesthesia Cardiac Disorders Hypotension MedDRA System Organ Class Common >1/100 to< 1/10 Uncommon >1/1,000 to <1/100 Eye disorders Diplopia Respiratory, thoracic and mediastinal disorders Coughing Gastrointestinal disorders Dry mouth Nausea Oral discomfort General disorders Feeling drunk Fatigue Feeling abnormal Increased appetite Shivering Skin and subcutaneous tissue disorders Sweating Chapter 10: Pain Management

202 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com CONTRAINDICATIONS TO (METHOXYFLURANE) Penthrox is not approved for use in the following situations: • For anaesthetic use • In children (under 18yrs) • Non-traumatic pain, e.g. chronic back pain, myocardial infarction • Elective surgical procedures • Use of more than 6ml in a single episode • Use of more than 15 ml in one week. Penthrox contraindications, some of which require some history and clinical assessment of the patient include: • Previous hypersensitivity or serious reaction to and inhaled anaesthetic agent (fluorinated volatile – if they understand) • History or family history of malignant hyperthermia • History or features of liver impairment, especially after anaesthetic • Clinically significant renal impairment • Altered conscious level, e.g. head injury, drugs or alcohol excess • Clinically evident cardiovascular instability, e.g. shock • Clinically evident respiratory depression. THE LAW Penthrox is not classified as a Controlled Drug under the UK Misuse of Drugs. Act 1971 and it is not described as a drug of dependence, as there is no evidence for neuroreceptor dependency effects in the brain, (such as dopamine mediated interactions in the mesolimbic region of the brain). In summary, methoxyflurane for analgesia is generally well tolerated. In over 5 million cases worldwide there has been no serious adverse effects attributed to its use. Remember that the analgesic dose restrictions are as follows: • A single dose of methoxyflurane is 3 mL (one bottle)1 which provides up to one hour of analgesia when used intermittently or 25 – 30 minutes if used continuously1. • The maximum dose in one episode should not exceed 6mL (two bottles of methoxyflurane)1 which could provide up to a maximum of two hours of analgesia. • The maximum amount of methoxyflurane in a week is 15 mls. Summary Methoxyflurane the analgesic safety and adverse reactions Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 203 Patient selection and safety This section is a simple summary which we use in the User course to define which patients can and can’t have Penthrox. • Penthrox is for use in adult patients over 18 years of age • Penthrox is for use in Trauma patients • Penthrox is for use in moderate to severe pain (scoring between 4 and 10 on the ten point pain scale) Penthrox must not be used in the following situations: • Clinically significant cardiovascular instability or shock • History from the individual or their family of malignant hyperthermia or previous inhaled anaesthetic reaction • Patients with a reduced level of consciousness, e.g., following a head injury, drugs or excess alcohol • Minor surgical or elective procedures beyond the immediate management of traumatic injuries • Patients with clinically significant renal or liver impairment • If the patient is taking antibiotics or drugs which induce the enzyme systems in the liver, leading to increased metabolism, e.g. isoniazid, rifampicin and phenobarbitone. Other antibiotics that are nephrotoxic should also be avoided, including gentamicin, tetracycline, amphotericin and polymyxins. If you are uncertain, as the casualty cannot remember the names, perhaps include any antibiotics for safety • Penthrox is not to be used in cases of marked respiratory depression, e.g., drug overdose or stroke. It will also be poorly effective in cases where there is difficulty breathing – where the patient is unable to inhale the vapour effectively. But unlike Unlike Entonox is can still be used in chest trauma such as rib fractures or stabbings • Whilst Penthrox has been used widely around the world for pain relief in labour, it is not currently licenced for such use in the UK and therefore must not be used for this purpose other than in a pre-hospital situation or an emergency outside the labour ward • Penthrox can be used for trauma in all trimesters of an uncomplicated pregnancy. As a simple aid memoir Galen have produced this in conjunction with the MHRA: CHECK ALLL appears on your pre-checklist for all patients and it is essential that it is used for each case. PRE-ADMINISTRATION CHECKLISTS This is how the checklist can appear. You can see the ‘CHECK ALLL’ on the front and then the supplementary cautions on the back, which also lists the drugs that should be avoided with Penthrox. PENTHROX® (methoxyflurane) Checklist for administration IMPORTANT RISK MINIMISATION INFORMATION FOR HEALTHCARE PROFESSIONALS This checklist is essential to ensure the safe and effective use of methoxyflurane and appropriate management of important selected risks. Before using methoxyflurane ...please CHECK ALLL. The patient is not known to have: Cardiovascular instability Hypersensitivity to methoxyflurane (or any fluorinated anaesthetic) Elevated temperature from an anaesthetic (malignant hyperthermia) Consciousness reduced (including due to alcohol) Kidney impairment Age below 18 years Lung or respiratory impairment Liver impairment Last administration of methoxyflurane C H E C K A L L L If patient has any of the conditions listed here or is taking any of the drugs listed on the reverse DO NOT administer methoxyflurane. This medicine is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions to the MHRA via the Yellow Card Scheme online at www.mhra.gov.uk/yellowcard. Any suspected adverse reactions should also be reported to Galen Limited on 028 3833 4974 and select the customer services option, or e-mail [email protected]. PMR-APR-2015-0070. Date of preparation: August 2015 Instruct patient on the correct administration of methoxyflurane. Reminder: Please read SmPC before administering and give patient PIL and Alert Card. Ensure lowest required dose is administered and maximum dose of 6ml (2 vials) is not exceeded. Patient is not taking: CYP-450 enzyme inducers (e.g. alcohol, isoniazid, phenobarbital or rifampicin). Antibiotics with known nephrotoxic effect (e.g. tetracycline, gentamicin, colistin, polymyxin B or amphotericin B). Concomitant use of methoxyflurane with CNS depressants may produce additive depressant effects and patients should be observed closely. Chapter 10: Pain Management

