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December 2017

Author: Chris Connolly / Codes: Podcast / Published: 01/12/2017

Who should get HIV testing in the ED?

Authors: Nikki Abela and Colm O’Mahoney

Codes: CAP28, C3AP7

Colm O’Mahon is an Infectious disease and Sexual Health consultant working in Chester.

This interview was recorded at the RCEM Annual Scientific Conference in Liverpool in October 2017

References:

BASHH Guidance on PEPSE

Right its Xmas time (ish) and EDs are getting more and more full. Party season is here. Maybe your Tuesday night is becoming more like your Saturday night. Therefore you may see some more patients with acutely disturbed behaviour, be that drug induced or otherwise. We thought therefore we’d have a look at the RCEM guidance on behavioural disturbance in the ED, published in May 2016.

The recent NICE guideline deals in violence and aggression, and prevention. The RCEM guideline was developed largely as NICE neglected excited delirium, a condition at the extreme end of the agitation spectrum which carries significant risk, to staff, other patients and most importantly to the patient themselves of death.

Excited delirium and Acute behavioural disturbance are interchangeable terms that lack a fixed definition, but are typified by sudden aggressive and violent behaviour associated with autonomic dysfunction. Think of the patient being brought in by the police agitated or when youre called to the waiting room because ‘someone’s kicking off’.

So here’s some gold we discovered when reading the guidelines:

  • Death is more likely in the summer months when its warm and humid
  • It happens in men more, often with stimulant ingestion such as cocaine
  • Theories behind cause of death have been mooted as asphyxia related to restraint, toxicity causing arrhythmia and unmasking undiagnosed cardiac disease.
  • When we have these patients it’s an emergency and as such we should be on point and on our A game. Don’t send the junior doc in as ‘its character building’. Get in there. Fix this.

But how do we fix this?

The aim of the game is to rapidly gain control, usually with tranquilisation and ending the hyper-exertional state.

Now all of us that have undertaken some training on aggressive behaviour in healthcare will have learnt a bit about de-escalation techniques, and these can be tried here, but the likelihood is that they wont work in this cohort due to the altered mental status. Remember this is a delirium.

Physical restraint may be needed to keep your patient and staff safe. When you move depts. Find out who and where your security guys live, as you will need their help.

Any physical restrain should be justifiable and proportionate and as short lived as possible. Face down with pressure on the neck and shoulders is probably the worst position. It may promote asphyxia and furthermore cause deterioration of acidosis

What about sedation?

3 types of drugs are recommended by the Guideline – Benzodiazepines, antipsychotic and Ketamine.

Benzodiazepines currently Lorazepam is recommended by NICE. Risk of very variable effect either ineffective or too drowsy/apnoeic. We have used Lorazepam most frequently but have been often found reaching for more. Reuben Strayers talk from SMACC Dublin mentions that midazolam IM best benzodiazepine to use in his opinion. Caution the window between respiratory depression and sedation is very narrow with benzodiazepines!

Ketamine Strayer raves about it in this scenario. Becky uses this if she has IV access as she feels it is easier to control response better than benzodiazepines. Interestingly it is worth remembering that an increase in dose tends to extend sedation length rather than diminish respiratory drive. Remember that you may get more tachycardia hypertension and increased myocardial oxygen demand.

Antipsychotics Haloperidol is still recommended as second line by NICE. But only if theyve had an antipsychotic before or had an ECG before. Really unlikely to know this in advance in these patients so we tend to avoid unless certain.

Whatever you use, you must be familiar with it and ready to deal with any adverse effect.

Once you have gained a degree of control you need to rapidly move through and get a full assessment done:

  • ABCs
  • Check a temperature
  • BM if not already done
  • ECG
  • Bloods including a CK and coagulation screen and a gas which will probably look horrific immediately afterwards. Almost like a posts seizure gas.
  • Give fluid correct the loss, correct the acidosis, dont give bicarbonate routinely
  • Hyperthermia should be corrected with cooling techniques like stripping, cold fluid and ice packs etc.

