ED Rounds – Delirium in the ED

Delirium in the ED: How can we help?

Presented by: Dr Cherie-Lee Adams

 


Incidence of Delirium

  • 40% admitted patients >65yo
  • 10-20% on admission
  • 5-10% more during admission

Increased Risk of Delirium:

  • Male
  • >60yo, more prevalent >80yo
  • Hearing/visual impairment
  • Dementia
  • Depression
  • Functional dependence
  • Polypharmacy
  • Major medical/surgical illness


DSM-V Criteria

  • A) Disturbance in attention and awareness
  • B) Disturbance is ACUTE
  • C) Concurrent cognitive impairment
  • D) Not evolving dementia, nor coma
  • E) Can be explained by Hx/Px/Ix

 


 

Non – Pharmacological Approach

  • Nutritional support
  • Optimize hearing/sight
  • Maximize day/night/date/time cues
  • Minimize pain
  • Rehabilitate- ambulate, encourage self-care
  • Avoid restraints

Pharmacological Options

  • Treat only if distress/agitated/safety concern
      • don’t treat hypoactive delirium, wandering, or prophylactically
  • monotherapy
  • low dose
  • short course
  • Benzos- reserve for withdrawal
  • APs
        • Haldol 0.25-0.5mg
        • risperidone 0.25mg od-bid
        • olanzapine 1.25-2.5mg/d
        • quetiapine 12.5-50mg/d

 

Take Home Points

  • Delirium is common, esp in elderly
  • Significant morbidity/mortality associated
  • Brief screening with DTS/bCAM works
  • Intervention focus on limiting pathology, normalizing activities, minimizing drugs
  • Low dose APs for short period for agitation

 


 

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ED Rounds – April 2015

We were treated to 4 great presentations today, including some original research from Dr Robin Clouston. This months presenters included Dr Paul Vanhoutte, Dr Joanna Middleton, Dr Robin Clouston PGY2 and Dr Reid Sadoway PGY1.

Delirium in the Emergency Department

Dr Paul Vanhoutte

Acute Confusional State

  • Delirium
  • Dementia
  • Amnesia
Common Neuro pathway – structure, neurotransmission

Delirium

Its believed that acetylcholine levels are involved (low levels were noted in some studies)
Anticholinergic drugs therefore may make it worse
Environmental stressors are important
4 Key Features
  • Disturbance of consciousness
  • Change in cognition –  (dementia has a more insidious onset)
  • Short period of time
  • Clinical evidence
also psycho motor, sleep disturbance, emotional

Dementia

Insidious, Progressive, non fluctuating, months to years, normal attention
BUT – both can be confused with Psychiatric disorder
Long list of etiologies – see attached pdf of presentation

Investigations

ECG
CBC
Lytes
LFTs
TFTs
VBGs
Urine
Extended lytes – e.g Ca
Cultures – if febrile
Tox
Neuorimaging

Risk Factors

Previous brain injury
Senosry impairment
Elderly

Some Stats

64% of pts sent to ED from NH had some delirium
10-15% of all hospital admissions
5-10% of ED visits for altered mental status
70% mortality rate in elderly
70% miss rate

Confusion Assessment Method  (CAMS)

  1. Acute onset and fluctuating course
  2. Inattention/distractibility
  3. Disorganised thinking
  4. Alteration

Delirium if 1 and 2 with either 3 or 4

Management

Medication
Restraints?
O2 in all (careful if COPD)
Check blood sugar

A discussion on the use restraint followed
Maybe necessary in some circumstances
But should be closely observed
Enables diagnosis of cause and initial treatment

ACEP Guidelines on pharmacoligic treatment

  • Undifferentiated agitation: monotherapy with lorazepam/midazolam, droperidol or haliperidol
  • Agitation and psychosis: atypical or typical antipsychotic
  • Agitated and violent: combo therapy
  • Coma cocktail: Thiamine, dextrose, naloxone
  • Glucagon IM if no IV access for hypoglycemia
  • Treat underlying cause

Take Home Message

  • Need to differentiate ACS into Delirium vs Dementia vs Psychiatry
  • Big list of triggering differential diagnosis
  • High mortality
  • Majority will require early stabilisation and admission
  • Some maybe appropriately discharged e.g those from NH or with good family

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Diagnostic Utility of CRP in the ED

Dr Joanna Middleton

Should we be using it?
How should we use it?

