Week 5 Flashcards
What is the presentation of Ketamine?
200mg in 2mL
What is the treatment for a patient who falls under the mild/moderate agitation category?
Midazolam 5 - 10mg IM
repeat @10mins
Max dose 20mg
What are some potential differential diagnosis of excited delirium?
serotonin syndrome sympathomimetic syndrome diabeteic hypoglycaemia drug withdrawal heat stroke
When should sedation be administered for HYPERTHERMIC psychostimulant overdose?
administered early to help with cooling
What is Instrumental aggression?
Premeditated ‘COLD’ goal directed
More proactive
what are some psychiatric causes of excited delirium?
acute psychosis
mania
schizophrenia
WHat are the side effects of midaz?
depressed level of consciousness
resp depression
loss of airway control
hypotension
what is the peak time of midaz IM?
15 mins
In all cases where sedation is administered, supportive care should be provided as required, this includes what?
- airway management
- supplmentary O2 if sedated with midaz of ket
- perfusion management
- temperature management
- management of causes of agitation
what factors contribute to aggression?
hypoglycaemia psychiatric illness substance abuse head injury hypoxia metabolic imbalances frustration
What is the pharmacology of ketamine?
a rapid acting dissociative anaesthetic agent
What does cocaine do to affect dopamine levels?
chronic use leads to dopamine depletion, affecting dopaminergic balance, leading to:
- cardiac hypertrophy
What is the pathophysiology of excited delirium?
Dopamine hypothesis:
depletion of dopamine levels fucks with them basically.
What are the contras for ketamine?
hypersensitivity
sever hypertension >180
When should you consult before administering sedatives?
if GCS 10-14
or if outside guidelines
What is the treatment for a patient who falls under the extreme agitation category?
Ketamine IM
<60kg = 200mg
60-90kg = 300mg
>60kg = 400mg
If Ket unavailable:
Midazolma 20mgIM
Repeat @10min
Max 40mg
What is the onset time of ket IM?
3-4 mins
What are bath salts?
synthetic cathinones
What are the risks of chemical restraint?
decreased level of consciousness
resp depression
asphyxiation
hypotension
what are some metabolic/endocrine causes of excited delirium?
electrolyte imbalances hypoxia hyperglycaemia hypoglycaemia uremia thyrotoxicosis
what are some toxicological causes of excited delirium?
alcohol
amphetamines
cocaine
What is the presentation of midazolam?
5mg in 1mL
What are the elements of excited delerium?
bizzare/aggressive behaviour dilated pupils fear and panic hyperthermia incoherent speech tachypnoea nakedness profuse sweating shivering increased pain tolerance unusual strength mirror/glass attraction
What is the duration of ket IM?
12-25 mins
What are the 5 steps in behavioural assessment for hostile aggression?
- minor movements (clenching fists)
- verbal abuse and threats
- major motor movements (pacing)
- aggression
- exhaustion
How do bath salts work?
synthetic cathinones target monamine transporters:
they disrupt the function of monoamine transporter proteins expressed on neurons in the central and peripheral NS
What are the potential clinical caused for agitation to considers as per AV CPG’s?
AIEOUTIPS A- alcohol/drugs E - epilepsy I - Insulin or other metabolic cause O - overdose/oxygen U - underdose T - Trauma I - Infection/sepsis P - Pain/psychiatric S - stroke / TIA
How do you differentiate excited delirium syndrome (ExDS) from sympathomimetic syndrome?
more likely to dislpay bizarre abnormal behaviour with non-toxic amount of recent drug use
such as walking through traffic/being naked in public etc
What are the side effects of ketamine?
increase BP and HR
Resp depression
emergence reactions
enhanced skeletal tone
nausea and vomiting
Diplopia
Nystagmus
Lacrimation
Salivation
What is the onset time of midaz IM
3-5mins
What is the duration if midaz IM?
30 minutes
what is the pharmacology of midaxzolam?
short acting CNS depressant
What are the risk factors for aggression and violence?
Past history of aggression Male Youth Anti-social traits Substance misuse Intoxication Impulsivity Irritability Suspiciousness Mental Illness
What is the treatment for an elderly/frail patient who falls under the mild/moderate agitation category?
Midazolam 2.5 - 5mg IM
repeat @10mins
Max dose 20mg
What is the preferred site for IM administration?
antereo-lateral mid thigh
What are some of the more potential signs of aggression?
under influence slurred speech sarcastic and abusive intruding on personal space hostile facial expressions blood stained clothes possession of a weapon obvious motor restlessness
what are some neurogenic causes of excited delirium?
dementia
head injury
seizure
post-ictal state
what is aggression?
any offensive action, attach, or procedure or encroachment upons ones rights
Psychiatric definition: overt or suppressed hostility, either innate or resulting from continued frustration and directed outwards
What is hostile aggression
im[ulsive ‘HOT’ unplanned and driven by anger
reactive
What are two types of aggression?
Hostile aggression
Instrumental aggression
What are the contraindications of midazolam?
hypersensitivity to benzodiazepines
What other causes of agitation should you consider apart from AIEOUTIPS?
extreme grief
What is the target therapeutic dose of ketamine for patients affected my methamphetamines and classed under extereme agitation?
4mg/kg IM or 1mg/kg IV
what are some signals of agitation?
restlessness/fidgeting may try to remove IV or O2 no intent to injure may fight against interventions appear anxious
Define agitation?
the act or process of agitating, state of being agitated
it is an unpleasant state of extreme arousal, increased tension, irritability, restless or anxious
what are some causes of agitation?
Drugs/alcohol Head injury Intyracerebral pathology (eg dementia) Hypoglycaemia Hypoxia Post-ictal Extreme emotion, stress Psychiatric condition Pain or discomfort Delirium
What is the dose for ketamine administration in extreme agitation?
Ketamine IM
<60kg = 200mg
60-90kg = 300mg
>60kg = 400mg