204 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com When we see an adult patient with moderate to severe pain from a traumatic injury, the following checks should be performed. • Run through the pre-administration checks with the ‘CHECK ALLL’ checklist card. • Ensure the patient has never had Penthrox or a ‘green-whistle’ before, especially within the last 3-6 months. If all checks are satisfactory, then you can proceed to set up of the device. Start with a single 3ml dose of Penthrox for each patient and remember that this should provide up to one hour of analgesia when used intermittently or 25 – 30 minutes if used continuously1 Once the first dose has been completed, we can give a second dose, this is then the maximum dose in one episode and should not exceed 6 mL (two bottles of methoxyflurane)1. This could provide up to a maximum of two hours of analgesia. The contents of the Penthrox inhaler packaging includes: • The green inhaler • The AC chamber • A wrist strap – should be attached to the inhaler • The 3ml bottle of methoxyflurane • A sealable plastic disposal bag • The Patient Information Leaflet (PIL). We should carefully lay these items out on a clean, safe surface. Setup and administration Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 205 STEP 1: Take the Inhaler and if the AC chamber is not already attached, securely fit it into the dilutor hole as shown. STEP 2: Take the cap off the small bottle of Penthrox. If it is stiff to open, then the open end of the inhaler can be used to loosen it. Remove it from the inhaler and take the cap off by hand. STEP 3: Tilt the inhaler at 45 degrees with the wider open end uppermost. Gently pour in the contents of the bottle slowly into the inhaler, down the side and onto the wick, whilst slowly rotating the devices in your hand. If this is difficult then rotate the device as soon as you have finished pouring. Replace the cap on the empty Penthrox bottle. SETTING UP THE PENTHROX INHALER: Penthrox – Setup and administration Chapter 10: Pain Management

206 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Penthrox – Setup and administration STEP 4: Place the loop over the patient’s wrist and encourage them to inhale through the mouthpiece. Tell them to breathe gently at first and then normally to reduce the risk of coughing. STEP 5: Tell the patient to keep the device in their mouth and breathe out through it. This will ensure that the exhaled vapour passes through the activated carbon chamber. STEP 6: If more pain relief is required, the casualty can put their finger over the dilutor hole, on top of the AC chamber and this will increase the concentration of vapour as no additional air is entrained through the dilutor hole. SETTING UP THE PENTHROX INHALER: Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 207 Penthrox – Setup and administration STEP 7: Instruct the patient to use the inhaler intermittently until they have control of their pain. This will ensure that it also lasts longer. STEP 8: Once the use is completed. Replace the cap on the Penthrox bottle, if not done already and place it in the plastic disposal bag with the inhaler. Seal the bag and then dispose of it according to your unit policy. STEP 9: Remember to give the patient a Patient Alert Card (PAC), as well as the Patient Information Leaflet (PIL). SETTING UP THE PENTHROX INHALER: Chapter 10: Pain Management

208 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com For disposal, please place into the plastic sealable waste bag disposal and seal the bag. Please dispose of it responsibly in accordance with local guidelines. PATIENT INFORMATION LEAFLET AND PATIENT ALERT CARD During or just after administration, the patient must be given the Patient Information Leaflet (PIL), which they are told to keep along with the Patient Alert Card (PAC). All patients must be told that Penthrox is under additional monitoring as it is new to the UK. Explain that this is perfectly normal, but they are given this Patient Alert Card to explain that there can be some rare side effects and as a result, if they develop any of the following symptoms over the following days or weeks, they should seek medical attention and take this card with them: • Loss of appetite • Nausea and vomiting • Jaundice • Dark coloured urine • Pale coloured stools • Pain in the right stomach area • Reduced or excessive urination • Swelling of feet or legs. Penthrox – Setup and administration Penthrox is an inhaled agent for: Emergency relief of moderate to severe pain in conscious adults with trauma associated pain1 • Penthrox analgesic initial starting dose is 3 mL (one vial) • Pain relief: 25-30 minutes, 1 hr with intermittent use • Maximum dose of 6 mL (two bottles) lasts up to two hours • Maximum dose – 15 mls in one week • NOT classified as a Controlled Drug or drug of dependence • Once discontinued requires no further HCP monitoring • Adverse reactions are mild & transient • No reported drug interactions at analgesic doses, however drug interactions are known to occur at the anaesthetic dose. Summary Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 209 Self-assessment: TRUE or FALSE questions: Self test 3 True False Penthrox is self-administered Methoxyflurane is a Controlled Drug The STOP trial was conducted in Australia In the STOP trial maximum analgesic effect from methoxyflurane was reached within 5 minutes In the STOP trial the placebo had no effect on the pain scores ANSWERS: T,F,F,F,F Self test 4 True False Methoxyflurane at anaesthetic doses always caused renal failure Methoxyflurane is highly irritant to the eyes and nose Analgesic dose is equal to the safe limit for methoxyflurane Methoxyflurane may cause malignant hyperthermia in genetically susceptible patients Penthrox is approved for use in UK adolescents (12-18 years) ANSWERS: F,F,F,T,F Chapter 10: Pain Management

210 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Self-assessment: TRUE or FALSE questions: Self test 5 True False Penthrox is contraindicted for the pain of severe peritonitis Penthrox can be used in patients with reduced consciousness from hypothermia The AC chamber will only work if the patient exhales quickly The maximum dose of Penthrox in 1 week is 15mls Penthrox is currently subject to additional MHRA monitoring ANSWERS: T,F,F,T,T Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 211 References: 1. Penthrox. Summary of Product Characteristics. October 2015 2. Grindlay, J., & Babl, F. 2009. Review article: Efficacy and safety of methoxyflurane analgesia in the emergency department and prehospital setting. Emergency Medicine of Australasia. 21: 4–11. 3. US Federal Register, 2005, Vol 70, No. 171; 4. Data on file 01 5. Dayan AD. Hum Exp Toxico, 2015, 0960327115578743. 6. Crankshaw DP. 2005 Anaesthesiology 130; A756 7. Penthrox. Material Safety Data Sheet, Sept 2014 8. Anaesthesia UK. http://www.frca.co.uk/article. aspx?articleid=100594. accessed Nov 2015 9. Khan et al. 2014 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 14 Number 3 2014 doi:10.1093/ bjaceaccp/mkt038 10. Coffey, F. et al. 2014. STOP!: a randomised, double-blind, placebo-controlled study of the efficacy and safety of methoxyflurane for the treatment of acute pain. 11. Database of Adverse Event Notifications. Australian Government Department of Health Therapeutic Goods Association. Available from: http://apps.tga.gov.au/PROD/ DAEN/daen-entry.aspx Accessed November 2015 12. O’Rourke KM et al. Med J Aust 2011; 194(8): 423-424. 13. Entonox: Ward administration of Great Ormond Street Hospital. Available from: http://www.gosh.nhs.uk/healthprofessionals/clinical-guidelines/entonox-ward-administration Accessed October 2015 14. Patient-administered inhalation of nitrous oxide and oxygen gas for procedural pain relief. Available from: http://www. worldwidewounds.com/2003/october/Pediani/EntonoxPain-Relief.html Accessed October 2015 15. Royal College of Nursing. Standards for infusion therapy. The RCN IV Therapy Forum, 2010. Available from: http:// www.bbraun.it/documents/RCN-Guidlines-for-IV-therapy. pdf Accessed October 2015 16. Clinical Guideline for Intravenous Opioids for Adults in Recovery Areas - “The Recovery Protocol”. January 2008. Available from: http://www.rcht.nhs.uk/DocumentsLibrary/ RoyalCornwallHospitalsTrust/Clinical/Anaesthetics/ accessed November 2015 17. McQuay H. Lancet 1999; 353: 2229-32. 18. Entonox. Summary of Product Characteristics. November 2013 19. Data on file 02 20. Methoxyflurane: Drugbank http://www.drugbank.ca/drugs/ DB01028 accessed November 2015 21. Data on file 03 22. Application for inclusion of Methoxyflurane in the WHO model list of eesential medicines – Koulaouzos, Dec 2004 Pg 1-38 23. Chaplain S, Zeppetella G, Instanyl: intransal fentanyl for treating breakthrough pain. Prescriber 2010:19;40-1 24. Johnston S, Wilkes GJ, Thompson JA et al, Inhaled methoxyflurane and intranasal fentanyl for prehospital management of visceral pain in an Australian ambulance service; EMJ 2011;28; 57-63 25. Chin R, McCaskill M, Browne G et al. A Randomisedcontrol tiral of inhaled methoxyflurane pain relief in children with upper limb trauma J Paedtr Child Health 2002; 38; A13-14 26. Reported case of Mysathenic symptoms following exposure to Methoxyflurane in Obstetruc nurse: Emerg Med Australasia, 2009 21, 4-11 27. Klemmer PJ, Hadler NM; Subacute fluorosis; Annl of Internal Med 1978;89: 607-11 28. De Francisco CP; Penthrane dependence: a case report. Br J Psychiatry 1971; 119: 609-10 29. Ref: Mazze R, Methoxyflurane revisited, Anesthesiology 2006; 105:843–6 Chapter 10: Pain Management

