Best Practice Guidelines

Question 1

What are the discharge criteria following procedural sedation? (4)

Answer 1

Returned to baseline GCS
Return to baseline obs
No respiratory compromise
Pain addressed

Question 2

What is a body packer?
Body stuffer?
Body pusher?

Answer 2

Packer - carefully packed, well wrapped drugs, usually for international smuggling.
Stuffer - rapidly swallowed poorly wrapped drugs to avoid detection
Pusher - drugs concealed in vagina/rectum to avoid detection.

Ix - low dose CT

If CT positive for a packer then macrogol based isotonic laxatives advised to aid expulsion.

Stuffers and pushers can be observed for 8 hours post ingestion in ED.

Asymptomatic packers can be discharged to police.

Question 3

A procedural sedation safety briefing should include: (5)

Answer 3

• determining roles
• intended plan (inc length and depth of sedation, and when procedure can commence)
• confirmation of correct side (where applicable)
• confirmation that equipment checks complete
• Confirmation of location of rescue devices and drugs - anticipated
  Problems

Question 4

Invasive procedures should have (3):

Answer 4

• consent (verbal or written)
• two HCP’s (one ST4+) agreeing site of procedure
• all team members are aware of the plan and any plan B steps in the event of complications, as well as post procedure monitoring

Question 5

Cannabis hyperemesis syndrome - what treatments should be considered if standard anti-emetics fail?

Answer 5

Haloperidol (0.05mg/kg IM, max 5mg) or capsaicin 0.1% cream 5g applied to abdo

Question 6

Adolescent assessment should include a HEEADSSS Assessment. What is it?

Answer 6

• Home
• Education and Employment
• Eating
• Activities
• Drugs/Drinking
• Sex
• Self-harm, depression, suicide
• Safety (inc. social media)

Question 7

Results checking in the ED - what are the recommendations (5)

Answer 7

• In real time if critical and in 72hrs for non-urgent results. Identifiable and traceable
• Responsibility for review and actions should be clearly defined and recorded.
• Systems in place for referrals, follow up and further action.
• The review process should be recorded in an auditable manner that is available to the all of the clinical team to avoid duplication
• mechanisms for informing the pt should be in place

Question 8

What are the recommended agents and dosage for ABD?

Answer 8

Ketamine 4mg/kg IM
Droperidol 5-10mg IM

Question 9

What is the treatment in cases of suspected stimulant/serotonergic toxicity?

Answer 9

Chlorpromazine 25-50mg IV or IM (if severe psychosis or hyperthermia; use in addition to benzodiazepines)

Question 10

What should be used in cases of GHB/GBL withdrawal?

Answer 10

Baclofen (following ABD sedation)

Question 11

Indications for anaesthesia and intubation/crit care referral in ABD

Answer 11

Airway or ventilation issues
Severe agitation despite maximal safe sedation doses
Persistent met derangement
Mgmt of hyperthermia
Requirement to support interventions/investigations

Question 12

Anaesthesia in ABD - drugs to use and avoid.

Answer 12

Ketamine minimises haemodynamic instability
Avoid suxemethonium - hyperkalaemia likely
Avoid opiates - due to histamine release. Fentanyl can cause an efflux of serotonin

Question 13

What are the guidelines for pain mgmt in ED?

Answer 13

All pt’s with severe or moderate pain should receive adequate analgesia within 15 mins
All pt’s with severe pain (7-10) should have the effectiveness of their analgesia re-assessed within 15 mins of receiving their first dose of analgesia (30 mins for moderate (4-6), and 60 mins for mild (1-3))

Question 14

At what prevalence should HIV testing be performed in ED’s?

Answer 14

2/1000 or greater

Question 15

What are the indications for surgical removal of packages in drug traffickers?

Answer 15

Abdo pain (suspected obstruction/ileus)
N.b - acute abdo - CT with contrast

Radiological evidence of remaining packages which are too large to pass and evidence of sig/worsening toxicity.

Question 16

What 5 elements should be included in plans to reduce attendances for high intensity users?

Answer 16

ED care plans
Case management
MDT
Primary care involvement
Psychological therapy (for medically unexplained st)

Question 17

What should be included in a duty of candour conversation?

Answer 17

Tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong.

Apologise to the patient (or, where appropriate, the patient’s advocate, carer or family).

Offer an appropriate remedy or support to put matters right (if possible).

Explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened.

Question 18

Deaths requiring coroner referrals

Answer 18

Violent deaths, unnatural deaths (including suicides), if no one saw to the patient’s last illness, if a doctor had not seen the patient in the last 14 days, industrial accident, unknown cause, died during anaesthesia.