ED management of the Acutely Agitated patient

We all know what it is like to have an acutely agitated patient present to your ED. It is challenging, intimidating, dangerous and disruptive for your staff and and your other patients.

It can be difficult to take a step back from the evolving situation and assess . You may be consumed by the desire to regain control of the situation. It may be difficult to think about (let alone treat) whatever pathology is underlying.

What is ABD?

ABD = acute behavioural disturbance. There are several similar definitions and terminology used can be confusing (excited delirium, acute agitation or drug intoxicated or drug affected behaviour). My favourite is from the Royal College of Emergency Medicine in UK

  • Sudden onset of aggressive and violent behaviour and autonomic dysfunction
  • Often occurs in the setting of acute drug ingestion or serious mental illness

ABD is a presents as a spectrum of features that includes acute delirium, agitation as well as as adrenergic dysfunction

It is associated with sudden death in 10% cases and there have been several high profile deaths in recent years in several countries

It is important to recognise and to treat it quickly

How many patients are affected in Victoria?

If we look at 2013/ 14 Victorian ambulance data and assume that crystal methamphetamine-related presentations are resposible for most of our ABD patients then we have

  • 3.4 ambulance attendances per day (0 to 10 patients) in metropolitan Melbourne
  • 0.8 ambulance attendances per day (0 to 6 patients) in regional Victoria
  • Most patients present between midday and 6pm in metropolitan Melbourne, between the hours of 6pm and midnight in regional Victoria
  • The peak day was Sunday in metropolitan Melbourne, the peak day was Saturday in regional Victoria

What are the typical symptoms?

A person can display mildly erratic behaviour ranging to extreme agitation and physical exertion

Things to look out for

  • extreme aggression, violent behaviour
  • excessive strength/ continued struggling with police restraint
  • reduced reaction to pain
  • acute psychotic state
  • hyperthermia, tachypnoea, tachycardia

ABD patients may have symptoms that are similar to other conditions. Other things to think about are

  • hypoxia
  • substance intoxication or withdrawal
  • hypoglycaemia
  • head trauma
  • CNS infection, haemorrhage
  • seizure, stroke or post ictal state

Describe general management principles for this patient group?

The general approach to these patients is very important

Remember you are dealing with one of 3 different types of patients

  • cooperative
  • disruptive not dangerous
  • excited delirium

Listen to Reuben Strayer give a fascinating talk about this at #SMACCDUB in June 2016

General principles that I try to implement

  • Evaluate your patient in safe area – evacuate other patients if this is in the ambulance entrance area
  • Make sure your staff is safe, are there any concealed weapons, can you move the patient to a secluded area, involve your security staff early. Call a Code Grey!

De-escalation techniques are important

  • talk to your patient in a calm and confident voice
  • do not confront your patient
  • do not maintain prolonged eye contact
  • never stand over them
  • offer them food or a cigarette if this is appropriate
  • try reduce the amount of ‘testosterone’ in the room if it is safe to do so

Different patients will respond differently and there is no one approach that fits

Some patients are unsuitable for de-escalation and physical restraint may be required. This is defined as the ‘intentional restriction of a person’s voluntary movement or behaviour by the use of a device, removal of mobility aids or physical force’

In most cases, in ED we will use category 1 restraint (emergency single episode restraint) and documentation must include – reason for restraint, condition prior to restraint (see SAT score), form of restraint applied, details of event, length of time restraint was applied for and condition post restraint. Restraint devices should be removed as soon as the patient is adequately sedated

SAT tool for sedation assessment

The Sedation Assessment Tool is a 7 point scoring system, based on level of arousal and speech patterns

  • It was described in Emergency Medicine Australasia in 2011
  • It ranges from plus 3 which is highly agitated to minus 3 which is heavily sedated
  • Endpoint for sedation is -1 (patient is drowsy but rousable)

 

SEDATION ASSESSMENT TOOL (SAT)
Score Responsiveness Speech Scale
+3 Combative, violent, out of control Continual loud outbursts +1 to +3

Agitation

+2 Very anxious and agitated Loud outbursts
+1 Anxious/restless Normal/talkative
0 Awake, calm Speaks normally 0 = normal
-1 Asleep but rouses if name called Slurring or slowing -1 to -3

Sedation

-2 Responds to physical stimulation Few recognizable words
-3 No response to stimulation Nil

 

What drugs can you use?

