Patients requiring "medical clearance"

Majority of the disease burden that we see in Emergency Departments includes Geriatric pathologies and Psychiatric issues. Whenever Psychiatry evaluates any patient, they always ask for "medical clearance" and want us to mention this specifically on the chart. I often come across patients who visit Emergency Department more than I do as an A&E physician. Regardless, they go through this process of "medical clearance" every time. 

Frequently, it gets difficult to document "medically cleared". For instance, when psych patients have slightly high blood glucose but do not need anything besides some IV fluids or they might come up with a BP of 180/90 due to agitation. Additionally, getting a precise drug history can be a challenge in this subgroup of patients as they frequently take several medications for underlying chronic illnesses. It can be problematic if we document medically cleared on the chart and I believe "No acute medical concerns at this point or Fit for Psychiatric assessment" is a better way to clear these patients. Medical evaluation is used to determine whether the patient has a medical condition that is causing or exacerbating the psychiatric illness. 

At any cost we do not want to miss an underlying medical pathology. Things that we need to look for to r/o organic cause of Psych symptoms:

• ABCs as always
• Vital Signs (PR, BP, RR, Temp, SpO2, Glucose) - Do not ignore abnormal VS
• Pupils and Skin exam (pick cues for toxidromes)
• Focused History (Next of Kin/Paramedics) and Physical exam
• Focus on underlying Psych issues (Drugs/Alcohol, Sexual, Suicidal, Homicidal, Social aspects)
• Medications and Co-Morbidities 
• Document Mental Exam - Appearance, Behaviour, Cognition, Speech, Mood, Insight, Thoughts, Hallucinations

Most of them do not require blood tests. Bloods are done in those with:
1. New-onset psychiatric complaints
2. Abnormal vital signs
3. Elderly
4. Known co-morbid conditions. 

Even Urine Drug Sceen is not  required routinely for all. Most of them will tell you what drugs they have recently taken. Also remember, UDS may have false positive and negatives which can be misleading.


Signs suggesting underlying medical pathology are:

• Abnormal Vital Signs
• Clouded Consciousness 
• Age >40 with no previous Psych issues
• Focal deficits on exam
• Abnormal Physical examination 
• Visual Hallucinations 

Visual hallucinations can also occur in psychiatric illnesses but assume medical pathology until proven otherwise

Take Home:

• Spend more time on history and exam rather than doing bloods on everyone
• Do not ignore abnormal Vital Signs
• Look at issues that often co-exist with Psych illnesses - Drugs/Alcohol, Sexual, Suicidal, Homicidal, Social aspects

Further Reading:

• Korn CS, Currier GW, Henderson SO: Medical clearance of psychiatric patients without medical complaints in the emergency department. J Emerg Med 18: 173, 2000. 
• American Psychiatric Association: Practice guideline for psychiatric evaluation of adults. Am J Psychiatry 152: 63, 1995. 
• Korn CS, Currier GW, Henderson SO: “Medical clearance” of psychiatric patients with- out medical complaints in the emergency department. J Emerg Med 18: 173, 2000. 
• Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO: Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 4: 124, 1997. 
• Broderick KB, Lerner B, Mccourt JD, Fraser E, Salerno K: Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. Acad Emerg Med 9: 88, 2002. 

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

Getting better at diagnosing Delirium

Delirium can be defined as an acute confusional state caused due to medical or pharmacological triggers. Up to 10% of all older patients in EDs have delirium and only about one-third of them are recognized. As frontline healthcare providers, it is essential to recognize delirium as the symptom of a life-threatening underlying medical or surgical condition. The consequences of a missed delirium can be disastrous as they can bounce back with florid sepsis, trauma, seizures. In elderly, delirium may be the only sign of an underlying infection (Pneumonia, Sepsis, ACS, Abdominal infection, Intra-cerebral event). Delirium is often multifactorial in etiology and each cause should be investigated. 

