10 Questions
What is the main risk of not going to the hospital according to the doctor?
Becoming seriously unwell and dying
What is the doctor's main concern about the patient's decision to stay at home?
The patient's unwillingness to follow medical advice
What is the purpose of creating a follow-up plan with the patient?
To provide a safety net and ensure the patient's family understands the situation
What is the first step in assessing a patient's mental capacity according to the Mental Capacity Act 2005?
Determining if the person has an impairment or dysfunction of mind or brain
What principle guides the doctor's actions if the patient lacks mental capacity and there is no advanced directive or LPA?
Best interest principles
What is the estimated dose that can be life-threatening within 6 hours?
10-30mg/kg
What are the signs and symptoms of TCA overdose?
Mydriasis, dry mouth, sweating, agitation, tremor, and clonus
What is the treatment for arrhythmias despite Na+ blocking effects?
Lidocaine and Mg
What is the electrocardiogram (ECG) finding in TCA overdose?
QRS > 100ms
What is the dosage of sodium bicarbonate for treatment of TCA overdose?
50ml 8.4% Bicarb (max 6mmol/kg)
Study Notes
Assessment of Capacity and Refusal of Care
- A patient with an ischaemic leg and mild dementia is assessed for capacity to make a decision about their care.
- The patient's capacity is assessed through a conversation to determine if they can understand, retain, and communicate their decision and weigh up the risks and benefits.
Mental Capacity Act 2005
- A two-stage process to assess capacity:
- Stage 1: Determine if the person has an impairment or dysfunction of mind or brain.
- Stage 2: Determine if the impairment or disturbance affects their ability to make a particular decision.
Criteria for Capacity
- A person lacks capacity if they cannot:
- Communicate their decision
- Understand information about the decision
- Retain that information in their mind
- Evaluate, use, or weigh that information as part of the decision-making process
Decision-Making Process
- If the patient lacks capacity:
- Check for an advanced directive or Lasting Power of Attorney (LPA)
- Apply the doctrine of emergency or doctrine of interim (if short-term) or best interest principles (if long-term)
- Any action taken must be proportionate to the risk the patient is putting themselves at and believed to be in their best interests
TCA Overdose and Safeguarding
- Estimated dose of 10-30mg/kg can be life-threatening within 6 hours.
- Monitoring is crucial at least 6 hours post-ingestion.
Clinical Features
- Anticholinergic symptoms: dry mouth, flushed skin.
- Alpha blockade and Na+ blocking effects.
- Sympathomimetic symptoms: mydriasis, dry mouth, sweating, agitation, tremor, clonus, hyper-reflexia.
Cardiovascular Complications
- Arrhythmias, hypotension, and ECG changes.
- PR and QT prolongation.
- QRS >100ms increases risk of seizure.
- QRS > 160ms increases risk of ventricular tachycardia (VT).
Treatment
- Sodium bicarbonate (50ml 8.4% or max 6mmol/kg) administration.
- Hyperventilation (pH 7.5-7.55) to reduce sodium channel blocking effects.
- Lidocaine and Mg for arrhythmias despite Na+ blocking effects.
- Lidocaine and Mg thought to outcompete TCA and reduce Na channel blocking effects.
Assess a patient's capacity to make medical decisions in a scenario where a paramedic has already evaluated their medical condition. Consider the patient's situation and background to create a management plan.
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