Discussion Point 1

Nurses have noticed that its use has increased in last 2 years

?Change in practice, ?Switch from ESR to CRP

Is CRP the new D-DIMER?

History

An interesting historical outline – see attached pdf of presentation

Discovered in 1930

Used in the 50’s and 60’s extensively
Then lost favour
Resurgence in the 1990’s

Will it loose favour again?

Mechanism

Injury/illness stimulus (Tissue Injury)
IL-6 produced and stimulates liver production of CRP
Takes 4-6 hrs to appear in blood

Exponential rise

Peaks at 48-73hrs
Short hallf life
Levels drop quickly
Therefore good for following disease

What is Normal

Median – 0.8
90th – 3
99th – 10

Horizon: < 4.9

 

Most published literature has a CRP cut off of 10

 

Numerous causes of CRP elevation

Cannot differentiate viral from bacterial

Obseity elevate CRP
Class 1 obesity – 11% > 10

 

Take Home Points

Point #1 for EM CRP levels are not reliable in the first 12 hours after a stimulus…

Point #2: Serial measurements are much more useful than an isolated result

Point # 3 Healthy patients should have a CRP <2-3

Point #4: Much of the published literature used a CRP cut-off of 10…

POINT #5: LOTS OF THINGS ELEVATE CRP – Anything that causes tissue/cell damage

Point #6: CRP cannot differentiate between viral and bacterial unless…

Point # 7: CRP >100 is probably a bacterial infection

Point # 8: JUST ABOUT ANYTHING CAN ELEVATE CRP

Point #9: STEROIDS SCREW UP CRP LEVELS – So do some Auto-immune disease

Point #10 – Joanna’s Rule: If your patient in the ED has a CRP <0.3*…. Then there is probably nothing wrong with them – provided they have had symptoms for > 24hrs (excluding point 9)

 

See the pdf attached to this post for an analysis of CRP performance in specific conditions

 

Bottom Line

Maybe helpful in differentiating neonates with serious infection, but requires serial testing.

Maybe helpful in combination with WBC and PMN ratio for ruling out adult appendicitis if they present with pain > 24hrs

 

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Safety in the Emergency Department

Local research: Comparison of ED Crowding Scores

Dr Robin Clouston iFMEM PGY2

Dr Robin Clouston presented her research on ED Safety and Crowding.

The primary goal is to determine which of the six ED Crowding tools and five single variables studied is the best tool to measure the intensity of ED crowding, as compared to the outcome variable of physician rating, measured by Visual Analogue Scale (VAS). i.e. Which ED crowding tool produces a score most closely correlated with the physician VAS?

A secondary goal will be to determine which tool is the best correlated with early emergency department crowding, defined in this study as detection of crowding up to four hours before recognized by clinicians via the Visual Analogue Scale.

Key Results

Of the six formal crowding tools, the DEC ED Saturation Score had the best predictive value with sensitivity of 76.2% and specificity of 64.3%.

For predictions of current safety: the NEDOCS score had the best combined sensitivity and specificity at 80% each,

Single variable with the highest predictive value of safety at time 0 was the “# patients in beds/waiting

For prediction of safety in 2 hours: again the NEDOCS score most predictive, with sensitivity = 92.7% and specificity=89.5%.

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Burns – ED Assessment and Management – Literature Review

Dr Reid Sadoway PGY1

Download (PDF, 1.65MB)

 

 

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