DSM IV defines delirium as:

• Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
• Change in cognition that is not better accounted for by a pre-existing, established, or evolving dementia
• Development over a short period of time (usually hours to days) and disturbance tends to fluctuate during the course of the day
• There is evidence from the history, physical exam, or lab findings that the disturbance is caused by the consequences of a general medical condition

This can be remembered as:

A - Acute and fluctuating (Often reported by a family member or carers)

I - Inattention (Inattention is a hallmark feature of delirium - Can test with months of the years backwards, WORLD or serial 7s)

D - Disorganised thinking (incoherent, rambling, circumstantial, or vague. (irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)

A - Altered Mental Status (hyperactive, drowsy, stuporous, comatose)

  

Causes of Delirium:

• Systemic Diseases (Infections, ACS, Hepatic Enceph, Metabolic - Na/Glucose/Ca disturbances)
• Medications (Anticholinergic, Antiparkinsonian, Antiemetics)
• Withdrawal (Discontinuation or overdose of any medication, alcohol, sedative hypnotics)
• CNS Pathology (CVA, Subdural hematoma, Meningitis, Seizures – non convulsive, Hypertensive encephalopathy)

Infections are the most commonly encountered cause of delirium in elderly and medications are the most common reversible causes of geriatric delirium.

Why is Delirium missed in ED? 

We frequently assume that most older people have baseline cognitive impairment. Collateral History and paying attention to what caregivers say is crucial. Delirium can present in hypoactive, hypoactive or mixed form. Therefore, it does not always present as restlessness or agitation, in fact hypoactive delirium is the commonest. Using formal assessment methods is the best way to avoid such mishaps. 

Managing Delirium

Most delirious patients need admission unless we find a single, reversible cause and patient has good social support and someone to observe him at home. 

Non-Pharmacologic 

• Manage pain and avoid unnecessary restraints including catheters and non-essential monitor leads
• Promote mobility and encourage to eat and drink
• Address bowel and bladder function
• Increase sensory stimulation (hearing aid, eye glasses)
• Enhance orientation and familiar faces (family)
• Minimize medication changes 

Pharmacologic 

Medications should be used if evaluation is prevented or if the patient gets severely agitated. Haloperidol remains the drug of choice (Not Benzodiazepines). Use BZD only in case of drug withdrawals. Use Haloperidol 0.5mg-1.0mg PO/IM/SC/IV every 30min to 1hr and frequently reassess. Haloperidol is a potent anti-psychotic with limited anti-cholinergic effects though it may cause problems in Parkinsonian patients because of increased extra pyramidal symptom.

Preventing Delirium

ED Stay > 8 hrs itself is a risk factor for delirium. High Risk groups include dehydrated patients, demented and restrained patients, those who were left in the corridor overnight, visually and hearing impaired. 

Further Reading

• Altered Mental Status in Older Emergency Department Patients - Wilber, Scott T. Emergency Medicine Clinics , Volume 24 , Issue 2 , 299 - 316 
• The Acutely Confused Elderly Patient

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

The Crashing Patient Conference: A Must Go!

As I was putting together my slides for the ACEP 2017 Conference, I saw a tweet pop up. It was by Dr. Amal Mattu (@amalmattu) advertising about The Crashing PatientConference in Baltimore in October 2017. It was the very same month I was going to Washington DC for my one month of clinical rotation at George Washington University Hospital. I was super-excited! It became a top priority to register myself for the conference. I was dreaming of meeting my Emergency Medicine gurus in person and this was an excellent opportunity, which I could hardly lose.

The Crashing Patient Conference is an annual one da conference which has many short lectures with ‘to the point’ pearls. This year’s theme was resuscitation and risk management. There were different lectures encompassing critical care, resuscitation, shock, cardiology, endocrine emergencies, orthopaedics, paediatrics, urology, burns and most importantly medico-legal.

I will summarize the pearls here from each session. Dr. Mike Winters reviewed critical care quickies with an interesting case that he had encountered.

1)     Before intubating the patient,  preoxygenate with 40-60L/min by NRBM

2)     RSI drugs: remember TBW for etomidate and IBW for ketamine (Obese patients were found to be dosed inappropriately)

3)     ED ventilator settings matter, especially if there is increased length of stay in ED!

