EUPD - Boderline Personality Disorder

What is BPD?

BPD is a type of ‘personality disorder’ in which people struggle with emotions ultimately affecting their relationships with others. It is also called as Emotionally Unstable Personality Disorder (EUPD). It is believed that BPD results from traumatic childhood experiences (neglect or being abandoned, physical, emotional or sexual abuse). People with BPD may experience:

• feeling isolated/ abandoned 
• self-harm or suicidal thoughts
• difficulty coping with stress
• strong emotions 
• misusing alcohol and prescription drugs
• Using illegal drugs and substances
• Understanding others points of view
• Being able to maintain a home

People with BPD typically have at least five of the symptoms below:

• Feeling worried about people abandoning you, and would do anything to stop that happening
• Feeling intense emotions that last from a few hours to a few days and can change quickly (for example, from feeling very happy and confident to suddenly feeling low and sad)
• Having a strong sense of who you are, and it can change significantly depending on who you're with
• Finding hard to make and keep stable relationships
• Feeling empty a lot of the time
• Acting impulsively and do things that could harm you (such as binge eating, using drugs or driving dangerously)
• You often have feeling of self-harm
• Having intense feelings of anger, which are really difficult to control
• Feeling paranoia or dissociation

Types of EUPD

• Borderline- More difficulties with relationships, self-harming and feelings of emptiness.
• Impulsive- Issues with impulsive behaviour and angry feelings.

Treatment for BPD

1) Dialectical Behaviour Therapy (DBT)
DBT helps to build skills to deal with distress. DBT can help to learn how to control harmful ways of coping with distress, such as self- harming or using drugs or alcohol. DBT usually involves weekly individual and group sessions.

2) Mentalisation-Based-Therapy (MBT)
MBT helps people who make assumptions about what other people think or feel. The goal of MBT is to improve your ability to recognise your own and others' mental states, learn to "step back" from your thoughts and examine them to see if they're valid. MBT is based on the concept that people with BPD have a poor capacity to mentalise. Mentalisation is the ability to think about thinking. 

3) Cognitive Behavioural Therapy (CBT) – Aims to help understand how thoughts and beliefs might affect feelings and behaviour.

4) Cognitive Analytic Therapy (CAT) – Combines CBT's practical methods with a focus on the relationship between the patient and therapist. 

5) Other talking therapies – such as schema-focused cognitive therapy, psychodynamic therapy, interpersonal therapy or arts therapies.

ED visits and typical presentations

• Self-harm - Do Risk Assessmnet and manage overdoses based on the type of drug taken
• Drugs and alcohol - Observe, give time to sober up and re-assess
• Impulsive behaviours (driving erratically, having more sexual partners, and spending money without thinking)

Emergency Medicine Physicians should adopt a calm and non-threatening attitude towards this group of patients. With no rapport, it can be challenging dealing with these sensitive induviduals in the midst of a chaotic ED. People with BPD often find that simply talking to somebody who understands their condition can help bring them out of a crisis. It becomes critical to step back and try to understand the crisis from the person’s point of view and explore their concerns. Use empathetic and open questioning including validating statements. Being a good listener and listening without interrupting goes a long way in such situations. If you come across a frequent attender, then check their anticipatory care plan on records. 

Prior to dishcarge, ensure they have helpline contact details before discharge (Mental Health Nurse, Social Worker) and in case of a severe crisis when behaviour poses a significant risk, discuss with MH team for admission or detention. No medication is currently licensed to treat BPD but medications are often used if you have another associated mental health condition, such as Anxiety/Depression. 

Posted by:

              

     Lakshay Chanana

     

     ST4 Trainee

     Royal Infirmary of Edinburgh

     Department of Emergency Medicine

     Edinburgh

     Scotland

     @EMDidactic

Sub-dissociative Dose Ketamine

Introduction

Pain is one the most common presentation to the emergency department (ED) and therefore, we should be aware of novel treatments options, adjuncts that can be used in addition to conventional therapies. Opioids are among the most commonly used analgesics in ED. Recently, a lot has been written about Low Dose Ketamine or Sub-Dissociative doses  (SDK) of ketamine to treat intractable pain or as a part of multimodal approach. 

Classically, ketamine has been used as an anesthetic agent for procedural sedation or intubation but low dose or sub- dissociative dose ketamine (SDK) may be used as an adjunct to opioids or as a single agent. SDK dosing is anywhere from 0.1-0.3 mg/kg where ketamine acts not as an anesthetic, but rather as an analgesic. Generally,  SDK does not produce many of the potentially adverse respiratory or hemodynamic effects of other analgesics, and may be used as a safe and effective alternative or adjunct to opioids. Ketamine is both hydrophilic and lipophilic which allows administration via various routes. 

It has been found that SDK lowers pain scores and has functionally equivalent efficacy to morphine for short-term analgesia in the ED. WHen used with opioids, SDK also reduces the overall dose of opioid analgesics and the need for re-dosing. 

