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Drugs for agitated patients?

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Posted · Report post

Whats everyone using for agitated patients? Our region just removed haldol and now has versed only listed as our options.

Apparently haldol has too many side effects for it to be used anymore??

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Posted · Report post

Well, first of all we use that long lost ambo trick of talking to the patient and trying to verbally de-escalate the situation utilising friends/family as appropriate

Chemically we can use morphine and midazolam but have never been in a situation where I'd want to use it nor have I ever heard of it being used.

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Posted · Report post

When I was working in EMS I used to pick up a patient frequently that had a hx of Hyperglycemia due to non-compliance with medications. The patient would present extremely agitated to say the least. Although talking to the patient was an option, it rarely worked. The patient had a prescription for Halaparodol however, the patient was rarely compliant with that either. The patient had poor venous access also, We would calm the patient down with 5mg of Haldol IM as well as 2mg of Versed IM. She would be much more compliant UOA at the hospital, her V/S were more in line with normal standards and the hospital was able to treat her accordingly w/o incident.

For others, just talking to them does work. Part of patient care is the ability to listen and communicate with the patient as you are well aware I'm sure. Anxiety and patients with Panic attacks first need to control their breathing. Coaching them to breathe in through their nose and out through their mouth seems to work. Personally, I don't try to get to far into my patients problems. Some have real issues that are far beyond my scope and understanding. I will tell them that the hospital is far better equipped to help them with the resourses they require. I have the hardest time with sexual assault pateints, male of female. I mean, I can't tell them it'll be alright because I don't know. I can't say I know how they fell because I don't. I usually try and make some small talk, try and be as gentle as I can and always ask if it's ok to do certain interventions as simple as obtaining vital signs, but now I rambling.

Versed is a good drug. But isn't there a (artificial) shortage of that too? :wtf:

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Posted · Report post

Currently we just have lorazepam, but our new protocols will give us the option to use either lorazepam, midazolam or haldol. Never needed to use chemical sedation, though once our new protocols take effect and we don't have to call for it, I might be more inclined to employ it more liberally over physical restraints.

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Posted (edited) · Report post

Whats everyone using for agitated patients? Our region just removed haldol and now has versed only listed as our options.

In the past, I have used diazepam, midazolam, lorazepam, haldol and droperidol. The issues with haldol and droperidol tend to be that they tend to have a slow onset, can cause QT prolongation (especially droperidol), and tend to lower the seizure threshold, which can be particularly bad when the patient has coingested cocaine.

Of all of these, I think my personal preference has been the sublingual ativan for patients I can convince to take it. It's nice to have someone acutely psychotic / cracked out, and be able to say, "Hey, how do you feel about taking one of these", and have things calm down a little. For the honest-to-god combative, five cops sitting on them patient, I like midazolam IV, just because it has a very rapid onset, and can be titrated nicely.

[Edit: Of course, my personal preferences as a paramedic mean very very little. They're based on a small subset of patients that I've directly come into contact with, aren't controlled, etc. and are limited by the small amount of knowlege of medicine that I have, right?]

I don't know what the EBM is in this area.

Apparently haldol has too many side effects for it to be used anymore??

See above. Personally, I wouldn't have an issue working without haldol or droperidol. I'm quite comfortable rendering people different degrees of unconscious with benzodiazepines.

Well, first of all we use that long lost ambo trick of talking to the patient and trying to verbally de-escalate the situation utilising friends/family as appropriate

Chemically we can use morphine and midazolam but have never been in a situation where I'd want to use it nor have I ever heard of it being used.

I'm surprised. I used to do this quite regularly with patients who were acutely psychotic, especially with a lot of people who'd be doing too much meth or coke/crack.

I agree that many situations can be avoided by using good communication skills, and not scaring the crap out of someone with an altered sensorium (who's often already terrified) by trying to pretend to be a cop. (I think some people are far too aggressive and confrontational with these patients).

But, some of these patients aren't thinking rationally, and can't be talked down. Some of them are fighting from the moment you or the cops walk through the door. They're going to end up physically restrained, and chemical restraint means you can minimise the number of times they have to get TASERed, maybe avoid them getting pepper sprayed. And it means when they're tied down to the stretcher they're not thrashing around, screaming, getting all tachycardic, and maybe sensitising their myocardium to any drugs of abuse they have circulating around.

