1.5.5 Medication

Contents

1.	Introduction
2.	Prescribed Medication
	2.1	Ordering Ongoing Medication
	2.2	Visits to the GP
	2.3	Collecting Prescriptions
	2.4	Receiving Collecting Medicines
	2.5	Medicines Received from Parents
	2.6	Recording Receipts
	2.7	Administration
	2.8	Self Administration
	2.9	Storage and Expiry Dates
	2.10	Disposal
3.	Controlled Drugs
	3.1	Receipts
	3.2	Administration
	3.3	Disposal
4.	Homely Remedies
	4.1	Recommended Homely Remedies
5.	Medication Profile
6.	Individual Medication Record
7.	Procedure for Administration of All Medication
	7.1	Administration
8.	Medication Issues
	8.1	Swallowing Problems
	8.2	Medication Refusal
	8.3	If a Young Person is Absent when the Medicine is Due
	8.4	Covert Administration
	8.5	Lone Working
	8.6	Spilled Medicines
	8.7	Detached or Illegible Labels
	8.8	Secondary Dispensing
	8.9	Medication Errors
	8.10	Verbal Alterations
	8.11	Adverse Drug Reaction
	8.12	Drug Recalls
9.	Administration and Recording of Medication During Time Away from the Home
10.	Stock Checks
11.	First Aid
12.	First Aid Boxes
13.	Skilled Health Tasks
14.	Staff Training
15.	Procedure Guidance for First Aid
16.	First Aid Kits
17.	Epilepsy
18.	Ritalin
19.	Drugs
20.	Burns
21.	History
22.	First Aiders
23.	Liability
24.	Hypothermia
25.	Anaphylaxis (The Hidden Peril)
26.	Paediatrics
27.	Chest Pain
28.	Trauma
29.	Shock
30.	The Acute Asthmatic
31.	Head Injuries
32.	Diabetes

1. Introduction

The purpose of this policy and guidance is that staff can handle and administer medicines safely in their working environment.

Clifford House recognise the right that each young person should be able to see a G.P. of their choice (if appropriate).

When a young person is prescribed a medicine then that medicine can only be given to that individual young person.

A young person has the right to refuse their medication if they wish. They cannot be forced to take the medicine.

Only the prescriber can vary the dose of the medicine.

2. Prescribed Medication

2.1 Ordering Ongoing Medication

Some young people will have prescribed medication, which is ongoing. This should be ordered on monthly basis where possible. Responsibility for ordering these medicines is that of the Registered Manager or Designated Person for each home. In this home....................................           that is ..........................................or...........................................

When ordering, a note must be made of:

• The name of the young person
• The name, strength, form and quantity of the medicine
• The name of the surgery/G.P.
• When the prescription will be ready

Staff should check stock levels before ordering any more medication. To minimise wastage and reduce risks of errors, stock levels should be kept to a minimum (No more than six weeks stock).

2.2 Visits to the G.P.

When a young person sees the G.P., a member of the residential staff should accompany them.

2.3 Collecting Prescriptions

Staff should collect prescriptions from the surgery and check to make sure that they have received all the prescriptions they have ordered and that the quantities are correct before taking to the pharmacy.

If a medicine has directions of 'as directed' or 'as before' then the surgery should be asked to amend the prescription to show exact directions for administration.

A photocopy of the prescription should be made and stored in the home until the medicine is received back from the pharmacy. Staff should check with the pharmacy regarding when the prescriptions will be ready for collection (They may be able to wait for collection on the same day).

2.4 Receiving Collecting Medicines

When the medicines are collected, staff should check the medicine against the photocopied prescriptions  stored in the home . Any discrepancies should be brought to the attention of the pharmacy and rectified as soon as possible.

The Pharmacy will be able to give advice on :

• Potential side effects
• Advice on how the medicine should be taken
• Advice on whether the medicine may be affected by any other medicine
• Whether the medicine should be stored in the fridge
• If the medicine is a Controlled Drug see Section 3, Controlled Drugs

Staff should ensure that the medicine has been properly labelled. If the medicine does not have a dispensing label on it then it should be returned to the pharmacy. Staff should also make sure that they have received a Patient Information Leaflet from the pharmacy. If it hasn't been received then the pharmacy should be contacted and one requested.

2.5 Medicines Received from Parents

When a young person arrives at the Unit with medicines brought by their parents/guardians then staff should contact their last G.P. to confirm whether these medicines are still being used and the doses are correct. Preferably the G.P. should confirm this in writing (a fax would be appropriate).

2.6 Recording Receipts

Medicines should be recorded onto a number of records, when received into the house.

These are :

• Young person's Mediation Profile (also known as the Master copy)
• Medication Inventory monthly checklist
• Individual medication sheet (Medication Administration Record)
• Receipt and disposal record
• Controlled Drug register if applicable

A unique reference number should be assigned to the mediation by the house (this will follow the house reporting code e.g. Arrowbridge numbers will start ARR001). The log of these numbers will be kept on the Medication Receipt and Disposal record. An Individual Mediation sheet should also be completed for each medication prescribed. When completing the Individual Medication sheet, the records should be countersigned by a second member of staff to ensure that all medication is recorded as appropriate.

Staff should also check that they have guidelines available for all medicines that are administered on a 'When required' basis. These guidelines should state how often the medicine could be administered, how much should be given at any one time, what the trigger is for the medicine to be given and what should be done if it doesn't work. When compiling these guidelines, advice should be sought from the young person's G.P.

The medicines should be placed as soon as possible into the appropriate locked storage areas. They should never be left lying about.

2.7 Administration

A trained member of staff must undertake the administration of medicines. Staff must follow the Procedure for Administration of all medication document. Records should be completed immediately after administration. When a medicine hasn't been administered for any reason then the appropriate non-administration code must be used and the doctor should be informed (where appropriate).

If staff are required to administer medicines, a Control of Substances Hazardous to Health (COSHH) Regulation Assessment should be undertaken on all medicines that may be encountered. Staff must ensure that they do not touch medicines when administering. Gloves should be used when applying creams and ointments. Tablets etc should be placed into dry, clean medicine tots. (see Section 7, Procedure for Administration of All Medicines)

It is the responsibility of the Registered Manager of the homes to maintain an overview/ appropriate checks of any young person's management of their own medication, ensuring that it is taken as prescribed.

Staff must ensure that messages are left in the message book for all staff, to inform them that a young person is on prescribed medication. Daily checks must be made via the Handover Checklist to ensure that the medication is being taken.

The Registered Manager has overall responsibility for ensuring the appropriate administration and maintenance of records regarding medication. However they may after consultation with their Operations Manager, appoint a senior Residential Support Worker or those with two years or more residential support work experience to maintain the records on their behalf. Medication of young people should ideally be reviewed on a six monthly basis.

2.8 Self Administration

In some circumstances it may be appropriate for a young person to administer their own medicines. In this situation then a risk assessment must be undertaken by a Clifford House Registered Manager or Operations manger to determine whether it is safe for them to hold this medication. Permission must be sought from the parents and the Field Social worker. This risk assessment should be detailed in the young persons Placement Plan. Self administration encourages young people to be pro-active in taking responsibility for their health needs i.e. asking for medication or booking health appointments. Where a young person has been deemed able to self -administer then they should be provided with a lockable drawer or cupboard in their room to store the medicine. Staff should carry out random check to make sure that the medicines are locked away. A spare key should be kept in the key press in the staff office in case of emergencies. Staff should not enter the drawer/cupboard unless permission has been given.

2.9 Storage and Expiry Dates

Staff must make sure that all medicines are locked away as soon as they are received into the Home. New stock should go to the back of the cupboard and the old stock should be moved forward (stock rotation).

