Got droperidol?

If you’ve been following blogs such as THE PHARM recently, you’ll probably have seen reference to a chap called Minh le Cong and a drug called ketamine.  Now it’s no secret that many in the prehospital and emergency fields are fond of ketamine – it’s a useful dissociative agent with analgesic properties and can be given IM, IV or IN and used for analgesia, sedation and induction.

Like any drug it requires familiarity with use and titration to effect (although I prefer pre-drawn drugs for RSI, with doses based on IBW and haemodynamics).  I reckon that if I polled a roomful of doctors and asked them to give a dose of ketamine, many would be hesitant having not used it before.  Safe practice mandates familiarity with the drug and appropriate training and monitoring…

Sedation of the Acutely Agitated Patient – a High Risk Procedure

But there is an area of practice that has bugged me for some time, namely the management of an acutely agitated patient. This is a difficult situation – the patient is agitated and may be a risk to self and others. The staffing in a rural hospital is minimal – there is no ‘Code Black’ with security officers –  the team may involve an RN and EN initially, with the on-call doctor off site and taking some time to arrive.

Whilst a calm environment and de-escalation is ideal, sometimes situational urgency mandates use of agents to calm the patient. It’s all well and good if the patient is cooperative and insightful enough to take a dose of oral medication (typically olanzapine antipsychotic +/- oral diazepam)…but if not, they may require a rapid ‘takedown’ with IM or IV medication.

And this is a problem, as the agents commonly recommended by many Health Department protocols STILL include short-acting agents associated with profound respiratory depression.  Alternating cycles of extreme agitation, and administration of short- and long-acting agents can lead to increasing amounts being used and a slide into respiratory collapse.

Looking few various protocols from various sources can be confusing; there’s a wide variety in suggested agents – a quick search in an (unnamed) rural ED showed a variety of available protocols. This is potentially dangerous – in a crisis, the ‘occasional sedatonist’ is likely to seek some form of protocol..and yet may lack familiarity with the agents in use.

The Occasional Sedationist may be reassured by a protocol and lulled into a false sense of confidence in administering drugs without adequate backup

Many protocols seem to encourage polypharmacy, including the use of IV midazolam. Other agents in some of these protocols include ;

ORAL – olanzapine, diazepam, lorazepam, risperidone

IM – olanzapine, haloperidol, clonazepam, midazolam, lorazepam zuclopenthixol

IV – midazolam, diazepam, lorazepam

Even though there have been recent Coroner’s reports on deaths of such patients, a recent report failed to address the issue of safe sedation and instead focus on the need for more rapid transfer. Whilst I am in favour of rapid transport of patients requiring retrieval (not least because of the demands on staff in a resource-limited environment), it’s not the lack of a helicopter that kills these patients – it’s the cycle of agitation-sedation and cardiorespiratory collapse, occasionally exacerbated by restraint that is dangerous. Couple this with a general failure to approach the clinical situation with the same diligence as we would for providing procedural sedation in ED or OT, with it not unheard of for these patients to be nursed in a dark room, supervised by a mental health worker outside the door, with occasional recording of routine obs – scant appreciation of the fact that we are giving administering anaesthetic agents!

Moreover, many of the protocols available in EDs make vague reference to ‘safe environment’ without specifying the need for airway equipment, the use of ETCO2 to monitor nor airway or anaesthetic risk assessment.

Pertinent Coroners reports are here :

David Lee Coroners report

Lyji Vaggs Coroners report

Adam Fernandez Coroners report

 

Droperidol & ketamine – safer than short-acting benzos!

So the Twittersphere was abuzz today with the announcement of the DORM-2 study from Melbourne – a prospective observational study looking at the safety of droperidol for management of these patients.  Older readers may remember concerns from 15 years or so ago regarding droperidol and prolongation of the QTc causing torsade de pointes. The study demonstrated no prolongation of the QTc in the cohort studied, nor any incidences of torsades de pointes (a criticism is that this is relatively rare and would require a larger study). More importantly, the study demonstrated the effectiveness of droperidol in achieving a state of rousable sedation – the goal in this situation.

