Well folks.
It's been over a year. Thought I'd make another post.
It's an interesting take on the screening neuro exam.
Thoughts?
https://youtu.be/fgwN1P5PDaA
Wednesday, July 13, 2016
Friday, June 26, 2015
Ketamine for Depression in the ED.
Ketamine, a dissociative anesthetic agent, is the world's most widely used general anesthetic. It is the battlefield anesthetic agent of most modern militaries, and is the drug of choice for surgery in remote areas by bush surgeons, and organizations such as Doctors without borders. It is also, as most of us know, increasingly the drug of choice for procedural sedation for adult patients, as well as it's more traditional role in paediatrics, and across an ever widening range of indications. It is also, surprisingly, turning out to be an excellent agent for acute, or even chronic depression, particularly acute suicidal depression, which so often presents to our EDs.
The principal barriers to its use in ED are the possibility of excessive salivation, the possibility of laryngospasm, and the so called emergent reaction. The hyper salivation used to be treated in an anticipatory fashion using atropine or glycopyrrolate, however, this side effect is now considered so rare, that most clinicians who use the drug frequently, will only give these meds if the hyper salivation actually occurs.
Laryngospasm is also exceedingly rare, occurs more often with high doses, - above what we use for depression, - and can usually be managed by bagging.
None the less, both these reactions need to be borne in mind when using the drug, and information concerning them should be a part of informed consent.
Many ER docs and anesthetists are concerned about managing the emergent reactions which can occur. The most likely patient to develop an emergent reaction is a young woman between the ages of 17 and 23 who dreams in colour.
The best way to manage an emergent reaction is to discuss its possibility prior to administering the drug, informing the patent that when emerging from the effects of the drug, things may seem a little unusual for 5 - 15 minutes, and emphasize that this is an effect of the medication, that it can be odd sometimes, but that it will assuredly pass, and we can give something to the patient if it is troubling. The usual medication used is 1 - 2 Mg of Midazolam I.V..
There are many protocols for using Ketamine for depression. The dosage is usually .35 Mg/Kg I.V.. Some workers put it in a mini bag and infuse it over 15 minutes. Others give it by I.V. push.
The protocol I have used most frequently is .35 Mg/Kg. I.V. push. I always stay with the patient for the first five minutes or so, and sometime longer. I also put my phone under their pillow and play some relaxing music, - what Ali once called "Spa Music." The type music itself is not particularly important, except that it should never contain English words, and should be calming rather than excitatory.
I prepare the patient for the experience by telling them that the psychological material which surfaces can be a bit dreamy like, that occasionally it can be weird or even frightening, and that two things are important to understand. Firstly that these images and sensations are the because they have taken the drug, and that they will pass, and secondly, that they should not try to interpret or talk about the experiences in any way during the experience itself. Instead, they should simply breathe through whatever is happening, and we can discuss it at the end of the experience. I try to emphasize this aspect of the experience if they become distressed or agitated - which can sometimes happen, - during the experience. It is important to note that often on emergence, at least partial amnesia has occurred.
At NGH ER I have given Ketamine to approximately 15 people in the course of the time I have been using it for this indication. 13 have had excellent short term results, and two have had very unusually successful log term results. One of these was a man who was acutely suicidal, partly as a result of drinking a dozen beers and some wine per day for several years, as a result of a PTSD he experienced after an assault. When I saw him again for anther indication nine months later, his depression had lifted and he was down to one glass of wine at supper.
One of the two failures was a woman who I misdiagnosed. Her actual reason for being in the ED was drug seeking for her Benzos which had run out prematurely, which I did not recognize until she said, "that was interesting, but I am not any better. Now can I have a prescription for my Ativan." The second was a woman in an acute situational crisis. She did not have any bad effects from the Ketamine, even though her experience was among the weirdest of the patients I have treated in this fashion, but neither did she get any relief. She was hospitalized at BGH later that day, and has ultimately done well.
Ketamine can also be used in large doses for sedation for the wilder patients who come in wishing to re decorate Exam 2. Doses of up to 200 Mg. I.M. have been used for this indication, quite safely, instead of the usual Haldol/Ativan combo. It is however important to understand that at these dosages, - as opposed to .35 Mg/Kg., you are doing procedural sedation, and all the safety requirements associated with this need to be in place.