The room temperature where the medicines are stored should not exceed 25C. This should be monitored daily and the temperature recorded. The cabinet in which medicines are stored is securely fixed to the wall in the staff office. Keys for this cabinet should be kept separately to those of the main house and kept in the locked key press when not in use. The medicine cabinet must be kept locked at all times. The Registered Manager of the resource should hold a Spare key. There should be a handover procedure in place to make sure the keys stay on the premises.

Staff should ensure that medicines that are taken internally should be stored separately to those used externally in the medicine cabinet, with liquids preferably on the bottom shelf.

Medicines that require refrigerated storage should be kept in either a dedicated lockable fridge (in the staff office) or a locked box inside the food fridge. In both cases the maximum and minimum temperature should be recorded on a daily basis on the handover sheet. Both these temperatures should be between 2 and 8C.

All medicines have expiry dates and staff should record the date on which the container was opened.

Common Expiry Dates
Eye, nose and ear preparations	28 days
Tubs of creams and ointments	28 days
Tubes of creams and ointments	3 months
Monitored dosage blister packs	8 weeks
Liquids in amber dispensing bottles	6 months

2.10 Disposal

Medication should be disposed of when:

• The expiry date has been reached
• The course of treatment is completed
• The medication has been discontinued

All medication to be disposed of must be recorded on the individual Receipt and Disposal Record and returned to the pharmacy as soon as possible. A certificate of disposal should be obtained from the pharmacist and filed in the relevant individuals section in the house medication file.

Records should show:

• The name of the young person the medicine was for
• The name, strength and form of the medicine   
• The quantity returned
• The name of the staff members returning the medicine and signature
• The name and address of the pharmacy and signature

The unit should have a record of the preferred pharmacy to be used. The name, address and telephone number should be held in the home.

In the event of the death of a young person, the medicines must be retained for a period of seven days, in case the coroner's office or courts require them.

3. Controlled Drugs

Controlled Drugs are the most tightly regulated medicines residential staff will handle. When collecting Controlled Drugs from the pharmacy, staff should take identification (preferably photo I.D.) with them.

When staff are ordering stock, then it is advisable to keep the minimum amount where possible (this would be close to having no more than 28 days supply).

In addition to records being kept in the Receipt /disposal sheet and individual medication sheet, a controlled drug register must also be used. This register contains pre-printed numbered pages. Two members of staff should be present to record the information. Each young person receiving controlled drugs should have a full page designated to one medicine and strength (e.g. Concerta XL 18mg tablets should be on a separate page to Concerta XL 36mg tablets if a young person has two strengths)

3.1 Receipts

When staff receive a Controlled drug, in addition to the above records an entry should be made in the register recording the name, strength and form of the medicine and young persons name along with:

• The date
• The time
• The quantity of the medicine received
• Where the medicine has come from (e.g. the name of the pharmacy)
• Two staff signatures (one to administer and one to witness)
• Stock balance

3.2 Administration

When administering a Controlled Drug, two members of staff should be present. After administration, an entry should be made on both the Individual Medication form and the Controlled Drugs register. Both members of staff should sign the Controlled Drugs register.

Staff should record :

• The date
• The time
• The name of the young person
• The amount given
• Two signatures
• Stock balance

A check must be carried out to make sure that the amount that physically can be counted is the same as the amount in the register. Any discrepancies in this stock check must be brought to the attention of the  Registered Manager immediately.

Spot checks should be carried out on a regular basis.

3.3 Disposal

When returning unwanted Controlled Drugs to the pharmacy, staff must record, in addition to the Receipt/Disposal sheet, an entry in the Controlled Drugs register with the following details:

• The date
• The time
• The quantity returned
• Why it is being returned
• Where it is being returned to (this may be the pharmacy or back to a parent)
• Two staff signatures
• Signature of the person receiving the medicine (where possible)

4. Homely Remedies

Homely Remedies are medicines that can be bought over the counter. This group also includes homeopathic, herbal, aromatherapy, vitamin supplements or alternative therapies.

Homely Remedies are only for the use of the young people in that Unit.

Clifford House's policy is that the young people in their care only receive Paracetamol (either in a soluble form or as a suspension) where suitable (i.e. the young person is not already taking a paracetamol based product) unless a documented discussion /agreement has been undertaken with the young person's Social Worker and G.P. allowing other Homely Remedies (to ensure that this medicine does not interfere with any prescribed medicine)

Homely remedies, which are purchased, should be recorded on the Mediation Inventory Sheet. This should be updated monthly with stock being replaced or disposed of.

When a Homely Remedy has been agreed by the Social worker and G.P. and it use is ongoing, then the container should be labelled with the young person's name so that it will only be used for that person. This is especially important with external remedies such as creams.

When a Homely remedy container is opened then staff should record the date of opening to ensure it is not kept beyond its expiry date.

Homely remedies should not be given for more than two consecutive days. If there is no improvement in the condition after this time then doctor should be consulted. Staff should record administration on the Individual Medication Homely Remedies record sheet and detail what the medicine was being used for.

For young people who wish to self-administer then a risk assessment should be carried out (see Self Administration of Medical Risk Assessment form - to follow).

4.1 Recommended Homely Remedies

Paracetamol is used for mild to moderate pain. It is also used for reducing fever. It can be used for conditions such are headaches, toothache, teething, post vaccination fevers and symptoms of cold and flu.

Calpol 6 Plus Suspension (Paracetamol 250mg/5ml)(Sugar Free preferably)
Dosage	Two to four 5ml spoonfuls every four hours (dosage is age dependant - check container)
Maximum Dosage	There must be four hours between doses. Maximum of four doses in twenty-four hours
Known Side effects	Rare, but can have allergic reaction (breathing difficulties, skin reaction)
Important: do not use with any other Paracetamol based product
Soluble Paracetamol Tablets (Disprol 120 mg tablets)
Dosage	Two to four Tablets every four hours (dosage is age dependant - check container)
Maximum Dosage	There must be four hours between doses. Maximum of four doses in twenty-four hours
Known Side effects	Rare, but can have allergic reaction (breathing difficulties, skin reaction)
Important: do not use with any other Paracetamol based product

5. Medication Profile

This document is also can be called a Master Copy. This shows an on-going history of the individual's health and medication. It is normally kept in the young person's Placement Plan. It is used in conjunction with the Individual Medication Record sheet.

The Medication profile should contain the following information:

• The full name of the young person
• Their date of birth
• Details of any allergy or where there are none then 'none known' should be recorded
• The name of the unit
• The name of the young person's G.P.
• Details of medicines prescribed

The following facts should be recorded concerning the medicine:

• The name of the medicine
• The strength of the medicine
• The form of the medicine
• The route of the medicine
• The dose of the medicine (e.g. two to be taken each day)
• The times of day that it should be given
• The date of which it was first prescribed
• The name of the doctor who prescribed it
• Any relevant information from the pharmacy or the G.P. (e.g. to be swallowed whole)
• The date on which it was discontinued and by whom. It is good practice to ask the G.P. to sign the profile
• A review date for the medicine

6. Individual Medication Record

This document is used to record the administration of the young persons medication. Each prescribed medication should be recorded on a new Individual Medication Record sheet with the following details:

• The full name of the young person
• Their date of birth
• Details of any allergy or where there are none then 'none known' should b recorded
• The name of the unit
• The name of the young person's G.P.
• The dates for which this record applies (including year)
• Details of medicines prescribed
• Staff signature of the person administering the medicine. Where the medicine is a Controlled drug, then the signature of a second staff member and the stock balance

The following facts should be recorded concerning the medicine:

• The name of the medicine
• The strength of the medicine
• The form of the medicine
• The route of the medicine
• The dose of the medicine
• The times of day that it should be given
• The date of which it was first prescribed
• The name of the doctor who prescribed it
• Any relevant information from the pharmacy or the G.P. (e.g. to be swallowed whole)
• Expiry date

7. Procedure for Administration of all Medication

All medicines must be administered strictly in accordance with the prescribers (or as advised on the packet in relation to homely Remedies) instructions. Only the prescriber can vary the dose. Medicines must be locked away in the locked storage areas when not in use and the keys for these areas must be kept in the key press.