212 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com C CVS stable H No previous anaesthetic reactions E No elevated temperatures C Fully conscious K Normal kidney function A Adult L No respiratory difficulty L No liver disease L Has never had Penthrox before Case studies 1: A 25 year-old man has sustained a stab wound to the right thigh. There is massive haemorrhage, he is conscious and screaming in pain. YES • He is an adult male with severe pain from a traumatic injury • He is otherwise fit and well. We now have a series of clinical cases to review and consider if they are suitable for Penthrox. Use your pre-administration checklist cards and the ‘CHECK ALLL’ acronym. Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 213 A 32 year-old man with a fractured pelvis who has an orthopaedic external fixator in place. The x-ray, suggests that he needs some adjustment to the fixator, this is not a long or difficult procedure and does not require a general anaesthetic. He gets very sick with morphine which he had when he had his laparotomy after his accident. He also has two broken ribs on his left side. The patient is anxious about it and concerned about the pain involved, as he has been told that it will be a bit uncomfortable. NO • This is a man with a fractured pelvis who has an orthopaedic external fixator in place • But open to discussion as not an emergency but not elective and recent exposure to Penthrox. Case studies 2: A 28 year-old lady has called an ambulance because she has worsening upper abdominal pain. • She is needle phobic, has a history of duodenal ulcers and takes omeprazole. • She cannot move with the pain and her abdomen is rigid • She says that she cannot be pregnant. NO • This is not traumatic pain Case studies 3: Chapter 10: Pain Management

214 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com A 19 year old lady has been the victim of a terrorist bomb blast and she has severe lower leg injuries with massive blood loss. • She was very distressed when found but she is now complaining less and is quite drowsy (could be shock or head injury but not complaining of pain now either). NO • Reduced conscious level from head injury or shock • She was very distressed when found, but she is now complaining less and is quite drowsy. C Possible shock H No previous anaesthetic reactions E No elevated temperatures C Reduce conscious level K Normal kidney function A Adult L No respiratory difficulty L No liver disease L Has never had Penthrox before Case studies 4: Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 215 A 40 year old lady with her armed trapped in a machine, but has no other injuries. • Screaming and sobbing with the pain when fire crew arrived • Ambulance ETA 12 minutes • She was given a 3ml single dose of Penthrox by the fire crew who were trained and carrying it • She has a history of epilepsy • Can you give her Penthrox in the ED?. YES • 40 year old woman with major trauma. Case studies 5: C CVS stable H No anaesthetic reactions E No history of MH C Fully conscious K Fit and well A Adult L No respiratory difficulty L Fit and well L She has had single dose Penthrox 1hr ago Chapter 10: Pain Management

216 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com A very large man has been involved in a serious road traffic collision • He is fully conscious, but was in severe pain with a fence post through his lower abdomen • He was trapped for over 45 minutes during which time access to the casualty was very difficult inside the crashed car. • He has had intravenous morphine on the scene, but it made him feel very unwell and he is not keen to have any more despite being in significant pain • His is a known hypertensive and has diet-controlled diabetes. YES Case studies 6: C Stable H No reactions to anaesthetic E No MH or elevated temperature reactions C Fully conscious K Normal kidney function A Adult L No respiratory difficulty L Liver normal L Has never had Penthrox before Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 217 • An eight year old has fallen off the climbing frame at school and hurt his arm • His teacher has improvised a simple splint but he is still in so much pain he cannot be moved to hospital. NO • This is a traumatic injury, but he is a child and Penthrox is not licensed for use in those under 18 years. Case studies 7: C CVS stable H No reactions to anaesthetic E No MH or elevated temp reactions C Fully conscious K He is fit and well A Adult L No respiratory difficulty L Fit and well L Has never had Penthrox before • A 20 year old gentleman has been punched in the face and he is complaining of severe pain in his nose and jaw, which he is struggling to open fully • He does not think that he was knocked out and he is fully awake now. YES Case studies 8: Chapter 10: Pain Management

218 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com • A 17 year old boy with a very painful knee following a violent tackle. • He is unable to stand and the coach thinks that he has ruptured his ACL. • His pain score is 9 out of 10. NO • He is in pain from trauma but he is only 17 years old. Case studies 9: C CVS stable H No reactions to anaesthetic E No MH or elevated temperature reactions C Fully conscious K He is fit and well A 18yrs L No respiratory difficulty L Fit and well L Has never had Penthrox before • This 18 year old man has a shoulder that frequently dislocates. • The shoulder has dislocated again while taking off his heavy diving cylinder at his local swimming pool • He has severe pain in his right shoulder and is unable to use his right arm. • He can usually relocate it with Entonox • He is otherwise fit and well YES Case studies 10: Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 219 • A man is an IV drug abuser. He has Hepatitis C • He has jumped from a first floor window and dislocated his knee. He is in terrible pain. • He has very poor veins. He has no other apparent injuries. • He is feverish and unwell and may have some degree of sepsis NO Case studies 11: C CVS unstable – possible degree of sepsis but not shocked H No reactions to anaesthetic E No MH or elevated temperature reactions, but mild fever at present C Fully conscious K No kidney disease but degree of sepsis A Adult L No respiratory difficulty L Known IV dug abuser with hepatitis C L Has never had Penthrox before Chapter 10: Pain Management

