Drugs for agitated patients?

[GhostRider]

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??

[Kiwiology]

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.

[JakeEMTP]

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?

[Bieber]

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.

[systemet]

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 January 27, 2012 by systemet

[Vorenus]

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.

[1EMT-P]

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.

[usalsfyre]

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

[paramedicmike]

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

[croaker260]

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 January 29, 2012 by croaker260