emergency - quality, education and safety teleconference...rosengren, d. b. building motivational...
TRANSCRIPT
Emergency - Quality, Education and Safety
Teleconference
Dr Louisa Ng | Advanced Trainee | Emergency Care Institute
October 28 2019
Thanks for joining
House rules
Confidentiality
Respect
AGENDA
• Case reviews
• Underlying causes
• Clinical context
• NSW Health guidance
Participation encouraged throughout
(But please turn off camera & mute mic when not talking)
Closing the loop on a cyclical
vomiter…
Case 1 – Initial presentation to MPS
• 19 y Female BIBA 1628 with vomiting, dehydration and tachycardia
• Vomiting at home for the last 2-3 days
• Multiple presentation for similar symptoms (frequent flyer known to her
department quite well) – previous admissions for cannabinoid hyperemesis
Bit of background
Patient History
• Childhood diabetic (diet and lifestyle)
• Insulin dependant diabetic
• Cannabis user – uses regularly
• Estranged from parents who are also
diabetics and have D+A involvement
• Well known to FACS from a young age
Medication
• Lantus 15U nocte, admitted to not taking for “Weeks”
despite having medication at home
• Endep 30mg mane
• Ondansatron 4mg PRN
Primary Survey conducted:-
Airway: patent, maintaining own
Breathing: spontaneous, nil sob, RR22, spo2 100% RA
Circulation: well perfused, BP 129/102, PR 129-reg, CR<2, skin moist, 20g IVC in L)CF
Disability: Nausea and vomiting for 2-3 days, 0/10 pain
GCS: GCS 15, quiet, minimal conversation
Exposure: temp 35.7
Fluids: IVT Hartman's 1000mls commenced by AO’s, minimal oral fluid intake tolerated
Glucose: 21.4mmols
Ketones: 7.2 mmols
Venous gasI-STAT CG4+
PH - 7.3
Po2 - 30mmHg
PCO2 - 23.0mmHg/L
SO2- 56%
HCO3- 12.5mmol/L
Base Excess- -13mmol/L
Bicarbonate- 13mmol/L
Lactate- 1.4mmol/L
Sodium- 128mmol/L
Potassium-
4.7mmol/L
Calcium- 14.mmol/L
THOUGHTS ON THE CASE?
Confidentiality
Respect
Venous gas
Diabetic Ketoacidosis
I-STAT CG4+
PH - 7.3
Po2 - 30mmHg
PCO2 - 23.0mmHg/L
SO2- 56%
HCO3- 12.5mmol/L
Base Excess- -13mmol/L
Bicarbonate- 13mmol/L
Lactate- 1.4mmol/L
Sodium- 128mmol/L
Potassium-
4.7mmol/L
Calcium- 14.mmol/L
How would you mange this patient?
1. Fluids
2. Insulin
3. Potassium
4. Precipitant
5. Other
Concurrently!
Fluids
1L hartmann’s with ambulance officers
What is her fluid status?
• A) Severe hypovolaemia
• B) Euvolaemia
• C) Mild Hypovolaemia
• D) Cardiogenic shock
Mild hypovolaemia
• Well perfused, BP 129/102, PR 129-reg, CR<2, skin moist
• Corrected sodium is 133-135
• [Na+] + (glucose -10)/3
• Normal saline 0.9% over 1-2 hours and recheck (can give faster if
turns out she is dryer than she looks)
• Needs fluid balance – input and output
Insulin
K is normal
BSL is 21
Ketones 7.2
Would you start an insulin infusion?
Yes or No?
Looking at her blood capillary ketones
of 7.2 though sugars are 21 it puts her
in a higher severity scale or you can
have a suspicion that something else
is going on? (startvation ketonemia,
alcohol excess)
Advice by local friendly
endocrinologist to help guide your
therapy
• Start at 0.1 units/kg/hour (actrapid
50units in 50ml 0.9% sodium
chloride)
• If not eating do not forget to add 5-
10% dextrose when their BGL is
<15
• Check their electrolytes, BUN,
venous pH, Cr and glucose every 2
-4 hours until stable
End points of therapy
If a patient is able to eat then you can restart their subcutaneous insulin regime
Potassium
When starting your insulin infusion you will need to routinely check serum
potassium and other electrolytes
Using i-STAT is a simple easy way to track where you going with BSLs as well
Formal bloods would be nice to confirm these are all correct readings
Diabetic ketoacidosis –Potential precipitants
Potential precipitants?
