#RCEMasc 2019 – Day 2

Paracetamol 12hr SNAP regime: 2014 & 2019

  • What is it? 
    • Pre-NAC – 4mg Ondansetron IV
    • Bag 1 – 2hr 100mg/kg NAC in 200ml 5% Dex
    • Bag 2 – 10hr 200mg/kg NAC in 1000ml 5% Dex
  • Advantages
    • Saves 9hrs
    • Significant reduction in anaphylactoid reactions 2% vs 11%
    • Significant reduction in gastric symptoms (if either ondasetron or 12hr regime used)
    • Significant reduction in treatment pauses
  • What next?
    • 10 centres using (inc Edinburgh, Newcastle, Guys St Thomas’)
    • We can’t implement the 12hr regime just yet (however, discussions are going on with Acute Med and Hepatology)
    • Pre-NAC ondasetron does seem like a good idea


  • Comprehensive Frailty Assessments
    • NNT to prevent a death 17
    • NNT to prevent NH admission @ 6months 20
  • Frailty Score @ Triage 
    • Initially 50% accuracy (esp. around 4/5)
    • Addition of props significantly improved triage accuracy
      • Do you find walking more difficult or do you need mobility aid? Yes > 4+
      • Do you do your own shopping & housework? No > 5
      • Do you need help washing & dressing? Yes > 6
      • Do you live in a care home or have carers?
        • If carers > 5+
        • If needs assistance with personal care > 6-7
      • Are they confused or have a diagnosis of dementia? Yes > 5
  • Delerium
    • PINCHME  – for all frail patients they may not have delirium now but soon…
    • Parkinson’s Disease and can’t swallow
      • Find the right dispensable regime or patch – use pdmedcalc
    • Other ways of doing things
      •  TRAWL
        • South Tees frailty team call all discharged frail patients to ensure things are going well and arrange further input as needed
      • Falls Rapid Response Team
        • Newcastle and Gateshead, paramedic and OT in a car reduce, conveyance to ED from 75%(with Ambos) to 45%


We all do it and we all want the best death possible – But we often do it badly

  • 1:3 patients admitted on acute adult take are in their last year of life
  • 80% of NH patients are in the last year of life

But we don’t always know which patient or recognise how quickly this will happen – think about the following:

  • Parallel planning: we can be both treating the patient, and making plans how we can allow them the best death if they are dying.
  • Sedating For Scan: PAUSE – this might be the last time they are conscious, consider them and their family and do they need time
  • Use the word Dying: find out what is important to them, and their family, what are their fears and what they want to know, allow silence.
  • Society is unfamiliar with death: Narrating whats happening for the family can help, e.g “that rattley noise you can hear is only a small amount of fluid in their throat, it can sound horrid but its not bothering them at all” Remember we are used to these stages but to families they are scared and they often assume that the patient is suffering.

You may want to look at the talking about dying resources from the RCP

Top 10 papers

Go to St Emlyns’ see the whole thing and read the papers, subjects include:

  • Should every ROSC go straight to the Cath Lab?
  • AF: Mg & Early Shock
  • Dose Criocoid press just make things more difficult?
  • Can we bag during RSI?
  • Vasopressors: septic shock & haemorrhagic shock?
  • POCUS in cardiac arrest


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