With respect, because I know you're a smart guy and you care about doing this sort of thing the right way.

Edited by systemet
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Posted · Report post

Well, we carry Diazepam tablets (those are obviously not for the I-will-kill-you-and-rip-your-body-apart-Blokes ;) ).

Aside from that, we have Midazolam and Haldol, although I`ve never used Haldol/seen it used. Had some blokes who were fit for a dose of Midaz, though.

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Posted · Report post

I've used Diazepam IM/IV & Versed IM/IV also with good results in the past, but personally I like Ativan IM or IV the best. It seems to work well for most patients.

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Posted · Report post

Kinda late to the party, but midaz IM or especially IN (assuming you can get hold of a nostril) works wonders.

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Posted · Report post

I've had good luck with both midaz and ativan. But that's just with my experiences. There's nothing scientific behind it.

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Posted (edited) · Report post

THis is a topic I feel strongly about.

First: Kiwis forst comment on verbal de-escelation is right on..

Second: Failing #1, an immediate risk assessment must be had. Severity of the patient, Safety (yours and Your patients), risk of occult pathologies, co-morbid factors(obesity, drug use, prolonged exertion, withdrawal, trauma) , risk of agitated delirium (or what ever name you wish to use), and presense of stimulant drug use all must be taken into consideration in a manner you can clearly articulate after the fact both in your documentation and to a board of inquiry if things go horribly wrong.

THIRD: You must understand that when you interdict in a combative patient, especially when you restrain one, even when you do everything right, sometimes things go horribly wrong. Make sure you are prepared.

FOURTH: THe things that alter these patients are wide and complex. AEIOU-TIPS ..remember. Never assume they are "just a drunk", or "just a psych".

FIFTH: You must understand the concepts of Excited/Agitated delerium and positional asphyxia (and how they perpetuate each other). Undestanding is the first step to mitigation, and in some cases a degree of prevention.

SIXTH: The things that we control that may kill these patients can be broken down into 5 H's. Hypoxia, Hyperthermia (from exertion), H+ (Acidosis), Hyperkalemia (from Rhabodo, muscle breakdown), and "High and Mighty" syndrome (not taking them seriously).

We can treat all of these through a combination of decreased stimulation, sedation, position, and environment. Oh yes, education too (of ourselves and our peers)

Now as far as sedation, I strongly favor Bezo's, specifically Ativan or Valium...They are predictable and their side effects are as well. Haldol, Inapsine, Phenergan, and other non-narcotic medications we used to use all have way to many side effects and problems that are the last thing you want to manage in an agitated patient. The only reasosn we ever used them as much as we did is because there was a bias against using "controlled substances" in EMS for many years...so we perpetuated bad medicine.

BTW, as Kiwi and I are discussing in another thread, I dont favor Versed for these patients, unless you have nothing else. Valium is way better for sedation outside of RSI.

Besides, Vailum is actually preferred in cases of cocaine toxicity, and (IMHO ) likely preferred in all drug induced hyperdynamic crisis.

Contrary to Kiwi's statement , we (at least here locally, when other efforts fail..its not first line by any means) do this here in the US, but perhaps we see more methamphetamine, cocaine, bath salts, and general alcohol/drug related stupidity through out the US than they do elsewhere. Not sure that is something to brag about though.....

Kinda late to the party, but midaz IM or especially IN (assuming you can get hold of a nostril) works wonders.

My luck with Versed IN has resulted in narcotic snot being blown across my uniform...but thats just me. (I do like it for SZ activity though...)

Edited by croaker260
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Posted · Report post

BTW, as Kiwi and I are discussing in another thread, I dont favor Versed for these patients, unless you have nothing else. Valium is way better for sedation outside of RSI.

Besides, Vailum is actually preferred in cases of cocaine toxicity, and (IMHO ) likely preferred in all drug induced hyperdynamic crisis.

Great post. Just wondering if you have a source for valium being preferred over versed?

Thanks.

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Yes and no, I Have some citations that discuss Benzo's for toxicological induced agitation as being better than any of the Haldol , inapsin, or similar drugs , and by default it seems that (IIRC) 99% specifically discuss Valium specifically though that may be because of the age of some of the studies...