220 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com • A Police Officer has been pushed off a high wall and hurt his lower back during a stand-off at a firearms incident • He is complaining of severe pain in his back, has tingling down both legs and is unable to stand • He is otherwise fit and well and has no drug allergies or reactions • An ambulance has been requested but the scene is not currently considered safe. YES Case studies 12: C No CVS instability H No anaesthetic hypersensitivity E No MH or elevated temperature reactions C Fully conscious K Fit and well A Adult L No respiratory difficulty L Fit and well L Has never had Penthrox before Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 221 *However, she may have normal renal function, but we do not know this prior to hospital. • A 75 year old lady has fallen down three steps whilst out shopping. She has badly hurt her ankle, but she is a stoic lady and is only complaining of moderate pain • We need to apply a splint for transfer to hospital • Her medical problems include asthma, mild angina and had a kidney transplant 10 years ago • She has no allergies. NO Case studies 13: C No CVS instability H No anaesthetic reactions E No MH or elevated temperature reactions C Fully conscious K Previous kidney transplant* A Adult L No serious respiratory difficulty L No liver disease L Has never had Penthrox before Chapter 10: Pain Management

222 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com • You have been called to attend a serious road traffic collision. A stolen car has ridden over the top of a stationary car and hit the front of a building at high speed, which has collapsed and is still at further risk of collapse. There are three adult casualties in the car who are in severe pain from chest and limb injuries. They are all fully conscious • The extrication is going to take at least 40 minutes and the Safety Officer is asking if we can temporarily withdraw the medics to a safe distance from which we can observe progress • Are we able to use Penthrox for the casualties who are all fit and well with no allergies? They have never had Penthrox before. YES Case studies 14: C Not shocked H No hypersensitivity or reaction anaesthetic E No history of elevated temperature or MH after anaesthetic C They are all fully conscious K No kidney impairment A All over 18 years L No difficulty or depression of breathing L No liver disease L Has never had Penthrox before Chapter 10: Pain Management

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 223 Part 3 Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach Preparing for medical emergencies This section covers first aid and the common medical emergencies that may be encountered by responders and how they recognise and manage these conditions until further help arrives. Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

224 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Providing first aid safely? Safety is our greatest priority for both you and the casualty. The first step in delivering effective first aid is to be safe yourself. The last thing that we want is for you to become another casualty. Although, this may sound easy and obvious, in reality when confronted with someone in severe distress, especially someone we know, or perhaps a child, we can forget the simplest and most obvious safety principles. Our world is dominated by health and safety and many of you may feel that we live in a ‘nanny state’ where we wrap people in cotton wool. Signs, rules, restrictions and limits are everywhere but as first aiders we will often face injured people who have ignored the warnings. Sometimes there may not even be any warnings and therefore we have to be extra vigilant to avoid becoming a casualty ourselves. Appreciate the risks Every environment we find ourselves in or face as first aiders has risks, whether it be within a kitchen or in industry. Even simple domestic products found in the kitchen or bathroom, for example, can cause burns, eye injuries, breathing problems from fumes or fires. Similarly, devices and machines can also cause serious injury if they are faulty, misused or safety procedures are ignored. In industry, this is an even greater problem as chemicals can be far more concentrated and machines can be larger and more dangerous. Yet again, for a first aider the appreciation of any such risks is all the more important, especially if called to a place or area where you do not normally work. Following an accident, good health and safety may be even more important to prevent further injuries. LEVEL OF RISK? • Nature of work • Environmental • Personal training & PPE • Failure to follow SOPs Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 225 NATURE OF WORK / ENVIRONMENT If we consider the level of risk, this may be obvious or actually quite subtle, yet still very high. If we consider the nature of work, it is obvious that being a lion keeper and entering the lion’s den each day has very real risks. Similarly, if you work in confined spaces such as a ships engine, then many of the risks are clear and obvious. However, what if you work in a busy coffee shop? Are there any risks? Clearly there are, and although initially you may view them as trivial, bear in mind the fact that you are working with boiling water, steam under pressure, in an environment with wet floors combined with demanding customers from a seemingly never-ending queue. All this plus fatigue and you have the makings of a very dangerous environment. Increased risk? Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

226 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com NATURE OF WORK / ENVIRONMENT Even working in an office has risks. These may seem trivial and perhaps they are in comparison to the role of the lion keeper, but they still exist and have the potential to cause real harm. Some of that harm could be minor but cause significant effects, such as repetitive strain injury, but some of it could also be serious, such as the following: • Electrical fires • Falls downstairs • Slips and trips • Broken glass • Office related injuries • Kitchen related injuries. These are all potential hazards that we could face even in an office environment. The key issue here is that whilst the risks may be far lower than in other industries, hazards exist everywhere and are often not marked or obvious. Increased risk? Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 227 Another key factor is the use of safety equipment. Risks may have been identified, clearly defined and safety equipment may have been provided, but if staff don’t have it, don’t use it or are not trained to use it, those risks have not been mitigated and injury or even death is far more likely. You would not expect a steeplejack or rigger to not be wearing all their safety equipment, since the risks of falling are so great. However, they may argue that they are entirely comfortable at height and for a quick and easy job, they does not consider the risk that great. Rules and safety devices are there for a reason, and this is even more important where you may not appreciate the hazards. A crucial part of your safety may be to simply accept that you cannot enter a dangerous area without the necessary training and equipment e.g. a house fire. BASIC LEVEL (PPE) The simplest personal protective equipment (PPE) you will wear as a first aider are gloves, which protect you as well as the casualty. Gloves protect you from contact with blood and body fluids and protect the casualty from the risks of infection from your hands. ADVANCED LEVEL (PPE) At the other extreme, PPE may be there to protect you from some very hazardous materials and therefore must be worn and used correctly with no short cuts or changes. This can be frustrating if the equipment is difficult to wear or work in, or the environment is very warm or humid. In these situations, training can help to better prepare the individuals. A real awareness of rescuer welfare is crucial to avoid exhaustion or excessive fatigue. INFECTION Other than scene related risks, blood and body fluids present the most significant risk to the first aider and everyone needs to be aware of these risks in order to protect themselves adequately. Body fluids can potentially transmit infection. The most significant risks are from blood borne viruses (BBV) such as Hepatitis B, C and HIV. However, the greatest risks occur from needle-stick injuries. Getting blood onto your skin is highly unlikely to cause a serious infection unless you have cuts and open wounds, in which case you should seek medical advice if contaminated. The other risk is called mucous membrane contamination, which is basically any area of your skin that has a moist lining e.g. mouth, eyes. If infected body fluids or blood comes into contact with these areas of your body, you should also seek medical advice. The incidence of BBV infections in the UK population is less than 1%, so the vast majority of casualties will present no serious risk to you. However, it is impossible to predict that risk. We should be aware that IV drug abusers or known infected patients do present a greater risk, but you may not have this information when you reach a casualty. The key is to protect yourself: • Use gloves • Wear eye or face-shields if there is a risk of splash or spurting • Take care when cleaning up contaminated areas • Clear guidance is available on the HSE website which should be read and adapted for the potential risks in your working environment. Increased risk? Personal - Training & PPE Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