4)     Deep sedation is known to increase mortality. Target lighter level of sedation. Opioids (Fentanyl) are first line!

Dr. Khoujah talked about delirium, which is misdiagnosed most of the time.

1)     In patients with suspected delirium, pay attention to “attention”.

2)     Use modified Richmond Agitation and Sedation Scale to screen delirium.

3)     Delirium = predisposing condition + precipitating insult; treat the underlying cause

4)     Change the environment ie allow relatives to be besides the patient, put a date time and location on wall facing the patient, try to minimize physical restraints.

5)     Most importantly, prevent delirium before you have to treat it!

Dr. Manning discussed on ventilator settings in severe asthmatics.

1)     Stick to the basic asthma medications

2)     Maintain permissive hypercapnia by balancing acidosis and auto-PEEP

3)     Indication for intubation: cardiac arrest, exhaustion, agitation, silent chest and severe hypoxia

4)     Lower the respiratory rate, allow patient time to breathe. Reduce I:E ratio to 1:4.

5)     Increase tidal volume to 8-10ml/kg, lower the PEEP and increase the flow rate 80L/min and gradually taper FiO2.

6)     Trouble shooting : a)Post-intubation hypotension- disconnect from vent, let them exhale then check for pneumo. b) Post-intubation hypoxia- do the above and check the tube c) post-intubation arrest- ACLS, go easy on bagging, needle the chest

7)     When in doubt, disconnect and let the air out!

Dr. Bontempo discussed about deep neck space infection and things to remember.

1)     The most common etiology of deep neck space infection is odontogenic; specifically infections of lower 2^nd and 3^rd molars.

2)     One should be worried if voice change, shortness of breath, neck pain, DM, CRP >100

3)     Anticipate a difficult airway, start broad spectrum abx, drain the pus out.

Dr. Dubbs discussed about the law suits faced due to missed diagnosis of cancer in ED. She suggested:

1)     Always have a high index of suspicion- prolonged symptoms, weight loss, B symptoms, voice change, stool change, anorectal lesions, post-menopausal bleeding

2)     Watch out for the fine printed reports- incidental findings, abnormal cell counts, etc.

3)     Discuss with the patient

4)     Document your discussion and have a great QA process

Dr. Bond (@Docbond007) talked about spinal epidural abscess and posterior shoulder dislocation.

1)     The incidence of epidural abscess has increased in past 2 decades, keep a high suspicion for patients presenting with spine pain.

2)     In patients with spine pain without any neuro deficit, but with fever, risk factors, then check CRP/ESR; if elevated get an MRI spine.

3)     Get X-ray axillary view in suspected posterior shoulder dislocation. Ensure humeral head is in glenoid cavity.

Dr. Lu discussed the complications of myocarditis. It can be deadly in kids. Hence

1)     Always be wary of subtle signs

2)     Consider myocarditis if dyspnoea, chest discomfort and antecedent viral illness.

3)     Consider myocarditis if persistent unexplained tachycardia.

In the section on ‘Salt, sugar and sex’, Dr. Willis summarized that

1)     Persistently hypoglycemic- think adrenal insufficiency

2)     Hypoglycemia +hypotension – Adrenal insufficiency until proven otherwise

3)     If there is any suspicion give empiric steroids. (Hydrocortisone 100mg iv, Dexamethasone 5mg iv, fludrocortisone 0.1mg iv

During the conference, Dr. Mattu kept the audience engaged by his fun quiz. He was kind to gift me the signed copy of the second edition of ‘Avoiding common errors in Emergency Department’ which I will treasure the most.

Although it was a long day, but due to short engaging presentations in a TEDx like format, it was very fun filled, motivational and interesting conference. A definite must go!

Summary prepared by:

Nikhil N. Tambe - @nikhil16mar
M.B.B.S., ECFMG (USA)

Emergency Medicine Resident 

Masters in Emergency Medicine (GWU)

Kokilaben Dhirubhai Ambani Hospital, Mumbai

Instructor (American Heart Association)
Lifesupporters Institute of Health Sciences, Mumbai