• Poor compliance!
• Acute abdomen?
• Cannabinoid hyperemesis
• Gastroenteritis/UTI
• Other sources for infection
Percipitant
Abdomen is soft
Unlikely acute abdomen
Rule out infectious
Cannabinoid hyperemesis
Non compliance
Make sure to rule out pregnancy
Other
• Electrolyte balancing
• Antibiotics or treatment of the underlying precipitant
• Administer antiemetics eg metoclopramide or ondansetron
• Consider an antispasmodic eg buscopan
• If N+V persistent can consider droperidol 1-2.5mg IV or midazolam 0.5-1mg
boluses titrated to effect
Quick review of THC
In Australia
Cannabis is the most widely used illicit drug
Strong links with alcohol use or other drug use
In February 2016, the Australian Parliament passed legislation to enable the cultivation of
cannabis for medicinal and related research purposes. The changes came into effect on
30 October 2016.
Medicinal cannabis products are available for specific patient groups under strict medical
supervision. There are currently reviews complete or underway relating to the use of
cannabis for epilepsy in children and adults, multiple sclerosis, nausea and vomiting
resulting from chemotherapy and HIV/AIDs therapy, chronic pain management and
palliative care (DoH 2017). Cannabis cultivated for other purposes remains illegal.
Canabinoid Related Hyperemesis
Well documented but relatively rare syndrome involving episodic severe
nausea and vomiting and abdominal pain which is relieved by exposure to hot
water (shower or bath)
Patients are almost always daily cannabis users for one year a
Most do try to manage at home but some are unable to and require medical
support
Postulated…
Susceptible patients develop a hypersensitivity to cannabis following several
years of exposure
Cannabis has a long half-life of weeks or months in the body and regular use
leads to accumulation and this fives rise tot toxicity in the hypersenstivie patient
Cannabis delays gastric emptying and the toxic patient may lead to gastric
stasis and hyperemesis
The compulsive bathing is because of the presence of cannabinoid reeptors in
the limbic system of the brain and the toxicity may disrupt the thermorgulatory
systems of the hypothalamus and this disruption might settle with hot bathing or
showering.
Differential Diagnosis
Hyperemesis gravidarium
Metabolic disorder’s like Addison’s disease
Migraine variants
Drug withdrawal syndromes
Bulimia and anorexia nervosa
Quick Quiz
A parent rushes in their 3 year old child that consumed a number of their “happy
brownies”. They are interactive and asymptomatic at time of assessment.
What would be the next most appropriate action?
A) Make FACS referral immediately
B) Plan for airway compromise and observe
C) Discharge back home
D) Expect severe vomiting and observe
B) Plan for airway compromise
Resuscitation is rarely required in adults apart from children who may require
intubation and ventilation for a reduced GCS.
It is dose related and will be difficult to know how much THC is in a brownies so
always plan for worse situation. (Uptodate)
Children can present with a life threatening rapid coma which occurs with
hypotonia, abnormal movements, tachycardia and bradycardia lasting for 24-36
hours.
Quick Quiz 2
Which of these would you not see in cannabinoid toxicity?
A) Pinpoint pupils
B) Ataxia
C) Pneumothorax
D) Orthostatic hypotension syndrome
Quick Quiz 2
Which of these would you not see in cannabinoid toxicity?
A) Pinpoint pupils
B) Ataxia
C) Pneumothorax
D) Orthostatic hypotension syndrome
So what happened as an inpatient?
Left after 3 days if IVF
Back to the case…
Would you change anything to her management?
How should we address these presentations? And her future
presentations?
What are some long term options when there has been zero success with
engaging with this patient to make lifestyle changes, cease smoking
cannabis?
Would you have instituted an iDAT?
• Diabetic educator and close follow up in the community
• Update insulin management
• Give a crisis plan to her and when to seek medical assistance
• Attending a diabetic clinic in the next few days
• Follow up phone calls in the community by chronic care team or outreach
team or GP
What about….
What are some long term options when there has been zero success with
engaging with this patient to make lifestyle changes, cease smoking
cannabis?
Would you have instituted an iDAT?