Before administration, staff should :

• Wash their hands
• Make sure they have a pen that works
• Enough glasses for each young person receiving medication
• A jug of water
• A supply of clean dry medicine tots

7.1 Administration

The procedure for administration is as follows:

• Check the young persons identity (a photo is normally kept in the young persons file). Only one young person should be administered medication at a time, this reduces the risk of mistakes being made.
• Check the young persons medical profile
• Check the medication on the Individual Medication records corresponds with that on the young persons Medical Profile
• Check the Individual medication record sheet to ensure that someone else has not already given the medication.
• Check the expiry date and use by date (where appropriate) on the medication
• Check the amount to be given at that time.
• If opening a new container, add the date
• Measure or count the dose without touching the medicine. (See COSHH assessment)
• If the medicine is a solid (such as a tablet) then carefully place into a medicine tot and offer to the young person. They may wish to put it in their hand or swallow straight from the medicine tot.
• If the medicine is a liquid, take care not to drip onto the label. If the amount to be measured is less than 5ml, then use a medicine syringe otherwise use a medicine spoon or measure.
• If the medicine is a cream or ointment, then it should be squeezed directly onto the young person's finger to apply them. If necessary to be applied by staff, then latex/pvc gloves must be worn.
• When administering a Controlled Drug, another member of staff prior to it being given must check the dose
• Watch the young person as they take their medicine- some are known not to swallow the dose.
• Offer the young person a drink of water (where appropriate)
• Check that the medication is recorded in all the appropriate records (the individuals prescribed or homely remedies medication record sheet, the significant events box on the young persons daily summary sheet and the hardback house record)
• Print and sign your name against each medicine administered
• When administering a Controlled Drug, remember to record in both the individual medication sheet and the Controlled Drugs register (another member of staff must act as a witness)
• Record when medicine has been refused / not taken and the reasons why
• If a young person is absent when medication is due- this should be recorded.
• Do not sign for any medicines that you have not administered or witnessed yourself
• If a young person refuses to take medication, under no circumstances should they be forced to do so.
• Medication must be kept in the original labelled (by the pharmacy) containers and not put into weekly/daily medical boxes.
• After administration the medicines should be returned to the cabinet immediately and the cabinet locked. The key should be returned to the key press
• Each time you give medication, remember that it is important to consider the time of administration. Care should be taken to ensure that if the medicine is required to be taken before food, that this is made to occur. Similarly the administration of some medicines such as eye drops or inhalers may not be suitable to be given at meal times. Not all medicine administration times will fall in line with meal times.

8. Medication Issues

8.1 Swallowing Problems

Staff may find that some young people may struggle with swallowing their medicines. The young persons doctor should be contacted for an alternative. Under no circumstances should staff take it on themselves to crush tablets without seeking advice from the doctor or pharmacist. Any advice given should be recorded.

8.2 Medication Refusal

When a young person refuses to take their medicine, then the G.P. should be contacted for advice. This information must be recorded and followed. Young people cannot be forced to take their medicines.

8.3 If a Young Person is Absent when the Medicine is Due

When a young person is absent and their medication is due, this should be recorded. When the young person returns to the unit, then staff must consider the time delay and seek advice from the pharmacist, the doctor or NHS Direct website depending on the time of day. To miss taking a medicine completely can be dangerous depending on the medical condition.

8.4 Covert Administration

Covert administration is where a medicine is hidden in food and the person does not know that they are taking it. Residential staff must not hide any medicine in food.

8.5 Lone Working

In some units, a staff member may be required to work on their own for a period of time. It may be the case that the administration of a medicine will have to happen during this period. Staff should ensure that they double check themselves and record the period of time for when they were lone working.

This can be a problem when administering Controlled Drugs. It is important that the young person receives their medicine at the correct time therefore the member of staff administering the medicine, must also record that they were lone working in the register. It is not acceptable for a staff member to sign the register when they come in. You cannot be a witness to something you have not seen happen.

8.6 Spilled Medicines

When a medicine has been dropped on the floor then this must be placed to one side for disposal and a note must be made in the records. A second dose should be offered to the young person.

When a medicine has been spat out then again this must be placed to one side for disposal and a note made in the records. However a second dose must not be offered, as staff will not know how much has been absorbed. The doctor should be contacted.

8.7 Detached or Illegible labels

If a label becomes detached from a container or is illegible, then staff must seek advice from the pharmacist. Until this advice is received then the container should not be used.

8.8 Secondary Dispensing

Staff must ensure that medicines stay in the containers supplied and labelled by the pharmacist. Medicines must not be placed in daily or weekly medicine trays.

8.9 Medication Errors

In the event of an error being made in the administration of any medication, advice must be sought from the young persons G.P. or another medical practitioner/ help line (e.g. NHS Direct) immediately or as soon as the error has been discovered. Staff must record the advice that they have been given and follow that advice. Staff must contact Clifford House management starting with the Shift Leader, Manager on-call and Operations Manager. This is a notifiable event and must be reported to OFSTED.  See Notifiable Events Procedure. An investigation will be undertaken to determine the cause of the error and procedures will be implemented to make sure the error does not happen again. The member of staff will have to work under a period of supervision before administering medicines again. DO NOT TRY TO COVER UP ERRORS.

8.10 Verbal Alterations

There may be times when it is necessary to stop or change the dose of a young person's medication without receiving a new prescription. Verbal requests to change medication by the doctor must be confirmed by fax before any changes are permitted. These changes must be recorded on the Individual Medication Record in the file. Staff must note the change, the name of the doctor, the time the fax was received and the date. Staff must not alter the dispensing labels. A note may be added saying 'Refer to record for new instructions'. Staff should check the next prescription to make sure these new changes have been implemented.

8.11 Adverse Drug Reaction

Any adverse drug reaction or suspected adverse drug reaction should be reported to the G.P. before further administration is considered. Advice should be sought on whether the medicine should be stopped or the treatment carries on.

8.12 Drug Recalls

When a Drug Recall notification is received then staff should check the medication to see if the unit is holding any stock. If there is none in stock then the notification should be signed, dated and filed for reference.

When stock if found that is listed on the drug recall, then staff must follow the directions given after isolating the stock.

9. Administration and Recording of Medication During Time Away from the Home

If a Young Person spends time away from the Home, either on home visits, holidays or time spent at school, any medication due to be taken must be kept in the original labelled container. Any medication taken away from the Home should be appropriately recorded on the individual medication record sheet and medicines taken away from the home document. Any record of medication being taken away from the resource needs to be countersigned by a witness (i.e. the person taking responsibility for the medicine away from the Home).

Staff must record:

• The name of the young person
• The name, strength and form of the medicine
• The quantity of medicine being taken away
• Signature of the member of staff dealing with it
• Signature of the person taking responsibility for it

The medication should always be handed over to someone responsible for the young person while they are away. Should a young person return to the home with new or unused medication, again all appropriate records should be completed.

If the person who is responsible for the young person is a member of staff, then they must complete the documents for administration while they are away as normal.

If issues arise surrounding medication being taken away from the Home, then staff must draw this to the attention of the Manager and Operation Manager, to resolve the situation.

