On this episode I am lucky to have Dr. Reuben Strayer on to discuss the management of agitated patients. Dr. Strayer is an emergency physician in New York City and has interest and expertise in the management of agitation as well as sedation and airway management. Agitated patients are often challenging to treat. They require a high-level of assessment skill and a tailored treatment plan. There is a spectrum of agitation and it is important to determine where your patient falls to choose the correct management. This episode is a framework of the agitation spectrum and treatment options for the various types of patients we see.

Ketamine dose continuum (all doses IV unless indicated) With ketamine the two therapeutic ranges are analgesic and dissociation. We generally avoid the two middle ranges. For agitation, the only reliable use is to target dissociation using at least 3 mg/kg IM.

A Law Enforcement Approach to ExDS

References and Resources

https://www.nuemblog.com/blog/chemical-sedation

https://www.acepnow.com/article/droperidol-is-back-and-heres-what-you-need-to-know/

http://www.tamingthesru.com/blog/2019/4/20/the-return-of-droperidol

https://havokjournal.com/fitness/medical/ketamine-it-may-not-be-a-solution-for-everything-but-its-not-at-fault-here/

Vilke GM, Payne-James J, Karch SB. Excited delirium syndrome (ExDS): Redefining an old diagnosis. J Forensic Leg Med. 2012;19(1):7-11. doi:10.1016/j.jflm.2011.10.006


Riddell J, Tran A, Bengiamin R, Hendey GW, Armenian P. Ketamine as a first-line treatment for severely agitated emergency department patients. Am J Emerg Med. 2017;35(7):1000-1004. doi:10.1016/j.ajem.2017.02.026


Parsch CS, Boonstra A, Teubner D, Emmerton W, McKenny B, Ellis DY. Ketamine reduces the need for intubation in patients with acute severe mental illness and agitation requiring transport to definitive care: An observational study. EMA – Emerg Med Australas. 2017;29(3):291-296. doi:10.1111/1742-6723.12763

Miner JR. Ketamine is a good first-line option for severely agitated patients in the prehospital environment. Am J Emerg Med. 2018;36(3):501-502. doi:10.1016/j.ajem.2017.12.015

Michaud A. Restraint related deaths and excited delirium syndrome in Ontario (2004-2011). J Forensic Leg Med. 2016;41:30-35. doi:10.1016/j.jflm.2016.04.010

Linder LM, Ross CA, Weant KA. Ketamine for the Acute Management of Excited Delirium and Agitation in the Prehospital Setting. Pharmacotherapy. 2018;38(1):139-151. doi:10.1002/phar.2060

Isbister GK, Calver LA, Downes MA, Page CB. Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2016;67(5):581-587.e1. doi:10.1016/j.annemergmed.2015.11.028

Hopper AB, Vilke GM, Castillo EM, Campillo A, Davie T, Wilson MP. Ketamine use for acute agitation in the emergency department. J Emerg Med. 2015;48(6):712-719. doi:10.1016/j.jemermed.2015.02.019

Gonin P, Beysard N, Yersin B, Carron PN. Excited Delirium: A Systematic Review. Acad Emerg Med. 2018;25(5):552-565. doi:10.1111/acem.13330

Khokhar MA, Rathbone J. Droperidol for psychosis-induced aggression or agitation. Cochrane Database Syst Rev. 2016;12(12):CD002830. Published 2016 Dec 15. doi:10.1002/14651858.CD002830.pub3

Lai PC, Huang YT. Evidence-based review and appraisal of the use of droperidol in the emergency department. Ci Ji Yi Xue Za Zhi. 2018;30(1):1-4. doi:10.4103/tcmj.tcmj_195_17

Klein LR, Driver BE, Miner JR, et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018;72(4):374-385. doi:10.1016/j.annemergmed.2018.04.027

Nobay F, Simon BC, Levitt MA, Dresden GM. A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Acad Emerg Med. 2004;11(7):744-749. doi:10.1197/j.aem.2003.06.015

