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Crisis Management During Anaesthesia: Pulmonary Oedema

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Abstract

Background: Pulmonary oedema may complicate the perioperative period and the aetiology may be different from non-operative patients. Diagnosis may be difficult during anaesthesia and consequently management may be delayed.

Objectives: To examine the role of a previously described core algorithm “COVER ABCD–A SWIFT CHECK”, supplemented by a specific sub-algorithm for pulmonary oedema, in its management occurring in association with anaesthesia.

Methods: The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved.

Results: Pulmonary oedema was identified in 35 (<1%) of the first 4000 reports to AIMS. The most frequent presenting sign was hypoxia (46%) and the most specific sign was the presence of frothy sputum (23%). The core algorithm, although successful in the management of the initial physiological upset,...

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The Surgical Hypertensive Patient

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Abstract

We reviewed the pathophysiology and treatment of hypertension in a recent edition of this journal (see key references). In this article, we discuss the management of the hypertensive patient presenting for surgery and anaesthesia.

Key points

Arterial hypertension is a risk factor for cardiovascular complications after anaesthesia and surgery.

Ideally, all hypertensive patients should be treated before elective surgery; in practice only patients with stage 3 (systolic >180 mm Hg; diastolic >110 mm Hg) are regarded as needing preoperative treatment.

The importance of isolated systolic hypertension in the surgical patient is not well defined.

Patients with moderate hypertension (stage 2) but significant target organ involvement should be considered for preoperative treatment.

Most antihypertensive agents do not have adverse interactions with anaesthetic agents and should be continued throughout the perioperative period except for ACE inhibitors and angiotensin II receptor antagonists where the evidence for continuation or cessation is unclear..

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Fluoxetine Delayed Release Capsules

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WARNING: SUICIDAL THOUGHTS AND BEHAVIOR

 Antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was a reduction in risk with antidepressant use in patients aged 65 and older [see Warnings and Precautions (5.1)].  psy

In patients of all ages who are started on antidepressant therapy, monitor closely for worsening and for emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber [see Warnings and Precautions (5.1).

Fluoxetine is not approved for use in children less than 7 years of age [see Warnings and Precautions (5.1) and Use in Specific Populations (8.4)].  Indications and Usage for Fluoxetine Delayed Release Capsules

Fluoxetine delayed-release capsules are indicated for the treatment of: ...

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Extended Release Drug Delivery Strategies in Psychiatry

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Abstract

Objective: An overview of the emerging field of long-term delivery strategies for improved convenience and adherence with psychiatric medications is provided. This review is motivated by the hypothesis that adherence to treatment is an important determinant of clinical outcomes in a wide range of settings and is particularly important in psychiatry practice where patients require treatment for months or years and premature discontinuation can have serious consequences for patient health and quality of life.

Design: The author reviews the relevant literature and highlights several approaches to providing improved access to continuous medication through new and innovative delivery strategies ranging from days to annual intervals.

Benefits and Disadvantages: Several solutions to the problem of discontinuous access to pharmacotherapy are being developed in the form of new, long-acting drug-delivery systems, which gradually release medication over a period of several days or weeks with a single application. Long-acting formulations of psychiatric medications offer...

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Is Succinylcholine Really Superior for RSI?

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Background:

Intubation is arguably the most important procedure performed by Emergency Physicians (EPs). Ideally, it would be performed successfully on the first attempt each and every time, but this of course cannot always be the case. Rapid Sequence Intubation (RSI) has become the preferred method for emergency intubations, as it improves visualization of the vocal cords, and decreases complications such as aspiration and increased intracranial pressure. Succinylcholine, a depolarizing agent, is the most widely utilized paralytic due to its rapid onset and short half-life. However, there are certain circumstances in which succinylcholine is contraindicated, including suspected hyperkalemia, known prior adverse reactions, concern for head injury, neuromuscular disease, or spinal cord injury. Rocuronium, a non-depolarizing agent with a considerably longer half-life, is frequently used in these situations.

Prior studies evaluated by the Cochrane review suggest succinylcholine produces superior intubation conditions when compared to rocuronium.[1]However, there is concern that succinylcholine's advantage...

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How to Keep Out Unwanted Guests at Family Funerals

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Are Funerals Public or Private?

When planning a wedding, it's easy to ban unwanted family members — simply don't invite them. The bride and groom, bride and bride, or groom and groom (and possibly their parents) get to choose who does and doesn't share the special day. No invitation = no entry.

But what about funerals? Although they are also highly personal occasions, they typically are wide open. Anyone and everyone who knew the deceased could come and pay their respects.

If you are in the position of planning a funeral or memorial service for a loved one, you have a lot to do in a short amount of time. If there have been estrangements, feuds, or tensions within the family, you have those to contend with as well.

Here are some questions to ask yourself:

Can you restrict attendance? Should you restrict attendance? What if the person you don't want at the funeral is...  

