ECG 2016.7 antwoord a man with gastric discomfort

Regarding the 65-year-old man with a history of chronic stable angina, epigastric discomfort radiating to his left shoulder and arm with nausea. Diagnosis: sinus tachycardia, first degree AV block (AV delay), acute inferior wall ST segment elevation myocardial infarction, possible posterior wall infarction There is a regular rhythm at a rate of 100 bpm. There … Lees verder ECG 2016.7 antwoord a man with gastric discomfort

Het bericht ECG 2016.7 antwoord a man with gastric discomfort verscheen eerst op Dutch Emergency Medicine Cases (DEMcases).

It depends. By Yoanna Skrobik

Hola a todos, mis queridos amigos.

Last week was published in Intensive Care Medicine a new article by the IC-HU Project about restricted visitation policies for children in adults ICU.

Yoana Skrobik, from Canada, was surprised after reading the article, and she sent me an email with her opinion. She has let me share it. In the end, everything depends on where you are living, as we discussed las week talking about the ICU where only "Dad and mom can enter".

As you can understand, things are on one way or another depending on the part of the world where we work, but in any case, we make it possible. Read this and get your own conclusions:

"Dear Gabi,

I must tell you I am rather taken aback by your attached text.

In 1991, I started working in an intensive care unit in the largest bone marrow transplant centre in Montreal. The patients were often in their 30s or 20s, and so often had young children who wished to come and visit.

At the time, a child psychiatrist told me what has guided my practice ever since.

He explained children have no fear of death and no notion of the consequence of illness and suffering. These notions are adult, and children experience fear only if adults convey it. Having had and raised several children, I agree that the notion of consequence is indeed one we spend much time attempting to instill.

The psychiatrist also said that when a child is small, and even into adolescence, their perception of adults is a perception of a powerful person who makes decisions. In that frame, if the loved adult disappears, the child perceives the adult's disappearance as having been willed by the adult. The psychiatrist then went on to say that children who are isolated from loved adults who are ill subconsciously or consciously perceive abandonment. He explained that this sense of abandonment is much more damaging to a child then any exposure to illness. In addition, he mentioned that children who are so called 'protected' from illness are de facto also completely isolated from the experience that the rest of the family is going through. They never learn how to share sadness and loss, and are perhaps less well equipped when those inevitable moments come later in their own lives.

Since that conversation, I have let children of any age into the intensive care unit if they wish to come. The nurses usually accompany them and explain to them what they will see, so that the parents are not burdened with this.

I have never worked in a Canadian intensive care unit that did not allow children in. In over 20 years of practice, I have never seen a child react badly to intensive care exposure, nor have a parent report later that this visit or exposure was in some way traumatic. Some children do not wish to come in (and I would never force the issue in that case), but most of the resistance comes from adults.

The only exception to limiting children in an ICU I worked in was a brief contained time in which pre-12 schoolchildren in Montreal where the primary vectors for the H1N1 virus. Only then were age restriction policies applied, and they were lifted this soon as it was feasible.

The psychiatrist who was telling me his thoughts smiled at the end of expressing his opinion and said we live in a society that completely isolates the old from the young, the healthy from the sick, and creates artificial divides that do not serve any group well. I agree with him to this day.

I would encourage any revision of policy that isn't grounded in any data, to better accommodate the wishes of both patients and families.

Yoanna Skrobik
Department of Medicine. Centre Universitarie de Santé McGill

Montreal, Canadá.


Chemical RestraintThe world can be a scary and dangerous place, but few things are as dangerous as an acutely agitated patient in your emergency department.  While violent adults in the ED seem nearly commonplace (although still deserve provider’s vigilance), the agitated and dangerous child is also becoming more prevalent in our EDs.  The management of acute agitation in children can be challenging, so let’s spend a minute considering our options.


Agitation: What is it?

  • This seems like a silly question, but the literature does not use a consistent definition. [Sonnier, 2011]
  • Most definitions include behavior that may lead to harm to the patient or healthcare providers if no intervention is taken.


