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.


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





Looking out for our patients. And each other.

Download PDF


What does the term “got your six” mean?

In the military, “got your six” means “I’ve got your back.”
The saying is thought to have originated with World War I fighter pilots referencing the rear of an airplane as the six o’clock position.
As you sit facing forward, you are on the centre of an imaginary clock face.  The area directly in front of you is twelve o’clock. Six o’clock is what lies behind you. The stuff you are unaware of, or do not have control over.

So, your “six” is your most vulnerable place.

When someone tells you that they’ve “got your six,” it means they’re watching your back.
By extension, that person expects you to have their back as well.

Reference: Got Your 6 | Bridging the civilian-military divide [Internet]. [cited 2015 Mar 17]. Available from: http://www.gotyour6.org/

Nielson – Extravascular Lung Water and Transpulmonary Thermodilution

Managing complex patients with ARDS can be challenging.  Many believe the Berlin criteria we use to identify ARDS are largely confounded and often identify the disease too late. Additionally, how do you manage the patient who’s intravascularly depleted but is drowning from pulmonary edema? (Classic – they are wet and dry!!)  What if there was a way…

The post Nielson – Extravascular Lung Water and Transpulmonary Thermodilution appeared first on MarylandCCProject.org.

Ebola Suit for Patients Allows for More Normal Clinical Work


Victims of ebola are kept in special isolation environments into which only specially suited staff can gain access without contracting the disease themselves. This means that one patient may require multiple clinicians to be suited up throughout the day, each of which has to undergo a complicated process of putting on and removing the protective suit. Renfrew Group International, a product design firm that does a lot of work within the medical field, has designed an isolation suit for the patients to wear.

The sort of inside-out suit is meant to keep the patient supplied with fresh air and fed through a tube, while the clinical staff can work safely and comfortably nearby. The suit is apparently unbreachable, and conveniently for everyone, there’s a built-in emesis tube that’s connected to a bag that collects all the vomit. Let’s just hope the ventilation works great inside or patients might be testing just how impervious the suit really is.

Link: Renfrew Group International…

(hat tip: The Engineer)

The post Ebola Suit for Patients Allows for More Normal Clinical Work appeared first on Medgadget.