I think this is important. I use droperidol occasionally in theatre for both sedative and anti-emetic properties; it’s available in most hospital or can be ordered in.  And I think it’s a useful addition to the armamentarium. So much so that I’ve dropped haloperidol from my approach and will run with initial olanzapine where possible; if this fails, IM droperidol titrated to target sedation score.

Of course ketamine DOES also have a role; and I am a particular fan of it’s use for transport of such patients without the need for risking RSI in an unfasted patient with unproved airway (obesity, OSA and COPD are not uncommon in these patients, as are complications of intubation such as aspiration and the need for an ICU bed at the other end). There are protocols available for running ketamine infusions once initial sedation is achieved. I won’t reproduce them (for examples see here and here), but suggest that early consultation and advice from the retrieval service is mandatory…

Safe Sedation Guidelines 2015

Moreover, it helps bolster a rationale approach to sedation of the acutely agitated psychiatric patient – there’s been a bit written on this recently, with release of a Consensus Statement – The Acutely Agitated Patient in a Remote Location as well as a collaborative effort between some emergency and rural clinicians in Australia to guide practice in rural ED or on the wards.

We’ve termed it ‘Surviving Sedation Guidelines’ in recognition of the very real risks that use of these agents can pose.

Listen to a podcast here on the “aikido of emergency sedation” from Minh, Casey and myself

See also posts on Surviving Sedation Guidelines 2015 from the PHARM here, from BroomeDocs here and from KIDocs here

KEY PRINCIPLES OF SURVIVING SEDATION GUIDELINES

Early Goal Directed Sedation (EGDS) – titrated sedation to an objective level using a validated sedation scoring system

Consideration of emergency sedation as a form of procedural sedation/anaesthesia. 

 Minimum standards of patient assessment, resuscitation equipment and clinical monitoring 

De-emphasis on sedative drug choices with more emphasis on continuous clinical assessment and titration to effect

There is a lot more to psych sedation than just bunging in a dose of benzo and walking away…I’d encourage people to read the extensive notes on Minhs blog post regarding this, and consider the use of droperidol, as well as stalwarts olanzapine and diazepam in a stepwise approach titrated to a desired sedation level.

Other than oral diazepam, there is no mention of using short acting benzos such as midazolam…and I think this is a GOOD thing! See what you think….

An updated version of the guidelines is here: SSG2015 v6.0

 

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Frozen Out

Disappointing news this week from CountryHealth SA – on April Fools Day they announced that an agreement has been reached with the AMA(SA) regarding rural doctor contracts

…but neglected to inform the Rural Doctors Association of SA, who not only represent rural doctors in this State but with whom CHSA were supposedly negotiating.

The current impasse remains – apparently around 50% of doctors have signed contracts with CHSA – which means 50% have not.  Whilst the AMA(SA) appear to endorse the contract, the RDASA do not.  Which makes one wonder with whom CHSA are negotiating….

You can read details from the RDASA webpage media release and letter to members.

Sticking points remain :

(i) a freeze on free-for-service payments for three years

Rural doctors work in private practice and provide oncall services to their local hospital. Freezing fee-for-service payments disadvantages the oncall doctor, who not only forgoes clinic income by attending the hospital, but also faces CPI increases in rent, utilities, staff costs etc.

(ii) EPAS system

The EPAS system has been trialled in some SA hospitals an universally condemned by frontline clinicians. It detracts from patients care and takes significantly longer to complete notes.  Whilst not adverse to using an electronic system of hospital notes, such a system needs to be fit for purpose. Rural doctors are hesitant to endorse this system until it is proven to work effectively.

(iii) Payment for ADMITTED non-Medicare patients

It has always struck me as perverse that the oncall doctor attends the hospital for emergency presentations…but in the case of patients involved in a car crash or seriously unwell from overseas, CHSA reneges on it’s obligations to pay the doctor and somehow insists that such patients are ‘private patients’ – which requires the oncall doctor to bill privately.

This is problematic. Critically ill patients are in no position to provide informed financial consent. Moreover, rural hospitals are public hospitals. The fact that the hospital has no resident doctor and requires an on call contractor to attend, should not negate the need to pay that doctor for attending.