I will have to dredge them up later though as I have a full day today and I am getting family aggro to get my butt off this computer and outside for family fun , LOL

But, to explain myself....

I prefer Valium for its profile: slower more even onset than versed, longer duration than versed, and less respiratory depression than versed at clinically equivalent doses, whereas those differences are exactly the reasons why I prefer Versed over valium for RSI/MAI/Post ETT sedation (as opposed to combative patient sedation which is what we are discussing here)

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Posted · Report post

Speaking of drugs for agitated patients, I almost used some last night. Thankfully, dimming the lights and just creating a calm and quiet environment was able to do the trick.

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Called me old fashioned but if all else fails I break out the Ativan and Haldol and dose based on how much I feel is needed. I've also used geodon and zyprexa with success. I hate to snow pts because it means a longer ER stay. Just enough to keep the staff and the pt safe is all I give.

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Posted (edited) · Report post

I use a variety of drugs for acute agitation. My standby is a combination of haldol (5mg) and ativan (2mg). The haldol treats acute psychosis, while the ativan provides more general sedation and counters the sympathetic outflow of someone who is truly amped up. By using the combination, I can get control without getting too many of the side effects from either (EPS from haldol and respiratory depression from ativan). I give these together as a unit dose, a "B52" that is typically given IM. After reassessment in 10 minutes, I can repeat the dose, and do that every 10 minutes until the patient is under control.

Local EMS protocol is 5mg versed IV/IM/IN as needed. They do not carry antipsychotic drugs.

Denver has had good experience with droperidol 5mg IM for agitation. They reviewed 1500 uses. While a decent percent had prolonged QT, they did not have any significant complications. Another study showed droperidol to gain more rapid control of agitated patients with less complications of respiratory depression than benzodiazepines. It's also a great drug for migraines as well as nausea. Our hospital took it off formulary entirely because of a death we had associated with it at 10 mg. There are several studies questioning the clinical relevance of the QT prolongation, and many, including myself, advocating for wider use. Excited delirium itself has a mortality rate of 10%, even when treated, so I think our one death is too little evidence to get rid of the drug. Lots of things cause QT prolongation, including haldol, zofran, phenergan, compazine, and reglan, and these our alternatives for treating migraines, nausea, or agitation.

Among the benzodiazepines, valium crosses the blood brain barrier a little faster than ativan. It can be problematic in the elderly because of active metabolites that may be present for up to 200 hours, but in healthy patients it is not really an issue. Ativan is our go-to drug in the hospital, but requires refrigeration, making it impractical for field use. Versed is a fairly "clean"drug without active metabolites and a fairly quick onset of action. Duration of action is much shorter than the others, so redosing may be needed. The nice thing about benzos is that they prevent seizures, as well as treat alcohol withdrawal syndrome, so if either of these are a possibility, they are a good way to go. People wring their hands about the hypotension associated with them, but my experience is that this is never a concern in an agitated patient.

Ketamine is another drug that is being used for agitation. As a dissociative anesthetic, you can treat the agitation without impairing their ability to protect their airway. But a benzo is recommended to prevent emergence reactions.

I've used atypical antipsychotics, usually Geodon IM, in the acutely agitated schizophrenic or manic with psychotic features. I've been happy with a dose of 10mg, which is light as far as the manufacturer's literature goes, but in my experience takes the edge off but doesn't leave the patient comatose. 20mg knocks them down pretty good, which is not a bad way to go if the patient will require transport somewhere. But for us, it makes it very difficult for the social worker to interview them.

If it's an agitated trauma patient, they get etomidate, fentanyl, propofol, rocuronium, and a ventilator. I do not screw around with these patients, as time is ticking away while you are waiting for the sedatives to work otherwise, and if there is a serious underlying injury, there is a risk of delay in diagnosis and treatment. For these patients, chemically paralyzing and intubating them may be needed to facilitate a decent exam and workup. There is also a linear correlation of likelihood of doing this with how many times the patient calls me "motherfucker".

'zilla

Edited by Doczilla
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Ketamine is another drug that is being used for agitation. As a dissociative anesthetic, you can treat the agitation without impairing their ability to protect their airway. But a benzo is recommended to prevent emergence reactions.

