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

Suicide: Sailing on Uncertain Seas

Hi All

Last week I was lucky enough to be able to present this talk to the SWEETS Emergency Medicine Conference in Stockholm.

Thanks to Dr. Katrin Hruska for the invitation.

This is a video of my lecture and slides as presented by myself and local Broome Psych resident Dr Nick Gilbert.

The first 15 minutes is my discussion of suicide risk assessment, then 5 minutes from Nick on the biochemistry, future and therapy for suicidal patients.

Summary take home messages:

  1. Suicide is tough to predict
  2. You have to ask about suicide in your daily practice
  3. Formal risk assessment tools are sensitive, but very non-specific
  4. Predicting behaviour and making a “risk assessment” are not the same thing.
  5. To make the best call you need to delve deep into the cognitive processes that your patient is experiencing
  6. Empathy is key – you need to be able to understand their perspective
  7. Imagine that you and your patient are sailing together over some rough seas – do you have all the data, resources and share a common goal?

OK, if that makes no sense then listen to the podcast and hit me on the comments below:

DIRECT DOWNLOAD HERE 

Casey

 

Being A Doctor’s Doctor – Penny Wilson and Geoff Riley

Have you ever treated a fellow doctor?  How did it feel?  Did you feel confident or intimidated?

Consulting and treating our colleagues can be really tricky.  The dynamics seem a little alien, there is a huge risk of assumption leading to errors and of course there is always the nagging doubt that you may need to go against their wishes in some circumstances.

Dr Penny Wilson @nomadicgp – a regular in the O&G corner of Broome Docs and now the co-creator of the Bit & Bumps podcast has chipped in this week.  She has interviewed Prof. Geoff Riley – former rural GP and Psychiatrist – who was until recently my boss at the Rural Clinical School in Western Australia.  Geoff has developed a practice over the years as a doctor’s doctor.  He has treated many fellow doctors including some with significant impairment.

So sit back and relax, grab a cuppa and listen to this fascinating discussion about how we ought to approach being a GP to another doctor – and also how we can be better patients when we go along to see our own family doctor.

Yes – we should all have a GP.  Do you see one? If not – I would love to hear why – hit me on the comments below.

Onto the podcast DOWNLOAD HERE

Casey

Mental Health Assessment in the ED by Dr Andrew Webster

Assessing the mental health patient in ED

First of all, forget about ‘medical clearance’ of mental health patients – this terminology misses the point of the ED assessment of MH patients – after all, true medical clearance of ANY patient, let alone a MH patient ,is probably impossible. Really what we are aiming to do here is to provide an assessment for this important subset of patients so that they receive timely and appropriate care from the right part of the health care service.

If you only read one article about this topic check this one out – a snappy summary of the important issues in the area with some nice tables of information.

What is the goal of the ED assessment?

Essentially it this:

  1. Gain an overview of the biopsychosocial factors influencing the presentation – precipitating or perpetuating factors that have resulted in the patient’s presentation to hospital today.
  2. Ascertain the appropriate location of care for the patient – general vs. MHU vs. outpatient vs. prison
  3.  Investigate for an organic cause for the patient’s symptoms or behaviors. Particularly important if 1st presentation
  4. Identify medical issues which may require treatment during inpatient admission and determine which patient’s may not be fit for management on psychiatric ward
  5. Attempt to exclude medical emergencies

What should you include in your assessment?

The following are the high yield points of assessment you should consider including each time you assess a MH patient.  For the best rundown on the evidence behind the suggested hierarchy below, read this nice review article.

  1. History

  2. Review of systems

  3. Assessment of orientation

  4. Physical examination

  5. Tests???

The formal mental state examination is of limited use in the ED setting for a variety of reasons, not least because our patient population do not often fit well into the rigid descriptive framework of this testing. Forget about it and just describe what’s going on. [CP:  Although the Psych lingo, the description of psychiatric phenomenology which a formal MSE involves should be included in your assessment.]

History

  • Collateral sources
    • Friends, family, other hospital staff
    • GPs, MMex – sometimes good for medications etc.
    • Old inpatient notes. Discharge summaries. Psolis database entries
    • Community mental health triage team
    • Call RuralLink (1800 552 002) after hours and they can hook you up.
  • HPC, PMHx, Meds, Allergies
    • Think about acuity of onset, fluctuating course, atypical presentation.
    • Could this be delirium/dementia/organic brain syndrome?
  • PΨHx – can be very important. If first presentation psychosis late in life, be suspicious of organic origin.
  • Social supports, carers – I usually start with ‘who’s at home with you?’
  • Brief risk assessment:, use your own –  or a specific form which gives a good overview of important factors to consider when assessing risk.

 

IS THIS PATIENT LIKELY TO NEED ADMISSION? IF SO, WHY???

Review of symptoms

I think in terms of ‘head to toe’ so that I don’t forget a system. It’s a bit like a secondary survey in ATLS but I do it before the physical examination.

