EMS Protocol of the Week - Excited Delirium (Adult and Pediatric)

Ever wonder why the occasional crew would look to give a whopping 10mg IM midazolam to the curmudgeonly, 50-pound grandma?

Historically, the only protocol that has allowed for sedative medications to be given to facilitate transport has been that for excited delirium, which by definition is supposed to be the hypermetabolic state in which the patient that is presenting an acute risk to self or others; there has not been a protocol for the simply agitated, uncooperative patient. That is still the case now, but in instances of dangerously aggressive geriatrics and pediatrics, there is now a greater shift to weight-base dosing when administering these meds. This has been an overarching change to many of the updated protocols this year, and it means that while the young, large, violent adult may still get the appropriate 10mg IM midazolam by Standing Order, the old, tiny, violent nana might only get 5mg, or less. Time will tell, but hopefully this leads to fewer instances of oversedation, without a large increase in OLMC calls requesting additional meds.

Happy sedating! www.nycremsco.org and the protocol binder for more.

Dave

POTD: Dialysis Catheter Placement

General:

·      Non-tunneled catheters and Tunneled cuffed catheters

o   Non-tunneled: IJ, subclavian, femoral vein

o   Tunneled: Cuffed catheters are inserted under fluoroscopic guidance into subclavian vein

·      Catheters placed through the IJ or subclavian optimal tip location is at the junction of the superior vena cava and right atrium roughly around 15cm in length is appropriate.

·      Subclavian vein less commonly used in acute emergency setting because as flow rates may be more reduced, the site carries associations with subsequent subclavian vein stenosis, making placement of a tunneled cuffed catheter or surgical AV fistula more difficult in the future.

·      Femoral vein catheters should be >20cm in length so that the tip of the catheter can pass through the common iliac vein and reach the IVC

·      Wikem Lengths:

o   Right IJ: 12-15cm – less complications like kinking, obstruction, stenosis

o   Left IJ: 15-20cm – more tortuous leading to reduced flows

o   Femoral: 19-24cm – reduces patient mobility. If the RRT Circuit is constantly shutting down, or having low flows, check the HD catheter length.  If the catheter tip is not long enough to reach the distal IVC, the RRT pump will often shut down secondary to inadequate flows.

Contraindications:

·      Local infection over insertion site

·      Thrombosis or stenosis within the target vein

·      Distorted anatomy

·      Local vascular injury

Complications:

·      Similar complications to central lines

·      Thrombosis

·      Infection

·      Pneumothorax

·      Stenosis of central veins

·      Dialysis catheter kinking or poor position of tip

Interesting Article from 2015:

https://www.ebmconsult.com/articles/catheter-related-blood-stream-infections-femoral-vs-internal-jugular-subclavian

·      Two RCTs independently demonstrated no significant difference in major infection (sepsis) rates between the three sites.

·      Similarly, a Cochrane review and systematic review/meta-analysis reported no significant difference in complications (CRBI or DVT) between the femoral and subclavian or IJ sites.

·      Femoral line colonization, however, was intuitively noted to be increased in morbidly obese patients.

References

https://www.statpearls.com/ArticleLibrary/viewarticle/37044

https://www.ebmconsult.com/articles/catheter-related-blood-stream-infections-femoral-vs-internal-jugular-subclavian

https://emcrit.org/emcrit/femoral-central-lines/

https://wikem.org/wiki/Dialysis_catheter_placement

Wellness: Second Victim Syndrome

Medicine is a stressful career, and health care provider wellness is sometimes neglected within the culture of medicine

Throughout our medical training we have had the opportunity to treat and learn from the patients every day. We are exposed to an extremely difficult working environment and are constantly witnessing terrifying traumatic events that most people never see in their lifetime. 

During the past few months in our emergency department, we have recently seen multiple level 1 traumas, pediatric, and adult cardiac arrests. In this stressful environment it is very easy for medical errors or patient safety issues to occur. It is important that we take care of ourselves, support each other, and to utilize extra help if/when needed.

Today, I wanted to speak about second victim syndrome.  

What is second victim syndrome?

·      The second victim syndrome (SVS) is defined as the Health Care Providers (HCP) who commit an error and are traumatized by the event manifesting psychological (shame, guilt, anxiety, grief, and depression), cognitive (compassion dissatisfaction, burnout, secondary traumatic stress), and/or physical reactions that have a personal negative impact (similar to symptoms of acute stress disorder)

·      Examples: incorrect medication dosages, missed diagnosis, incorrect medical management, accidental harm during a procedure, among several others.

·      These types of cases are unforgettable and can leave lasting emotional scars on providers.

·      After an adverse event, the prevalence of SVS varied from 10.4% up to 43.3%.

·      Almost half of HCPs experience the impact as an SVS at least one time in their career

What are the impacts of second victim syndrome on providers?

·      Anxiety, depression, guilt, sleep disturbances, loss of confidence in their practice, and decreased job satisfaction.

·      Isolation, depression, and suicidality

·      Numerous reports in the literature discuss providers (nurses, residents, attending physicians) who died by suicide following a significant event that led to patient harm.

RESIDENTS ARE AT VERY HIGH RISK!

·      Residents are in the learning phase and are expected to make mistakes during their training given their relative levels of inexperience combined with high levels of clinical accountability.

·      According to one study, the prevalence of fourth-year students involved in a medical error was 78% - compared to 98% of residents.

·      A survey of more than 3100 physicians from the U.S. and Canada found that 81% of those who had been involved in a clinical event (serious error, minor error, or near miss) experienced some degree of emotional distress.

How can we identify this?

·      May display similar emotions and behaviors to those experiencing burn out or acute stress disorder or burn out

What can we do to help each other?

·      Peer supporters, patient safety, and risk management all play a critical role in ensuring the provider has a safe space to recover from the event.

·      While support from friends, significant others and supervisors are important, most providers prefer support from a trusted colleague

·      Receiving support from a colleague from within one’s own specialty offers a sense of shared understanding about the complex nature of patient care. It also normalizes the situation for the affected provider.

·      Projects such as clinical event debriefing and help recognize systems errors, near misses, incidents, etc. They can also be used to help set up peer meetings and services if individuals are suffering.

References

https://omh.ny.gov/omhweb/bootstrap/crisis.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697646/

Second victims in health care: current perspectives

www.ncbi.nlm.nih.gov

Medical errors are a serious public health problem and the third-leading cause of death after heart disease and cancer. Every day, the health care professionals (HCPs) practice their skill and knowledge within excessively complex situations and meet unexpected ...

https://www.emra.org/books/emra-wellness-guide/ch-8.-second-victim-syndrome/#:~:text=The%20second%20victim%20is%20the,becomes%20traumatized%20by%20the%20event.

Thank you for your time!