228 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com The following points apply regardless of the scale of the spillage: • Gloves should be worn throughout and should be discarded safely after use • If there is broken glass present, it is essential that the fragments are not gathered up by hand either before or after treatment with disinfectant. Bunches of paper towels or newspaper, pieces of card or a plastic dustpan should be used to remove the fragments to a safe container without risk of injury. Small spots of blood or small spills: • Gloves should be worn and cuts or open wounds on exposed skin covered with a waterproof dressing • Contamination should be wiped up with a paper towel soaked in freshly prepared hypochlorite solution containing 10,000ppm available chlorine • Towels and gloves should be placed in a clinical waste bag for incineration and hands washed. For larger spills other than urine (unless the urine is bloodstained). If spillage is extensive: • Disposable plastic overshoes or rubber boots may be necessary • If splashing is likely to occur while cleaning up, other protective clothing should be worn • Liquid spills should be covered with dichloroisocyanurate granules and left for at least two minutes before clearing up with paper towels and/or a plastic dustpan • Alternatively, the spill may be covered with paper towels and the contaminated area gently flooded with hypochlorite solution containing 10,000ppm available chlorine* (again this should be left for at least two minutes before attempting to clear up) • Towels, gloves, disposable overshoes and contaminated clothing should be placed in a waste bag for incineration and hands washed; (rubber boots may be decontaminated with dilute disinfectant) • Finally, the area should be washed with water and detergent and allowed to dry • In open areas, for example playgrounds and roadways the spillage should be hosed down with large amounts of water. Heavily contaminated clothing should be considered high risk and should be professionally laundered to remove all risk of infection transmission. Useful references and advice: www.hse.gov.uk/pubns/indg342.pdf Immunisation against infectious diseases – ‘The Green Book’, 2006 Edition, HMSO, ISBN 9780113225286. Hepatitis B information is available at link: http://www.dh.gov.uk/ prod_consum_dh/idcplg?IdcService=GET_FILE&dID=11 5985&Rendition=Web) A summary of requirements designed to protect health care workers from BBV exposure is provided in The Health Act 2006: Code of practice for the prevention and control of healthcare associated infections -known as The Hygiene Code Guidance on Personal Protective Equipment at Work Regulations 1992. L25 HSE Books 2005 ISBN 0 7176 6139 3 Health Protection Agency - Reporting of occupational exposure to blood borne viruses – history and how to report Safe Management of Healthcare Waste (2007). Royal College of Nursing. ISBN 978 1 904114 76 5. http://www.rcn.org.uk/__ data/assets/pdf_file/0013/111082/003205.pdf *Note that urine may promote the release of free chlorine from the treated area when hypochlorite or other chlorine-containing compounds are applied. Ventilation of the area will be necessary. Increased risk? Personal - Training & PPE Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 229 Finally, injuries and deaths can occur as a failure to follow standard operating procedures (SOPs), rules or simple safety guidance. These include many of the issues raised above but also involve many of the wider practices at work, which if not adhered to correctly, may result in serious injuries that a first aider may face. APPRECIATE ANY INCREASED RISKS TO YOU At the very least there is a need for a clear appreciation of the risk involved with the work you are doing, especially if working with hazardous materials. Is the containment vessel suitable? Simply washing these materials down the drain is neither appropriate or acceptable as there could be huge environmental and public safety issues somewhere further down the water course. Training plays an essential part in this. If you are untrained or not suitably equipped, do not take on the task. This includes first aid, as discussed above. INDUSTRIAL SPILLAGE Where procedures have not been followed, an incident such as a chemical spillage can occur and a casualty may already have been involved. Here the SOPs and the safety or emergency procedures are even more important to prevent further casualties occurring, and to ensure that any casualties are given the best opportunity of being helped or saved. If in doubt then call the experts in your organisation or call the emergency services. SCHOOL LAB Even a chemical spill on a much smaller scale, such as a school laboratory, can still have huge significance and risk if badly managed. A clear protocol or SOP should exist for any dangerous material to define the response if a spillage or accident should occur. In doing this, the incident can often be managed easily and safely without increased risk to anyone. If in doubt, evacuate the area and call the Emergency Services. SAFE APPROACH As discussed earlier in the chapter, some hazards are obvious and we need little convincing not to rush in, but others may not be so obvious. A good example are water rescues. Every year people die attempting to rescue others who have got into difficulty in lakes or open water. The rescuers, who are often strong swimmers, enter the water confident that they can help, but as a result of the cold water, they often become victims themselves. Being within easy reach of the shore often gives a false sense of safety. DO NOT RUSH IN! Even domestic incidents can involve hazards. If you see someone who has collapsed, hold back for a moment and take a look at the scene. What hazards can you see? Why has this person been injured or collapsed? This should not delay us excessively as we obviously need to reach the casualty, but do not rush in and do not under-estimate the dangerous effects of doing so, even for experienced rescuers, especially if the casualty is a child or a loved one. DO NOT BECOME A CASUALTY YOURSELF - the best you may be able to do for the casualty is to make an emergency call to get professional help quickly. Increased risk? Failure to follow SOPs Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