  • Neuro – headache, poor coordination, difficulty walking, dropping things, tremors
  • ENT – dental pain, dentures, ear pain or effusion
  • CVS/Resp – hemoptysis, chest pain, SOBOE, symptoms of HF
  • GIT – abdo pain, anorexia, PR bleeding, change in bowel habit and weight loss
  • MSK – back, bone, joint pain and disability
  • Skin – especially at this time of year… pus is everywhere.

Assessment of orientation

  • Aim to ascertain whether patient is disorientated – ? secondary to drug/infection/electrolyte imbalance or psychosis
  • Consider simple opening questions – how did you get here today? What is this building called? What time of year is it (wet vs. dry)?
  • Elderly patient? Consider MMSE or KICA-Cog assessments. If pushed for time, consider doing a clock-drawing test only (good single test for dementia) – see here.
  • [CP:  I would add that a basic assessment of the patients ability to “hold attention” – e.g. recall 3 items, or stay focused during interview is also gold.]

Physical exam

Targeted exam based on findings of systems review but usually including the following:

  • Review the patient’s observations including BSL. Remember – VITALS ARE VITAL!
  • If pregnant urine HCG (risk Ax)
  • Abbreviated CVS, respiratory and abdo exam
  • Targeted neuro exam – gait, gross assessment of function. Looking for focal neurology or abnormal movement patterns

 

DOCUMENT THE EXTEND OF ASSESSMENT AND ANY DEFICITS

TIME TO THINK ABOUT CALLING THE PSYCH TEAM

What do psychiatrists like to know?

Basically, the Psychiatrist wants you to have considered the range of possible causes of this patient’s presentation and to consider what it is they actually NEED and what benefit would be had from admitting them to BMHU.

They want a synopsis of the patient including a formulation of the patient’s and your concerns, rather than regurgitating what the patient has said to you. Consider MH patient’s like other specialty patients – e.g. referral to cardiology for probable NSTEMI because they’re going to need an angiogram.

If you’re going to be ordering tests and you want to facilitate your referral to the mental health unit then it probably makes sense to consider what the Psychiatrists want to know about.

Bloods:

  1. ‘Metabolic screen’ – FBC, UEC, LFTs, TFTs, Ca2+, Fasting lipids, Fasting glucose or HbA1c
  2. Drug levels (valproate, lithium, clozapine)
  3. Prolactin if on antipsychotics
  4. bHCG if woman child bearing age

Imaging

  1. CT head – very low pre-test probability in acute psychiatric assessment (see here). In essence, you probably shouldn’t CT the patient’s head in ED unless there is focal neurology or something atypical.

Other

  1. Urine drug screen
  2. ECGs – should probably do for most patients on antipsychotics [CP: for more on QTc and Psych – see Antipsychotics, ECGs, QTcs and Catastrophes.]
  3. Sometimes EEG (can’t be done in Broome)
  4. Very occasionally  – lumbar puncture

Casey’s 5 cents on investigations in the ED:

The ordering of investigations falls into 2 main categories –

1.  Those that have been indicated by your history and physical exam – e.g. you think the patient might actually have a low sodium due to delusional water intoxication – because they told you!

2. Those tests which the Psych team will order anyway – e.g.. fasting lipids on the middle-aged, fat patient on chronic olanzapine

Here is how I see it – ONLY order tests that fall into one of these categories.  If they are in category 1. then you need to “clear them” before they leave your care in the ED.

If they are from category 2. then they can wait until tomorrow – you can order them, but they will not mean the patient needs to be kept in ED.

And finally.  This is the controversial bit:  INTOXICATION is a clinical diagnosis – you do not need a breath-analyser to tell you that the patient is drunk.

You are a doctor, you see this every day, you can diagnose “drunk” based on history and exam.  In fact, most of the patients I see with a BAL of 0.10 are quite sober – they live in this zone, can make decisions and function there.

A high BAL in the absence of any signs of intoxication is worthless.  You should be more concerned about the patient who appears to be drunk, but blows a low alcohol – there be demons (other drugs and intracranial pathology there!)

Summary

  • Forget about medical clearance – think about assessment to determine appropriate and timely care and avoid medical emergencies
  • Think about where the patient will best be managed – avoid the knee-jerk referral to inpatient MH for all patients with MH issues
  • Think about what the MH ward can offer the patient and what they lack
  • Take a history, including a review of systems. Assess for orientation and consider additional cognitive testing (clocks). Perform a targeted physical examination but particular attention should be paid towards an abbreviated neurological examination.
  • Consider whether the patient is intoxicated, if so, what are they on?
  • Special attention should be given to the patient who is presenting for the first time. This is particularly true at the extremes of age or if displaying any atypical features.
  • Consider doing a psych term to fully understand the perspective of the MHU and the mental health team.

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

OR Direct DOWNLOAD

Casey