Agitation: Common?

  • Estimated that 10-20% of children and adolescents have mental disorders and/or substance abuse.
  • ED visits for psychiatric conditions in children continue to increase. [Pittsenbarger, 2014]
  • The resources required to care for pediatric patients needing psychiatric care in the ED continues to increase also. [Sheridan, 2015]
  • During psychiatric evaluation, about 1 out 15 of kids required restraint. [Dorfman, 2006]


Agitation: What is it due to?

  • This question is incredibly important to address.
    • Similar to the trauma patient, do not get distracted by the obvious injury and overlook the more substantial, occult one.
    • Violent behavior may be why the patient is in the ED, but think of it as a symptom rather than the diagnosis.
    • The acutely agitated patient is not a “psychiatric patient” until you’ve consider the other emergent medical conditions.
  • Undifferentiated agitation (abridged) Ddx:
    • Broad Categories:
      • Medical Conditions
      • Substance Use
      • Psychiatric illness
    • AEIOU TIPS (yes… this is the one for Altered Mental Status… I’m not smart enough to remember more than one acronym)
      • Alcohol – while often a sedative, ETOH can cause agitation
      • Electrolyte derangements (ex, hyponatremia, hypercalcemia)
      • Insulin (got hypoglycemia??)
      • Opiates and Other Drugs (got a toxidrome? anticholinergic vs sympathomimetic? NMS? Serotonin syndrome?)
      • Uremia
      • Trauma – Look closely for signs of trauma
      • Infection – Meningitis/encephalitis?
      • Psychiatric disorder – really should be the last one considered
      • Space occupying lesion
    • While each year a new set of “designer” intoxicants may be added to the list, don’t become enamored with them and forget more “boring” entities (ex, hypoglycemia!).


Agitation: Management?

  • Primary Goal = keep patient and staff safe while allowing continued evaluation.
    • The least restrictive method that attains this goal should be used. [Adimando, 2010]
    • Unfortunately, how to safely restrain pediatric patients is not often taught. [Dorfman, 2004]
  • If not immediately dangerous, attempt simple, nonrestrictive strategies: [Adimando, 2010]
    • Verbal de-escalation
    • Reduction of environmental stimuli (a quite room is much better than a loud hallway)
    • Offer basic needs (ex, food, warm blanket)
  • If simple tactics don’t work, or the patient is initially dangerous, move onward to restraint.
  • Ideally, before selecting a medication, the etiology would be known so risk could be minimized…
  • In reality, evaluation and management occur concurrently, so some Rx options may be less desirable in the undifferentiated acutely agitated patient.
  • “Chemical Restraint”

    • Oral vs Intramuscular
      • If the patient is cooperative, offer oral medications first.
        • May give the patient sense of some control.
        • Avoid trauma of being physically restrained for IM shot
        • Many medications are equally effective in oral form
      • If patient is not cooperative, the oral route is not going to be an option.
    • There is no perfect medication option for every scenario, and the true efficacy of the various options is unknown in children, so be conservative and keep a few options in mind: [Carubia, 2016]
      • Benzodiazepines
        • Lorazepam – 0.05-0.1 mg/kg/dose (PO/IM/IV)
        • Midazolam – 0.25-0.5 mg/kg/dose PO; 0.2-0.3 mg/kg IN; 0.1-0.15 mg/kg/dose IM
      • First Generation Antipsychotics
        • Haloperidol – 0.5-5 mg PO; 0.05-0.15 mg/kg IM (up to 5 mg/dose)
        • Droperidol – 0.03-0.07 mg/kg/dose (IM/IV)
          • Has become scarce in the USA after FDA black-box warning regarding QT prolongation — which other antipsychotics cause as well (some even more so)
          • Has been shown to be safe and effective for acute agitation in pediatric patients in ED setting. [Szwak, 2010]
        • Chlorpromazine – 0.55 mg/kg/dose (PO/IM)
      • Second Generation Antipsychotics
        • Risperidone – 0.25-2 mg PO/ODT
        • Olanzapine – 2.5-5 mg PO/ODT
      • Others:
        • Diphenhydramine – 1 mg/kg/dose (PO/IM)
        • Ketamine (ok, so I’m biased, but this is awesome!) [Kowalski, 2015]
          • Rapid onset due to high bioavailability (even when given IM)
          • No QT prolongation issues
          • Safe even in overdose (important when you aren’t sure of patient weight)
          • No respiratory depression (rarely, may see laryngospasm)
          • Should likely avoid in patient with known schizophrenia
  • Physical Restraints