230 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 1950’S STYLE SAFETY The image above is a 1950’s view of a ‘safe approach.’ to demonstrate the dangers of electricity and electrocution and to highlight the risks to any rescuer if the power is still turned on or the casualty is still in contact with the source. Increased risk? Failure to follow SOPs 21ST CENTURY This is a 21st century equivalent safety advertisement, which is typically more graphic and hard hitting. In some ways it appears to be less informative, but it is far more hard hitting in its message about electrical safety in the home and also approaching an electrocution victim on a wet floor, when the power may still be on. Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 231 THE CASUALTY MAY COME TO YOU As a first aider, many of your casualties will approach you and ask for help. This often gives you little time to think or prepare yourself, but if you follow the simple principles shown in this course, you will be able to quickly assess, react and manage the situation confidently. YOU MAY BE CALLED TO THE CASUALTY For other first aid situations you may be called to attend and assist. This may often be in an unfamiliar environment, which may take you out of your comfort zone. In such situations it is all the more important to remain calm and focused on your key principles and methods to avoid missing anything serious that you could identify and manage. INTRODUCE YOURSELF (AND MAKE EYE CONTACT) A crucial element of all first aid is the initial contact with the casualty. Introduce yourself with something such as “Hello, my name is….” and if at all possible make eye contact. Do not simply rush in and grab the casualty. I AM A TRAINED FIRST AIDER Make a clear statement that you are a first aider and that you are there to help. You can open the conversation by asking some general questions and this will also help you to assess what has happened. The following are good examples: • What has happened? • May I take a look at your injury? • Do you have any pain? • Where does it hurt? CAN I TRY TO HELP YOU? Consent can be a confusing area with patients who are injured, combative, disorientated or frightened. It is important that you offer your help and accept that it may be refused. It can come as quite a shock when a casualty refuses help or treatment either if they don’t actually want it, or alternatively because they are confused. It is important to respect the patient’s wishes wherever possible. However, if they refuse your help, but clearly need it for their injuries, you should try and talk them into allowing you to help, whilst awaiting professional support. DO NO HARM - DO SOMETHING A key message from this course is to not be afraid, since with your first aid skills you are highly unlikely to make a situation worse. You are more likely to fail your casualty by not getting involved or missing something potentially serious. In other words, doing nothing is often far worse than doing something. The old first aid mantra of ‘do not move the casualty’ can be appropriate on rare occasions, but in most situations it will hinder their care. Gentle movement will rarely, if ever, cause serious harm, even to a casualty with potential spinal injuries. The casualty Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

232 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com DO NOT ATTEMPT RESUSCITATION (DNAR) A dilemma that can present when attending a casualty you do not know is DNR or DNAR – ‘do not attempt resuscitation.’ In other words, for whatever reason, this person does not wish to be resuscitated in the event of a cardiac arrest. This can be found on medic-alert type bracelets or necklaces, but may also be found on tattoos. In addition, family members may thrust pieces of paper in front of you or declare that the patient is not for resuscitation etc. This can make the whole situation very stressful and confusing and even create fear about doing the right thing. It is difficult to give rigid guidance on this, as orders may have varying conditions or may not be legally binding. However, if the patient is refusing help or clearly has a medical bracelet or legal document from a solicitor stating that they are DNR/DNAR then this should be respected. However, in most other circumstances or if in doubt, do what feels right. This will usually mean starting resuscitation. Do what feels right, which will usually be the wishes of the patient or the family. DO YOUR BEST Finally, many first aiders hear stories of people being sued or prosecuted for doing the wrong thing. However, as a first aider doing your best with basic skills, you will not get sued. The key part of this is to simply do your best in the situation. No one could ask anything more, and at least you will have tried to help. You will be highly unlikely to ever make things any worse in the time before help arrives. The casualty Chapter 11: First Aid & Medical Emergencies – B.U.R.P.S Approach

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 233 Providing First Aid Calling for Help FTACC approach - Level of response required IMMEDIATE ASSESSMENT OF SITUATION CALL FOR HELP IMMEDIATE ACTIONS LEVEL OF RESPONSE REQUIRED - 999 An essential part of First Aid is to make an effective call for help. However, people are often confused about: • What to do first • How to make the call • What to say • What is needed. There is also the issue of how serious is the injury? Chapter 11: First Aid & Medical Emergencies – Calling for Help MINOR FIRST AID For example, an injury such as this laceration to the hand may look very nasty at first with significant bleeding and pain, but on closer inspection it is actually quite a small wound and quickly stops bleeding. However, there may be other things to consider which could be associated with the injury. In this case we would be concerned that there may be tendon injuries affecting finger movements or nerve injuries affecting sensation in the hand. FTACC will help you to make these decisions. Sometimes these may be obvious but on other occasions they could be more challenging.

234 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com LIFE SAVING FIRST AID – YOU MAY NEED HELP! In some situations it may be immediately obvious that the injury is very serious or even life threatening. FTACC will help you to identify these quickly and then to manage them in tried and tested ways which are known to work. As described above, FTACC will also guide you on how and when to call for help. This is a key element of this course, as unlike others, we will teach things which are effective and known to work, rather than more traditional skills, which we now know offer little true value, but have simply become the normal approach in many first aid courses. CAN SOMEBODY HELP ME PLEASE ? An essential part of asking for help, especially when facing a life-threatening emergency is to shout out to attract the attention of anyone around you. This may mean actually shouting to be heard. HELP Depending upon where you are when the emergency occurs, there may be an emergency button or an automated emergency call such as a Fire Alarm or a cardiac arrest buzzer in the hospital. The emergency button may also stop a machine or halt a process which could prove to be life-saving, such as someone in serious difficulty trapped in a machine, such as an escalator or a lathe. FTACC approach - Level of response required Chapter 11: First Aid & Medical Emergencies – Calling for Help

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 235 FTACC approach - Level of response required Chapter 11: First Aid & Medical Emergencies – Calling for Help One of the challenges for a first aider is what to manage yourself, what requires nursing or medical attention and finally what is a life- threatening situation. These may not always be as obvious as you might think. To help with this, throughout the course we will have colour coded slides. Green slides usually do not require hospital treatment and can usually be managed with first aid skills. FIRST AID MEASURES GREEN SLIDES USUALLY DO NOT REQUIRE AMBULANCE OR HOSPITAL Yellow slides indicate the need for medical or nursing review. This may be a GP, a walk-in centre or hospital, but does not require a ‘999’ emergency response. You may be able to provide transport yourself, eliminating the need for an ambulance. Remember you can also call the ‘111’ NHS Helpline for advice. You may receive additional guidance and advice about the best place for the situation you are managing. DOCTOR/HOSPITAL YELLOW SLIDES SUGGEST WHEN TO CONSIDER TRANSPORT TO HOSPITAL/GP - 111 RISK TO LIFE RED SLIDES INDICATE WHEN THERE IS AN IMMEDIATE OR REAL RISK TO LIFE ‘999’ Ambulance Call Finally, we have red slides, which suggest a life-threatening problem requiring immediate action or a ‘999’ emergency ambulance call, such as someone with severe chest pain.