As emergency care providers we should consider the mental health and also
dependency issues with our patients as we may be the first and last people
they tend to see in these emergency situations.
Link with drug and alcohol
Motivational interviewing?
Motivational Interviewing
Evidence based counselling technique that helps patients work through
ambivalence and empowers them to create behavioural change by eliciting
“change talk”. This is more effective than just telling your patient not to do
something which can lead to patient resistance and provider frustration and
apathy.
EMCASES podcast quickhits 7 and 9
Rosengren, D. B. Building motivational interviewing skills: A practitioner
workbook. New York: The Guilford Press. 2018.
Principles and Skills of Motivational Interviewing: RULE OURS mnemonic
The principles of MI are to Resist the righting reflex, Understand your patient’s
motivation, Listen to your patient, and Empower your patient (RULE).
The basic skills of MI are to use Open ended questions, Affirmations, Reflective listening,
and Summaries (OARS).
Readiness ruler of Motivational Interviewing
The readiness ruler is a tool that can be used to elicit change talk that is brief and easy to
use in the emergency department setting with three simple questions:
On a scale of 1-10 how important is it for you to make this change?
How confident are you to make this change?
How ready are you to make this change?
Once they have rated themselves on the scale, an example of a follow up MI question
includes “Why are you at a 5 and not a 3?” to elicit patient directed discussion of what
motivates them to change their behaviour.
Motivational interviewing uses three communication styles: asking, listening and informing.
1.Asking. Use DARN to help generate questions and illicit change talk:
Desire: “What do you want, like, wish, hope?
Ability: “What is possible? What could you do? What are you able to do?”
Reasons: “Why would you make this change? What would be some benefits? What negative outcome or risk would you like to
decrease?”
Need: “How important is this change?”
2.Listening. Let the patient know you are listening, hearing and understanding them by providing short summaries. Offer them as
statements rather as questions. This encourages patients to continue taking.
“You are worried alcohol is affecting your health”
“You feel trapped”
“This is really important to you”
3.Informing. While our job is often to inform, you can do so within in the framework of motivational interviewing:
Ask for permission
Offer several choices
Talk about that others do
Check in to make sure the patient understands “ What do you make of that? What does that mean for you? What more would you
like to know?”
iDAT – Involuntary Drug and Alcohol Treatment Program
Short term care, with an involuntary supervised withdrawal component, to protect the health and safety
of people with severe substance dependence who have experienced, or are at risk of, serious harm
and whose decision making capacity is considered to be compromised due to their substance use.
The NSW Health Drug and Alcohol Treatment Act 2007 (the Act) provides the legislative basis
The Act aims to ensure that involuntary treatment is only used when it will be in the best interests of
the individual and when no other less restrictive means for treating them are appropriate. The Act also
protects the rights of people while they are undergoing involuntary treatment.
Eligibility
•The person has a severe substance dependence, meaning they:
•have a tolerance to a substance
•show withdrawal symptoms when they stop or reduce levels of its use
•do not have the capacity to make decisions about their substance use and
•personal welfare primarily because of their dependence on the substance AND
•The care, treatment or control of the person is necessary to protect the
•person from serious harm, AND
•The person is likely to benefit from treatment for his or her substance dependence but has refused treatment, AND
•No other appropriate and less restrictive means for dealing with the person are reasonably available.
Referrals will be accepted from all over the state as long as the person is 18 years or older.
In deciding whether a person requires involuntary care the AMP may also have regard to any serious harm that may occur
to children in the care of the person, or other dependants.
CLINICAL TOOLS AND GUIDELINES
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/273938/dka-and-honk-chart-2-
2013.pdf
E-QuESTs so far•Atypical Chest Pain - ACS
•Sepsis in the elderly
•Abdominal pain in the elderly - AAA & Ischaemic gut
•Scrotal emergencies
•Deadly headaches
•Paediatric deterioration
•Head injuries
•Opthalmological emergencies
Looking to next month, please…
•Share your cases
•Share your patient safety actions
•Spread the word with your colleagues
What would you like to see / hear about?
Level 4, 67 Albert Avenue
Chatswood NSW 2067
PO Box 699
Chatswood NSW 2057
T + 61 2 9464 4666
F + 61 2 9464 4728
www.aci.health.nsw.gov.au
Many thanks!
Next E-QuEST
26/11/2019 08:00 am
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