10. Stock Checks

The Registered Manager or designated Residential Support Worker/Senior Residential Support Worker should make stock checks of both the First Aid Inventory and the Medication Inventory on a monthly basis. This should be cross-referenced with the Individual Record Sheets and recorded on the Inventory Monthly Check Sheets, Where a discrepancy is found, and then an investigation must take place. When staff are undertaking these checks, care must be taken not to touch the medicine. Stock levels of Controlled Drugs kept in the Home must be completed each time they are administered.

11. First Aid

In the event of a young person requiring the administration of First Aid, then a record should be made on the Individual Medication Homely/First Aid sheet. Again all appropriate checks should be made on the Young Person's Medication Profile to check for any allergies or sensitivity to any treatment.

12. First Aid Boxes

First Aid boxes must have a white cross with a green background. The inventory must include the full quantity of each item stipulated in the box. When an item has been used, then it should be replaced as soon as possible. Antiseptic wipes should be used where necessary (not TCP).

13. Skilled Health Tasks

For example:

• Diabetics
• Physiotherapy programme
• Buccal Midalozam
• Rectal Diazepam

If a young person requires a skilled health task to be undertaken, this will only be carried out with the written authorisation of the prescribing doctor in relation to the child concerned, appropriate training must be sought for staff, to ensure that they have the necessary level of skills before undertaking such duties. This training must be documented, stating who carried out the training, what is covered, the date, the tasks that the staff will be able to now undertake themselves and a Renewal date.

A policy and procedures must be developed specifically for each child who requires a skilled health task.

For Example- for a child with diabetes

The policy for example should include:

• The names of staff members who are trained to undertake the tasks
• The tasks that they have been trained to undertake
• Details of the trainer and their qualifications
• When training needs to be refreshed
• How much insulin to give and when
• If the amount of insulin can be varied following blood tests
• The sites to inject the insulin
• Records to be kept
• The details of all the products used e.g. insulin, type of needles, lancets, blood testing machines, pens etc
• What to do if blood sugars are too high or too low
• Next review date
• How to record blood sugar levels, times that they have to be taken and frequency of tests
• Check other medicines are sugar free where possible

14. Staff Training

All staff at Clifford House will receive induction training in the use of medication and should read the Home's policy on medication. All staff after 6 months will be trained in First Aid to ensure that on each shift, there is a Certified First Aider.

All staff will also receive accredited training in administering medication and staff competence will be maintained via in- house supervision and the completion of an in-house training checklist.

All training will be documented, reviewed and evaluated by the training department.

Medication training is normally refreshed after 3 years.

15. Procedure Guidance for First Aid

Useful Numbers

Confidential Helpline	07770 923503
Anaphylaxis Campaign	01252 542029	The Anaphylaxis Campaign
Epilepsy Action	0808 8005050	Epilepsy action
Department for Children	0845 6022260	www.dcsf@prolong.uk.com
Schools & Families Publication Centre "Guidance on First Aid for Schools & Supporting Pupils with Medical Needs"
First Aid Supplies	0500 676999	SPservices
Herefordshire Children's Services, Health & Safety Department, Blackfriars	01432 260860
Worcestershire Children's Services, Health and Safety Department	01905 766189
HSE Books	01787 884148	Health and Safety Executive
Asthma UK	0845 7010203	Asthma UK
Meningitis UK	01173 737373
NHS Direct 24 hour advice line "Staying Sane" Dr Raj Persaud     ISBN 0-553-81347-1	0845 4647
Stroke Association	0845 3033100

16. First Aid Kits

The contents of a first aid kit:

A leaflet giving general guidance on First Aid
20 x individually wrapped plasters
4 x triangular bandages
6 x medium unmedicated dressings
2 x large unmedicated dressings
1 x pair disposable gloves
2 x sterile eye pads
6 x safety pins

If there is a need for additional materials and equipment, for example scissors, adhesive tape, disposable aprons, individually wrapped moist wipes.  These may be kept in the first aid container if there is room.  But they may be stored separately as long as they are available for use if required.

Where mains tap water is not readily available for eye irrigation at least 1 litre of sterile water or Normal Sterile saline in sealed, disposable containers should be provided.

Where the qualified First Aider (not Appointed Person) wishes to hold extra first aid supplies, they must be able to demonstrate both the need for the extra equipment and that they have been adequately trained. 

Contents List For Personal First Aid Kit - Grab Bag

6 x no. 9 dressings 2 x medium dressings 4 x triangular bandages 12 x pairs inspection gloves 1 x 'savlon dry' 2 x 25ml sterile water    24 x 'steri wipes' 6 x packs of 5 gauze swabs Strip of chewable aspirin 1 x 'wasp-eze' 1 small bottle burn gel

2 x extra large dressings 2 x eye dressings 100 assorted plasters (individual) 1 x pair paramedic tuf-cut shears 1 x 0.5 litre sterile water Dextrose tablets or 'Hypostop' Tube of anti-histamine cream Roll 'hypafix' tape Pocket mask Roll of cling film Salbutamol inhaler and spacer - beware, it's a prescription ONLY medicine

This equipment may be kept in the First Aider's personal 'grab bag', which must not be available for general use.

The most effective suppliers at present are SP Services 0500 676999.

17. Epilepsy

Epilepsy is a poorly understood condition, which affects approximately 1.4% of the population.  It presents in various forms.

Group 1

Absence Seizures

Usually affecting children, characterised by a short period of absence - the patient is conscious but unresponsive for about thirty seconds.  On recovery the patient is a little disorientated and confused.

Management

These fits are short lived 30 seconds or so.  The patient will require reassurance and rest.  If the patient has been incontinent, they clearly will need cleaning up.  After this they may need a short sleep.

Group 2

Major Seizures

Can affect anyone at any age, characterised by a short period of absence, a fall or collapse, then a period of rigidity, then a convulsion, then sleep or short loss of consciousness.

Management

These fits are more likely to last longer than the above 1 to 3 minutes.  Whilst the fit is taking place, do not restrain the patient or put anything in their mouth.  You must however prevent the patient from harming themselves.  Also, you should talk to the patient.

After the fit, place the patient in the recovery position.  After approximately 10 minutes or so get the patient away to somewhere quiet to get cleaned up and then several hours sleep.

Occasionally a patient may have prolonged fitting.  If the patient fits for more than 5 minutes they should be taken to hospital by Ambulance.

Group 3

Febrile Convulsions

Usually affects small children and follows a period of illness where the patient has a relatively high body temperature.  Then, often due to over clothing, their temperature rises very rapidly and they have a seizure.

Management

Remove the patient's clothing but do not cool the patient down, this is usually sufficient.  Then seek the appropriate level of medical attention.

18. Ritalin

Ritalin is Methylphenidate Hydrochloride and is a member of the Amphetamine group of drugs.  It is used in the management of children who have a condition know as "Attention Deficit Hyperactivity Disorder" in whom it is believed that the drug stimulates the release of a neurotransmitter, which has the effect of calming the person.

Ritalin is a Controlled Drug and comes under Class B of the Misuse of Drugs Act 1971 and Schedule 2 of the Misuse of Drugs Regulations 1985.

This means that:

The drugs must be kept in a controlled drugs cabinet dedicated for storing controlling controlled drugs

A  controlled drugs book  must be kept with double entry records.

Each time new stock is received it must be entered and signed for by two people.

Each time a tablet is issued an entry must be made, again by two people.

The dose, the time, date and to whom issued, and the remaining number of tablets must be recorded.

The book must be bound and not loose leaf, no entry may be altered or destroyed and the entries must be made in ink.

The tablets must be kept inside a locked receptacle inside the controlled drugs cabinet, being kept inside a filing cabinet in a locked office will not do!

The CSSIW, Ofsted or Pharmaceutical Inspector have the right to inspect this record at any time.

Having stated all of the above, the drug is clearly of profound importance to those children who have to take it, but proper supervision of the drug is essential.