Silbergleit R, Lowenstein D, Durkalski V, Conwit R; Neurological Emergency Treatment Trials (NETT) Investigators. RAMPART (Rapid Anticonvulsant Medication Prior to Arrival Trial): a double-blind randomized clinical trial of the efficacy of intramuscular midazolam versus intravenous lorazepam in the prehospital treatment of status epilepticus by paramedics. Epilepsia. 2011;52 Suppl 8(Suppl 8):45-47. doi:10.1111/j.1528-1167.2011.03235.x

Ramsay RE, Wilder BJ, Uthman BM, et al. Intramuscular fosphenytoin (Cerebyx®) in patients requiring a loading dose of phenytoin. Epilepsy Res. 1997;28(3):181-187. doi:10.1016/S0920-1211(97)00054-5

Hopkins U, Arias C. Large-volume IM injections: a review of best practices. Oncol Nurse Advis. 2013;4(february):32-37.

Harrington L. Administer single-site 30-mL intramuscular injection? Medsurg Nurs. 2005;14(6):379-382.

Del Mar CB, Glasziou PP, Spinks AB, Sanders SL. Is isopropyl alcohol swabbing before injection really necessary? Med J Aust. 2001;174(6):306. doi:10.5694/j.1326-5377.2001.tb143279.x

Fleming DR, Jacober SJ, Vandenberg MA, Fitzgerald JT, Grunberger G. The safety of injecting insulin through clothing. Diabetes Care. 1997;20(3):244-247. doi:10.2337/diacare.20.3.244

Khawaja RA, Sikanda R, Qureshi R, Jareno RJM. Routine skin preparation with 70% isopropyl alcohol swab: Is it necessary before an injection? Quasi study. J Liaquat Univ Med Heal Sci. 2013;12(2):109-114.

Sponsored by Prodigy EMS

This is Part II of my discussion with Michael Perlmutter on asthma and COPD management. In this episode we discuss interventions used for advanced/severe asthma exacerbations including magnesium, epinephrine, ketamine, non-invasive positive pressure ventilation, and advanced airway management.

Facebook: https://www.facebook.com/paramedicpractitioner/
Instagram: @paramedicpractitioner
Email: amerelman@gmail.com
Twitter: @amerelman


Image: PulmCrit

References and Further Reading
UpToDatehttps://emedicine.medscape.com/article/296301-overview
https://canadiem.org/management-of-severe-asthma/
http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/
https://rebelem.com/rebelcast-crashing-asthmatic/
https://emcrit.org/ibcc/asthma/
https://asthma.net/treatment/prevention/
https://www.jems.com/2018/04/01/a-modern-approach-to-basic-airway-management/
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1742-6723.2009.01195.x
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/
https://err.ersjournals.com/content/22/129/227.full
https://www.ncbi.nlm.nih.gov/books/NBK430901/
https://www.ncbi.nlm.nih.gov/pubmed/11406055
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2743582/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/
https://www.ncbi.nlm.nih.gov/pubmed/23235634
https://www.ncbi.nlm.nih.gov/pubmed/22479740
https://www.ncbi.nlm.nih.gov/pubmed/26033128
https://www.ncbi.nlm.nih.gov/pubmed/25447559
https://www.ncbi.nlm.nih.gov/pubmed/27289336
https://www.ncbi.nlm.nih.gov/pubmed/18922662
https://www.ncbi.nlm.nih.gov/pubmed/28754601
https://www.ncbi.nlm.nih.gov/pubmed/24865567
https://www.ncbi.nlm.nih.gov/pubmed/24731521
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3777369/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6036522/

In this two-part series I discuss asthma and COPD. These diseases are complex and have a spectrum of severity and presentation. The sickest of these patients require prompt, aggressive care to prevent further deterioration so a thorough understanding of the disease is essential. Michael Perlmutter, flight/critical care paramedic and medical student, joins me for a great conversation on prehospital management of these diseases. This is Part I which covers pathophysiology, diagnosis, and early management. Part II will be released in a couple weeks and will cover treatments used in our more critical patients and advanced stages of exacerbations. As always, please follow us on our various social media accounts and let me know if you have any questions, feedback, or personal experiences to share.


Note: in the podcast at one point I say ipratropium and tiotropium are muscarinics but they are muscarinic antagonists.