Bad stuff could include rhabdomylosis, DIC and hyperkalaemia – look for and treat each.

Head CT in the post-arrest patient.

Who gets a scan post-ROSC in your ED?

Authors: Andy Neil and Dave McCreary

Codes: HMP2

Title: Use of early head CT following out-of-hospital cardiopulmonary arrest [link]

Author: Reynolds, December 2016, Resuscitation

Background:

  • Massive ICH can cause sudden cardiac arrest. It is unclear how often this happens but if it was common then it would like impact on practice and lead most likely towards early palliation and/or potential organ donation

Methods

  • Chart review. Once again limited methods in how they obtained and defined data from the charts.
  • Unclear how they were identified. I suspect it was all their cardiac arrests with ROSC from some kind of audit or registry but they don’t tell us
  • There was no routine head CT protocol here so it doesn’t tell us why any head CTs were or were not ordered
  • They define “early head CT” as within 48 hours but that is definitely not early head CT for me.

Results

  • 213 ROSC patients surviving greater than 24 hours
  • Half got CT within 24 hrs, most of these within the first 6 hours but we dont know why these were done
  • Around 10% of the CTs showed bleeding. More commonly they found various signs of oedema and ischaemia.
  • They try to tease out how the CT changed management but I think this is a real stretch to draw anything substantial from

Bottom Line

  • This data set is very limited (like all the others looking at this) and doesn’t tell us if or when we should be doing head CTs on post ROSC patients.

Some additional non scientific thoughts

  • If we’re moving towards more intensive post arrest care with PCI for all and the remote possibility of extracorporeal life support for cardiac arrest victims then I think early advanced imaging is totally appropriate. We can image sick and unstable trauma patients so why not head and possible CTPA for all post ROSC patients. The cost of imaging is peanuts compared to the ICU stay weve committed ourselves too and finding ICH or PE would definitely alter management. Its hard to over investigate the critically ill.
  • The downside of course is the impact on your radiology resources.

Links

  • Found this via the legendary Emergency Medical Abstracts who commented that this isn’t the first paper to look at this issue but they’re all of similar quality

What antiemetics are safe to give in Early Pregnancy?

Author: Charlotte Davies

Codes: HAP27

We all know that nausea and vomiting in pregnancy is common affecting 5075% of pregnant women any time from the 4th week of pregnancy, most common in the 9th and 12 week, and we probably misdiagnose some of these people with hyperemesis gravidarum which affects less than 1%. To me, I’m not sure that the precise difference matters, as I think I’d struggle to send home a ketotic pregnant lady with at least some of the hyperemesis protocol…

Hyperemesis Gravidarum is persistent, intractable nausea and vomiting beginning in the first trimester

Associated with a weight loss of >5% of pre-pregnancy weight

Causes

Likely multifactorial – typically higher levels of human chorionic gonadotrophin

  1. pylori may have a part to play

Make sure you exclude other causes – molar pregnancy is the most serious. These patients are unlikely to improve enough to be able to go home.

Treatment

Antiemetics:

Ginger – evidence base says ginger tablets improve symptoms in four days

Other:

Small meals (6 times a day). Eat as soon as you feel hungry. Avoid likely triggers – like fatty food.

Fluids- cold, clear, and carbonated like ginger ales and lemonades as well as smoothies or slushies.

Thiamine – thiamine requirements increase in pregnancy, so give if “prolonged” vomiting. Some say if no meal in a weak, others say vomiting for more than three weeks.

Oral thiamine 100mg / day, or IV thiamine (pabrinex is OK, but does have other B vitamins). Toxbase suggests overdose of thiamine is low risk.

Antiacids- treat non ulcer dyspepsia if there are signs of it. PPIs are thought to be safe. There is some evidence that H. pylori increases vomiting, so if the patient has prolonged vomiting, consider

Corticosteroids – can be used as a third line. I’d like O&G do that bit.

