You walk into a room where a patient is screaming and thrashing about in his/her gurney from some stimulant abuse. PCP, cocaine, methamphetamine... or all of the above.When the number of people (police officers, security guards, nurses) is greater than the patient's pupil size, you KNOW that you'll need some chemical sedation.
What intramuscular sedation regimen do you use?
Regimens for chemical restraint vary by institution. Before droperidol was black-boxed by the FDA for allegedly causing QTc prolongation arrhythmias, it was widely used. I called it "vitamin D". What a wonderful single-agent medication. It's really debatable whether the black-box label was justified.- HAC: Haldol 5 mg, Ativan 2 mg, Cogentin 1 mg IM all in 1 syringe
- Midazolam (versed): 5 mg IM single agent - This is a very short acting benzodiazepine which is more consistently absorbed intramuscularly than lorazepam (ativan).
- B52: Haldol 5 mg, Ativan 2 mg, Benedryl 50 mg IM
- Haldol: 5 mg IM single agent
What regimen do you use?
5&2 without the cogentin.
ReplyDeleteBut I personally prefer IV when possible (if you're going to have to hold someone down, often I find you can hold them down and safely get a line in). Works much faster.
Graham - Agreed. IV ideally. For some reason, often it's the people with poor IV access who are gettin' into trouble and causing a ruckus. Plus I think your security folks may just be stronger than ours.
ReplyDeleteI generally go with Geodon, 10-20mg IM with the addition of a benzo if the patient is highly aggitated.
ReplyDeleteHey Rob: I've only used Geodon once. I gave 20 mg IM. The patient slept for a looooooong time. Do you ever give 5 mg? Good seeing you at CORD/MERC.
ReplyDeleteIV Valium 10, 10, 20... keep going... much easier to titrate. especially in PCP OD
ReplyDeleteAt my institution, we don't mess around with IM, doesn't work quick enough, especially when patients are endangering themselves, staff and other patients... We pop in a line, and either go with 10 of midazolam, 10-20 of diazepam or 2-4 of lorazepam.. with the ativan, we typically give haldol 5, and at times benadryl.
ReplyDeleteWow, how DO you get so close to the patients to get an IV? Our institutional police clearly need to work out more.
ReplyDeleteMichelle, I agree! I can't imagine getting close enough for the length of time needed to even quickly pop in an IV. Rather put on restraints - 4 points and give IM B52 and be done. When they fall asleep the restraints come off and they are calm.
ReplyDeleteAudra: Whew! I thought I was crazy being the only one doing these IM regimens.
ReplyDeleteI have used all of the above approaches and find them relatively similar in efficacy and safety (but I'm kind of new at this) which leads to my comment and question to all:
ReplyDeleteHow do you balance having an opinion about what's a good, safe, regimen while at the same time allowing the senior resident make their own choices vis a vis the agitated, potentially sick, and possibly dangerous patient?
I have for now a fairly laissez-faire attitude unless I think it's dangerous, so I'll try to avoid anti-psychotics in patients with lower sz thresholds and avoid bzd when etoh is the primary substance on board. In the end I'm not sure if the learner/resident would appreciate more or less guidance in this arena.
One approach I have not used but I am curious about and would love to hear about if anyone has experience in Ketamine- any thoughts? I know it is contraindicated in CAD and psychosis, maybe if high ICP, but it was the protocol (at least in theory) for the agitated patient in the trauma bay, if there was no IV access.
Demian
Demian: Interesting questions. I wish I had a better answer than - it's a risk-benefit, case-by-case balancing act. You take into account:
ReplyDelete* the patient's danger to self/you/staff/other patients
* the risks of the medicine(s)
* the degree of agitation (maybe give a smaller IM dose than usual? give single agent?)
* the duration of action desired by your medication (versed shorter acting than ativan, but then maybe you want a longer acting agent to let the patient sleep off the offending drugs)
Regarding allowing the senior resident to make their own choices about sedation: Usually the acutely agitated patient is making such a huge scene in the ED that it gets the primary attention of the senior resident and attending. We discuss a tailored sedation plan for the case asap. Even if the patient is agitated from an acute medical illness, the patient needs sedation to get all the studies done (CT head, labs, blood cultures, etc).
I HAVE NOT used ketamine in the ED for the reasons explained above, but have heard of 2 success stories with it. You do worry, however, about its other side effects of n/v, myoclonus, and emergence phenomenon as well (http://emergency-medicine.jwatch.org/cgi/content/full/2008/905/1). I personally don't feel comfortable with it yet...
Intranasal works great till u can get a line
ReplyDeleteExcellent idea. I hadn't realized that this was an option. Thanks for the tip!
ReplyDeleteHaldol,Ativan, Benadryl...all at the same time ?
ReplyDeletewhat for ?
You need to control Psychosis...what ever the et of Psychosis is ..Be it drugs...PCP..amphetamines..and so forth. or Funcational illness..
Haldol 5mgm q half hour or 10mgm q one hour till patient sedated,
The total amount required to get to sedation....the oral dose will be 1.5 times. one third in the morning two third at night.
Adding Ativan ..benzo, does what ? ...Nothing. May cause Respiratory disttess
Benadryl...an antocholinergic may create more confusion...
and Sudden Death Syndrome....reported just mixing Ativan to Haldol and injected at one site.