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Opioid Overdose Prevention for Law Enforcement and First Responders

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What is naloxone?
Naloxone is a medication designed to rapidly reverse opioid overdose. It is an opioid antagonist meaning that it binds to opioid receptors and can reverse and block the effects of other opioids. It can very quickly restore normal respiration to a person whose breathing has slowed or stopped as a result of overdosing with heroin or prescription opioid pain medications.

How is naloxone given?
There are three FDA-approved formulations of naloxone:

Injectable (professional training required)
Generic brands of injectable naloxone vials are offered by a variety of companies that are listed in the FDA Orange Book under "naloxone" (look for "injectable").

Note: There has been widespread use of improvised emergency kits that combine an injectable formulation of naloxone with an atomizer that can deliver naloxone intranasally. Use of this product requires the user to be trained on proper assembly a...

See Also: Opioid Overdose Reversal with Naloxone (Narcan, Evzio)

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The Thyroid and the Mind and Emotions | Thyroid Dysfunction and Mental Disorders

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The Thyroid and the Mind and Emotions

Summary of an address to the Kitchener-Waterloo Area Chapter

The psychiatric disturbances which accompany hyperthyroidism and hypothyroidism, the two commonest thyroid disorders, mimic mental illness. People with an overactive thyroid may exhibit marked anxiety and tension, emotional lability, impatience and irritability, distractible overactivity, exaggerated sensitivity to noise, and fluctuating depression with sadness and problems with sleep and the appetite. In extreme cases, they may appear schizophrenic, losing touch with reality and becoming delirious or hallucinating. An underactive thyroid can lead to progressive loss of interest and initiative, slowing of mental processes, poor memory for recent events, fading of the personality's colour and vivacity, general intellectual deterioration, depression with a paranoid flavour, and eventually, if not checked, to dementia and permanent harmful effects on the brain. In instances of each condition, some persons have been wrongly diagnosed, hospitalized for months, and treated unsuccessfully for psychosis....

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Hyperkalemia in Emergency Medicine

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Practice Essentials

Hyperkalemia can be difficult to diagnose clinically because symptoms may be vague or absent. The fact, however, that hyperkalemia can lead to sudden death from cardiac arrhythmias requires that physicians be quick to consider hyperkalemia in patients who are at risk for it. See the electrocardiogram below.

Widened QRS complexes in hyperkalemia. See also Can't-Miss ECG Findings, Life-Threatening Conditions: Slideshow, a Critical Images slideshow, to help recognize the conditions shown in various tracings.

Signs and symptoms

Patients with hyperkalemia may be asymptomatic, or they may report the following symptoms (cardiac and neurologic symptoms predominate):

• Generalized fatigue
• Weakness
• Paresthesias
• Paralysis
• Palpitations

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Hyperkalemia (High Blood Potassium)

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What is hyperkalemia?   Hyperkalemia is a common diagnosis. Fortunately, most patients who are diagnosed have mild hyperkalemia (which is usually well tolerated). However, any condition causing even mild hyperkalemia should be treated to prevent progression into more severe hyperkalemia. Extremely high levels of potassium in the blood (severe hyperkalemia) can lead to cardiac arrestand death. When not recognized and treated properly, severe hyperkalemia results in a high mortality rate.

Technically, hyperkalemia means an abnormally elevated level of potassium in the blood. The normal potassium level in the blood is 3.5-5.0 milliequivalents per liter (mEq/L). Potassium levels between 5.1 mEq/L to 6.0 mEq/L reflect mild hyperkalemia. Potassium levels of 6.1 mEq/L to 7.0 mEq/L are moderate hyperkalemia, and levels above 7 mEq/L are severe hyperkalemia.

How does hyperkalemia affect the body?

Potassium is critical for the normal functioning of the muscles, heart, and nerves....

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Hypothyroidism: An Important Diagnostic Consideration for the Psychiatrist

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Hypothyroidism is a clinical state of thyroid hormone deficiency that may have a primary or secondary (central) cause. Primary hypothyroidism, which is more common than secondary hypothyroidism, is defined as failure of the thyroid gland to respond appropriately to thyroid-stimulating hormone (TSH) produced in the anterior pituitary gland. Primary hypothyroidism can be caused by autoimmune disease (Hashimoto disease), iodine deficiency, or infiltrative diseases, or it can be caused iatrogenically by surgery or irradiation of the gland. Subclinical hypothyroidism refers to mildly increased TSH levels in the setting of normal thyroxine (T4) and triiodothyronine (T3) levels. Secondary hypothyroidism is defined as insufficient thyroid gland stimulation by the hypothalamus or pituitary gland.

What new information does this article provide?

This article provides a simple and concise review of the varied physical and neuropsychiatric presentations of hypothyroidism and important diagnostic and treatment information.

