Ondansetron Administration to Altered Patients
Question# 826
Can we administer an ondansetron to an altered patient?
Withholding dimenhyDRINATE in this patient cohort is intuitive due to its sedative effects, but what is the reasoning for withholding ondansetron to someone slightly altered GCS 14?
Answer:
Undifferentiated patients with altered mental status are inherently high-risk, as the underlying cause of the alteration is unknown. There are many pathologies that need to be investigated to diagnose the underlying condition.
Administering PO medications to this subset of patients also presents a choking hazard with patients who are altered and/or unable to swallow. The clinical considerations for providing PO medication is ultimately a risk/benefit one. We want to treat the patient’s underlying symptoms; while balancing an unnecessary risk to the patient (we weigh the benefits of the symptoms relief properties with the risk of aspiration, or allergic/adverse reaction). As with every patient interaction we have, this involves having an informed conversation with respect to these risks.
A patient who is altered due to an underlying dementia for example, who normally feeds themselves and performs their activities of daily living relatively independently, is a much different patient than the patient altered secondary to a head injury.
At its crux, this decision is based on how we define “altered”. With respect to that definition, the ALS PCS (p. 15) states:
The word ‘altered’ refers to a GCS that is less than normal for the patient.
The word ‘unaltered’ refers to a GCS that is normal for the patient. This may be a GCS <15.
Thus, if the patient’s GCS is their baseline, we can consider them unaltered, and a patch may not be required. That said, if the patient is altered from baseline, and you feel the risk of choking is minimal and the benefit outweighs this risk, we encourage you to patch for a new order for this patient cohort. As always, please document your rationale in the remarks section.
Administering PO medications to this subset of patients also presents a choking hazard with patients who are altered and/or unable to swallow. The clinical considerations for providing PO medication is ultimately a risk/benefit one. We want to treat the patient’s underlying symptoms; while balancing an unnecessary risk to the patient (we weigh the benefits of the symptoms relief properties with the risk of aspiration, or allergic/adverse reaction). As with every patient interaction we have, this involves having an informed conversation with respect to these risks.
A patient who is altered due to an underlying dementia for example, who normally feeds themselves and performs their activities of daily living relatively independently, is a much different patient than the patient altered secondary to a head injury.
At its crux, this decision is based on how we define “altered”. With respect to that definition, the ALS PCS (p. 15) states:
The word ‘altered’ refers to a GCS that is less than normal for the patient.
The word ‘unaltered’ refers to a GCS that is normal for the patient. This may be a GCS <15.
Thus, if the patient’s GCS is their baseline, we can consider them unaltered, and a patch may not be required. That said, if the patient is altered from baseline, and you feel the risk of choking is minimal and the benefit outweighs this risk, we encourage you to patch for a new order for this patient cohort. As always, please document your rationale in the remarks section.