19. Drugs

Paracetamol

Paracetamol is the most common cause of admission to hospital for drug overdose.  There are very few signs and symptoms during the early phase, by the time the patient has live pain there is often potentially lethal liver and kidney damage.

It is therefore extremely important that anyone suspected of taking a high dose is taken to hospital ASAP despite the absence of symptoms!

Iron

Iron tables are commonly available and if taken by children they will cause vomiting, diarrhoea and abdominal pain.  This type of poisoning is potentially fatal and the patient should be taken to hospital.

Heroin

Heroin overdoses are not very common and usually occur in addicts.  When they do occur, the most important feature is respiratory depression.  The respiratory rate should be watched and the patient ventilated if necessary (use a resusci-aid).

Ecstasy

Ecstasy is a very commonly taken drug, which in reality causes very little problem.  However occasionally people do become chronically dehydrated and require active rehydration and cooling.

LSD

Lysergic acid diethylamide overdose causes severe hallucination and fear.  Often the most appropriate treatment is reassurance in hospital.  However an altered level of consciousness and respiratory arrest may occur.

Volatile Substances

Volatile substance abuse is very common and has caused many deaths over the years.  Glue sniffing and aerosols are the most commonly abused.  The propellant in the aerosol and cause kidney and liver damage with prolonged use.  Occasionally the patient's heart can be sensitised to certain hormones - a sudden shock could prove fatal.  The major problems are an altered level of consciousness and respiratory depression.

Plants

Plants, whilst not drugs do cause many admissions to hospital.  The important ones are: Cotoneaster, Diffenbachia, Monstera, Philodendron, Holly, Laburnum and Lupin.  Most of these plants require quite a large dose, although it only requires five mistletoe berries to cause weakness, slow heart rate and circulatory failure.

20. Burns

Burns - A major cause of shock, one of the most painful injuries it's possible to have.  They are caused by:

• Heat - wet or dry
• Corrosive chemicals
• Cold
• Abrasion
• Electricity

These injuries are identified usually by the history as well as the appearance.

The first consideration is the depth of the burn, this is divided into three groups:

Superficial - redness around area of burn, quite painful
Partial thickness - blistered or broken skin, often red and usually intensely painful, slow to heal, may require a skin graft
Full thickness - damages the full thickness of the tissue, dead, white or charred in appearance, will almost always require grafting

The second consideration is that of the area of the burn.  It is the area of burnt tissue that determines how much fluid (plasma) loss there is and the consequent degree of shock the patient will sustain.

Measure the area of burning, if possible, by comparing the PATIENTS palm area to that of the burn.  The PATIENTS palm area is equal to approximately 1% of their body surface area.  In some patients it only takes 5-10% burn to be life threatening!

Small superficial burns can be treated with cold water, Savlon dry and a non-adherent dressing.

Superficial burns of 50p size or bigger will require definitive care i.e. to a Doctor.  If it's Partial or Full Thickness they MUST all go to hospital.

If the burn is twice the size of the patient's palm they are to go to the hospital by AMBULANCE.  Use at least 10 minutes cold water irrigation on all burns, but beware the patient becoming hypothermic.  If you want to dress the burn use cold wet dressings.  If the burn is very cold or full thickness you can use cling film.

Electrical burns are slightly different in that the damage they do is often to tissue inside the body and consequently not visible.  Electricity will take the path of least resistance through the body.  This is through nerve tissue and blood vessels.  With low burning, such as a burn mark.

The higher the voltage shocks and burns all go to hospital because of their potential to cause kidney and / or heart failure.

21. History

History taking is evidence gathering and the route to sorting out whatever and wherever the problem is!

First follow the standard protocol:

	Assess scene for safety and clues
A	Assess patient for consciousness - AVPU Establish and / or maintain airway
B	Look, listen and feel for breathing, establish heart rate and quality
C	Feel for the pulse, establish rate and quality and stop serious bleeding

Or DRABC - Danger, Response, Airway, Breathing, Circulation

Then take a "SAMPLE" history:

Signs & Symptoms	what signs and symptoms has the patient got?
Allergies	is the patient allergic to anything?
Medications	is the patient on any medication - whatsoever?
Past Medical History	relevant medical or surgical history
Last meal	when did the patient last eat or drink?
Event and Exposure	what happened leading up to the accident? Expose the part concerned.

Medical reporting: 112 or 999 - medical reporting uses the same format as MPDS:

Medical Priority Dispatch Systems

The very first question is POSTCODE, followed by address and if appropriate a map reference.

Age	approximate age of the patient
Sex	male or female
Chief complaint	what is actually wrong with your patient
What you've found	your observations of the patient
What you've done	your treatments
Outcome	what has your treatment done?

22. First Aiders

Health and Safety Executive guidance for First Aid

The Health and Safety Executive issues guidance on the requirements for First Aid, laid out in the Code of Practice L74.  This is implementation of the Health and Safety (First Aid) Regulations 1981.

The Management of the Health and Safety at Work Act 1999 makes a requirement: "every employer shall make a suitable and sufficient assessment of:

1. the risks to health and safety of his employees to which they are exposed whilst they are at work
2. the risks to the health and safety of persons not in his employment arising out of or in connections with the conduct by him of his undertaking"

This should enable the employer to calculate the amount of resources they require for First Aid.

These regulations are very wide ranging in their application: "employment business - means a business (whether or not carried on with a view to profit and whether or not carried on in conjunction with any other business) which supplies persons (other than seafarers) who are employed in it to work for and under control of other persons in any capacity".

What the above means is that for about every activity whether voluntary or paid, the 1974 Health & Safety at Work Act, the 1981 First Aid Regulations and the 1999 Management of Health and Safety at Work Act apply.

First Aid

The First Aid Regulations make it incumbent upon an employer to ensure that there is "adequate provision for First Aid" for anyone who has reasonable cause to be on their property.  This includes: staff, visitors, children in the home, including people at charity or voluntary events.

Lower Risk	Fewer than 50	At least 1 Appointed Person
Shops and Libraries	50 to 100	At least 1 First Aider
Schools	More than 100	1 additional First Aider for every 100 people
Medium Risk	Fewer than 20	At least 1 Appointed Person
Light engineering	20 to 100	At least 1 First Aider for every 50
Food Processing	More than 100	1 additional First Aider for every 100 people
Some School Activities, mountaineering, water sports etc
High Risk	Fewer than 5	At least 1 Appointed person
Construction	5 - 50	At least 1 First Aider
Chemical Works	More than 50	1 additional First Aider for every 50 people
		1 additional First Aider for specific risks

The risk assessment should make provision for multiple building and multiple floor sites as well as remoteness and shift work.

23. Liability

Legal Liability

There are various statements made by people as to the legal liability of first aiders.  The Health and Safety Executive made the following statement in 1993.

"In legal terms correct first aid practice is when first aiders act in accordance with the standards of the ordinary skilled first aider exercising and professing to have that special skill of a first aider.  What will amount to the ordinary standard is a question of law to be decided by the courts.  However, where it can be shown that the first aider acted in accordance with general and approved practice current at the time in question, then he / she is unlikely to be viewed as having fallen short of the skill required of him or her.  Even if there is not complete agreement as to what is approved practice, provided he / she acts in accordance with any practice approved by a responsible body of medical opinion this will be sufficient".

Perhaps one of the most important issues is that of consent.  The following extract is taken from Advanced Paediatric Life Support.  "Proof of negligence in malpractice cases may be based on failure to obtain informed consent.  The Plaintiff must prove that the provider failed to disclose all the material facts that a reasonable person would require to make an informed decision, that the patients injury was caused by the providers act (for which the patient granted uninformed permission), and that a reasonable person would have withheld consent had the material facts been disclosed".