Mechanism of action - Ketamine

After cell injury, the NMDA/glutamate receptor complex is activated in the dorsal horn of the spinal cord and these receptors are pivotal in developing hyperalgesia, allodynia and ultimately, central sensitization and wind up phenomenon (Wind-up is a frequency-dependent excitability of neurons in the dorsal horn of the spinal cord and the activation of the NMDA/glutamate receptor complex is a necessary step in the development of the wind-up phenomenon), which leads to the development of persistent and neuropathic pain as well as opioid-tolerant pain. SDK non-competitively blocks the NMDA receptors with its antihyperalgesic, antiallodynic and anti-tolerance effects. This mechanism of action of ketamine is responsible for its utility in managing a variety of acute and chronic (neuropathic, malignant, opioid-tolerant, opioid-induced hyperalgesic states) painful conditions as an adjuvant analgesic or single agent.

Ketamine undergoes extensive hepatic metabolism (via cytochrome P450 enzymes) with norketamine being an active metabolite with 1/3 of the potency of ketamine. Ninety percent of the drug is excreted in urine in the form of metabolites with 2-4% of the drug remains unchanged

In theory, patients with severe liver and renal dysfunction may have prolonged clearance and accumulation but there is no data to imply that SDK is unsafe in patients with liver or renal dysfunction

SDK Dosing:

0.1-0.3mg/kg over 15 minutes diluted in 100ml NS for short infusion - No monitoring necessary

0.15-0.2mg/kg/hr (continuous infusion): 100mg Ketamine in 100ml NS, IV pump is

necessary, titrate q30 min by 5mg until the pain is optimized or develop psycho-perceptual effects, monitoring is preferred

• Analgesic dose (0.1-0.3 mg/kg) - At these low doses, ketamine has minimal psycho-perceptual effects and works as a strong analgesic. Typically, these doses do not require monitoring.
• Recreational dose (0.2-0.5 mg/kg) ketamine works as a great analgesic but also leads to distortions of perception. 
• Dissociative dose (>0.7 mg/kg) ketamine - These doses keep them awake but unconscious. Typically this range of dose is used for PSA or intubation. 

Sitiations where SDK can be used:

Acute traumatic and non-traumatic pain

Complex regional pain syndrome

Functional abdominal pain

Migraine headache

Neuropathic and radicular pain

Sickle cell crisis

Chronic pain syndromes. 

Note: SDK does not cause respiratory depression or increase in intra-cranial or intra-ocular pressure. 

Side effects (directly related to speed of administration):

Nausea/Vomiting, Dizziness, Lightheadedness, Feeling of unreality, dysphoria

Emergence reactions - Not seen at low doses

Indications

• Acute pain: traumatic, non-traumatic, brief painful procedures, post-operative pain
• Chronic: central pain (post stroke pain), phantom pain, neuropathic pain, cancer pain
• Opioid-tolerant pain
• Opioid-induced hyperalgesic states

Contraindications

• Allergy to ketamine
• Age <2 months
• History of schizophrenia

Take Home

SDK used alone or in combination with opioids is safe and effective for the treatment of acute pain in the ED and may result in opioid sparing. Its use has been associated with relatively high rates of minor and short lived adverse side effects that can be reduced by utilizing a short-infusion of ketamine via IV of 0.3 mg/kg over 15 min.

References:

1. Johansson P, Kongstad P, Johansson A. The effect of combined treatment with morphine sulphate and low-dose ketamine in a prehospital setting. Scand J Trauma Resusc Emerg Med. 2009 Nov 27;17:61.
2. Galinski M, Dolveck F, et al. Management of severe acute pain in emergencysettings: ketamine reduces morphine consumption. Am J Emerg Med. 2007 May;25(4):385- 90
3. Ahern TL, Herring AA, Anderson ES, Madia VA, et al. The first 500: initial experience with widespread use of low-dose ketamine for acute pain management in the ED. Am J Emerg Med. 2015 Feb;33(2):197-201
4. Miller JP, Schauer SG, Ganem VJ, Bebarta VS. Low-dose ketamine vs morphine for acute pain in the ED: a randomized controlled trial Am J Emerg Med. 2015 Mar;33(3):402-8
5. Motov S, Rockoff B, Cohen V, Pushkar I, et al. Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2015 Mar;22(3):251-7
6. Goltser A, Soleyman-Zomalan E, Kresch F, Motov S. Short (low-dose) ketamine infusion for managing acute pain in the ED: case-report series. Am J Emerg Med. 2015 Apr;33(4):601.e5-7.
7. Ahern TL, Herring AA, Miller S, Frazee BW. Low-Dose Ketamine Infusion for Emergency Department Patients with Severe Pain. Pain Med. 2015 Jul;16(7):1402-9.
8. Yeaman F, Meek R, Egerton-Warburton D, Rosengarten P, et al. Sub-dissociative-dose intranasal ketamine for moderate to severe pain in adult emergency department patients. Emerg Med Australas. 2014 Jun;26(3):237-42
9. Motov S, Mai M, Pushkar I, Likourezos A, et al. A prospective randomized, double-dummy trial comparing IV push low dose ketamine to short infusion of low dose ketamine for treatment of pain in the ED. Am J Emerg Med. 2017 Aug;35(8):1095-1100. doi: 10.1016/j.ajem.2017.03.004. Epub 2017 Mar 3.

