EMS

No. 3 - Christmas 2014

Lavatory
Learning

Welcome to the 3rd

Lavatory Learning.
Weve collected
some things we
didnt know last
month on one-page:
designed for the back
of the loo door.

CPD whilst having a wee!

This is intended as a
WAST community
production - please
send us something
youve learned this
month that youd
like to share.

Ondansetron & prolonged QT intervals

By now, many of you will have had the opportunity to use ondansetron,
which is a more effective anti-emetic than metoclopramide (in fact,
metoclopramide in one trial was no better than placebo in preventing
opiate-induced vomiting).
Whilst ondansetron is marvellous stuff, it does have a downside - like
many other drugs, it can prolong the QT interval. If you give it to
someone who already has a prolonged QT interval, you may trigger
polymorphic VT, better known as Torsades de Pointes.
Be cautious about using ondansetron in patients with arrhythmias,
possible electrolyte imbalance (low serum potassium and magnesium),
known long QT interval & congestive cardiac failure. Youd be well
advised to check the 12-lead ECG and QTc first!

East of England Ambulance Service

NHS T rust

Rare conditions
This document provides clinicians
with a brief synopsis of a range of rare
medical conditions.
As a clinician you may only come across these
conditions once in your career, so this document is
designed to assist you with your clinical
decision making.

The Rare Conditions

booklet
Have you seen this yet? WAST staff can
download it from the intranet News page, but it
has been disseminated to all UK ambulance
services.

It is a fantastic collection of brief must-knows

about a selection of rare conditions, produced
by East of England ambulance service
following the sad death of 21-year old Adam
Cash. Adam (who had diabetes and Addisons
disease) was vomiting, attended by ambulance clinicians and diagnosed
with norovirus and advised to stay home and rest. The next day he
suffered a cardiac arrest and died.
Hopefully this vignette has prompted your brain to think about Addisons
disease and Addisonian/adrenal crises, and you can read about these
plus many more (autonomic dysreflexia, Brugada, caudal equine, cerebral
palsy, DTs, diabetes insipidus, Factor V Leiden, Guillian-Barre syndrome,
Kawasaki disease, Lupus, Long QT, Marfans, Myasthenia Gravis,
neutropeniac sepsis, sick sings syndrome, thalassaemia, Wernicke
encephalopathy & Wolff-Parkinson-White syndrome!) in the booklet.
An informal technical update - this issue produced by guest contributors the North Wales APP/
TAPP Clinical Supervision Group with a little help from @mmbangor of Bangor ED

Is that VF or VT?
Our top tip for this month - from one of the team
who saw their first ever Torsades not in a textbook
recently - is that on a small defib screen, the
classic sine-wave shape of the variations in
amplitude arent immediately apparent.
If you find yourself saying its-VT-its VF-no, its
VT in a compromised patient for whom urgent DC
cardioversion is required, hit the synch button
first, and make a mental note that it may be
Torsades. If in full cardiac arrest, ALS guidelines
are to defib as normal.

Deciding not to start CPR

(and no, you don't need to phone a
doctor for permission)
It is a myth widely acknowledged amongst paramedics
in Wales that you arent allowed to independently
decide to withhold CPR from a patient in whom it is
clearly inappropriate.
It really is a myth, and there is specific
acknowledgement of this in the WAST Cardiac Arrest
Response Form (CARF). Under the "Resuscitation not
attempted" section, you have final stages of terminal
illness where death is imminent and unavoidable and
CPR would not be successful.
This boxes off the situation when you respond and find
someone about to die who obviously should be
allowed to pass away peacefully in their own bed - and
dont forget, severe dementia is a terminal illness as is
end-stage COPD and heart failure.
Learned something youd like to share?
Help us compile the next issue:
email contributions to Alison.Woodyatt@wales.nhs.uk