Facebook: https://www.facebook.com/paramedicpractitioner/
Instagram: @paramedicpractitioner
Email: amerelman@gmail.com
Twitter: @amerelman

Below are some quick guides to home management of asthma and COPD. The treatment approaches between the two diseases vary. One of the biggest differences is that asthma patients are started on inhaled steroids relatively early in their progression but if you see a patient with COPD on an inhaled steroid, they are likely late in their disease process. By looking at a patient’s home medications you can infer some information about the severity and pathophysiology of their underlying disease.

Image: PulmCrit

References:

References
UpToDate
https://emedicine.medscape.com/article/296301-overview
https://canadiem.org/management-of-severe-asthma/
http://www.emdocs.net/critical-asthma-patient-pearlspitfalls-of-management/
https://rebelem.com/rebelcast-crashing-asthmatic/
https://emcrit.org/ibcc/asthma/
https://asthma.net/treatment/prevention/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157154/
https://www.ncbi.nlm.nih.gov/books/NBK430901/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6434661/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169834/
https://www.ncbi.nlm.nih.gov/pubmed/23235634
https://www.ncbi.nlm.nih.gov/pubmed/22479740

On this quick episode I discuss hyperkalemia, a life-threatening condition commonly missed by out-of-hospital providers. It is essential to recognize the signs and symptoms of hyperkalemia as these patients may require prompt treatment to prevent fatal dysrhythmias.

References:

    http://hqmeded-ecg.blogspot.com/search/label/hyperkalemia
    https://emcrit.org/ibcc/hyperkalemia/
    Durfey N, Lehnhof B, Bergeson A, et al. Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?. West J Emerg Med. 2017;18(5):963–971. doi:10.5811/westjem.2017.6.33033
    Lehnhardt A, Kemper MJ. Pathogenesis, diagnosis and management of hyperkalemia. Pediatr Nephrol. 2011;26(3):377–384. doi:10.1007/s00467-010-1699-3
    Ryuge A, Nomura A, Shimizu H, Fujita Y. Warning: The ECG May Be Normal in Severe Hyperkalemia. Intern Med. 2017;56(16):2243–2244. doi:10.2169/internalmedicine.6895-15

(ECGs from Smith’s ECG Blog http://hqmeded-ecg.blogspot.com)

Subtle hyperkalemia indicated by peaked T-waves and ST segment flattening in V3-V5
Hyperkalemia indicated primarily by peaked T-waves in V2-V4
Wide QRS and significantly peaked T-waves indicating hyperkalemia
Substantially widened QRS with sine wave morphology indicating severe hyperkalemia

Severe Crashing Acute Pulmonary Edema (SCAPE) is a life threatening complication of heart failure. In this episode, I discuss the pathophysiology and modern treatment modalities with flight paramedic and medical student Michael Perlmutter.

References

    Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719–723. doi:10.4103/0972-5229.195710
    Hsieh YT, Lee TY, Kao JS, Hsu HL, Chong CF. Treating acute hypertensive cardiogenic pulmonary edema with high-dose nitroglycerin. Turk J Emerg Med. 2018;18(1):34–36. Published 2018 Feb 2. doi:10.1016/j.tjem.2018.01.004
    Levy P, Compton S, Welch R, Delgado G, Jennett A, Penugonda N, Dunne R, Zalenski R. Ann Emerg Med. 2007 Aug;50(2):144-52. Epub 2007 May 23
    Paone S, Clarkson L, Sin B, Punnapuzha S. Am J Emerg Med. 2018 Aug;36(8):1526.e5-1526.e7. doi: 10.1016/j.ajem.2018.05.013. Epub 2018 May 10.
    Scott Weingart. EMCrit Podcast 1 – Sympathetic Crashing Acute Pulmonary Edema (SCAPE). EMCrit Blog. Published on April 25, 2009. Accessed on July 10th 2019. Available at https://emcrit.org/emcrit/scape/
    IMAGE 2 – Pathophysiology of heart failure, Image from CORE EM
    IMAGE 3 – Spiral of death in heart failure, Image from CrashingPatient.net