Such work is stressful, involves medicolegal risk and a high degree of emergency medicine skill.  To spend several hours stabilising a sick patient who is then retrieved to the mainland and then not to be paid for it is a slap in the face for rural doctors – especially when everyone else involved in the patient care is paid (nurses, retrieval, tertiary centre doctors).

Of course, such presentations are not uncommon in places such as Kangaroo Island which have high tourist visitation (200,000 tourists to 4500 locals) and where unsealed roads and wildlife are not infrequent causes of car crashes.

Rather than practice “Airway-Breathing-Cash or Credit Card?”, would it be too much to ask CHSA to pay the doctor for attending – and let CHSA admin chase the insurer?

Hopefully CHSA will re-engage with RDASA in negotiation to achieve a workable contract.  Read more in media release and letter to members

Being Expert Enough….

I reckon that I am lucky to be a rural doctor.  It wasn’t an area of medicine to which I was exposed as a student or trainee, and it was only good fortune that lead to my career evolving the way it has. Rural medicine offers all of the “best bits” of medicine without the tedium of being confined to one area as a “partialist”. Whilst much of the work of a rural generalist involves office-based primary care, we also have responsibility for emergency medicine via the local hospital and some of us will participate in elective and emergency procedural skills, such as anaesthesia, obstetrics and surgery.

Swiss Amry Knife

It’s no secret that my interests revolve around trauma, prehospital care and anaesthesia, particularly in the rural context. But I am also interested in palliative care, paediatrics, chronic pain, depression, internal medicine and chronic disease management. As my colleague Casey Parker at BroomeDocs put it, the generalist rural doctor is the “swiss army knife” compared to the partialists “scalpel”. Each has their uses. In the bush, you need the multitool!

And therein is the dilemma for the generalist – how to maintain skills and clinical knowledge across such a  broad array of clinical arenas? Particularly in fast-moving areas such as emergency medicine and critical care, where evidence-base may be rapidly evolving?

The answer, of course, is to use FOAMed – Free Open Access Medical Education – the rapid dissemination of ideas and learning resources, via the tools of Web2.0, to allow distributed, non-hierarchical, asynchronous learning “anywhere – anytime – anyone”.  To my mind, FOAMed is particularly useful for those seeking to develop mastery, rather than teach the basics (for that, it remains textbooks and standard alphabet courses).  The use of Web2.0 (blogs, podcasts, social media such as twitter, Google+, even Facebook) affords rapid sharing of ideas amongst peers – and extends the reach from local colleagues to allow exchange with a global community of like-minded peers and experts….all of whom willing to share ideas and content for free.

This is not a new concept in medicine – as Joe Lex points out, it dates back to Hippocrates “and to teach them this art – if they desire to learn it – without fee and covenant” – this is from the Hippocratic Oath and sharing of knowledge is part of being a clinician.  But for some, the technology and terminology in social media and FOAMed can be a barrier.

This is a shame. FOAMed has been a revelation for my practice.  A few years ago I was “comportable” in my practice. I met the required needs of credentialling (attendance at an entry-level emergency course every triennium), easily accrued my CPD points with my College and felt pretty happy in my practice. But I was not challenged. My interest in trauma and airway management lead to some online resources, at about the same time that Chris Nickson and Mike Cadogan were launching the “lifeinthefastlane” website for emergency physicians and the concept of FOAMed.

Since then I’ve been swept up in a rich learning environment, that has forced me to be challenged, to engage in discussion of concepts in my areas of interest which I would never have been able to do before. It’s made me submit papers for publication, to abandon traditionally safe roles (such as directing on EMST) and join the faculty of more modern courses, to speak at conferences, lead simulation training with paramedic and nursing colleagues and to run airway workshops. I feel connected to a rich information flow, of which I was previously oblivious. And trather than drown in a sea of information overload, apropriate use of filters allows me to receive and engage only in content which interests me.

It’s well worth exploring.

And so leads to the topic of this post – “Being Expert Enough”. I am helping out at the inaugural “Critically Ill Airway” workshop at The Alfred in May – the brainchild of Chris Nickson and anaesthetic/intensive care/emergency medicine colleagues. It should be a good course – Scott Weingart is an external consultant, there will be the likes of Andy Buck from ETMcourse and many others as Faculty.

