Surviving Sedation 2015

It has been a busy month behind the scenes here at Broome Docs – lots of big projects and plans going on…  wait and see what we are have in the offing.

One project that I have been working on with a group of great clinicians from all over Australia.  It is called SURVIVING SEDATION 2015. Yes – that is a deliberate pun on the “Surviving Sepsis Guidelines” – and we want to install the idea that this is a high stakes situation, with lots of potential morbidity and unfortunate track record of mortality for these patients.  The goal is to use early, goal-directed sedation to maintain a safe environment for staff and allow patients to be cared for in a standardised, safe fashion.

We have been sharing ideas, data and experience around the acute sedation of patients with psychosis or other behavioural disturbance.  If you have been following the blog from the outset – then you will know that this is something that I am passionate about.  There have been a lot of changes to the way I practice when it comes to sedating Psychiatric patients.  This set of guidelines represents the vest available evidence, interpreted by front-line clinicians and presented in as simple, usable possible format.

Our lead “author” is Dr Minh le Cong – @ketaminh – the foremost Aussie researcher in Psychiatric retrieval.  Also on the panel were Dr Tim Leeuwenburg @Kangaroobeach , Dr Andy Buck @edexam and Dr George Douros.

Pre-publication peer review was also done by Dr Amit Maini @sithlord2004, Dr Peter Fritz @pzfritz & Dr Michael Downes @ToxTalks.

It is really difficult to write a set of guidelines that can be applied to all scenarios – our panel practice everywhere from major tertiary EDs to tiny remote clinics with near-zero resources for this scenario.  There is also a lot of variation in practice depending on your location. Many practitioners are working in locations that need to transfer Mental Health clients by air to a secure facility. Others work in hospitals that can provide this care immediately [though often not…]   However, as a panel we have tried to come up with a basic toolkit of medications, a strategy and logistical considerations that may be applied in any setting.

For the full detail of the rationale – pop over to Minh’s blog on the PHARM to read his thoughts.

The actual short version (2 pages – front and back) is designed to be laminated for reference in the clinic / ED / ward etc.

You can see it HERE SURVIVING SEDATION 2015

I am going to leave it up on the blog here in the permanent top menu under clinical resources.

SO – what is new in this set of guidelines?  Nothing too controversial.  The main changes are to the way we plan the sedation.

  1. Treat any Psych sedation as a “procedural sedation” – where the procedure is the safety of the patient +/- transfer to an appropriate centre.
  2. Pharmacological minimalism – using less agents in a titrated fashion
  3. There is a specific objective sedation score (SAT) – with goals of therapy clearly laid out.
  4. Ketamine is used in several potential situations: as a 2nd line IV / IMI agent in severe agitation and also as an infusion for transfer by air.
  5. There is emphasis placed on making a pre-sedation assessment of the airway / Anaesthetic / medical risk of sedation for a given patient.
  6. We have deliberately recommended that appropriate airway equipment and personnel be present.  No more dark, back room sedation supervised by the grad nurse up the far end of the ward.
  7. You will notice that midazolam does NOT feature in the mix.  This is the result of several papers showing it can be dangerous.  Diazepam is the chosen benzo – although this was largely due to its wide availability and clinical familiarity.  [Personally I will be using long-acting benzos such as clonazepam or lorazepam in my ED.]

Now it is your turn – I know that there are a lot of experts out there – and I want to hear your thoughts on this project.  So please have a read of the guidelines and the rationale on the PHARM site. Let us know what you like, don’t like or disagree with.  If you have any evidence that you feel might be incorporated – then send me the link.

Thanks

Safe sedating team

Casey

Migraine Prophylaxis: preventing you a headache

Migraine headaches are common.  They can be really disabling for patients and if they occur with any frequency they can make life miserable.  Fortunately there are many options out there for the longer term management and prophylaxis of migraine and other primary headaches.

The only problem for us is that there are so many, seemingly effective remedies – it can be a real headache deciding which to try with your patient.