All this means that, assuming you have either fully informed consent or implied consent (the patient is unconscious and unable to consent) and that you do not deliberately do the wrong thing, you cannot be held liable.  Also your employer is obliged to have Employers Liability Insurance.  Your Employers Liability Insurance covers you at work to provide the skill and knowledge you have gained on your First Aid course.  You must not use techniques for which you have not trained or are inappropriate.

Numbers

The number of people on a premise determines the number of first aiders required.  Low risk e.g. a children's home at least 1 First Aider on shift. You must consider everyone who has reasonable cause to be on your premises. The first aid training  undertaken must be  appropriate for the risks likely to be encountered.

24. Hypothermia

There are three groups of hypothermia, those patients who cool very slowly such as the elderly, those that cool quite quickly such as mountain hypothermia and sudden cooling as in emersion hypothermia.

Group 1

By far the largest group with up to twenty thousand people affected annually, once identified the patient should only be rewarmed at scene if fully conscious.  Otherwise the patient should be insulated from further heat loss and taken to hospital.  No active rewarming should take place outside of hospital in the elderly hypothermic patient.

Group 2

With mountain hypothermia, two to three hundred people are affected per annum but with only two or three people actually die from hypothermia.  The majority of mountain or outdoor deaths, whilst complicated by hypothermia, are from associated other factors, such as trauma.

If the patient is still shivering it is probably possible to rewarm the patient at scene.  Isolate from the environment and insulate the patient.  This can be achieved by placing the fully clothed wet patient in a survival bag, then insulating the survival bag with a sleeping bag, then further surrounding that with a second survival bag.  The patient carefully remove the wet clothing, dress in dry clothing and evacuate from the hill.  If the patient has stopped shivering it will not generally be possible to rewarm the patient outdoors, they are too cold.  So as above isolate and insulate and carry the patient to safety.

An extremely important consideration is that if there is one hypothermic patient in a group, then everyone else is at risk including yourself, take great care!

Group 3

In the case of immersion hypothermia the patient has been cooled very quickly and consequently can be rewarmed equally quickly when possible.  Place the patient in a tepid or even cool bath, then gradually, over say ten minutes, feed the bath hot water and the patient will warm up.  Once warm remove to a warm bed.  If the incident happens in a remote area remove the wet clothing ASAP and then replace with dry.  The patient should then be evacuated as appropriate.

Serious Accidents

In the event of a serious accident the Qualified First Aider will initiate an emergency procedure: Emergency treatment will be carried out by appropriately qualified members of staff.  The carer / family will be contacted .  An ambulance will be called.  The patient will be accompanied either by an appropriate member of staff or carer / family member.

For accidents which do not require immediate attendance at Hospital, appropriate first aid will be carried out by the qualified members of staff.  The carer / family will be contacted.  Treatments will be carried out using the following equipment:

Steri-wipes, plasters, dressings-non adherent & tape, savlon dry, wasp-eze.  Where a fracture is suspected an assessment will be made and the patient referred to hospital accordingly.  Asthma will be treated by using the patient's inhaler and spacer device to standard protocol.

For minor accidents and injuries the patient will be treated by the appropriate member of staff using the equipment detailed above and the carer / family contacted as and when appropriate.  Minor head injuries will usually be reported to the registered manager

Salbutamol inhalers will be kept in a safe, but easily accessible place, available for immediate use by the child.  A spacer will be available for emergency treatment, used in conjunction with the patient's salbutamol.

25. Anaphylaxis (The Hidden Peril)

Anaphylaxis is indeed a hidden peril, in that it can catch you completely unaware and only by the correct, prompt treatment can the patient's life be saved.  Anaphylaxis is one of the most acute medical emergencies and requires immediate and aggressive management or the patient can die in minutes.

A definition of anaphylaxis is a state of immediate hypersensitivity following exposure to a foreign protein or drug with a massive and uncontrolled release of histamine.  It is therefore caused by exposure to a specific allergen, either by injection of ingestion.

These allergens can be very diverse:

Drugs

Penicillin and other antibiotics	Sulpha drugs e.g. sulphonamide
Mismatched blood transfusions	Animal serum products
Salicylates	Vaccines
Enzymes e.g. penicillinase	Local anaesthetic
Radio opaque dyes	Hormones e.g. insulin and heparin

Foods

Shellfish and other seafood's	Peanuts and pecans
Milk and milk products	Egg whites
Chocolate	Some fruits e.g. strawberries

Insect stings

Wasp

Bee

Hornet

A severe reaction will follow the injection of a foreign substance, much more quickly than ingestion, except in the very sensitive individual.

With the introduction of the allergen into the sensitive person, the reaction is the release of a large amount of histamine into the blood stream.  This will have effects both locally and systemically.

The local effect is:
Swelling and / or itching
Red weal's around the point of injection

The systemic effects are:
Swelling around the eyes- generalised red blotches
A flushing and feeling of warmth- swollen tongue and throat
Difficulty in breathing - a tight feeling in the chest
Voice may become hoarse or stridorous

The large amount of plasma leaking into the patient's gut will cause:

Nausea	cramps	bloating
Vomiting	diarrhoea
The reduction in cerebral perfusion will cease:
Headache	dizziness	confusion

A feeling of impending doom

The decreased circulating blood volume will cause their heart rate to increase.  This progresses until the blood pressure drops and finally, a profound slowing of their heart rate.  Most of the problem is caused by the release of histamine, and the consequent dilation of blood vessels and dropping of blood pressure.  To manage the patient these effects must be negated and reversed.

The first and most important step is to recognise that the patient is suffering the effects of anaphylaxis

Conscious patient - lie down with their legs elevated
Unconscious - use the recovery position to help maintain their airway

The only intervention that will reverse the systemic effects of anaphylaxis is the administration of Adrenaline.

The most common device available is the 'EPI Pen', this delivers a patient specific dose into the quadriceps muscle or occasionally you may find a MINI-I-JET, which also gives a self-administered, measured dose intramuscularly.
OR
If - there is an established protocol, and you have been trained, and are experience, administer adrenaline.  If not get someone who is!

Use a solution of 1 / 1000 adrenaline with deep intramuscular injection ASAP.

<1 year - 0.05ml      1 year - 0.1ml      2 years - 0.2ml 3 years - 0.3ml
5 years - 0.4ml 6-10 years - 0.5ml Adults - 0.5ml

This is then backed up by antihistamine and corticosteroids in hospital.

The adrenaline may be repeated at 5 to 15 minute interval depending upon the patient's condition.

Ensure that the patient is taken to hospital ASAP.

References:

The Essentials of Immediate Medical Care by Dr. C. J. Eaton
Churchill Livingston 1992
Emergency Care in the Streets by Nancy Caroline MD
Little and Brown 1991
Shock the Unrecognised Killer by Martin T. Bennett E. M.T
British National Formulary (March 97)
Various Journals 1990

26. Paediatrics

Children are not 'small adults'.  They present a unique challenge to the First Aider.  As children age they become less prone to damage from illness and more prone to damage from trauma.  The child also has anatomical and psychological differences, these differences reduce as the child approaches adulthood.

History

Getting a good history, particularly from a small child can be very difficult.  Following and standard format helps a lot.  This information should be part of the young persons health profile:

In the absence of such information a  'SAMPLE' history should be compiled:

Signs & Symptoms	what signs and symptoms has the patient got?
Allergies	is the patient allergic to anything?
Medications	is the patient on any medication - whatsoever!
Past Medical History	relevant medical or surgical history?
Last meal	when did the patient last eat or drink?
Event & exposure	what happened leading up to accident? Expose the part concerned.

The most important technique is to speak directly to the child.