236 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com FTACC approach - Level of response required RISK TO LIFE Chapter 11: First Aid & Medical Emergencies – Calling for Help To request an ambulance we have two choices, we can either call ‘999’ or call ‘112’ - both will immediately connect you to an emergency operator who will ask which service you require. Remember that you can even make an emergency call on anyone’s mobile phone, even if it is blocked.’ CALLING AN AMBULANCE Before actually making the call, take a second or two to compose your thoughts. • Which service do you require? Police, Fire or Ambulance • What has happened – explain in a short, concise fashion • When you ring they will usually know what number you are ringing from and they will usually repeat it to confirm your identity • Make sure that you know where you are and be as specific as possible • Be prepared for the operator to ask you questions which may appear to be unnecessary They are working through a well-defined process • Do not hang up unless they tell you to and do not be surprised if they ring you back. EVERYONE FEELS ANXIOUS Do not worry about feeling anxious. This is perfectly normal as people rarely ring the Emergency Services, and it will usually be a stressful situation that makes the call necessary. You may also feel like this when handing over to the ambulance paramedic or crew. Adrenaline will help you to respond to such an emergency but it will also make you shaky or anxious and you may feel your heart racing, but do not worry as this is normal.

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 237 FTACC approach - Level of response required RISK TO LIFE Chapter 11: First Aid & Medical Emergencies – Calling for Help ISBAR HANDOVER One way to perform the handover of the casualty details is to use something generally used in hospitals, called the SBAR handover. This sometimes extends to ISBAR with the ’I’ being included for ‘I am… To give your name and status’ The ISBAR acronym stands for: I – Introduce yourself S – The situation, as in what is the problem? B – What is the background, in terms of the preceding events or any known medical problems? A – Your assessment of the current situation? R – What response do you require? Consider an example of an elderly gentleman with crushing central chest pain who is clearly distressed. Let’s prepare our ISBAR message. SPECIFIC QUESTIONS? As discussed earlier, the ambulance control room staff will ask you a number of specific questions and may also give you specific advice. Listen carefully and if necessary put the phone on to ‘speaker mode,’ so that you can do as they request. AN AMBULANCE CAR WILL OFTEN COME FIRST The first ambulance to arrive for a serious emergency may be a car or ‘rapid response vehicle’ which will usually be driven by an experienced paramedic. This vehicle will not carry a casualty but will provide some immediate response for any serious emergency. It is essential that you have considered how the ambulance will find you, how they will access your building, and even your site if there is security controlled access. You may need to assign someone the role of meeting the ambulance and then escorting them to the incident. AN AMBULANCE The main ambulance will arrive with a crew of two and the stretcher etc. Ideally provide access so that it can get as close as possible to the incident. Even at the scene, make room for them to work, remove any unnecessary staff or witnesses and provide some privacy and dignity for the patient. HELP THE AMBULANCE CREW • Inform main gates, security or reception • Arrange for someone to meet them • Ensure doors or access points are open • Make space for them to work. ISBAR - Handover (Example) I INTRODUCE: I am our First Aid Trainer S SITUATION: I have a 63 year old man with severe chest pain B BACKGROUND: History of angina for several years, he is also a diabetic. Collapsed rushing up the stairs. A ASSESSMENT: Conscious, but says angina is worse than normal, he looks unwell & has vomited with the pain. R RESPONSE / RECOMMENDATION: I have reassured him, called an ambulance, encouraged him to use his Angina spray. I also have our AED here.

238 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com SBAR Scenario 1 – Severe stomach pain S SITUATION: I am ‘X’ a Trained First Aider at ‘Y’ I have a: 25YR OLD LADY WITH SEVERE LOWER ABDOMINAL PAIN B BACKGROUND: She is normally fit and well but this started 2 hrs ago A ASSESSMENT: She looks unwell, has vomited and feels very hot. Her pain score is 5 out of 5 R RESPONSE: I have reassured her, called an ambulance and laid her down here in the first aid room Skill Session Call for an ambulance / handover scenario SBAR SCENARIOS This session will be followed by a series of short exercises which can be conducted individually or in groups of up to four people. As a group, we would like you to assess the casualty outside, formulate an SBAR handover (one element each if in a group of four) and then come back in and handover to the rest of the candidates. THREE INCIDENTS TO REPORT. GROUPS OF 4 • Each group assess one casualty with SBAR • Take a minute to prepare • Give SBAR hand over to group. Chapter 11: First Aid & Medical Emergencies – Calling for Help

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 239 Skill Session Call for an ambulance / handover scenario Chapter 11: First Aid & Medical Emergencies – Calling for Help SBAR Scenario 3 – Patient Fitting S SITUATION: I am ‘X’ a Trained First Aider at ‘Y’ I have a: 18YR OLD MALE CASUALTY WHO HAS HAD A 2 MINUTE SEIZURE B BACKGROUND: He just collapsed in the reception area A ASSESSMENT: He has a Med-alert bracelet confirming epilepsy. He is breathing and un-injured R RESPONSE: I have put him into the recovery position SBAR Scenario 2 – Fallen Downstairs S SITUATION: I am ‘X’ a Trained First Aider at ‘Y’ I have a: 30YR OLD FEMALE WHO FELL DOWN A FLIGHT OF STAIRS B BACKGROUND: She is apparently normally fit and well A ASSESSMENT: She was unconscious for 30s but is awake and complaining of pain in her lower back. She can feel her legs & move her toes R RESPONSE: I have not moved her and she is safe here

