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New ambulance guidelines on adrenal crisis


ADSHG

  • New clinical guidelines for pre-hospital emergency care were published in September 2017 by the national ambulance regulator, the Joint Royal Colleges Ambulance Liaison Committee (JRCALC).

In a most welcome development, the new guidelines incorporate extensive input from ADSHG and the Pituitary Foundation; our shared input was steered by the Chair of the ADSHG’s clinical advisory panel, Prof John Wass. 

 

Importantly, the new guidelines bring ambulance practice into line with a key recommendation in the ADSHG’s GP Diagnosis leaflet, that patients in adrenal crisis should be stabilised with injected hydrocortisone and IV fluids before being moved. Where a patient with severely low blood pressure cannot be transported flat on a stretcher (e.g. domestic stairs) they must not be moved until circulatory volume has been restored with IV fluids and they have received injected hydrocortisone.

 

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Steven Irving, AACE director, with Lorna Dowling from Class Publishing

at the launch of the 2017 JRCALC supplementary guidelines

 

Cathryn James, clinical support manager for JRCALC and the Association of Ambulance Chief Executives, writes: 

 

“The guidelines have been updated to put more emphasis on recognising and managing anyone that may be in adrenal crisis or/and be steroid dependant. Additional wording has been added to the medical emergencies section and to the section around the use of hydrocortisone. 

 

“We are really pleased to have worked with both the Addison’s Disease Self-Help Group and the Pituitary Foundation to update our guidance for these important groups of patients. The groups have assisted us with ensuring we get the right emphasis and clarity and we thank them for their input.

 

“We anticipate these changes will improve clinical practice and ensure that all ambulance clinicians consider adrenal crisis when assessing and managing patients. Ambulance clinicians respond to a very wide range of types of emergency calls, and the pre-hospital guidelines need to reflect the best and current evidence based practice so that we can treat all patients appropriately and give the best possible care whatever is wrong with them.”

 

Julie Watson, ADSHG’s ambulance awareness co-ordinator, commented: 

 

“This is very encouraging news. We have been delighted to help in the improvement of the national guidelines for ambulance clinicians. We are especially grateful to Prof Wass for his time and commitment on this important aspect of adrenal patient safety.”

 

“The ADSHG’s submission particularly emphasized the need for immediate treatment of anyone showing signs of adrenal crisis PRIOR to transportation to hospital. This has been acknowledged in the revised guidelines in several ways. Addison’s disease is now explicitly named in the guidelines for patients presenting with altered levels of consciousness. Another new inclusion is the very important advice that it is always better to give injected hydrocortisone than to wait.

 

“We look forward to these guidelines being rolled out to all ambulance services across the UK. The guidelines take us a step closer towards having a network of national ambulance services all operating in the same way and with the same emergency response procedures towards patients with specific conditions such as ourselves.”

 


 

August 2017, by email

 

Dear Katherine

 

We write to formally record our appreciation for your recent involvement in the compilation of the next JRCALC guidelines. We are very appreciative of the time and expertise that has been given to ensuring that the ‘JRCALC Guidelines’ remain the very best for paramedics and other clinicians. Thank you for your comments regarding the general guidance and especially your invaluable work on Addison’s Disease and steroid dependant patients.

 

Thank you again for your expert help and assistance. 
Yours sincerely

Dr Dhushy Surendra Kumar     Dr Julian Mark              Mr Martin Flaherty OBE
JRCALC Chairman                      NASMeD Chairman       AACE Managing Director

 

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Who is JRCALC and what is in the JRCALC guidelines?

 

The Joint Royal Colleges Ambulance Liaison Committee (JCALC) is the national regulator of clinical standards across the UK’s independent ambulance trusts. It has representatives from all the major medical colleges representing specialist disciplines, including the Colleges of Emergency Medicine, Paramedics, the Royal Colleges of Physicians, GPs, Psychiatrists, Midwives and Nurses. It first met in 1989, and its guidelines are updated periodically, as required. Its role is to provide robust clinical specialty advice on the instruction of the Association of Ambulance Chief Executives (AACE) and its advisors, the National Ambulance Service Medical Directors group (NASMeD).

 

AACE is a formally constituted private company wholly owned by the English Ambulance NHS Trusts and it exists to provide ambulance services with a central organisation that supports, coordinates and implements nationally agreed policy. The ambulance trusts for Scotland, Northern Ireland, Wales and Ireland are affiliate members of AACE.

 

The 2006 JRCALC guidelines were a watershed for adrenal patients; these allowed paramedics to give injected hydrocortisone for adrenal crisis for the first time, where previously it had only been authorised for asthma and anaphylaxis.

 

Today, it’s hard to imagine that barely 11 years ago, paramedics received no training in adrenal crisis and were unable to treat it even if they recognised it.

 

This important safety advance reflected the joint ADSHG and Pituitary Foundation submission of 2005, co-signed by Prof John Wass, explaining the risks of adrenal crisis and the need for ambulance training in adrenal crisis. The ADSHG’s 2005 initiative, engaging the Pituitary Foundation on a joint submission to JRCALC, was the first big medical awareness project we took on after gaining charitable accreditation in late 2004. It achieved its success thanks to a working party spearheaded by former trustee Sue Thompson, and assisted by the Deputy Clinical Director at London Ambulance, David Whitmore.

 

In many countries across Europe and some states/provinces in North America, ambulance crew are still not authorised to treat adrenal crisis. Within the UK, paramedic shortages mean it is still advisable for family members to learn how to give an intramuscular injection, and to do so before phoning 999 for help in the event of adrenal crisis.

 

In 2013, the intellectual property rights for the JRCALC clinical guidelines were novated from the Ambulance Service Association (ASA) to AACE who now act to protect the copyright of the clinical guidelines. The guidelines are available to purchase via the AACE website and can be obtained in both electronic and print formats.

 

At present, JRCALC are unable to host free access to the guidelines. This is because there is no longer any contribution from central government to JRCALC’s funding and all monies from the sale of current guidance is reinvested into future updates.

 

Extracts from the guidelines relevant to adrenal crisis can be found in the members’ forum, published with very kind permission from JRCALC.

 

Katherine White

 

This article was first published in the December 2017 edition of the ADSHG newsletter.



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The Addison’s Disease Self-Help Group is the support group for people with Addison’s disease or adrenal insufficiency and their families in the UK and Ireland.The group was formed in 1984 and is a UK registered charity no. 1179825.

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