Chemical sedation or rapid tranquilisation may also be required for an ABD patient.

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Australia is fortunate to have access to droperidol, this is thought to be the first line agent to treat most cases of  ABD. However it is not available in Ireland, UK or in the USA

The main drug categories I use are benzodiazepines, antipsychotics and sometimes ketamine

Benzodiazepeines are familiar to most emergency doctors, they are safe you can give them via the oral and parenteral route. The main side effect to watch out for is respiratory depression. Lorazepam is not readily available in Bendigo Health and this acts as a useful bridge between (short acting) diazepam and other longer acting agents

Antipsychotic medications include droperidol or olanzepine. They are dopamine receptor antagonists and this is why they may work well in ABD – theory is that is caused by dopamine excess. Be careful with acute dystonic reactions

My treatment approach is based on the patient’s SAT score

  • SAT +1 – patient is cooperative 

Offer them something orally – use diazepam or olanzapine – any sedative will suffice

  •  SAT +2 – patient is agitated, vocal loud and probably hard to reason with

Now they are disruptive (but not yet dangerous) this is a difficult group to treat and requires tactical negotiation and experience

If possible try something oral but you may need IM meds early

Start with droperidol 5 – 10 mg IM and wait 15 minutes to see how this works

Repeat this dose if needed and now add in midazolam 5mg IM as a 2nd line agent

  • SAT+3 – your patient is aggressive and dangerous this is a full blown excited delirium!

Draw up 2 syringes – 10mg IM droperidol and 10mg IM midazolam

Use an IM injection and get your patient to resus to monitor them

What about ketamine – can I use it?

Things to consider

  • In recent years, there has been a splurge in the number of articles written by authors espousing the use of ketamine for the “Chemical takedown”
  • We use IM ketamine sucessfully for paediatric sedation – it is reasonable to consider it’s use in this situation
  • Many of the studies that describe droperidol use are done in Australia – maybe this is why ketamine has not been adopted (yet)
  • Ketamine has been incorporated into Victoria prehospital guidelines as a first line agent in excited delirium – see CPG A0709
  • A suggested single dose agent  is ketamine 5 mg/kg IMI, see Reuben Strayer again
  • My feeling is that ketamine will be introduced on a gradual basis once practitioners become more used to using it

Post sedation care for ABD patients

  • Be careful with a patient that may have taken a combination of drugs – benzos could cause respiratory depression or hypotension in this group
  • If you get IV access once the patient is settled then you could use this for further doses – no need to make this a priority at the start
  • Monitor them as if the have had procedural sedation – this means regular pulse ox, ECG and BP monitoring as well as SAT score
  • If a patient develops a dystonic reaction as a result of antipsychotic use then reach for benztropine 1-2mg IV
  • When the patient is sedated, the care is mainly supportive – check electrolytes, rehydration will often be useful, do a full examination and get imaging if this is indicated

What does the literature say about drugs for ABD?

The science here is pretty scarce

There have been a few papers published in recent years – led by Australian authors

  • The 1st DORM study was published in the Annals of Emergency Medicine in 2010 by Isbister et al. It used 3 arms to compare droperidol, midazolam and the droperidol/ midaz combo for 91 agitated ED patients.It showed that there was no difference in time to sedation when using droperidol, midaz or the combination. There was less top up sedation needed when the combination was used and the incidence of prolonged QT interval was the same in all groups
  • DORM 2 was published in the Annals of Emergency Medicine in August 2015 by Calver et al. It had over 1000 patients in a prospective observational study across 6 Australian EDs. Their main finding was that droperidol was safe to use for sedation – 13 of 1009 patients had abnormal QT intervals and 7 of these were using another medication that could explain this. DORM 2 had it’s limitations but seems to support safety of droperidol
  • The SOOTH study was been published in 2016. This was a RCT in 2 Melbourne metropolitan EDs and included at 349 acutely agitated patients requiring intravenous sedation. The authors found that midazolam and droperidol used IV for sedation is better than monotherapy using either droperidol or olanzapine alone

What about children?