240 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Immediate Assessment – B.U.R.P.S A key part of providing first aid is how we assess the casualty, especially if the problem is not immediately obvious or we are unsure how serious it is. NEW METHOD TO ASSESS A CASUALTY. Courses traditionally talk of primary surveys, ABC, MARCH and many similar approaches to casualty assessment. However, these are not based on conditions, but rather body systems such as airway, breathing, circulation. We are going to offer you an alternative approach, which rather than confuse things further, will actually offer a far more practical and simple assessment process to rapidly identify problems and their likely causes. B.U.R.P.S – Immediate assessment We will be using the acronym ‘BURPS’ which allows immediate assessment, simply and quickly to identify serious problems and also avoids missing injuries or signs. In other words, when we approach the casualty we ask: B – Bleeding: Is there any sign of bleeding? Each element will be further broken down to identify the serious from minor. U – Unconscious: Is the person unconscious or very drowsy? R – Respiratory Distress: Is the patient having difficulty breathing? P – Pain or Numbness: is there any pain or altered sensation. Pain is obviously very variable in its intensity and this spectrum will be considered in the pain section later in the course. S – Skin Changes: Are there any rashes, heat, blisters or skin changes? In the skin section we will highlight the important signs to look for, such as: • RASH • TEMPERATURE - HOT • TEMPERATURE - COLD • WOUNDS & ABRASIONS • BURNS & BLISTERS. BURPS B BLEEDING U UNCONSCIOUS OR SEMICONSCIOUS R RESPIRATORY/BREATHING DIFFICULTY P PAIN, DISTRESS OR NUMBNESS S SKIN CHANGES Chapter 11: First Aid & Medical Emergencies – Immediate Assessment - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 241 B.U.R.P.S supporting questions Once the B.U.R.P.S assessment is completed, additional supporting questions may prove useful, depending upon the problem. These include: • Do you have any health problems? • Has this ever happened before? • Are you taking any medication? • Do you have any allergies? B.U.R.P.S assessments DOCTOR/HOSPITAL BURPS – Hand wound with nerve injury B NO MAJOR BLEEDING U FULLY CONSCIOUS R NO BREATHING DIFFICULTY P PAIN FROM WOUND & NUMB LITTLE FINGER S WOUND Chapter 11: First Aid & Medical Emergencies – Immediate Assessment - BURPS Consider these first aid problems and apply the B.U.R.P.S assessment and the colour coded triage for the recommended level of response required.

242 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com FIRST AID MEASURES BURPS – Isolated Headache B NO MAJOR BLEEDING U FULLY CONSCIOUS R NO BREATHING DIFFICULTY P BAD FRONTAL HEADACHE S NO SKIN CHANGES RISK TO LIFE BURPS – Severe chest pain B NO MAJOR BLEEDING U FULLY CONSCIOUS R SHORT OF BREATH P SEVERE CHEST PAIN S SWEATY AND PALE B.U.R.P.S assessments Chapter 11: First Aid & Medical Emergencies – Immediate Assessment - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 243 DOCTOR/HOSPITAL BURPS – Significant ankle injury B NO MAJOR BLEEDING U FULLY CONSCIOUS R NO BREATHING DIFFICULTY P PAIN & UNABLE TO WEIGHT BEAR S BRUISING & SWELLING DOCTOR/HOSPITAL BURPS – Toe Injury B NO MAJOR BLEEDING U FULLY CONSCIOUS R NO BREATHING DIFFICULTY P PAINFUL BUT BEARABLE S MILD SWELLING & REDNESS B.U.R.P.S assessments Chapter 11: First Aid & Medical Emergencies – Immediate Assessment - BURPS

244 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com RISK TO LIFE BURPS – Dislocated shoulder B NO MAJOR BLEEDING U FULLY CONSCIOUS R BREATHING QUICKLY P SEVERE PAIN FROM SHOULDER S SWEATING WITH SEVERE PAIN RISK TO LIFE BURPS – Bacterial Meningitis B NO BLEEDING U DROWSY, IRRITABLE CHILD R INCREASED BREATHING RATE P IRRITABLE, HEADACHE S SKIN RASH – NON BLANCHING B.U.R.P.S assessments Chapter 11: First Aid & Medical Emergencies – Immediate Assessment - BURPS

Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com 245 Bleeding – B.U.R.P.S Working from the B.U.R.P.S assessment we are going to considering bleeding. Now in traditional approaches to first aid, this would come much later, but as trauma care has progressed there has been an increasing realisation that in the most severe injuries blood loss can be the biggest preventable killer. As such, with early recognition of such major bleeding and prompt action, we may well be able to save that person, but if we get bogged down in airway and breathing assessments then it may well be too late. The majority of bleeding injuries will not be too severe. We will therefore be able to temporarily dismiss them and move on to assess the other essentials such as airway and breathing. Minor bleeding, major bleeding and shock We need to quantify what we mean by bleeding and in simple terms we can split it into MINOR and MAJOR. The latter is clearly of more concern and can ultimately result in elements of shock and even death. That said, we must also appreciate that even a small and relatively minor bleed, if left unattended for a prolonged period, may eventually become major, much like a dripping tap or leaking pipe. BLOOD IS ESSENTIAL TO LIFE Blood is essential to life and we only have a limited amount of it, which in a typical adult is 5 litres. This is equivalent to 15 cans of Coke or one gallon of petrol. Smaller adults and children have significantly less blood and are at even greater risk from blood loss as a result. Once the blood is gone, we cannot quickly replace it and make more of it. MINIMISE BLOOD LOSS Traditionally we think of people simply having a blood transfusion, but there are problems associated with this. Firstly, we have to have transfused blood immediately available, blood has to be of the correct blood type and it will still never be the same or as good as the patient’s own blood. In emergencies, the paramedics will use saline as a ‘temporary fix’ but this is just ‘salty water’ and doesn’t have the special properties as blood and may actually create more problems. As a result, the best way of managing blood loss is the most obvious, and that is to control or reduce it, preserving your own precious blood in your body. Your blood is the best blood to have in your circulation. Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS

246 Tel: 03333 222 999 | Eml: [email protected] | www.ataccgroup.com Stopping bleeding can be very simple or from a more major wound it can be hugely challenging. There are two things to remember: • Firstly you may well be saving that persons life • Their body will help you to try and stop bleeding, it just needs a chance to form a blood clot • REMEMBER YOUR OWN SAFETY FIRST – what caused the injury and are you protected from the casualty’s blood? With effective pressure in the right place, 90% of bleeding will stop, but to do this we must first expose the wound and find out where the bleeding is coming from. In a serious bleed, simply pressing on blood soaked clothing or generally in the direction of the bleeding may mean the difference between life and death. However, for most first aid bleeding, we need to find the wound and use simple measures such as: • Applying direct pressure • If bleeding is from a limb, elevate it where possible • Only move to bandaging or dressings once the bleeding is controlled. In other words, bandaging is fiddly and awkward if you are not doing this regularly. If you add in the ‘gloves of panic,’ inevitably you will be all fingers and thumbs. Even experienced providers can drop a bandage or get it tangled etc, but more importantly, this won’t be providing effective direct pressure. FIRST AID MEASURES Bleeding DIRECT PRESSURE WILL CONTROL 90% OF BLEEDS FIND THE SOURCE ELEVATION OF LIMBS ONLY ‘BANDAGE’ ONCE BLEEDING CONTROLLED Chapter 11: First Aid & Medical Emergencies – Bleeding - BURPS Minor bleeding, major bleeding and shock