A dive into the literature reveals a broad range of medications and classes of medications that may be suitable – but the data is difficult to get one’s head around.  There are many ways that headache prevention can be measured and weighed – making it hard to compare apples with apples.  And to make things worse – a lot of newer agents come with a hefty price tag if you are prescribing off-schedule…   so how to choose?

Well I have been diving into the literature and have tried to summarise the data around migraine prophylaxis as cleanly as I possible.  How?  The NNT and the NNH for these meds are a fair place to start – you can weigh the risks and benefit with your patient if you know the rough numbers.  And then it is a matter of individualising care to your patient’s other needs and medical problems.

So here we go a whirlwind tour through Migraine Prophylaxis !

A quick explanation of the statistics is required!  When researchers look into migraine prophylaxis interventions – they tend to use a slightly odd, but useful measure of “effect”.  Clearly if you wanted you could measure the number of headaches per month / year etc and have a scale of effect – but that is a bit messy.  So instead they use the arbitrary bar of “50% reduction in headache frequency”.  So when I tell you that the NNT for drug X is 7 – that means that you would have to treat 7 patients with that drug for whatever time period in order to reduce their headaches from 12 to 6, or 8 to 4 – or whatever you like.  Hope that makes sense.

Now usually when we look at drugs in medicine – they get NNTs of 10 or 20 – which most folk would regard as useful.  [NB: aspirin has an NNT of 42 for mortality in acute STEMI.  Its NN to harm is about 167.]

When we look at migraine prophylaxis we are talking about NNTs in the range of 3 – 10.  Now that may sound like these drugs are really great!  But recall we are using “50% reduction in headache frequency” as the end point.  That is a reasonably low hurdle to jump over.  If we were to ask for “complete prevention, absolute prophylaxis” then the NNT would be much higher- I am guessing in the 100s.

So who needs prophylaxis?

  • Most Neurologists would consider 2 – 3 severe / disabling headaches per month a reasonable threshold for considering prophylaxis
  • This may vary depending on the patient’s choice
  • Some patient’s will feel strongly about preventing any headaches due to the severity; interference with life, work, family etc.
  • This needs to be explored with each migraine sufferer  on a case-by-case basis.  That is what they pay us the big bucks to do!
  • Remember that this is an “optional” intervention – so do not be too precious with particular drugs – it is a fine balance between potential harms and benefits – very much in the realm of “shared-decision making” and being pragmatic.

Most of the agents used for abortive therapy / acute management of migraine run the risk of causing rebound if used more than 10 – 15 times a month.  So another way of looking at it would be to use prophylaxis as a means to limit the amount of “acute abortive care” required and therefore maintain its efficacy.

OK – so that is the boring biostats explained.  Lets look at the candidates available to you and your patient to choose from.  I have lifted this very useful table from the Med Journal of Australia 2008 – link is here – it is a really well written piece.

Migraine prophylaxis (Click for the summary table from the MJA 2008 paper)

The Players:

This is a really old agent dating from the 60s. There is not a lot of quality evidence – but it has been the benchmark and default drug for a lot of doctors for many years. It is the oldest 5HT antagonist – the main side effects are weight gain and drowsiness. It is cheap and we know it. Specifically it is touted to help more with vestibular migraines.

Propranolol is the 2nd oldest agent out there. Usually dosed at 20 mg BD (not great for a long term med). It has been well studied. A NNT of 4, and a NNH of 40. Dirt cheap Some benefit for the anxious, tremulous or hypertensives – but can cause exacerbation of asthma / COPD in some punters.

Old TCA well known to most GPs. Going out of favour in Psych but still widely used.  Has it share of anticholinergic side effects and we all worry about OD! There is consistent evidence that amitriptyline works over a long period.  Of course, if the patient has depression as a comorbid diagnosis – this is a good option. None of the SSRIs etc have been shown to help.  Generally the dose required is at the lower end of the spectrum

This is a tough one – these agents have been looked at and I find mixed signal when I read the papers.   Some say it works, but the Forest plot is inconsistent!  At best I would say that there are better / more efficacious agents out there.  Also there was a pretty strong harm signal – dizziness, somnolence and cognitive dysfunction all being  significantly more common with these drugs!  So I would imagine a reasonably high rate of drop out after a period taking these drugs.  Here’s the Cochrane review from 2013.