    • Can be dangerous (i.e., Rhabdomyolysis and Airway compromise), but there are safe methods to use.
    • Use as last option
    • Remove as soon as no longer needed


Moral of the Morsel

  • Acutely agitated patients can be hazardous to themselves and the entire ED; anticipate how you will deal with them (because eventually one will be requiring your acute attention).
  • Acute agitation is a symptom — look for the cause while keeping everyone safe.
  • Consider non-restrictive means to controlling the situation first, if possible.
  • There is no perfect medication that is good for every scenario and patient — keep several in your tool belt.



Carubia B1,2, Becker A3,4, Levine BH5. Child Psychiatric Emergencies: Updates on Trends, Clinical Care, and Practice Challenges. Curr Psychiatry Rep. 2016 Apr;18(4):41. PMID: 26932516. [PubMed] [Read by QxMD]

Sheridan DC1, Spiro DM, Fu R, Johnson KP, Sheridan JS, Oue AA, Wang W, Van Nes R, Hansen ML. Mental Health Utilization in a Pediatric Emergency Department. Pediatr Emerg Care. 2015 Aug;31(8):555-9. PMID: 25834957. [PubMed] [Read by QxMD]

Kowalski JM1, Kopec KT, Lavelle J, Osterhoudt K. A Novel Agent for Management of Agitated Delirium: A Case Series of Ketamine Utilization in the Pediatric Emergency Department. Pediatr Emerg Care. 2015 Oct 13. PMID: 26466151. [PubMed] [Read by QxMD]

Pittsenbarger ZE1, Mannix R. Trends in pediatric visits to the emergency department for psychiatric illnesses. Acad Emerg Med. 2014 Jan;21(1):25-30. PMID: 24552521. [PubMed] [Read by QxMD]

Sonnier L1, Barzman D. Pharmacologic management of acutely agitated pediatric patients. Paediatr Drugs. 2011 Feb 1;13(1):1-10. PMID: 21162596. [PubMed] [Read by QxMD]

Adimando AJ1, Poncin YB, Baum CR. Pharmacological management of the agitated pediatric patient. Pediatr Emerg Care. 2010 Nov;26(11):856-60; quiz 861-3. PMID: 21057285. [PubMed] [Read by QxMD]

Szwak K1, Sacchetti A. Droperidol use in pediatric emergency department patients. Pediatr Emerg Care. 2010 Apr;26(4):248-50. PMID: 20401969. [PubMed] [Read by QxMD]

Barzman DH1, DelBello MP, Forrester JJ, Keck PE Jr, Strakowski SM. A retrospective chart review of intramuscular ziprasidone for agitation in children and adolescents on psychiatric units: prospective studies are needed. J Child Adolesc Psychopharmacol. 2007 Aug;17(4):503-9. PMID: 17822344. [PubMed] [Read by QxMD]

Dorfman DH1, Kastner B. The use of restraint for pediatric psychiatric patients in emergency departments. Pediatr Emerg Care. 2004 Mar;20(3):151-6. PMID: 15094571. [PubMed] [Read by QxMD]

Sorrentino A1. Chemical restraints for the agitated, violent, or psychotic pediatric patient in the emergency department: controversies and recommendations. Curr Opin Pediatr. 2004 Apr;16(2):201-5. PMID: 15021203. [PubMed] [Read by QxMD]

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