Neurological

Question 1

Which patients are indicated for oral lorazepam?

Answer 1

Challenging behaviour patients >=16yrs where de-escalation has failed and who are cooperative with oral medications.

Question 2

Which challenging behaviour patients may be given IM droperidol without consult?

Answer 2

Patients who are all of
* 16-64yrs
* Uncooperative with oral medication
* SAT score >=+2
* non-medical cause of challenging behaviour

Question 3

What dose of droperidol may be given for acute behavioural emergencies?

Answer 3

5-10mg, repeat after 15min if SAT score still >=+2.
Max dose 20mg in 24hrs.

Question 4

What are the contraindications for droperidol?

Answer 4

Relative: age < 16 or > 64yrs (consult)
Absolute:
* Hx of neuroleptic malignant syndrome
* Parkinsons
* Pregnancy
* Phaeochromocytoma
* Long QT syndrome (challenging behaviour only; ok as an anti-emetic as lower dose unlikely to prolong QT interval)

Question 5

What are the components of the Mental State Examination?

Answer 5

• Appearance
• Behaviour
• Conversation
• Mood / Affect
• Perception
• Cognition
• Insight

Question 6

What monitoring should be performed after procedural sedation?

Answer 6

Nasal capnography (for RR, not EtCO2)
Regular vital signs
Continuous ECG

Question 7

What is the guideline for dealing with escalation of a mental health patient during inter-facility transport?

Answer 7

If SAT score increases to +2 during transport:
* De-escalate, if unsuccessful
* Consult EOC clinician for sedation consistent with previous management

If EOC clinician unavailable:
* IM droperidol 5-10mg
* 5 mg will be adequate in most patients
* Repeat after 15 mins if SAT still ≥ +2
* Total max dose 20 mg in 24 hours

Question 8

When should clinical support be considered in seizure patients?

Answer 8

Consider clinical support (e.g. ICP or MedSTAR) if:
* Specific cause of seizure e.g. TBI
* Prolonged transport time
* Generalized seizure if 2nd dose of midazolam administered

Question 9

When is midazolam indicated in seizures; what is the dose, dose interval, and max dose?

Answer 9

Midazolam is first-line pharmacotherapy for generalised seizures when there is risk of physical injury, hypoxia or aspiration

Indicated for generalized seizure > 5min (continuous or repetitive seizures without regaining consciousness).
Dose = 100mcg/kg, repeat after 5min if ineffective, max dose 200mcg/kg.

Question 10

When should clinical support / EOC clinician be called for seizure patients?

Answer 10

Clinical support if second dose of midazolam given (ICPs can give levetiracetam).
Consult EOC clinician of second dose of midazolam ineffective

Question 11

Do seizure patients need to be transported if seizure resolves?

Answer 11

Not if their seizure management plan indicates otherwise

Question 12

When should the Arm Chat Tap assessment be used?

Answer 12

Patients with a positive Rosier score

Question 13

When should Code Stroke be activated in patients with positive Rosier and negative ACT?

Answer 13

Activate code stroke if
* independent premorbid functioning and
* < 4 hrs symptom onset to arrival at closest available CSU/STS and
* < 60 mins travel time

Transport to CSU/STS for thrombolysis consideration

If all other criteria met but > 60 mins travel time, consult EOC clinician who may advise:
* transport direct to CSU/STS (Code Stroke activation)
* RV enroute to CSU/STS
* transport to alternate destination e.g. country ED

Question 14

When should Code Stroke be activated in patients with positive Rosier and positive ACT?

Answer 14

Activate Code Stroke if:
* independent premorbid functioning and
* < 24 hrs symptom onset to arrival at RAH and
* < 60 mins travel time to RAH

Transport aim is the Royal Adelaide Hospital (RAH) for eligible LVO stroke patients

If all criteria met but > 60 mins travel time to RAH, consult EOC clinician who may advise:
* transport direct to RAH (Code Stroke activation)
* transport and RV enroute to RAH
* alternate destination (CSU/STS preferred) and retrieval

Question 15

What is the procedure for code stroke notification / transport?

Answer 15

Confirm:
* patient identification details
* telephone contact details of patient’s substitute decision maker or close relative or carer

Notify ‘Code Stroke’ to CSU/STS stroke coordinator via SAAS Code Notification Line using ISBAR including confirmation of:
* Code Stroke eligibility criteria
* ETA

If SAAS Code Notification Line unanswered or where local procedure directs, request SAGRN notification to receiving hospital ED

Treatment: provided no delay in transport time, consider:
* 18 g IV access each arm
* 12 lead ECG

Question 16

What is the procedure for suspected stroke patients where Code Stroke criteria are not met?

Answer 16

If stroke is clinically suspected and:
* > 24 hrs symptom onset, and/or
* ROSIER positive and ACT negative > 4 hours and/or
* diminished pre-morbid independent living:

Transport to closest CSU/STS (preferred) or
ED (in country area)

Question 17

What are the components of the ROSIER assessment?

Answer 17

LOC or syncope (-1)
Any seizure activity (-1)

Is there new acute (< 24hrs) onset of
Asymmetric face weakness (+1)
Asymmetric arm weakness (+1)
Asymmetric leg weakness (+1)
Speech disturbance (+1)
Visual field deficit (+1)

Also assess for pre-morbid independence and BGL (if < 3.5 treat and re-assess)

Question 18

What are the components of the ACT assessment?

Answer 18

Arm - single arm drops within 10 sec

If right arm weakness -> Chat
* any language deficit (not just slurring, but mute, gibberish, incomprehensible)

If left arm weakness -> Tap
* Obvious gaze deviation of both eyes away from weak side or failure to turn to weak side when tapped

ACT positive is unilateral arm weakness and Tap/Chat +ve
ACT negative if no weakness both arms