Patient Advice

No proven effects on the fetus, except fetal growth restriction, pre-term delivery. The pregnancy may be complicated by triploidy, trisomy 21 and hydrops fetalis. It may be due to a molar pregnancy.

Mum can get problems from electrolyte derangement – wernickes, central pontine myelinolysis due to hyponatraemia, ATN, splenic avulsion and increased VTE risk. Peripheral neuropathies are rare. One case report of epistaxis due to vitamin K deficiency!

References

BMJ Best practice

RCOG Greentop Guide

Aortic dissection without Chest pain.

Can you spot the Aortic Dissection without chest pain?

Authors: Andy Neil and Dave McCreary

Codes: HMP4, HAP2, HAP5, HAP8

Paper number 2

Title: Clinical profile of patients of acute aortic dissection presenting to the ED without chest pain [link]

Author: Fan, December, 2016, American Journal of Emergency Medicine

Background:

  • Aortic dissection is by all means a tricky diagnosis
  • People have described it as standard of care to miss the diagnosis especially on first presentation
  • The IRAD study (which is very old now) was an observational data set that informed a lot about we think aortic dissection presents. However it didnt really highlight that this can be a painless phenomenon

Methods

  • This is a chart review with no clear systematic method to how they got the info out of the charts. This is a common problem in chart review studies and makes it hard to draw very definite conclusions.
  • They found these patients based on discharge diagnosis over the period 2004-2015 in Hong Kong. Meaning that you had to actually get diagnosed to get into the study so maybe these are less occult than we might think

Results

  • 141 patients
  • 43% with no chest pain on ED presentation – though let’s be clear that means that they had no clear documentation on the ED notes However these patients were more likely to have abdo or back pain
  • Compared with those with documented chest pain – those without chest pain were more likely to have signs of shock (20% v 6%)
  • Both groups were about equal in terms of type A v type B
  • Only about 40% had diagnosis made in the ED (though its not clear what this means)

Bottom Line

  • In this poor quality retrospective study aortic dissection without chest pain was common though most patients seemed to have pain in either back or abdomen
  • There’s a lovely citation from a prior study stating that for the average EM doc seeing 3-4000 patients a year you will only diagnose an aortic dissection every 3-4 years.

Links

Paediatric Early Warning Scores

Do you know your POPS from your PEWS?

Authors: Nikki Abela and Damian Roland

Codes: PAP5

Damian Roland is a Consultant in Paediatric Emergency Medicine in Leicester

This was recorded at the Don’t Forget the Bubbles conference in 2017

Refs

POPS score

Intra-nasal ketamine for ureteric colic.

Is IN ketamine for ureteric colic the newest use for the worlds favourite drug?

Authors: Andy Neil and Dave McCreary

Codes: HAP1, HAP2

Paper number 3

Title: Comparison of intranasal ketamine versus IV morphine in reducing pain in patients with renal colic

Author: Farnia, November 2016, American Journal of Emergency Medicine

Background:

  • Ureteric colic is painful
  • Morphine and NSAIDs are the commonest analgesics used here but we know that ketamine has some kind of an analgesic role in the ED. What about for ureteric colic?
  • I have certainly used small doses of ketamine IV for the poor folks who are still rolling around around 20-30mg of morphine. Anecdotally it seems to be useful. These guys look at the intranasal route for it

Methods

  • Double blind RCT
  • Ureteric colic confirmed by ultrasound
  • No details on allocation concealment or the randomisation process
  • Powered to look at the commonly used 13mm change in the VAS but unclear what time point they were powering it for
  • Ketamine 1mg/kg IN v 0.1mg/kg IV Morphine with fentanyl as rescue if no decrease in VAS. A lowish dose of morphine and I don’t know about the ketamine dose. They don’t mention NSAID use