If you are faced with an agitated child the general management principles remain the same as in adults

  • deescalate the situation
  • offer oral sedation first, parenteral sedation if needed

The Royal Children’s Hospital Melbourne guidelines suggest a treatment algorithm

What does #FOAMed say?

There are many fantastic resources listed on this topic – here are my favourite

Listen to some of the experts talk about how you could manage the agitated patient

Also listen to the podcast that I recorded this month for RCEM FOAMed network with Andy Neill

Take home points to consider

  • There are many drug regimens that are available and safe
  • If you are a trainee, there is no need to be too gung-ho to use new drugs that are outside your EDs normal practice, talk to your bosses and choose wisely!
  • If you are a consultant developing a new policy then talk to your colleagues and see what others are using and what you could use in your setting
  • A combination of droperidol and midazolam seem to be the standard in Australia at the moment

Social Media workshop

In preparation for our Social Media ‘How to Get Started’ workshop, follow these links

The concept is called ‘flipping the classroom’ – encouraging you to pre-learn before we come together and discuss

The videos are taken from Rob Rogers @EM_Educator (of University of Kentucky EM, iTeachEM and The Teaching Course)

I had the good fortune of attending #TTCAus16 in July & can recommend it to anyone interested in this fascinating side of medical education! It’s on in Melbourne September 2017

@cianmcdermott

 

 

 

 

 

 

 

#FOAMed – is it all just froth!!

@cianmcdermott

In recent years, I have become very interested in #FOAMed. Too interested sometimes!

I am still amazed by the amount of people that do not use FOAMed to stay up to date. For this reason, I hope that this post will help you with the nuts and bolts of Twitter/ FOAMed. Please read on…

What is #FOAMed? Why should I use it?

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I hear so many reasons why we as doctors should not bother to use SoMe:

  • I don’t have the time
  • Its all a lot of nonsense – who cares anyway
  • My kids use it – I’m too old for it!

But Twitter can be a really useful resource to engage with.

What is it all about?

FOAMed stands for Free Open Access Medical Education. Simply put it is a collection of blogs and podcasts that is available online for anyone, anywhere to access. It is It is a decentralised, free, cloud-sourced, movement that has exploded since its introduction in 2012.

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Tell me about Twitter?

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Twitter is an online microblogging site. It is the main platform that is used to link all our online conversations together and allows a community of critical care physicians to connect together and post links, share ideas etc.

The FOAMed hashtag (#FOAMed) is a method of grouping together all social media conversations on twitter.

So FOAM is the concept, FOAMed is the conversation while #FOAMed is the hashtag that you use to search on Twitter.

What are the benefits?

FOAMed facilitates asynchronous learning via a flipped classroom environment. #FOAMed is a medium rather than an entirely novel system and it should integrate with traditional teaching methods.

At weekly registrar teaching, say we are going to learn about ED Procedural Sedation. You are away on leave but keen to join the conversation. You can pre read teaching material beforehand and then review the presentations afterwards. Now translate this idea to a world wide audience. The possibilities are limitless!

What are the drawbacks?

Without doubt, there is a lot of material out there! How do I know what to trust? Yes at times, it is intimidating to see all the commentaries on Twitter. I mean everyone just cannot be right? But everyone has a voice. It’s known as ‘drinking from the firehose’.

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In my experience, the cream always rises to the top. Twitter encourages an online peer-review process as soon as something goes live. So the really good material will be reposted, referenced, retweeted until it finds it’s way to you. However, you still need to examine the evidence, think about it, read the original paper and then listen to other people’s opinions as part of a community. This is after you read all the conventional wisdom from textbooks.