This is the drug I would take if I needed migraine prophylaxis.  Unfortunately, it is expensive and the PBS in Australia only covers it if you have failed on the other agents. But it was in the top performers in terms of NNT = 4.  Also it seems to be effective at lowish doses 50 – 100 mg – so less side effects potentially.  The NNH is quoted as 3 – 25, a big range! And it depends on the dose.  But one of the “harms” counted is weight loss.  So this is probably a welcome effect for many patients!  In fact this makes Topiramate the only agent that seems to not be associated with weight gain.  The other common SE was taste disturbance (maybe related??)  Biggest downside is the potential for birth defects – so you need to use with care in fertile women!

Another effective drug – with an NNT of 4. But the NNH a little harsher at 7 – 14. The major problem with Valproate is weight gain and the metabolic syndrome. There are whole websites devoted to this syndrome! Valproate 400 mg has been trialled head-head against topiramate 50 mg…. and Topiramate came out on top

Another epilepsy med that has been looked at. Not a lot of great data – small trials showed a NNT of 2 . Was effective – but had a NNH of just 2!  Nausea, vomiting, drowsiness, dizziness… not easy to sell as a long term solution to migraine I think.

There have been a few ACE inhibitors and ARBs tried – so I have chosen candesartan as it the most widely used in Australia for hypertension. In head to head against propranolol – it was equally efficacious and well tolerated. Clearly this is a viable option for a large group of patients who might get benefit from BP control or renal / diabetic disease.

Yes Botox! I am including this in my review as it is out there and used. Your patients will find it when they Google their options. In summary: there is not a lot of quality evidence. Some Neurologists believe it helps with some subtypes (“imploding”) of migraine. And it is sometimes used in patients where other options have failed with a modest 10 – 30 % rate of response. So it is certainly not first line! Maybe 3rd or 4th line! Of course, in patients with coexisting wrinkles or narcissism there maybe additional benefits (Jokes ;-))

 

OK – that is it for my quick review of the literature around migraine prophylaxis.  Would love to hear your experience or views on the data.  I stingily recommend reading the great MJA piece that is linked above.

Casey

A Tox Treat: Tox 101 with Drs Bryan Hayes and David McCoubrie

Hello and welcome back for another podcast.

This week I was lucky enough to do a double interview with 2 super-smart Tox gurus.  We discuss a basic approach to a common tox scenario – the poly-substance OD with a range of medications.  The ins and outs of paracetamol [acetominophen], decontamination, mixed fox, alcohol in the ED and fundamentals of supportive care.

Dr Bryan Hayes @PharmERToxGuy is a regular at Academic Life in EM and recently appeared on the Emcrit podcast. Bryan was last on the podcast a few months ago and we got a lot of great feedback and discussion started – so I wasreally happy to have him back at Broome Docs all the way from Baltimore in the USA.

Dr David McCoubrie is an Emergency Physician and Clinical Toxicologist here in WA.  David recently spoke at the ACEM Winter Symposium in Broome on the newer synthetic illicit drugs in Australia – great talk.  It was a great opportunity to be able to get these two guys on the line and hear them bounce ideas around – some really useful clinical and logistical pearls for you all.

So here we go – it is about 40 minutes. We discuss a case which involves specific decision points and then I ask what their top 3 clinical tips are for the occasional Toxicologist.  Gold!

Enjoy,  Casey
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Clinical Case 085: the trouble with Phineas

Imagine this scenario.

You turn up to work your day shift and see you have been assigned to the Obs ward for the morning.  It is your task to see the dozen or so patients sleeping off the evils of the night before in the small ward out back of the ED.  You know the drill – a few minor tox cases, a Psych sedation, maybe an old guy with a bump to the head etc….

As you look at the list of patients under your care – you have a heart-sink moment as you recognise Phineas’ moniker.

Phineas.  Well Phineas is a well known individual.  He is about 50, and you have seen him many times over your tenure in this ED.