Causes of Paediatric Cardiac Arrest

The causes of paediatric cause arrest are all centred around respiratory arrest.  The paediatric heart is usually fit and strong and will only give up after a long fight against hypoxia and acidosis.  If a child does become pulseless, the chances of survival are very small, for these critically ill patients the effort is to prevent cardiac arrest if at all possible.  This is usually by early admission to hospital.

Illnesses:
Bronchiolitis	Severe lower respiratory tract infection
Laryngotracheobronchiolitis (croup)	Severe respiratory tract infection
Epiglottitis	Severe infection of the epiglottis & larynx
Meningitis	See below
Pneumonia	Severe infection within the lungs
Asthma	Severe restriction of the airways
Trauma
Head injuries	The most common cause of death in children!
Hypovolaemia	Blood loss
Asphyxia	Choking & drowning etc
Hypothermia	Cold!!
Drug overdose	Mainly alcohol and household medicines
Poisoning	Household cleaning agents and plants

Paediatric Resuscitation

DANGER - ASSESS THE SCENE FOR SAFETY!!!!!!!

RESPONSE - SHOUT AND SHAKE THE PATIENT

SHOUT FOR HELP - dial 112

AIRWAY - CHIN LEFT - JAW THRUST (Exercise caution in the infant)

BREATHING - LOOK, LISTEN & FEEL for breathing, carefully assess for full ten seconds.  If breathing place in recovery.  If not breathing - CHECK IN THE CHILD'S MOUTH for obvious obstructions or vomit.

GIVE FIVE EFFECTIVE BREATHS, CHECK RISE & FALL OF CHEST

CIRCULATION - Check for circulation, if competent use CAROTID or BRACHIAL pulse (under one year) for a full ten seconds.

If there is no pulse or it is less that 60bpm start chest compressions.  The ratio must be 30:2.

WHEN IN DOUBT START RESUSCITATION Take the child to phone whilst trying.  If after one minute you have not been able to get help, leave and go for help.  DO NOT GIVE UP.

Choking

In the under 1 year old, 5 backslaps followed by 5 chest thrusts, check mouth, repeat as necessary.

In the over 1 year old 5 backslaps, 5 abdominal thrusts, then repeat as necessary.

Meningitis

Although relatively rare this disease strikes fear into our hearts.  There are around 3000 infections per annum with up to 250 deaths, around 100 of these will be children particularly the very young.

Signs & Symptoms:

Drowsy, irritable and discomfort on movement
High temperature with nausea and / or vomiting, joint and / or back pain
Headache, often severe
Photophobia
Confused or altered level of consciousness
Rash that does not blanch under pressure
Apart from this classic list, the intuitive response of the carer is profoundly important.

Children are more prone to all sorts of injuries than adults and are more difficult to diagnose.  For example greenstick and hairline fractures are common in children and can be extremely difficult to identify.  They frequently fall and graze themselves, which require careful cleaning and dressing.  The wounds are often grossly contaminated.

With children it is better to call for help earlier, rather than later.

27. Chest Pain

The patient with chest pain must be dealt with as a major medical emergency.  It has been shown that the people who have the greatest chance of living after a heart attack miss that chance because they are slow at getting to hospital.  Infact it has been shown that the largest single contribution the first aider can make, is the early recognition of chest pain and an early call to the Ambulance Service.

Aspirin

Aspirin can make a very important contribution to the management of the patient having a heart attack.  Aspirin has been shown to reduce the amount of clotting within the coronary artery.  However, there are risks when giving anyone a drug with such a serious condition.  The first aider will give the person having a heart attack a chewable aspirin unless they have:

Allergy to aspirin
Altered level of consciousness
Recent surgery
Recent stomach ulcer - within 1 year
Already taking a Heparin or Warfarin based drug
Recent stroke*

*Stroke

A stroke is a similar problem to a heart attack in that it is a blood clot, but within the patient's brain.  About 90% of strokes are due to clots or blocking of an artery, the remaining 10% are due to bleeds.  If a patient has a bleeding stroke and someone gave aspirin, the patient could bleed catastrophically.

Strokes are present in many different ways, such as altered level of consciousness, single sided paralysis including the face and difficulty in speaking.  If these features are transient then the 'stroke' is knows as a TIA.  These are perhaps more important to the first aider in that they precede a full-blown stroke.

EUROPEAN AND RESUSCITATION COUNCIL UK GUIDELINES FOR RESUSCITATION 2005

The resuscitation of the unresponsive adult patient.

D) Danger - FOR SCENE SAFETY

R) SHOUT AND SHAKE THE PATIENT

SHOUT FOR HELP

A) AIRWAY - HEAD TILT - CHIN LIFT

B) BREATHING - LOOK, LISTEN & FEEL
for breathing, carefully assess for a full ten seconds

No breathing

If you are on your own, go for help!
Remember, without defibrillation there is no hope of resuscitation

C) CIRCULATION Give 30 chest compressions at 100 chest compressions per minute.  Give 2 effective breaths

Unless there is an obvious response continue resuscitation at 30 chest compressions and 2 breaths until you are told to stop.  If help is available swap every 2 minutes.  If you are unable to unwilling to do mouth to mouth do compressions only until help arrives.  If possible, do ventilations with a pocket mask.

REMEMBER, WITHOUT DEFIBRILLATION, THERE IS NO HOPE OF RESUSCITATION

Begin resuscitation - Thirty chest compression's and two breaths sequentially.  The above protocol applies to a single or two rescuers.

Compression RATE should be 100 per minute, that is not 100 chest compressions in a minute, but at a rate of 100 per minute, just less that 2 a second.

Ventilation volume is a breath of 1 to 1 ½ seconds, allow chest to fully deflate after each inflation.

If you are unable or unwilling to do mouth to mouth ventilations do compressions only at the rate of 100 compressions per minute until help / pocket mask etc arrives.

Choking - five backslaps, if that doesn't work five abdominal thrusts and repeat as necessary.  If the patient becomes or is found unconscious initiate resuscitation.

28. Trauma

Blood loss - direct pressure & elevate for at least 10 minutes.  This is the mainstay of blood loss management and only extremely rarely would any alternative means be necessary.  Apply pressure carefully and precisely over the wound, it may be necessary to press quite hard.  Use an appropriate dressing and hold it in place for long enough!  As an absolute and last resort use a tourniquet.  Record the time you place it, loosen after 10 minutes if the wound is still leaking replace the tourniquet and leave in place to hospital.  Do not cover the tourniquet.

Minor cuts and abrasions - allow the wound to bleed.  SCRUB the wound clean with soap and water or a medi-wipe.  These injuries are often very tender and require great care.  Inspect the wound very carefully for depth and hidden damage.  Apply direct pressure until it stops bleeding, this could be as long as 10 minutes.  Dress with an appropriate sterile dressing - probably low allergy.  Any doubt, refer the patient to a GP or the Casualty Department.

Strains - the over stretching or tearing of a muscle.  They are identified by pain, swelling and / or discolouration in and around the muscle concerned.  The treatment is rest, elevation and pain relief where appropriate.  Remember that these injuries can be very severe.  Any doubt, refer the patient to a GP or Casualty Department.

Sprains - the over stretching of ligaments in and around a joint.  These are identified by pain, swelling and / discolouration in or around the joint.  In extreme cases the joint can dislocate (in which case surgery is frequently required).  The treatment is rest, elevation and pain relief where appropriate.  Remember that these injuries can be very severe and sometimes impossible to differentiate from a fracture.  Any doubt, refer the patient to a GP or Casualty Department.