OK, I’m interested. How do I start?

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Start with a Twitter account. Choose a username and write  a 3 line bio about yourself and maybe even upload a picture. Another few tips:

  • Dip your toes in – see how you like it
  • Follow topics that you like
  • Follow people who share your interests

But I want to go to #smaccDUB!

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The 2000 delegate tickets have been sold out for months. #smaccDUB will be one of the most eagerly-anticipated medical conferences yet. It takes place in Dublin, Ireland from June 13th to 16th and it will be truly AWESOME and AMAZING!

Don’t worry though, by the power of Twitter and FOAMed you can follow all of the action. Check out smacc.net.au and stay in touch with the ground-breaking talks from where ever you live. You can even catch up with the social night but it’s just not the same as being there! Never mind there’s always next year….

So follow my updates from #smaccDUB, I will be active on Twitter @cianmcdermott. Diana Badcock is speaking on the opening morning, follow her @djbdjm. Remember #smaccDUB is the hashtag!

A final thought…

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Join the community

@cianmcdermott

Aliem’s “Dirty Epi Drip”- I’m a convert

FOAM readers will have come across Michelle Lin and her Academic Life in Emergency Medicine blog and Tricks of the Trade spot on EMRAP. Recently she has been spruiking the “Dirty Epi” drip in anaphylaxis.

The idea is, when the patient fails to respond to two IM doses of adrenaline and you are looking at switching to IV everything is usually happening pretty fast. You really want that adrenaline up now, not in 5-7 minutes time, which is what it can take for a 6mg in 100mL to be made up and countersigned and a pump found and so on. So, while the nurses are scrambling for that, put 1mg of Adrenaline of any concentration into the bag of Normal Saline that has likely just been hung and just let it run in, titrating to effect. It will give 1mcg/mL and will run at about 20-30mL/min so you’ll be giving 20-30mcg/min which is a pretty good starting dose for IV adrenaline in refractory anaphylactic shock. Of course, you might have to titrate to effect by tightening up the little roller clamp or squeezing the bag but you titrate an adrenaline infusion to effect anyway.

The trouble is, how often do we see refractory anaphylaxis? So I read about it and thought, well, that’s great but I’m not going to use it.

Then comes the middle aged, not terribly well preserved man with hyponatraemia of uncertain cause, left lower lobe pneumonia, septic shock and respiratory failure who needs a tube. BP falling just as the need to get on and intubate becomes apparent. No pressors up yet. Arterial line quickly inserted shows BP 60/20. Bother, that’s a bit lower than the NIBP was showing. This looks like a perfect opportunity for one of Scott Weingart’s Haemodynamic Kills. No time for a formal pressor infusion to be drawn up. I pull out a milligram of adrenaline to make up some dilute “push dose pressor” and a little voice in my head says “try the dirty epi drip”. There’s a full bag of fluid just been hung, running into a good ACF vein via an 18g cannula. Perfect.

With the arterial line in it was a piece of cake to titrate the flow of adrenaline-saline with the roller valve while keeping an eye on the registrar’s intubation and the resident’s (frugal) dosing of induction agents. To get the BP up initially required a couple of squeezes of the hand pump on the resus giving set but the BP quickly came up to where I wanted it (120/70 ish) and never dropped below 90/60 for the duration of the intubation process.

I actually think it is safer than fiddling around calculating concentrations and doses for “push dose” adrenaline, a process that carries a high risk of giving too much by a factor of 10. The main caveat would be that you need to be prepared to run in a litre of fluid. If your patient is shocked and being intubated a litre is probably neither here nor there but there may be cases where you really couldn’t afford the volume.

For now though, I’m a convert. Thanks Michelle!

PS: I should add, this is a hands-on activity. You can’t make one of these up, set it running and go do something else. Consider it a big syringe full of dilute drug. Once the dust settles, take it down and replace it with something you can run hands free though a pump.