Phineas was a successful independent builder, running his own small company and living in a well-healed suburb with his wife and 3 kids until he had his accident.

About ten years ago Phineas had a few too many drinks and drove into a wall.  He suffered a nasty frontal brain injury and spent a month in ICU, a craniotomy and a prolonged rehab saw him back to full physical function. But…. his brain injury left him with seizures and “Phineas Gage” persona.  Phineas became impulsive, disinhibited, drank to excess and had trouble organizing his life.  His marriage had disintegrated over a few years and he couldn’t hold any sort of job.  Phineas doesn’t have a diagnosable primary mental illness and he has seen a number of Psychiatrists who have all agreed – he does not need their help.

Over the last few years he has been living in a series of supported housing units, but he tends to get into a lot of fights and never stays anywhere longer than a few months.  However, the ED is one of the few permanent fixtures in Phineas’ life.  He frequently presents via ambulance after experiencing secondarily generalised seizures in public.  He is prescribed phenytoin but whenever he gets a level done in ED it is close to ZERO.

You read through the chart from the night before – same old story.  He was drinking in a local park, when he had a convulsion.  A passerby called 000 and the Ambos brought him in.  He was GCS 14/15 on arrival and blew 0.09 on the BAL analyser.  All his obs and examination were “normal for Phineas”.  He received an IV load of phenytoin 1000 mg over an hour, some thiamine and a hot meal.  He required a few doses of diazepam after this for “twitches”.

The resident decided to admit him for “Neuro obs and  Neurologist review in the AM”  This brings a momentary smile to your face!  This is Phineas’ 23rd admission in 3 years.

You wander into his cubicle, and he greets you with a knowing smile.  “Gday Doc!  I’m glad it is you on today.  That young guy last night seemed very serious!”  Phineas is his usual, jovial self.  

After you check him out and talk about the footy for a while Phineas is keen to leave.  He tells you he is staying in a nice flat with a few other “mental defectives” and plans to head back there for a rest and to make sure they have not knocked off his stash of Bundy rum.

So here we are.  The point of the exercise today is to explore a few issues that this sort of patient can present to us, Emergency Physicians who are sometimes by default the primary carers for some patients.  SO have a ponder on these questions;

Q1:  Would you load Phineas with phenytoin each time he presents “post-ictal”?  If so, would you give him IV phenytoin, or something else?

Here is a post from Dr Bryan Hayes of the Academic life in EM blog on oral Phenytoin loading in ED

Q2:  Clearly compliance is a problem. You are an ED doc.  How far do you go to try and get Phineas to take the meds he needs?  Do you give him a prescription?  Hand him a bottle of pills with instructions?  Get a blister pack made up.  Get a Social worker / community health worker involved?  Do you go round to his flat and check on him?  OR is it ethical to accept that Phineas will not take anything you give him and not bother with the meds?

Q3:  Is this a competence question?  That is – is this man competent to make his own health decisions?  Given the facts:   he has clearly and repeatedly put himself in harms way, has a brain injury yet seems insightful enough when you talk to him.  How do we go about deciding on competence in this situation?

OK.  Enough clinical and ethical food for thought there.  Hit me on the comments page or twitter @broomedocs with your thoughts.

Casey

PS: in a modern version of the Phineas Gage story – here is one from Brazil (thanks Dr Tim for sending it in.)  A lucky man indeed.

5 Quick Tox Cases – Dr Bryan Hayes gives the answers

Last week I put up a series of 5 quick tox cases for you all to ponder. In case you missed it – it is HERE

And you all gave great answers.  In there amongst the commenters was Dr Bryan Hayes  – Clinical Pharmacist, Academic Life in EM author tweeting as @PharmERToxGuy

Bryan works at the Uni of Maryland – which is a hotbed of FOAM goodness – with Amal Mattu, Mike Winters, Rob Rogers and Haney Mallemat sharing the hallways of his hospital.

We got together and went through the cases one by one and I asked all the stupid questions I have always wanted to ask a really smart clinical pharmacist!

It is 30 minutes of toxicology goodness.  Enjoy

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Casey