For January we’ll look at patients with mental health or substance-related presentations. This was a patient presenting with overdose, being cared for in the ambulatory area of the department. This was the first live-streamed session. I hope shortly we will be able to do this with the majority of simulations so that the wider team can benefit. The simulated case: A man in his 20s presenting after an overdose of mirtazapine and propranolol, tachycardic with some muscle ache but with normal blood pressure. What happened? The healthcare assistant recorded observations and recorded the patient’s history. The importance of safeguarding children was explained and the details of the patient’s children were recorded. TOXBASE was consulted for management guidelines. It was decided to move the patient to majors due to the tachycardia, with a view to move to CDU once medically fit for liaison psychiatry consultation. What did we think? In debrief we discussed: Safeguarding: We talked about how we explain to patients the need for information about children in their care. This can clearly be an emotive topic and one in which intentions can be misunderstood. The group consensus was for a focus on the identification and provision of support as an outcome. Remember that adults who present who do not have children may still care for parents or other vulnerable adults - ask about this. Ask about vulnerability factors: do they feel safe at home? Do they have a support network? Have a look at the SCARF acronym in the “to-do” section below. The specifics of these medications: We talked about some of the specific risks with propranolol (e.g. hypotension - potential to be prolonged especially if sustained release) and mirtazapine (serotonin syndrome) and importance of ECG (QTc), bloods (e.g. CK) and a good examination. Bedside manner: We sometimes see people repeatedly attend with overdose. So it’s really important that we do maintain empathy and don’t burn out. Men with EUPD may be more likely to experience aggression and attend via police custody so it’s important to maintain the same appreciation that they need our help and support. Referring to PLNs: Have a look at the recent referral guidance sent out by email 14/01/21: “In brief the main message is refer early - from START or immediately behind START. Referrals can be made by medical or nursing staff after initial assessment… Mental health assessment can be made in parallel with medical treatment and referral for such assessment should not be delayed”. Cannulation: Consider the likelihood of the cannula being used before putting one in “just in case”. One review has suggested a median of 32.4% cannulas inserted in ED are not subsequently used, and clearly there are well documented risks of them. To do: Have a read of the email on referrals from 14-01-21. It also contains links to the RCEM mental health toolkit [ ] Think about using “SCARF” to cover vulnerability factors with the patient, and ask about them directly: feeling Safe at home? Are there others with Control? Abuse? Relationships? Family/friends? [ ] If you took part in the sim or watched on the livestream, you can use this blog as a starter to reflect on your own experience of it [ ] Blog by: James Keitley ED sim fellow --------------- For clinical decisions please refer directly to the guidance. This blog may not be updated. All images copyright- and attribution-free in the public domain or taken by the author.
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For January we’ll look at patients with mental health or substance-related presentations. In this sim a man with alcohol withdrawal presented following a presumed seizure. We'll repeat this sim next week. The simulated case:
A man in his 40s brought into ED after a presumed unwitnessed seizure having cut down on alcohol during COVID19 lockdown. He moved through START into majors but following another seizure he moved into resus. This self-terminated. What happened? Joint nurse and doctor assessment to establish history and examine the patient. Blood tests, Pabrinex and withdrawal treatment were started. It was decided that the patient needed to be admitted given that he had multiple seizures. What did we think? In debrief we discussed: Role of vitamin replacement: This patient received IV Pabrinex. In alcohol misuse thiamine (vitamin B1) deficiency is more likely, and Pabrinex is used to rapidly replace this vitamin in order to prevent or treat Wernicke’s encephalopathy. Without treatment Wernicke’s can be life-threatening. We talked about the same people may well have nutritional deficiencies that mean they are at risk of refeeding syndrome whilst in hospital. Alcohol liaison: Alcohol liaison specialists are available 08:30-17:00 Monday to Friday. You can find the number in the ‘daily email’ 30/11/20, and I have also added them to the Induction app under “alcohol liaison”. Remember not to presume they are already in contact with services, or presume based on previous presentations that they don’t want to be. The relevant organisations for us are: Plymouth patients - Harbour Cornwall patients - Addaction Devon patients - RISE recovery Raising the alarm: During COVID19 we’ve welcomed many new members of staff to the emergency department. We talked about differences between ED and areas of the hospital that staff have previously worked in, in terms of reasons to pull emergency buzzers. A seizure is a perfectly good reason to pull an emergency buzzer, as is any scenario where you need a greater number of people to be present immediately. To do: If you see a patient like this in-hours, speak to the alcohol liaison team and find out what additional help can be put in place for them [ ] If you took part in the sim, you can use this blog as a starter to reflect on your own experience of it [ ] Blog by: James Keitley ED sim fellow --------------- For clinical decisions please refer directly to the guidance. This blog may not be updated. All images copyright- and attribution-free in the public domain or taken by the author. |
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The Derrifoam BlogWelcome to the Derrifoam blog - interesting pictures, numbers, pitfalls and learning points from the last few weeks. Qualityish CPD made quick and easy..... Archives
October 2022
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