I think Ketamine as a treatment for acute suicidal depression is worth while considering. It is no different than using Ketamine for procedural sedation, or for post intubation sedation and pain management. There is no need to be scared of the medication, and there is an emerging corpus of literature to support your decision. There is also a race on in the pharmaceutical industry to develop analogues of Ketamine that have the same effects, but are devoid of the dissociative effects. You may follow the link below to take a look at some of these.
http://www.npr.org/sections/health-shots/2015/05/28/409800015/ketamine-depression-treatments-inspired-by-club-drug-move-ahead-in-tests?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20150528
The principal barriers to its use in ED are the possibility of excessive salivation, the possibility of laryngospasm, and the so called emergent reaction. The hyper salivation used to be treated in an anticipatory fashion using atropine or glycopyrrolate, however, this side effect is now considered so rare, that most clinicians who use the drug frequently, will only give these meds if the hyper salivation actually occurs.
Laryngospasm is also exceedingly rare, occurs more often with high doses, - above what we use for depression, - and can usually be managed by bagging.
None the less, both these reactions need to be borne in mind when using the drug, and information concerning them should be a part of informed consent.
Many ER docs and anesthetists are concerned about managing the emergent reactions which can occur. The most likely patient to develop an emergent reaction is a young woman between the ages of 17 and 23 who dreams in colour.
The best way to manage an emergent reaction is to discuss its possibility prior to administering the drug, informing the patent that when emerging from the effects of the drug, things may seem a little unusual for 5 - 15 minutes, and emphasize that this is an effect of the medication, that it can be odd sometimes, but that it will assuredly pass, and we can give something to the patient if it is troubling. The usual medication used is 1 - 2 Mg of Midazolam I.V..
There are many protocols for using Ketamine for depression. The dosage is usually .35 Mg/Kg I.V.. Some workers put it in a mini bag and infuse it over 15 minutes. Others give it by I.V. push.
The protocol I have used most frequently is .35 Mg/Kg. I.V. push. I always stay with the patient for the first five minutes or so, and sometime longer. I also put my phone under their pillow and play some relaxing music, - what Ali once called "Spa Music." The type music itself is not particularly important, except that it should never contain English words, and should be calming rather than excitatory.
I prepare the patient for the experience by telling them that the psychological material which surfaces can be a bit dreamy like, that occasionally it can be weird or even frightening, and that two things are important to understand. Firstly that these images and sensations are the because they have taken the drug, and that they will pass, and secondly, that they should not try to interpret or talk about the experiences in any way during the experience itself. Instead, they should simply breathe through whatever is happening, and we can discuss it at the end of the experience. I try to emphasize this aspect of the experience if they become distressed or agitated - which can sometimes happen, - during the experience. It is important to note that often on emergence, at least partial amnesia has occurred.
At NGH ER I have given Ketamine to approximately 15 people in the course of the time I have been using it for this indication. 13 have had excellent short term results, and two have had very unusually successful log term results. One of these was a man who was acutely suicidal, partly as a result of drinking a dozen beers and some wine per day for several years, as a result of a PTSD he experienced after an assault. When I saw him again for anther indication nine months later, his depression had lifted and he was down to one glass of wine at supper.
One of the two failures was a woman who I misdiagnosed. Her actual reason for being in the ED was drug seeking for her Benzos which had run out prematurely, which I did not recognize until she said, "that was interesting, but I am not any better. Now can I have a prescription for my Ativan." The second was a woman in an acute situational crisis. She did not have any bad effects from the Ketamine, even though her experience was among the weirdest of the patients I have treated in this fashion, but neither did she get any relief. She was hospitalized at BGH later that day, and has ultimately done well.
Ketamine can also be used in large doses for sedation for the wilder patients who come in wishing to re decorate Exam 2. Doses of up to 200 Mg. I.M. have been used for this indication, quite safely, instead of the usual Haldol/Ativan combo. It is however important to understand that at these dosages, - as opposed to .35 Mg/Kg., you are doing procedural sedation, and all the safety requirements associated with this need to be in place.