Cardiogenic shock and thromobolysis (with some more challenges thrown in)

It is mid afternoon in your busy regional ED when the triage nurse calls for help. A 57 year old woman who drove herself to hospital managed to tell her that she has been having awful pain in her chest when she collapsed, collecting her forehead on the windowsill on the way down. You poke your head through the triage window to see her looking up at you from the floor, clearly not well.

By the time you unstick your head from the triage window the patient has been moved onto a gurney. She is awake but with a clouded conscious state (confused mumbling, eyes open but not fixing and focusing, localising to pain) and his vitals are HR 40, BP 60/-, RR 26 with end of the bed wheeze, SpO2 not readable, afebrile. She is bathed in sweat and pale.

This is her 12 lead ECG

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What to do? Read on and see what you think.

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What I learnt during the Victorian heatwave last week

Working in central Victoria last week, a week in which we experienced 4 days of top temperatures over 42 degrees Celcius cooling to the mid-upper twenties by 6 am gave me a wonderful opportunity to experience the spectrum of heat related illness in Emergency Medicine (it also gave me a wonderful opportunity to experience much more effective air-com than I have at home). Here are some things that I learned.

Heat Stroke is not what I thought it was.

From the books I knew that heat stroke represented a medical emergency with loss of sweating, altered mental status and imminent death from multi-organ failure if cooling was not rapidly instituted. What I didn’t know was just how promptly it can respond to good cooling efforts.

Without going into patient details, we saw several cases of heat stroke in a single, very busy, evening shift. You know you are having one of those shifts when the nurse in charge says to you “We’ve got another hot one Putty” and you just go “ok”  and shrug and head for resus. All were vulnerable people in various ways, with less luxurious accommodation, less robust physiology and possibly less decision-making resources than some other members of the community. All were found unconscious with temperatures between 41.5 and 42.7; one intubated at the scene, one GCS 6 following some nifty work with the garden hose, and the others GCS 3 on arrival. They had dry skin, tachycardia and tachypnoea. None had an abnormal BSL. All were on an antidepressant of some sort.

As each one arrived we infused 3 litres of fridge temperature Saline, put ice packs around the scalp and axillae, covered them with a wet sheet and set up our only fan to blow over them. All were rapidly cooled to below 39 degrees at which point they all started to shiver. We treated shivering with a little IV midazolam and continued cooling to normothermia during which time they all woke up properly (although a little befuddled seeming). We did not secure any airways, (except the one intubated at the scene), instead opting to stand close, ready to take the airway if required. As it happened, each one woke so rapidly as their temperature came down that there was no need to intubate anyone. Had we secured every airway early, as the exam answer would tell us to do, I do not know how we would have managed.

All of them had mild elevations of Creatinine, CK, INR, liver transaminases, Platelet count and White Cell Count but none of them progressed to multi organ failure.

It might be a small n but I now having watched this disease several times in a shift I have a much more nuanced understanding of it, particularly just how rapidly a person can be cooled with relatively simple measures and how rapidly their neurological function will respond to that cooling.

Less acute heat illness

Apart from the excitement of florid heat stroke, a heat wave also brings on a plethora of less severe illness. We had several cases that were on the way to being heat stroke (elevated core temp and confusion identified early by family members and brought to hospital in time for them to cool themselves in the air-conditioned environment. We had some heroic people working outside in environments where the ambient temp was up to 52 degrees, presenting in severe acute renal failure. One person needed urgent haemofiltration. What’s more, in a week like this you can expect countless presentations with syncope, headache, dizziness, lethargy, exacerbation of chronic renal or cardiac failure.

I’m Sorry… we did everything we could. Breaking bad news in the ED

Breaking bad news is probably the most miserable aspect of our job in Emergency Medicine. I’d rather go to an infection control committee meeting than tell someone I’ve never met before that their loved one has just died. However, just like working to cut down on nosocomial infections is really important work, so is breaking bad news, and doing it well at least leaves you with a sense that you have done something really important. Strangely, you will receive a lot more thanks and appreciation from the community for the work you do telling them their loved ones are dead than you will saving them from untreatable staph sepsis.

Read on for a look at how to do it and how to teach it.

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