Urgent surgical consult Consider admission to HDU as anticipation Discuss whether patient has pre-existing wishes around active treatment/advanced directive/ICU as likely to deteriorate with potentially incurable malignancy The nurse calls you 2 hours later to say that the patient has become confused, has pulled out his drips and is trying to climb out of bed. a) List 3 pharmacological options for managing this mans agitation (without him being intubated), with one pro and one con for each (9 marks) Agent/dose/route Pro Con Agent/dose/route Pro Con Analgesics – any appropriate Also treat man, minimally sedating Opiates can cause resp depression suggestion if used correctly (has sats of 90%) IV Benzodiazepines e.g midazolam Rapidly works if given IV 5mg titrated IM Benzodiazepines e.g. No canula required, Painful, unreliable unpredictable midazolam 5mg PO Benzodiazepines e.g. No drip needed, safe side effect Patient may not take it when lorazepam 1mg profile confused, patient Ketamine, 0.5-1mg/kg IV or Haemodynamically more stable Emergence, laryngospasm, IM vomiting Propofol infusion titrated Quick onset Requires an infusion/IV line/HDU. High risk of upset Typical antipsychotics e.g Readily available, can be given IM if Extrapyramidal, hypotension, haloperidol 0.5-1mg po or im no IV, tardive dyskinesia, anticholinergic SEs Atypical antipsychotics e.g Less dystonic Take time to work olanzapine 2.5-5mg reactions/hypotension/antichol Less dystonic reactions/hypotension/antichol There are many options here that are not included in this model answer d) List 5 things that may be contributing to this mans confusion (5 marks) Preexisting cognitive impairment Pain Full bladder/need to defaecate Sepsis Brain Mets Medications e.g opiates Hypoxia
Urgent surgical consult Consider admission to HDU as anticipation Discuss whether patient has pre-existing wishes around active treatment/advanced directive/ICU as likely to deteriorate with potentially incurable malignancy The nurse calls you 2 hours later to say that the patient has become confused, has pulled out his drips and is trying to climb out of bed. a) List 3 pharmacological options for managing this mans agitation (without him being intubated), with one pro and one con for each (9 marks) Agent/dose/route Pro Con Agent/dose/route Pro Con Analgesics – any appropriate suggestion Also treat man, minimally sedating if used correctly Opiates can cause resp depression (has sats of 90%) IV Benzodiazepines e.g midazolam 5mg titrated Rapidly works if given IV IM Benzodiazepines e.g. midazolam 5mg No canula required, Painful, unreliable unpredictable PO Benzodiazepines e.g. lorazepam 1mg No drip needed, safe side effect profile Patient may not take it when confused, patient Ketamine, 0.5-1mg/kg IV or IM Haemodynamically more stable Emergence, laryngospasm, vomiting Propofol infusion titrated Quick onset Requires an infusion/IV line/HDU. High risk of upset Typical antipsychotics e.g haloperidol 0.5-1mg po or im Readily available, can be given IM if no IV, Extrapyramidal, hypotension, tardive dyskinesia, anticholinergic SEs Atypical antipsychotics e.g olanzapine 2.5-5mg Less dystonic reactions/hypotension/antichol Take time to work Less dystonic reactions/hypotension/antichol There are many options here that are not included in this model answer d) List 5 things that may be contributing to this mans confusion (5 marks) Preexisting cognitive impairment Pain Full bladder/need to defaecate Sepsis Brain Mets Medications e.g opiates Hypoxia
GASTRO-LIVER-ANS.docx