Posted by:

              

     Lakshay Chanana

     

     ST4 Trainee

     Royal Infirmary of Edinburgh

     Department of Emergency Medicine

     Edinburgh

     Scotland

     @EMDidactic

Lisfranc injuries

The Lisfranc joint complex is composed of the bones and ligaments that connect the midfoot to the five metatarsals of the forefoot and Lisfranc ligament connects the base of the second metatarsal to the lateral aspect of the medial cuneiform providing stability to the joint, despite the absence of a ligamentous connection between the first and second metatarsal. 

Lisfranc injuries are a spectrum of injuries which typically occur when an axial load is applied to a plantar-flexed foot. The severity of injury may range from a simple sprain to complete disruption of the tarso-metatarsal joints in the midfoot. These injuries are easy to miss (often diagnosed as a sprain in EDs) because they are rare and often show only subtle or no x-ray findings (1/5 have normal X rays). 

It is important for emergency physicians to be aware of the anatomy of Lisfranc joint complex and have a high index of suspicion for this injury since missed injuries result in long-term misalignment and functional weight-bearing difficulties. 


Clinical Presentation

• Patients are typically unable to weight bear
• Hematoma/ecchymosis on the plantar aspect of the foot
• Significant dorsal midfoot swelling
• Signs of compartment syndrome
• Tenderness to palpation over the midfoot
• Tenderness on twisting the forefoot after stabilising the heel
• Exacerbation of pain with dorsal and plantar flexion of each digit 
• Exacerbation of pain when walking on tiptoes 
• Fleck sign - Small chip fracture from medial margin of the base of M2

Diagnosis

Normal findings on Ankle X Rays:

• On the AP view, the medial edge of the base of the second metatarsal should line up with the medial edge of the middle cuneiform
• The gap between the second metatarsal and medial cuneiform is <2 mm.
• On the oblique view, the medial edge of the third and fourth metatarsal should line up with the medial edges of the middle cuneiform and cuboid, respectively.1
• On the lateral view, the superior border of the first metatarsal should align with the superior border of the medial cuneiform 
• Look for widening between the bases of the 1st and 2nd or 2nd and 3rdmetatarsal bases. Widening >2mm is an indication for urgent surgical intervention

On the AP view (left), the medial edge of the base of the second metatarsal should line up with the medial edge of the middle cuneiform. On the oblique view (right), the medial edge of the third and fourth metatarsal should line up with the medial edges of the middle cuneiform and cuboid, respectively.

Superior border of the first metatarsal aligns with the superior border of the medial cuneiform 

Note widening between medical cuneiform and second metatarsal. Fleck sign - Small chip fracture from medial margin of the base of the second metatarsal

With high suspicion of Lisfranc injury but normal initial X Rays, obtain a30-degree oblique x-rays or do a CT of the foot. 

ED Management

Stable dislocation/fracture injuries are defined as having less than 2 mm of displacement between the first metatarsal and medial cuneiform. These can be managed non-operatively with reduction and casting. The patient should be placed in a non-weight-bearing below-the-knee cast for six weeks and have an outpatient orthopedic follow-up in 2 weeks.  Discharge instruction should include elevation of the leg and warning signs of compartment syndrome of the foot.

For unstable fractures and dislocations ((>2mm widening at the Lisfranc joint), immediate orthopedic consultation is needed for surgical intervention with internal fixation.

Posted by:

              

     Lakshay Chanana

     

     ST4 Trainee

     Royal Infirmary of Edinburgh

     Department of Emergency Medicine

     Edinburgh

     Scotland

     @EMDidactic

Surviving OHCA by Prof. Richard Lyon

This is the talk by Prof. Richard Lyon at The Bick Sick in Zermatt, 2018

Dr. Lyon is a consultant in Emergency Medicine and clinical lead for Medic1 at the Royal Infirmary of Edinburgh. He is the associate medical director of Kent, Surrey & Sussex Air Ambulance and chair or Pre-hospital Emergency Care at the University of Surrey. He completed a unique doctorate thesis on out-of-hospital cardiac arrest (OHCA) – the TOPCAT study, which has formed the basis of a successful programme of work to improve outcome from OHCA across Scotland. He has won numerous national and international awards for his work. 

Posted by:

              

     Lakshay Chanana

     

     ST4 Trainee

     Royal Infirmary of Edinburgh

     Department of Emergency Medicine

     Edinburgh

     Scotland

     @EMDidactic