“This is the challenge and discipline of rural medicine – our specialty is providing care across a broad range without immediate backup”

I will be speaking to a topic dear to my heart – that of the “occasional intubator” – this is pretty much is the default setting for much of the work we do as rural doctors, and requires us to have sufficient expertise to be safe and competent without backup across a large range of competencies.

https://vimeo.com/122820309

To that end, Chris is ‘flipping the classroom’ and including some content prior to the airway course itself. Above is a “teaser” of my lecture and skills station for the CIA course. It should be fun…

Even if airway management in the critically unwell is not your “thing”, do consider exploring FOAMed – I reckon it’s the best paradigm for post-Fellowship learning.  I am glad that both RAGP and ACRRM are allowing such online learning to be counted for CPD, not so much for the need for points – but because with increasing interaction amongst clinicians comes acceleration in learning and knowledge translation…which flows to us being better clinicians and patient benefit.

For us rural generalists, separated by distance and needing to maintain knowledge across a broad array of domains, FOAMed means that deficits in knowledge are no longer an excuse as the weak link in patient care.

LINK – REGISTER HERE for CRITICALLY ILL AIRWAY COURSE, May 7-8 The Alfred, Melbourne

 

 

 

 

 

 

Lessons for management of acute agitation in rural EDs

The South Australian Coroner has just released a report into the sad death of Mr Simos, who died whilst awaiting transfer from a rural ED back to a tertiary centre where he was under a current detention order.

The Coroners report can be accessed here. As with all Coroner’s reports, it makes for salutary reading and in due course I shall add it to the other list of Coroners cases of relevance for rural doctors, over at ruraldoctors.net.

Case summary

The full report can be read online. In essence though, this as a patient whose medical history involved :

  • florid psychosis, being treated as a “detained” patient (level 3 treatment order)
  • obesity
  • COPD
  • obstructive sleep apnoea
  • poorly controlled diabetes
  • hypercholesterolaemia

The patient absconded from an open ward, where he was under psychiatric care in the city. He was subsequently apprehended by police and taken to a rural hospital under existing treatment orders, with a view to being returned to the city psychiatric unit. During the course of this admission he required sedation with olanzapine and lorazepam, and an RFDS transfer was requested. Further episodes of agitation resulted in the administration of midazolam, then respiratory depression requiring assisted ventilation and reversal with flumazenil. Anaesthetic consultation was sought in regard to the pros and cons of intubation; this was deferred as patient was maintaining own airway.  Some 12 hours after admission, transfer had still not eventuated. On advice of liaison psychiatrist, haloperidol and promethazine were administered for further agitation.  A short while afterwards the patient suffered a cardiorespiratory arrest.  The cause of death was undetermined – respiratory depression, agitated delerium and QTc abnormalities were considered and dismissed.

Expert analysis and Coroner’s recommendations

The Coroner made comment of the need for timely transfer of such detained patients from rural facilities to tertiary centres, mindful of the limitations of managing such patients in rural SA.  Existing guidelines were acknowledged.

Expert opinion from the CountryHealthSA lead for emergency medicine was not critical of any particular management decisions. There was opinion given that management of such cases should involve

  • a structured response (rural doctors, hospital, retrieval service, psychiatric expertise
  • a “team leader” responsible for management decisions
  • a “flow chart” to guide delivery of care, including assessment, drug use, physical restraint, transport type and final destination

No criticism was made regarding decision to intubate/not intubate, nor use of medications.

Why does this matter?

Such cases are not uncommon in rural Australia. This sad case highlights several teaching points that I would encourage ALL rural doctors to consider, namely :

  • familiarity with initial “go to” drugs for managing acute agitation
  • assessment of risk of sedation vs exacerbating medical issues (this patient was obese, with OSA and COPD, probable underlying IHD)
  • appropriate monitoring
  • options for transfer or retrieval
  • demands of such acutely unwell patients on clinical staff in rural hospitals and ability to deliver care over a potentially prolonged period of time

The Coroner’s report doesn’t really cover these in much detail – of course in this case appropriate decisions were made and cause of death remains unclear. However I believe that the Coroner’s report could have done more to illustrate appropriate standards of care and to inform other rural clinicians. Tat it has not done so has prompted this post.

