Psych Sedation and transfer update
The Sedation and transfer of Psych patients is politically tricky. These situations pit agencies against one another like no other problem. There is a lot of arguing about safety, resource allocation and who is the boss when it comes to decision-making. However, we all have the same goals in the end.
Conflict between the treating ground team and the flight team can easily be avoided by using Dr. Minh’s objective measures of arousal, good communication and some inter-agency training – that way we are all speaking the same language and not second guessing one another. I cannot understate the value of knowing your friendly, local RFDS crew and having a good working relationship based on sound clinical judgement and trust in one another’s skills.
Dr Minh Le Cong from the Queensland RFDS out of Cairns is truly a high flyer when it comes to this topic. He is doing all sorts of great research on the topic of the safe transport of Psych / agitated patients and has been kind enough to send me a video of a lecture he gave on the topic at the recent World Congress of Aeromedical Retrieval. I am flabergastered that Dr Minh has the foresight to be doing prospective trials into this stuff, when most of us are lingering in the dark ages, doing the best we can in often bad situations. He has really taken the bull by the horns and come up with some great material and useful data.
So here is what you should do:
- For a case to consider – check out: Case 011 – Psych in extremis
- Go back to my post on the topic “Propofol: 1st line in Psychosis” and refresh my approach and my Sedation Matrix
- Download the video of Minh’s lecture for yourself. You can read the references here (In the small world of medical bloggers, the video you see here was actually shot by none other than Dr Cliff Reid – author of the Resus.Me blog for ED / prehospital practitioners out of Sydney. If you have not seen this – then follow the link and be prepared to have your brain filled with up to the minute evidence for what we all do!) Big thanks to Cliff for making this possible.
- Read my response to Minh’s lecture below.
I’m sure it is a good short-term solution, good for preflight / short flights. However – in the hospital we often are looking at 24 – 48 hours of sedation before the RFDS arrive. So we need an alternative or an infusion? Flights in WA are routinely 6+ hours, my fear is that the ketamine will wear off about the 3 hour mark – ie. mid-flight, so you would need to use repeated doses?
It might be good for the acute situation where you want to “get control” of a physically aggressive / dangerous patient and don’t want to endanger the airway – however I would advise caution – I would still be doing this in the best area of the hospital in case you do need to establish an airway with some type of plastic. ie. don’t let ketamine’s reputation of being “airway friendly” fool you into doing something in a place where you cannot go to plan B.
In terms of my Sedation Matrix – it might be good for the patients in the middle boxes – where you can try a sedative agent and see if they become a ‘lesser colour’ or need to be escalated.
The role of intubation is to avoid this window of heavy sedation without a definitive airway, and hence avoid the morbidity. I think this is the minority of Psych transfers – ie. those whom we know are dangerous from prior episodes OR those who have failed a decent trail of “safe sedation”. Minh’s service have a very commonsense protocol – follow the link.
Clinical Case 056: Momma got a rolling stone
Clinical Case 112: Pulled Elbow Tricks
First 10EM Journal Club: January 2018
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
thanks for posting this Casey. You are to be congratulated on raising the profile of this issue for rural and remote practitioners. I often get asked how long can you do ketamine sedation in the aeromedical retrieval setting with an agitated patient. Whilst we have not done it for 36-48hrs as you mention in your situation whilst awaiting RFDS , the longest I have recorded in RFDS QLD is 4 hrs and that was with an infusion as per our protocols you cited. Whats the highest dose we have given? the record to date is 200mg/hr infusion for a 3 hr retrieval. I heard the retrieval doctor calling it in as they were landing so went and examined the patient for myself on the tarmac when they unloaded. Believe it or not he was still alert, smiling and responding to voice. I try to audit all ketamine retrieval sedation cases and one was done last week between Mt isa and Townsville which is a 2.5hr flight. The retrieval doc gave a total of 280mg ketamine in divided boluses as well as 5 mg total IV midazolam. This is not an uncommon thing for us over here in RFDS QLD ops. The preflight sedation the patient had had in ED was total 20mg olanzapine, 5 mg haloperidol and 20 diazepam. probably the deciding factor in us being able to apply good retrieval sedation is the fact we try to take police security on board so it gives us some confidence to run the sedation a bit lighter. The patients are restrained with 4 point system as well. We monitor ETCO2 via maskas well as standard monitoring and we place IDC in for long trips like this.
Why not just tube them I often get asked? Sure we do that from time to time but the ketamine sedataion has dramatically reduced that rate. In fact I get calls from psychiatrists asking for their patients not to be tubed and requesting we trial ketamine sedation now!
Did anyone know that ketamine has been studied for its rapid antidepressant effects?