I've heard a lot of people are doing this, but have no direct experience myself. Is there any concern that we're taking a potentially aggressive patient, and giving them a close chemical cousin of PCP? It just seems a little counter-intuitive. Is there a risk of taking someone violent and making them fairly immune to pain, more disoriented, and more difficult to handle?

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I've heard a lot of people are doing this, but have no direct experience myself. Is there any concern that we're taking a potentially aggressive patient, and giving them a close chemical cousin of PCP? It just seems a little counter-intuitive. Is there a risk of taking someone violent and making them fairly immune to pain, more disoriented, and more difficult to handle?

I've not seen anyone get agitated with the administration of proper doses of ketamine. They can get agitated as it wears off, however, which is why a benzo should be given.

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For those who have given a lot of inapsine, ever had any problem with dystonic reactions/dyskinesia? I vaugely remember reading somewhere that it was a semi-common reaction that was quite pronounced. I only ever gave it a few times, but usually gave benadryl at the same time; some minor extra sedation and as a "just in case" deal. Was that even worth doing?

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For those who have given a lot of inapsine, ever had any problem with dystonic reactions/dyskinesia? I vaugely remember reading somewhere that it was a semi-common reaction that was quite pronounced. I only ever gave it a few times, but usually gave benadryl at the same time; some minor extra sedation and as a "just in case" deal. Was that even worth doing?

IIRC, the incidnce of EPS type s/s with Inapsine was slightly less than with phenergan and haldol, but more than with reglan and/or compsine. So .they do happen. Just not "a lot".

In our orders we have a reccomendation to co-medicate Haldol with Benadryl, but it wasnt required with Inapsine. Before they yanked it(due to the FDA's BS black box warning) I had given it hundreds (thousands even?) of times with only 1 incidence of PS, so I cant say that co-medicating with benadryl is indicated "routinely" :) (see other post on atropine... can I have a +1 for cross thread humor?)

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Posted (edited) · Report post

I've not seen anyone get agitated with the administration of proper doses of ketamine. They can get agitated as it wears off, however, which is why a benzo should be given.

There seems to be a great fear over your way about emergence syndrome and ketamine; I have only seen it once and the benefit of ketamine is far outweighed by the small chance of some hallucinations so, we do not routinely give midazolam to those who have had ketamine and only give it if the hallucinations are particularly severe.

Ketamine is just the bees knees its the most awesome stuff ever I love it to bits its totally freaking awesomeness wrapped in made of win

Interestingly it seems Intensive Care Paramedics may have been under-dosing people on ketamine so the new Guidelines encourage larger dosages of ketamine if required.

This one bloke got 80mg of ketamine one night, hell 80mg of ketamine would damn near anaesthetise me, which we are also using ketamine for now too

Oh and it's really awesome for giving House Surgeons the shits followed by "what on earth did you give him?" :D

Gosh you blokes really are missing out by not having House Surgeons ....

Edited by kiwimedic
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Posted · Report post

Used Haloperidol (very rarely), Diazepam (rarely) and midazolam (most of the times) for sedation.

Personally I prefer the Midazolam due to it's ability to give it IN and the fact that it wears of much faster...Which makes it much easier to control, especially if you don't know what else the patient did take....

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Posted · Report post

Los Angeles can use versed for agitated delirium. It's used pretty rarely, though. It's not meant simply for agitated or violent patients

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Posted · Report post

Los Angeles can use versed for agitated delirium. It's used pretty rarely, though. It's not meant simply for agitated or violent patients

Do you mean the sole use of midazolam is not just for agitation or that it is not a good choice of drug for agitated patients?

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Posted · Report post

It cannot be used for simple agitation, combativeness, or general chemical restraint. It is only to be used in the case of agitated delirium...which honestly I don't think we're trained thoroughly enough in. It's not just violent. It's not just altered. It's an unexplained delirious episode where the patient is working himself up physically....and at risk of sudden death.

And we also use it seizures.

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Posted · Report post

Are you referring to LA County specifically or midazolam generally?

In LA County nothing surprises me, but if you mean midazolam more generally it is an excellent choice for agitated patients or those in need of a little sedation and/or chemical restraint (what we in NZ use it for)

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