Typically such patients are unfasted. They require large doses of drugs for initial control of agitation and meticulous monitoring. My approach to these patients has been guided by knowledge gleaned from the FOAMed world, in particular an excellent discussion from the BroomeDocs blog a few years ago, as well as the ongoing work from Dr Minh le Cong and others on psych sedation in rural Australia.

A safe and structured approach to such patients might involve :

  • early telepsych consultation and teleconference with retrieval service re: transport urgency and available options
  • an agreed plan for both immediate and ongoing restraint
  • if using chemical restraint, to carefully consider risks of these agents in regard to unfasted airway, body habitus, cardiorespiratory effects and underlying concomitant medical conditions (anaesthetic risk)

risks of harm to self/others if agitation not adequately controlled

I like to think of such patients as medical emergencies (akin to a combative or resp depressed head injured patient), requiring full monitoring, including

  • 1:1 nursing by an acute care nurse
  • pulse, BP, ECG, RR, SpO2
  • waveform capnography
  • use of the Richmond-Agitation Sedation Score (RASS)
  • immediate access to O2, suction, airway equipment and difficult airway trolley
  • immediate access to skilled anaesthetic assistance
  • at least two IVs
  • consideration of safety for transport including maintenance of own airway vs ETT, and use of safety harness if not intubated

In particular, I would encourage rural doctors to be aware of the PSYCH RISK ASSESSMENT MATRIX (Casey Parker) and the use of KETAMINE for SEDATION and TRANSFER (Minh le Cong et al)

The Consensus Statement can be downloaded from the RFDS website here and I believe should be mandatory across rural SA hospitals.

If you are a rural doctor or nurse or paramedic with responsibility for these patients, please read the Consensus Statement and ensure follow the bulletpoints above. Not all rural doctors use RASS or ETCO2 monitoring, and often such patients are nursed in a dark environment without immediate access to airway kit, O2, suction.

THINK OF MANAGEMENT OF SUCH PATIENTS AS SIMILAR TO MANAGEMENT OF PROCEDURAL SEDATION

That it was not explicity referenced in the Coroner’s report is a missed opportunity – hence this post.

Consensus Statement – The Acutely Agitated Patient in a remote location at http://healthprofessionals.flyingdoctor.org.au/clinical-resources/?q=cat103%7Cref%7Cformat

 

 

 

 

smaccUS

A reminder that smaccUS is rapidly approaching – from the orginal smacc2013 held in Sydney, then smaccGOLD on the Gold Coast, in 2015 the world’s most exciting and innocative critical care conference will be held in Chicago.

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Wondering what all the fuss is about?  Have a read of the reviews from previous smacc conferences here

I am putting the final touches to my talk “All alone on Kangaroo Island” – the program looks fantastic….so hurry up and get your registration in, places are limited!

smacc.net.au

Critically Ill Airway

I am just putting final touches to the “Being Expert Enough” session for the forthcoming Critical Ill Airway Course to be held at The Alfred Hospital in Melbourne, May 7-8th 2015.

The course is being convened by that powerhouse of energy, Dr Chris Nickson of LITFLsmacc & RAGE podcast fame. Co-conspirators include external collaborators like Scott Weingart of EMCrit.org, Rick Levitan of airwaycam.com as well as local talent such as Andy Buck of ETMcourse, trauma and prehospital anaesthetist Dr Brent May and the combined brilliance of The Alfred ICU and Anaesthetic faculty.

This promises to be a well-run and fun course, with small group instruction and heaps of scenario-based training and hands on workshops. There are still some places left, so have a look over at the CIA website for more details.

CIA

Importantly this course is open to ANYONE who manages the airway of critically ill patients (doctors and paramedics). Of course I am interested – as a rural clinician I am no stranger to the concept that “critical illness doesn’t respect geography” and want to make sure we are all on the path to expertise, regardless of location. So expect a distillation of FOAMed goodness for occasional intubators whether in ED, ICU, rural or prehospital locations.

Register at the CIA website – first in, best dressed!

CIA Course will Grill Your Corn
Critically Ill Airway Course will Grill Your Corn

And remember – if all else fails in airway management, remember to fall back to a two-handed technique, squeezing the bag gently…

TwoHandTechnique

See you there!