What are the implications for psychiatric practice?

Hypothyroidism presents with a myriad of neuropsychiatric...

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Mechanisms Of Fatal Opioid Overdose.

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Abstract

There has been increasing recognition of the problem of fatal opioid overdose. This review examines the pharmacological basis of respiratory depression following opioid administration. Respiration is controlled principally through medullary respiratory centres with peripheral input from chemoreceptors and other sources. Opioids produce inhibition at the chemoreceptors via mu opioid receptors and in the medulla via mu and delta receptors. While there are a number of neurotransmitters mediating the control of respiration, glutamate and GABA are the major excitatory and inhibitory neurotransmitters, respectively. This explains the potential for interaction of opioids with benzodiazepines and alcohol: both benzodiazepines and alcohol facilitate the inhibitory effect of GABA at the GABAA receptor, while alcohol also decreases the excitatory effect of glutamate at NMDA receptors. Heroin and methadone are the major opioids implicated in fatal overdose. Heroin has three metabolites with opioid activity. Variation in the formation of these metabolites due to genetic factors and the use...

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Clinical Manual of Pain Management in Psychiatry

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While recognizing the multidisciplinary nature of pain management, the Clinical Manual of Pain Management in Psychiatry focuses on the role of mental health practitioners in evaluation and assessment, pharmacological management, psychotherapeutic interventions, and comprehensive treatment planning. It balances theoretical foundations of pain pathophysiology with applied clinical information, providing guidelines to psychiatric differential diagnosis of pain states and psychiatric comorbidities associated with pain and integrating diagnostic and treatment approaches. Because proper treatment requires understanding the whole person, the book views the patient from biological, psychological, and social perspectives. It stresses the importance of examining psychological variables that can limit outcomes and even preclude aggressive interventional approaches. The manual also includes considerations pertinent to the elderly, children, and cultural groups.

This manual expands on the author's previous Concise Guide to Pain Management for Psychiatrists to reflect significant advances in the field of pain medicine. It updates trends in treatment approaches along...

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Drug-Induced Orthostatic Hypotension.

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Abstract

Drug-induced orthostatic hypotension is an important clinical problem. When symptomatic, it is poorly tolerated by the patient, and can be a cause for discontinuing treatment. It may have more serious consequences if it leads to syncope, falls and injury, or to sustained loss of perfusion of vital organs resulting in heart attack or stroke. Orthostatic hypotension is easily detected by procedures available to all physicians, who should maintain a high index of suspicion when prescribing drugs commonly known to cause this condition, especially in the elderly. Since the medical conditions calling for the use of these drugs are extremely prevalent, the screening and monitoring of orthostatic hypotension should be instituted as a routine precaution in appropriate patients. Hypertension affects two-thirds of elderly patients. Orthostatic hypotension is an infrequent adverse effect of most of the drugs in current use in the treatment of hypertension; it is, however,...

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Excited Delirium Strikes Without Warning

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Learning Objective

• Discuss the pathophysiology of excited delirium • Recognize the signs and symptoms excited delirium • Identify the treatment for a patient presenting with excited delirium

Key Terms

Bells Mania: A condition that manifests with mania and fever in which the patient becomes exhausted due to mental excitement. Benzodiazepine: A medication that results in sedative, hypnotic, anxiolytic, anticonvulsant, muscle relaxant and amnesic action. Dissociative agents: Medications that produce a trance-like state by causing interruption of cerebral association pathways between the limbic and cortical systems. Dopamine: A catecholamine neurotransmitter produced in several areas of the brain, including the substantia nigra. Excited delirium: A condition that manifests as a combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances, disorientation, violent and bizarre behavior, insensitivity to pain, elevated body temperature and superhuman strength. Neuroleptic malignant syndrome: A condition that causes delirium and death as a result of abrupt withdrawal from psychiatric medication that blocks dopamine re-uptake....

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Variability of Undetermined Manner of Death Classification in the US

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Abstract

OBJECTIVES: To better understand variations in classification of deaths of undetermined intent among states in the National Violent Death Reporting System (NVDRS). DESIGN: Data from the NVDRS and the National Vital Statistics System were used to compare differences among states. MAIN OUTCOME MEASURES: Percentages of deaths assigned undetermined intent, rates of deaths of undetermined intent, rates of fatal poisonings broken down by cause of death, composition of poison types within the undetermined-intent classification. RESULTS: Three states within NVDRS (Maryland, Massachusetts, and Rhode Island) evidenced increased numbers of deaths of undetermined intent. These same states exhibited high rates of undetermined death and, more specifically, high rates of undetermined poisoning deaths. Further, these three states evidenced correspondingly lower rates of unintentional poisonings. The types of undetermined poisonings present in these states, but not present in other states, are typically the result of a combination of recreational drugs, alcohol, or prescription drugs. CONCLUSIONS:...

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