I think Ketamine as a treatment for acute suicidal depression is worth while considering. It is no different than using Ketamine for procedural sedation, or for post intubation sedation and pain management. There is no need to be scared of the medication, and there is an emerging corpus of literature to support your decision. There is also a race on in the pharmaceutical industry to develop analogues of Ketamine that have the same effects, but are devoid of the dissociative effects. You may follow the link below to take a look at some of these.
http://www.npr.org/sections/health-shots/2015/05/28/409800015/ketamine-depression-treatments-inspired-by-club-drug-move-ahead-in-tests?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20150528
Friday, June 5, 2015
Colorado Doctor Finds Way To Treat Common Vertigo « CBS Denver
Colorado Doctor Finds Way To Treat Common Vertigo « CBS Denver
Faster and easier to explain than the Epley I think.
Faster and easier to explain than the Epley I think.
Wednesday, June 3, 2015
Possible Approach to PEA
as discussed in http://rebelem.com/a-new-pulseless-electrical-activity-algorithm/
My perspective; very interesting idea. My only concerns would be that it generally goes against ACLS and that is a pretty concrete and pervasive guideline to go against, for better or worse.
Thoughts?
My perspective; very interesting idea. My only concerns would be that it generally goes against ACLS and that is a pretty concrete and pervasive guideline to go against, for better or worse.
Thoughts?
A New Simplified and Structured Method in the Evaluation and Management of Pulseless Electrical Activity
What are the traditionally taught H’s and T’s of PEA?
*Hypoglycemia and trauma have been removed from the most recent ACLS guidelines.
What is the new diagnostic classification of PEA?
- Step 1: Determine if the PEA is narrow (QRS duration <0.12) or wide (QRS duration ≥0.12) simply by looking at the telemetry monitor
- Step 2: Narrow-complex PEA is generally due to mechanical problems caused by right ventricular inflow or outflow obstruction
- Step 3: Wide-complex PEA is typically due to metabolic problems, or ischemia and left ventricular failure
Narrow-Complex PEA
Point of care ultrasound (POCUS) can quickly aid in identification of mechanical causes of PEA. A collapsed right ventricle suggests an inflow obstruction (i.e tamponade, pneumothorax, or hyperinflation) whereas a dilated right ventricle indicates outflow obstruction (i.e. Pulmonary emobolism).
Most Common Causes:
- Cardiac Tamponade
- Tension Pneumothorax
- Mechanical Hyperinflation
- Pulmonary Embolism
Treatment:
- Aggressive intravenous fluid administration
- Cardiac Tamponade –> Pericardiocentesis
- Tension Pneumothorax –> Needle decompression
- Mechanical Hyperinflation –> Adjust ventilator
- Pulmonary Embolism –> Thrombolytic therapy
Wide-Complex PEA
This typically suggests a metabolic or toxic ingestion problem. Hyperkalemia and/or sodium channel blocker toxicity.
Treatment:
- Hyperkalemia –> Intravenous calcium chloride or gluconate
- Hyperkalemia or Sodium Channel Blocker Toxicity –> Sodium bicarbonate
Discussion:
This new classification system of PEA has 3 potential benefits compared to the traditional ACLS 5 H’s and 5 T’s
- Rather than randomly listing 10 – 13 causes of PEA by memorizing the H’s and T’s, this new algorithm categorizes the possible causes of PEA based on the easy finding of QRS complexes being narrow or wide.
- Within each category there is a marked decrease in the etiologies one has to remember and is based on the etiologies with the highest likelihood and clinical relevance.
- This algorithm also provides specific treatment recommendations that are based on the initial QRS morphology.
What are the limitations of this classification system?
- This algorithm does not apply to the trauma setting
- This algorithm has not been systematically tested for inclusiveness or resuscitation outcomes
- Narrow-complex PEA almost always indicates a mechanical cause, but occasionally mechanical causes can present with wide-complex PEA. (i.e. pre-existing bundle branch blocks, massive PE causing RBBB, and acute MI causing new LBBB)
Conclusion: Using the new classification system of PEA simplifies the working differential and initial treatment approach in conjunction with bedside ultrasound, however this strategy has not been tested systematically, tested for resuscitation outcomes, and caution should be used before implementing this algorithm until further studies are performed in the clinical setting.
The inaugural post of the NGH EMERGENCY DEPARTMENT BLOG
I had discussed this idea with Sean and we felt it could be a great tool for us to collaborate with resources, as well as discuss issues and ideas regarding our department. I will do my best to get this set up so we can all contribute. I will be the moderator officially I suppose, but will serve mainly to keep things pruned down so that it is not too messy. I would be hoping for someone else to share this role.
You have all been invited.
You have all been invited.
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