May 28, 2020

Background Information:

Physicians have and continue to heavily contribute to the current opioid epidemic in the United States and Canada.1 Although much of the focus has been opioid prescriptions given to patients in the emergency department,2,3 not much attention has been paid to critically ill patients who survive to hospital discharge. The long-term sequelae of these opioids is concerningly overlooked especially when physicians utilize these medications as part of an “analgesia first” approach to sedating critically ill patients for the purposes of invasive mechanical ventilation (IMV).4 Previous observational studies in Canada found that approximately 85% of critically ill patients receiving IMV were exposed to opioids.1 Furthermore, the average daily opioid dosing for 2-7 days was 63 milligrams of morphine equivalent (MME), increasing to 106 MME per day for patients receiving IMV for greater than 7 days. The authors of this study performed a retrospective chart review of population-based data from Ontario Canada to investigate the frequency of new opioid initiation and persistent opioid use among critically ill patients who received mechanical ventilation. They compared this to patients who were hospitalized but not critically ill.

July 1, 2019

EMS rolls in with a 28 year-old male brought in for severe agitation after being found smashing glass bottles in the street. As police approached him, he cut himself with the broken glass and was bleeding significantly, though they could not fully evaluate his wounds due to his agitation. He was restrained by 6 officers and brought to you without IV access. He is thrashing around on the gurney in 4-point restraints, with blood soaking through the gauze bandages on his arms. What do you do?

November 26, 2018

Background Information: Delirium is defined as an acute disorder of consciousness which can occur in up to 80% of mechanically ventilated ICU patients.1-5 This acute cognitive dysfunction is associated with prolonged hospital stay, increased mortality, longer periods of mechanical ventilation and long-term cognitive impairment compared to patients without delirium.4-8  Haloperidol, remains one of the most commonly used typical antipsychotics used to treat delirium internationally and within the United States.9,10 The Society of Critical Care Medicine’s recent guidelines do not suggest the use of Haloperidol in the prevention or treatment of delirium11 and understandably so as two randomized trials showed no reduction in duration of ICU delirium.5,12 Alternative therapies for delirium include atypical antipsychotics such as ziprasidone, however the literature shows conflicting evidence, with one study showing a benefit and another showing no effect.5,13 The authors of this study sought to examine the effects of these two treatments in a large multicenter, randomized, double-blinded, placebo-controlled trial.      

August 13, 2018

Background: Emergency providers frequently care for agitated patients ranging from restlessness to verbally and physically aggressive. Agitation is a symptom, not a diagnosis and these patients require careful evaluation to rule in or out serious medical conditions. Unfortunately, the agitation itself often obstructs this evaluation and places the patient, other patients and staff at risk. While verbal de-escalation can be effective in select cases, administration of medications for behavioral control is often required. Numerous medications are available for this indication, but the optimal approach is still unclear.

July 3, 2018

Background: In recent years, ketamine use has dramatically increased in the Emergency Department (ED). There are four major indications for the use of ketamine in the ED: analgesia with low dose ketamine (LDK), induction for rapid sequence intubation, procedural sedation and sedation of the agitated patient. A number of relative contraindications for ketamine exist though many of them have been debunked through analysis of the evidence. This includes the dogma that ketamine cannot be used in patients with head trauma (for fear of increasing the ICP) or in patients with hypertension or tachycardia.

One contraindication that persists, though, is that of a history of psychiatric illness. Ketamine is an N-methyl-D-aspartic acid (NMDA) receptor antagonist and it can produce a broad range of cognitive and behavioral disturbances including psychosis. These disturbances are short-lived in the majority of individuals but there is a fear that ketamine can cause decompensation of psychiatric illness. The ACEP Clinical Policy lists psychiatric illness as an absolute contraindication for dissociative sedation with ketamine (Green 2011).