If you are new to Broome Docs, then you might have missed my mild obsession with Acute Psychiatric Sedation. (GO back and read the posts from earlier 2011 to get the background and some tricky cases to ponder.)
Last night I had my first opportunity to put Dr Minh Le Cong’s secret weapon (ketamine) into action. I had a large, schizophrenic patient who was very agitated and due to fly in an hour on the RFDS. The patient had good going sleep-apnoea, a thick neck, big belly and a history of aspiration pneumonia during a previous sedation-gone-wrong. This is one of those scenarios where you can make a bad situation worse without trying too hard. So how did I manage this?
- Communication. Get on the phone and make a plan with the flight crew. We decided to try and avoid intubation if possible, this patient had a lot of co-morbidities and would not do well with a day or two on the blower.
- Team huddle. Organise your own team, make it clear what the plan is and what plans B, C etc are.
- Move to the light => we moved the patient into the Resus area, fully monitoring (including ETCO2) and had the airway gear all ready to go
- Sedation. Titrated sedation is the only way to go. Give a dose and watch for a bit – chronic Psych patients have a wide range of tolerance to various drugs – so don’t just use a pre-formatted recipe – you have to give a bit and observe response, then repeat. As previously stated – I do not see why a Psych sedation should be done in a low-acuity area, where we would never do procedural sedation for a surgical problem.
- Change the plan if plan A is not great. This patient got quite deep with 4 mg of midazolam and required a nasalpharygeal airway. So I changed the plan – ketamine. This worked well – RR went up a bit, patient was tranquil and allowed us to site another IVC and an IDC with minimal fuss.
- Bedside vigil. You need to be nearby to monitor this patient – you cannot give drugs and wander off to other areas. I stayed around and actually went with the patient to the airstrip to ensure the plan was working. Maybe once we are all more familiar with these agents in practice we can relax a bit, but for now I plan to keep my eye on them.
At the end of the night all was well. The patient was sedated, but rousable, moving herself on the stretcher. Nobody got punched or spat upon. The RFDS crew seemed happy and her numbers remained perfect throughout.