Code white considerations

“Code white”, “Code black”, “Dr. Murphy to room 202″, every hospital has an overhead page that means that there is a disruptive person or patient who needs to be controlled, either for their safety or for the safety of others. Who attends these calls at your hospital? I had always assumed that these calls were similar to a code blue in mandating the immediate attendance of your critical care team leader (in my shop thats the ED doc). However at some hospitals the extra staff attending these calls is security staff, and the on call doctor is only notified by phone.

Most of these calls are for patients already admitted and on hospital wards. You might ask why we as emergency doctors should take this job onto our already overfull plate. The answer is simple, these are patients who have, with some regularity, severe underlying illness requiring recognition and treatment in a setting that allows for only incomplete information and evaluation. In other words, although these patients are (mostly) already hospitalized they require the particular set of skills and expertise that an emergency doctor brings to the table.

The classical approach to these patients has been to regard them as disruptive or demented and give them a dose of haloperidol and lorazepam and cinch the restraints nice and snug. This brute force approach fails the patients who need us most, and probably causes harm. Like everything in emergency medicine it pays to have an approach and a short differential to consider each time you evaluate an agitated patient.

Is this patient actually agitated?

When you walk into the scene assess if the patient is actually agitated or simply annoying. Occasionally sedation is being forced on the annoying and while we all know a few people who would benefit from sedation, forced sedation is an invasive action and only allowed in certain circumstances.

Does the patient understand the situation? This question assesses the patients capacity for medical decision making. Is the patient currently a risk to harm themselves or someone else? This question guides the pace of the intervention.

What are the patients vitals?

The usual answer is ‘unknown’, the patient is too agitated to take vitals. Actual vital signs are an early priority but prior to that look at the patients respiratory rate and effort, and assess their perfusion and skin colour. Your disruptive patient may actually be hypoxic, or in a shock state.

Is there evidence of trauma?

Elderly anticoagulated people at risk of falls are not suddenly not at risk by virtue of hospitalization. Trauma, including head trauma, can and does happen in the hospital.

Does the patient have alcohol withdrawal?

Elderly patients are at particular risk for unrecognized alcohol withdrawal. Delirium tremens is a life threatening but treatable medical problem. Many agitated patients are treated with antipsychotics such as haloperidol or loxapine, which have a limited role in alcohol withdrawal. Is the patient tremulous, tachycardic or hyperadrenergic? Consider alcohol withdrawal.

Does the patient have infectious or metabolic encephalopathy?

Consider (meningo) encephalitis, sepsis, uremia and elevated ammonia, if the picture fits.

Does the patient have a medication reaction?

Since hospitalization has the patient been started on a medication that could cause disinhibition and delerium? In particular look for anticholenergic drugs, tricyclic antidepressants and benzodiazipines.

In summary, the agitated hospitalized patient represents an emergency situation. Some of these patients do simply have behavioural problems, dementia or psychiatric disorders, but many others have emergency medical problems that need to be urgently addressed. The mortality rates for hospitalized patients who develop delirium of any cause is high (reported variously between 20 and 50% 6 month mortality). Some of that mortality is simply because delirium itself is a associated with frailty in the elderly, but some likely represents the various underlying diseases that can present as agitation and delirium.

When you are called to a ‘code white’ keep your wits about you, and evaluate the patient just like you would in the ED. Check vitals, consider hypoxia, trauma, shock, withdrawal, encephalitis and drug effects. and treat accordingly.

If you like saving truly sick patients from dangerous interventions then start attending these calls. You’ll find patients with hypoxia, PE’s, brain abscesses, intercranial bleeds and anticholinergic drug toxicity (all things I have actually found in these patients). And the best part is that the patient is already admitted!

 

There are bugs on that ECG (and other thoughts on severe alcohol withdrawal)

Your next patient is a man in his 50′s with a presenting complaint of ‘I don’t feel right’. He’s irritable and has psychomotor agitation. He’s tremulous, diaphoretic and looks unwell. His heart rate is 125, blood pressure 210/110, temp 38.4C. He seems anxious; ‘I’m gonna die doc, you’ve got to help me!’  He tells you he quit drinking 3 days ago after a 3 month bender.

Most community hospitals have some version of an alcohol withdrawal protocol. At my hospital it’s a CIWA score tied to a benzodiazipine dose. For mild to moderate alcohol withdrawal the use of such a protocol provides good care and good results. Whenever possible mild to moderate alcohol withdrawal should be referred out of the hospital to a community detox centre so the patient can receive concurrent early addiction treatment along with a safe medical detox.

Severe alcohol withdrawal is a different story. These patients are sick, have a propensity to die, and can be difficult to manage. Not only should they not be managed in a community detox, they should not even be managed on a regular hospital ward, rather they should be in a high dependancy unit or an ICU setting.

There are 2 schools of thought in the management of severe alcohol withdrawal; the sugar and spice approach (a dab of benzodiazipines, a dash of barbiturates, a sprinkle of antipsychotic) and the salty food approach (sprinkle benzodiazipines on the patient until the patient is just right). Neither approach is right, but personally I prefer and have had excellent success with a benzos only approach. The doses used in alcohol withdrawal protocols will usually be insufficient for these patients and in fact the entire approach is somewhat different.

The patient we started with will probably have been placed in an unmonitored area as far away from the nursing station as possible. My first job with severe alcohol withdrawal is to identify the patient as critically ill and move them to a monitored care area and put them on a monitor (remember, geography is destiny in the ED). My drug of choice is diazepam (Valium) and for the severely withdrawing patient the route should always be IV. I start with 10mg IV and quickly escalate my dose to 20, 30 and even 40mg at a time. The nursing staff will definitely be uncomfortable with this, fearing respiratory depression but you can reassure them that if needed the patient can be intubated and because of the high acuity area of the emerg the patient will be closely monitored. You can also remind them that if benzos fail to work you will be intubating the patient anyways.  The doses of benzodiazipines you will need to control severe alcohol withdrawal can be phenomenal! I have given patients 350mg of Valium over a couple of hours and seen them finally start to settle down. Some experts advise that benzodiazipines have only failed when doses exceed 400mg of Valium or equivalent.

Some patients will experience somnolence or respiratory depression without resolution of their autonomic  instability as the dose of benzodiazipine escalates. These are good candidates for intubation and maintenance on a propofol infussion. Some patients may have resolution of their autonomic instability but persistent hallucinosis and these patients are good candidates for a dose of haloperidol.

Many patients with severe alcohol withdrawal will also have hypokalemia, hypomagnesemia, and depleted glycogen stores. They will benefit from thiamine, electrolyte correction and a maintenance IV solution containing dextrose.

Severe alcohol withdrawal is fun to manage. The doses of benzodiazipine needed are often outrageous but if you’re willing to go there you can manage these patients well. These patients can be loud and obnoxious, and are often repeat visitors; don’t let that dissuade you, they are critically ill and unless you identify that they will end up under treated and unmonitored on a regular ward, at high risk for poor outcomes.