Fractures - a break in the integrity, either fully or partly of a bone.  They are usually identified by severe pain, swelling and / or discolouration, occasionally with obvious deformity.  If it's bent it's broke!  Sometimes it is impossible to identify hairline fractures.  Be guided by the patient, when in doubt - refer to hospital.  Patients with fractures are often very difficult to manage, call an Ambulance earlier rather than later.  Only fiddle with a fractured limb if there is no blood supply beyond the fracture site (this is extremely rare), and you have to wait more than 30 minutes for an Ambulance to arrive.  And then, only if you absolutely have to.  Use gentle, firm inline traction to position the limb to a normal anatomical appearance, check for capillary refill.

Cervical spine and spinal injuries - an injury to the spinal cord often associated with fractures to the neck or spine.  They are identified by the HISTORY or pain, swelling and / or discolouration, and / or numbness, pins & needles in the arms or legs and / or loss of sensation, function of maybe paralysis, occasionally a priapism.  They are assonated with all severe head injuries, all injuries where history indicates: falls from height, speed impact injury, rugby, diving into shallow water, severe electric shock, and any injury where there is a masking pain.  LISTEN to the patient.  Any doubts in your mind immobilise the patient.  Remember the AIRWAY must always take precedence.  Pay particular attention to the patient with an altered level of consciousness. It is often not possible to confirm or exclude on of these injuries, because of their implications manage the patient 'as if' there was a fracture present.

29. Shock

SHOCK - is a "STATE OF INADEQUATE TISSUE PERFUSION"
(a momentary pause in the act of death!)

Pain is not a cause of shock but it exacerbates shock when present.

• Blood loss: - internal, external, fractures, severe bruising
• Heart Attack
• Burns
• Dehydration
• Neurogenic
• Diabetes
• Septicaemia
• Anaphylaxis

Click here to view the Shock Diagram

Click here to view Asthma flowchart

30. The Acute Asthmatic

Asthma - from the Greek, meaning 'panting'

Due to the nature of Asthma is can very occasionally cause extreme problems in a patient.

To enable the First Aider to cope with this type of emergency I have detailed below the suggested guidelines:

1. Diagnosis
   
   This is perhaps the most important element.  The first part of the diagnosis is the suspicion.  As the First Aider you have probably been called to deal with someone having an Asthma Attack!
   
   The next part is quite simple, ask, "are you having an asthma attack?"
   
   It is necessary for the patient to have had an asthma attack in the past, and to have visited their Doctor, for them to know the answer to this question.
   
   These points are aided by your observations of the patient.
   
   Look at the patient.  What colour are they?  What do they sound like?  What sort of state are they in?
   
   The asthmatic is often quite pale, but can be flushed, particularly after exercise.
   
   They may be sweaty.  They are often to be found sitting up and leaning forward with a marked degree of respiratory effort.  This is evident by obvious muscle action around the neck and between the patient's ribs.  They often appear to be very frightened.  If you listen to the patient, they are often coughing a dry unproductive cough and have audible wheezes.
   
   If the patient's chest is silent, it is because they have good clear airways or is it because they have hardly any airflow?  Beware the silent chest.
2. When to call for help
   
   The British National Formulary details various levels of asthma.
   
   Uncontrolled Asthma - speech normal, pulse rate less than 110 beats per minute, respiratory rate less than 24 breaths per minute
   
   This type of attack may be managed on scene, with a referral to the patient's Doctor or Hospital ASAP
   
   Acute Severe Asthma - Cannot complete sentences, pulse greater than 110 bpm, respiratory rate greater than 24 breaths per minute
   
   Life Threatening Asthma - silent chest, pulse rate less than 60 and or exhausted.
   
   The latter two obviously require in hospital management.  CALL THE AMBULANCE.
3. Management
   
   The management of a severe asthma attack requires Salbutamol, this is a Prescription Only Medicine, carried out by the patient.  It is often the poor method of taking this drug that leads to our involvement in the attack.  Correct administration is absolutely essential.  For any everyday normal asthmatic, the dose is 2 x 100mcg from their metered dose inhaler taken periodically through the day, particularly before exercise.  This dose given through a volumetric spacer is surprisingly effective.
   
   If a proper volumetric spacer is not available, use a plastic coffee cup with a hole in the bottom, a rolled up magazine or best of all, a small lemonade bottle with a hole in the bottom.  If you use an adapted spacer without a non-return valve, give double the dose, 4 x 100mcg to compensate for the drug lost on exhalation.  The value or reassurance to this patient cannot be over estimated.  If you panic, they will panic even more.
4. Unusual Circumstances
   
   Most asthma attacks increase in severity over a period of time.  It is very unlikely for someone to have a severe, first attack.  If, however, you are unfortunate enough to encounter an undiagnosed person having a severe asthma attack, call an ambulance immediately.

Salbutamol is Prescription Only Medicine (P.O.M).  In certain circumstances it may be possible to have a reserve inhaler for use in an emergency.  This has to be on the explicit instruction of a GP.

References:  
British National Formulary
Emergency Care, a Text Book for Paramedics, K Porter et al
Emergency Care in the Streets, Prof. Nancy Caroline

31. Head Injuries

Click here to view Head Injuries Diagram

32. Diabetes

On one side there is insulin	On the other is glucose

In most people, most of the time there is a balance between blood glucose and stored glucose.  This balance is maintained by insulin.  In the Diabetic patient the balance is disturbed by either the insulin that is produced not working, or by not producing enough insulin, or producing no insulin at all.

Normally we eat food, convert it into energy (as glucose) or store it, to use later.  This process is regulated by insulin.  When there is a failure in the 'management system' (insulin) control is taken externally by the patient.  This could be by dietary control or by the use of injected insulin.

If the balance is tipped towards too little insulin and too much glucose the patient becomes ill as they fail to metabolise glucose.  This can take, in the early stages of the disease, many months.  (The patient becomes 'diabetic').  This part of the disease requires careful management, usually in hospital.

 

If the balance it tipped towards too much insulin and too little glucose, the patient will rapidly begin to lose consciousness as the glucose available to metabolise in the brain decreases.  This balance must be redressed very quickly.

To deal with this problem we will approach it in stages.

Stage 1

The patient is beginning to suffer from low blood sugar

They may be awkward, confused and / or have slurred speech (a little like being a bit drunk), stumbling or general poor co-ordination.  Sometimes there is an alteration in the use of language - different or bad language.  The patient may become quiet and withdrawn.

This is the best time for successful treatment.

Give the patient rapid access sugars i.e.

Soft drinks - coke, pepsi, tango, fruit juice, milk or a home made sugary drink.  This should then be followed by biscuits as 'digestive', rich tea, malted milk etc. 

Once this is done the patient should be given carbohydrate such as a sandwich or an ordinary meal.

Stage 2

The patient has established low blood sugar

They are stumbling around with bad language, often quite abusive and or aggressive.  Alternatively they have become very quiet and introverted.

If possible give the patient rapid access sugars as above, if however they are too aggressive back off don't get hurt yourself.  Most often the patient will eventually quieten down, if they don't they will collapse.

Stage 3

Collapsed or possibly unconscious

Because now the patient is possibly unconscious they may be unable to swallow, therefore the above treatments are unsuitable.  They need "Glucogel".  This is a proprietary glucose-dextrose gel for oral administration.  Squirt the gel very gently into the corner of the patient's cheek, then gently rub the outside of the cheek to speed the absorption rate.  It may take more than one tube to raise their blood glucose level.  As it does rise they should gradually regain consciousness.  As they do, carefully squirt the remaining glucose into their mouth.  Then treat as above.

CALL AN AMBULANCE just in case this does not work.

In the absence of glucose gel try the following in order of preference:

Honey or golden syrup, jams, marmalades etc, ordinary sugar (the least effective).  Do not give the patient chocolate unless you are sure that the patient normally eats chocolate as people with diabetes often do not eat chocolate.

WHEN IN DOUBT - GIVE SUGAR, NEVER INSULIN.

End