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

(louisa.ng@health.nsw.gov.au)

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

aci-info@health.nsw.gov.au

www.aci.health.nsw.gov.au

Many thanks!

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26/11/2019 08:00 am

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