Results

  • 40 patients
  • More severe pain (about 85 v 75) in the ketamine group at baseline
  • Morphine was better though pain got better in both groups.
  • They try to adjust for the baseline imbalance in pain but I never trust this as the whole point of randomisation is to avoid this…

Bottom Line

  • Do not use IN ketamine instead of IV morphine in ureteric colic. It may be useful as an adjunct but this study didnt look at that

Right its Xmas time (ish) and EDs are getting more and more full. Party season is here. Maybe your Tuesday night is becoming more like your Saturday night. Therefore you may see some more patients with acutely disturbed behaviour, be that drug induced or otherwise. We thought therefore we’d have a look at the RCEM guidance on behavioural disturbance in the ED, published in May 2016.

The recent NICE guideline deals in violence and aggression, and prevention. The RCEM guideline was developed largely as NICE neglected excited delirium, a condition at the extreme end of the agitation spectrum which carries significant risk, to staff, other patients and most importantly to the patient themselves of death.

Excited delirium and Acute behavioural disturbance are interchangeable terms that lack a fixed definition, but are typified by sudden aggressive and violent behaviour associated with autonomic dysfunction. Think of the patient being brought in by the police agitated or when youre called to the waiting room because ‘someone’s kicking off’.

So here’s some gold we discovered when reading the guidelines:

  • Death is more likely in the summer months when its warm and humid
  • It happens in men more, often with stimulant ingestion such as cocaine
  • Theories behind cause of death have been mooted as asphyxia related to restraint, toxicity causing arrhythmia and unmasking undiagnosed cardiac disease.
  • When we have these patients it’s an emergency and as such we should be on point and on our A game. Don’t send the junior doc in as ‘its character building’. Get in there. Fix this.

But how do we fix this?

The aim of the game is to rapidly gain control, usually with tranquilisation and ending the hyper-exertional state.

Now all of us that have undertaken some training on aggressive behaviour in healthcare will have learnt a bit about de-escalation techniques, and these can be tried here, but the likelihood is that they wont work in this cohort due to the altered mental status. Remember this is a delirium.

Physical restraint may be needed to keep your patient and staff safe. When you move depts. Find out who and where your security guys live, as you will need their help.

Any physical restrain should be justifiable and proportionate and as short lived as possible. Face down with pressure on the neck and shoulders is probably the worst position. It may promote asphyxia and furthermore cause deterioration of acidosis

What about sedation?

3 types of drugs are recommended by the Guideline – Benzodiazepines, antipsychotic and Ketamine.

Benzodiazepines currently Lorazepam is recommended by NICE. Risk of very variable effect either ineffective or too drowsy/apnoeic. We have used Lorazepam most frequently but have been often found reaching for more. Reuben Strayers talk from SMACC Dublin mentions that midazolam IM best benzodiazepine to use in his opinion. Caution the window between respiratory depression and sedation is very narrow with benzodiazepines!

Ketamine Strayer raves about it in this scenario. Becky uses this if she has IV access as she feels it is easier to control response better than benzodiazepines. Interestingly it is worth remembering that an increase in dose tends to extend sedation length rather than diminish respiratory drive. Remember that you may get more tachycardia hypertension and increased myocardial oxygen demand.

Antipsychotics Haloperidol is still recommended as second line by NICE. But only if theyve had an antipsychotic before or had an ECG before. Really unlikely to know this in advance in these patients so we tend to avoid unless certain.

Whatever you use, you must be familiar with it and ready to deal with any adverse effect.

Once you have gained a degree of control you need to rapidly move through and get a full assessment done:

  • ABCs
  • Check a temperature
  • BM if not already done
  • ECG
  • Bloods including a CK and coagulation screen and a gas which will probably look horrific immediately afterwards. Almost like a posts seizure gas.
  • Give fluid correct the loss, correct the acidosis, dont give bicarbonate routinely
  • Hyperthermia should be corrected with cooling techniques like stripping, cold fluid and ice packs etc.

Bad stuff could include rhabdomylosis, DIC and hyperkalaemia – look for and treat each.

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