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PHARM Podcast 013 – Acute agitation management in Retrieval medicine with Dr Casey Parker

All the way from the Jamaica capital of Western Australia, BroomeDocs blog author, Dr Casey Parker on stabilisation and retrieval of the acutely agitated patient

Hi folks!

Last week on Twitter, a health professional from Canada posted this news article on British Columbian doctors complaining of safety risks of sedating agitated patients with a mental illness for aeromedical transport. Casey and I are passionate about promoting best practice and improved care to any patients in remote areas but in particular acutely agitated patients with a mental illness. So we recorded an entire podcast on it and want to share our thoughts here!

I actually met Dr Wheeler last year at a conference. He is one of the few published authors on this specific topic, apart from myself. Here is his article on sedation for air transport of agitated patients. As the 2012 news paper article cites, this is being reviewed and revised in conjunction with the receiving psychiatrists.

Here is my original paper on ketamine sedation during aeromedical retrieval and a LITFL update screencast episode on retrieval of the disturbed patient

Show notes links as promised and more!

Townsville coroner case of sedation

DORM study

EmCrit article on the art of the chemical takedown

Excited delirium paper and ketamine sedation

Laryngospasm case with ketamine

Did you know ketamine is a rapid antidepressant that reduces suicidality in preliminary research?

Even Mt Sinai School of Medicine is researching its antisuicidality effect

 

Here are links to Casey and mine web resources on acute sedation, management of the agitated patient in a remote location and aeromedical retrievals of such patients.

BroomeDocs massive chapter of resources on acute agitation management and sedation

More from BroomeDocs blog on relevant cases including that 3 day road transport!

My RFDS STAR Youtube lecture on psychiatric aeromedical retrievals

Earlier PHARM podcast

Stay safe out there and send in your comments.

Minh

 

Now on to the Podcast

Right Click and Choose Save-as to Download the Podcast.

9 Comments Post a comment
  1. Minh and Casey,
    Fabulous discussion. Thank you. The concept of procedural sedation, with the procedure being transport, is a great one, and is an argument I’ve used here in Cincinnati as well (with limited success thus far). Thanks again for sharing your experience and wisdom.

    May 28, 2012
    • thanks Bill.gotta have You back on the mike again!

      May 28, 2012
  2. Would be interested to know your thoughts on intranasal medicines rather than intramuscular for sedating the agitated/psychosis patient? Certainly seems safer to use the mucousal atomiser over attempting to get a sharp long IM needle into somebody

    June 2, 2012
    • The human bite is probably one of the nastiest forms of attack we can deliver as human beings, without a weapon.As Mike Tyson. Last time I worked in ED several weeks ago, helped out in a restraint and sedation of a combative intoxicated trauma patient..did not need RSI but needed some sedation. It took 6 adults to safely restrain one average sized woman and if she did not have a neck collar on, probably 7 adults required.
      I know it has been done, intranasal sedation. I don’t think it is any safer than IMI but thats my opinion and I have yet to try to deliver nasal meds to a resisting patient.

      June 4, 2012
  3. I have an interest in the prehospital management of acute psych problems. One of the many things that troubles me about our system is the different standard of care an agitated patient with bipolar disorder may expect to receive compared, for example, to that of a similarly agitated hypoglycaemic patient. Very glad to see an ethical component in your discussion and I look forward to reading tomorrow some of the research mentioned.

    Just a thought from my own practice as a paramedic: I’ve had a lot of success with IN fentanyl for sedation of the mildly agitated pt.

    This isn’t obviously for the type of pt you mention in the podcast, Minh, but I consider it an option for those us who don’t have a lot else to play with.

    I’ve found it useful in the treatment of mild agitation in medical pts to facilitate treatment or even assessment. Fent is, in my experience, more predictable in its side affects, has a faster onset via the IN route than Midaz via the IM route (easier to titrate) and resp depression less common in the doses I’ve required to achieve the desired affects. It also has the added benefit of treating any pain that the pt was unwilling or unable to report. Obviously the pain may be a factor in the agitation of the hypoxic or brain injured trauma pt, but the same is not often considered in the agitated medical pt with altered mental status. I like fent as it covers that base, but ultimately provides a level of mild sedation and in general facilitates an increased level of comfort for the pt while we do to them all of the evil things that are part and parcel of the prehospital world.

    Not, perhaps, for the knife wielding, floridly psychotic, community psych pt with a revoked CTO and 7 coppers sitting on top of him, but something that has worked well for me in the past.

    Thoughts?

    June 29, 2012
    • thanks for comments and question. Intranasal fentanyl is a reasonable option as it avoids needles and there is a more rapid effect in general. Treating pain is always helpful if that may be cause of agitation. I must say I have only ever used IN fentanyl or midazolam in kids. for that matter IN ketamine is also useful in kids. I think with any sedation for agitation you want to get quick control and that is usually IMI or IVI. Sometimes the nose is just not a good route of admin. Epistaxis or rhinorrhoea, patient fighting you tooth and nail. IMI is then better as usually can find and hold a large muscle to jab.

      July 1, 2012
  4. I have an interest in the prehospital management of acute psych problems. One of the many things that troubles me about our system is the different standard of care an agitated patient with bipolar disorder may expect to receive compared, for example, to that of a similarly agitated hypoglycaemic patient. Very glad to see an ethical component in your discussion and I look forward to reading tomorrow some of the research mentioned.

    Just a thought from my own practice as a paramedic: I\’ve had a lot of success with IN fentanyl for sedation of the mildly agitated pt.

    This isn\’t obviously for the type of pt you mention in the podcast, Minh, but I consider it an option for those us who don’t have a lot else to play with.

    I\’ve found it useful in the treatment of mild agitation in medical pts to facilitate treatment or even assessment. Fent is, in my experience, more predictable in its side affects, has a faster onset via the IN route than Midaz via the IM route (easier to titrate) and resp depression less common in the doses I\’ve required to achieve the desired affects. It also has the added benefit of treating any pain that the pt was unwilling or unable to report. Obviously the pain may be a factor in the agitation of the hypoxic or brain injured trauma pt, but the same is not often considered in the agitated medical pt with altered mental status. I like fent as it covers that base, but ultimately provides a level of mild sedation and in general facilitates an increased level of comfort for the pt while we do to them all of the evil things that are part and parcel of the prehospital world.

    Not, perhaps, for the knife wielding, floridly psychotic, community psych pt with a revoked CTO and 7 coppers sitting on top of him, but something that has worked well for me in the past.

    Thoughts?

    June 29, 2012

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