Questions of the Week for 9/19/2023
Authors: Jeffery Ruggeri and Sean Lamb
You are seeing an intoxicated patient in bed 6. He endorses drinking 9 beers plus some fireball, and is obviously intoxicated on your exam. There are no signs of trauma, and you are planning to monitor him for sobriety through the night. He becomes agitated, yelling from his room and requesting to leave. How will you approach this situation?
-
Your initial approach to this patient to be attempting non-invasive de-escalation. Examples include verbal de-escalation, turning off the lights and minimizing other distractions, providing food, blankets, and other comfort items, showing force, and removing escalators from the situation.
The same patient from above does not respond to your initial de-escalation techniques. He is stumbling out of bed attempting to leave the emergency department, and is making threatening comments toward staff. How will you manage this situation?
-
This situation would call for chemical restraint. Given the patient’s alcohol intoxication, it may be preferable to avoid benzodiazepines and preferentially use antipsychotics. Drug choices include haloperidol (2.5-10mg IM/IV), droperidol (2.5-5mg IM/IV), or olanzapine (10mg IM). Note that neither olanzapine or haloperidol are FDA approved for IV administration. Keep in mind that olanzapine can be given PO or SL as well.
What is the current recommendation regarding patient positioning if there is an air embolism present in the left ventricle?
-
It is recommended that the patient be placed in supine positioning. For arterial air emboli, it is highly likely that the air will be propelled forward by arterial flow regardless of patient positioning. Therefore, it is recommended to place the patient in supine positioning as this is least likely to worsen cerebral edema which may occur as a result of air embolus within intracranial vasculature.
This is different from venous air embolism (if air was present in right ventricle). In that case, the recommendation would be to position the patient so that the right ventricular outflow tract was inferior to the right ventricle. This could be accomplished by positioning the patient in left lateral decubitus, Trendelenburg, or left lateral decubitus with head down.
What are the most common causes of air embolism?
-
Central line placement, neurosurgical or ENT procedures and penetrating injuries are common causes of air embolism.