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PHARM Podcast 33 : August 2012 EM and CC perspective with Amit and Matt

Amit Maini and Matthew MacPartlin for the August 2012 PHARM Australian perspective in EM and CC

Hi folks! Another great interview with not just one but two Australian Emergency Medicine/critical care specialists on the August Australian Perspective.

Amit Maini talks to us of this case of massive PE

Matthew MacPartlin of Intensive Care Network
provides great commentary on the case.

We then talk about another case, which turns out to be carotid dissection.

We move on to discuss prehospital ketamine sedation and a new case series published here.

Prehosp Emerg Care. 2012 Jul 18. [Epub ahead of print]

The Emergency Department Experience with Prehospital Ketamine: A Case Series of 13 Patients.

Burnett AM, Salzman JG, Griffith KR, Kroeger B, Frascone RJ.

From Emergency Medical Services (AMB, KRG) and the Critical Care Research Center (JGS), Regions Hospital , Saint Paul , Minnesota ; the Saint Paul Fire Department (BK) , Saint Paul , Minnesota ; and Emergency Medical Services, Regions Hospital (RJF) , Oakdale , Minnesota .

Abstract

Abstract Background. There are no published reports examining the effects that ketamine administered prior to hospital arrival has on patients after their transfer to the emergency department (ED). Objective. In order to better understand the risk-benefit ratio for the prehospital use of ketamine, we examined the ED courses of 13 patients to whom emergency medical services (EMS) had administered ketamine for chemical restraint. Methods. This project was undertaken as part of our EMS system’s continuous quality improvement (CQI) process. Data were collected retrospectively. All patients who were given ketamine by EMS providers under our medical direction were identified by prehospital care report queries. The treating paramedic and emergency physician were provided a CQI form after disposition of the patient from their care. The data were tabulated and descriptive statistics were calculated. Results. Thirteen patients were given ketamine by EMS providers, with 13 of 13 having EMS records and 12 of 13 having ED records available for review. Time from ketamine administration to peak sedation was <5 minutes in 11 patients and 20 minutes for two patients. On emergency physician examination, five of 12 patients had Richmond Agitation Sedation Scale (RASS) scores of -5 (unarousable), one of 12 had a RASS score of -4 (deep sedation), four of 12 had RASS scores of -3 (moderate sedation), and two of 12 had RASS scores of -2 (light sedation). Three patients developed hypoxia, two in the ED and one prior to hospital arrival. Two of these patients required intubation and one was treated with jaw thrust. Indications for intubation were recurrent laryngospasm and intracranial bleeding. One additional patient experienced a single episode of hypersalivation, which was successfully treated with suctioning of the oropharynx. Of the nonintubated patients, three of 10 were diagnosed with an emergence reaction and five of 10 required additional sedation. The primary diagnosis on ED disposition was drug/ethanol intoxication (3), psychosis (4), intracranial bleeding (1), seizure (1), suicidal ideation (1), agitation (1), and altered mental status (1). Five patients were discharged from the ED, seven were admitted (two to the intensive care unit, four to medicine, and one to psychiatry), and one patient’s disposition was unknown. Conclusions. In this series of 13 patients, ketamine administered by EMS produced moderate or deeper sedation. Respiratory complications included hypoxia, laryngospasm, and hypersalivation. Emergence reactions occurred in 30% of nonintubated patients, but they were successfully treated with small doses of benzodiazepines.

I mention two articles from the latest edition of Anaesthesia and Intensive Care journal

Observations on the assessment and optimal use of videolaryngoscopes

A potential technique for flexible scope-assisted intubation using an Ambu aScope 2 inserted via a supraglottic airway device

enjoy our chat!

Minh

Now on to the Podcast

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

8 Comments Post a comment
  1. Rob Bryant #

    Great episode, nice sick PE case.
    ‘can you take your sick patient to CT?’
    See emcrit episode 9, August 2009

    [audio src="http://media.blubrry.com/emcrit/p/traffic.libsyn.com/emcrit/EMCrit-Podcast-20090831-9-Sick-Pt-at-CT.mp3" /]

    August 12, 2012
    • Hi Rob,

      It’s interesting how this works in different places. I was always trained that the CT is a bad place for unstable patients and in general that still holds true. The concept of the Raptor suite in operating theatres and, by extension, in resus bays, means that in some centres the patient no longer has to go to the CT, the CT can come to the patient.

      However, most places still don’t have this luxury, so what to do? If your patient is already labile and at risk, like Amit said in the podcast, it’s hard to justify a troublesome transport and you need to stabilise as best you can, tackling probabilities until the patient can be moved or needs something/where else. That’s usually the easy path. It can be much harder when your patient was stable enough, but has now dropped out while in the CT. Now you are faced with the ambulance crew decision – stay & play or scoop & run. And which you pick comes down to how badly your patient is crashing and from what cause and how far you have to run to get back to a safe place ie the ED resus bay, the ICU or the theatre.

      The worse you patient is, the more likely that you’ll call for help and stay&play, but this has it’s own problems. Radiology suites are not known for their abundance of resus resources and many times that I’ve been in that situation I’ve almost always needed to designate a runner whose le job was to run back to the ED to get things like blood packs or specific drugs that are not routinely part of the transport pack.

      By the same token, performing CPR while trundling down the corridor to resus might look dramatic, but is fraught with all kinds of problems.

      In the end you can only do your best, which consists of understanding your particular hospital’s layout, facilities and resources and by developing a departmental approach to these potential situations.

      What do you think?

      Take care

      Matthew

      August 12, 2012
      • Rob Bryant #

        I would Take the pt to CT
        Manage every manage-able variable:
        Intubate
        Art line with push dose pressors drawn up
        Anticipate, and have a plan for every likely worst case scenario (ie, have lytics ready to give in CT)
        ‘avoid failure to plan for failure’
        Follow PHARM rule #2 and have a good nurse who knows the plan, and a good doc go to CT with the pt.

        It is easy to make a rational plan when the sick pt is not sitting in front of you.

        August 12, 2012
      • Excellent . This is a nice segue into THIRD RULE OF PHARM

        August 12, 2012
  2. Thanks Rob! To be honest, I fly critically ill patients all the time so taking them down the corridor to CT is not as daunting to me as it might be if I didnt do this retrieval work. Its shades of what you are prepared to deal with when out of your usual resus setting. In my region, the CT scanner is usually in another hospital, several hundred of kilometers away.

    August 12, 2012
  3. Although traditionally the CT (donut of death) is viewed as a bad place to be when badness is happening to the patient, depending on the location, and with careful planning and anticipation, it can still be an excellent resuscitation environment. Preparation is key. I.e you need all the toys, access, drugs and staffing required. When you imagine the logistical challenges faced by our retrieval colleagues, a trip down the corridor to CT doesn’t seem so bad.

    In this particular case, I would have been prepared to thrombolyse, as the diagnosis was certain, but given that the patient stabilised somewhat, we all felt more comfortable proving our diagnosis before pulling the trigger on the lytic.

    August 12, 2012

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