Drugs for agitated patients?

[Doczilla]

Actually, Geodon is pretty good for agitation. Works quickly enough, and if dosed properly, brings them down but not out. The side effects aren't any worse than haldol.

[sihi]

We have Diazepam, Midazolam and Haloperidol. I prefer Midazolam 1-5 mg i.v.

I.M. way --> Diazepam is not the best option for i.m. - absorbtion from muscle takes too much time.

[Kiwiology]

There is much good to be said about intranasal drugs (IN) which have become popular in the Ambulance Service here, esp midazolam

[systemet]

Case report in PEC about an episode of laryngospasm following intramuscular ketamine for sedation, here:

http://informahealthcare.com/doi/full/10.3109/10903127.2011.640766

Short version:

97kg male patient given 5mg /kg ketamine I.M. in the field for agitation, possible drug overdose, hx of bipolar disorder, suddenly desaturates in the ER @ +15 minutes, after previously appearing dissociated but hemodynamically stable.

Examining physicians report a SpO2 of 20% with good pleth, chest / abdominal motions consistent with attempted inspiration, with no A/E, and palpate spasm of the larynx. No improvement with bilateral NPAs and positioning. Sounds scarey.

They tried PPV, got A/E, and restored the SpO2. But then it happened again, so they elected to RSI with succinylcholine.

Transferred to ICU, but extubated and sent to psychiatry the same day. CBC / lytes normal, mUrine tox negative, noncontrast CT negative, CK normal. Discharge dx: bipolar affective disorder with acute mania and psychosis.

[croaker260]

Uhm, perhaps I am way off, but who would use Ketamine for sedation of a combative patient if they were not going to take more advanced airway intervention in the first place, especially with the dissascociation effects . I am missing the logic here.

Seems like using the hammer on the wrong type of nail....

[chbare]

One of the positive attributes of ketamine is that it commonly preserves airway protective reflexes. I've been on many procedural sedations where we had dissociated patients do quite well. Not all people who receive ketamine need to be intubated. In fact, many do not. However, the case does emphasise the fact that no matter how much we make like a medication, many can have serious side effects. It's always a risk benefit analysis when giving a medication. Ketamine is certainly no different.

[croaker260]

One of the positive attributes of ketamine is that it commonly preserves airway protective reflexes. I've been on many procedural sedations where we had dissociated patients do quite well. Not all people who receive ketamine need to be intubated. In fact, many do not. However, the case does emphasise the fact that no matter how much we make like a medication, many can have serious side effects. It's always a risk benefit analysis when giving a medication. Ketamine is certainly no different.

Well, I certainly dont disagree agree with you... The risk benefit equation for me doesn't equal out with ketamine as it does with say good ol fashioned diazepam or Ativan.. (I dont like haldol, but that is a different discussion)

[HarryM]

Uhm, perhaps I am way off, but who would use Ketamine for sedation of a combative patient if they were not going to take more advanced airway intervention in the first place, especially with the dissascociation effects . I am missing the logic here.

Seems like using the hammer on the wrong type of nail....

We used to only use morphine or midazolam for combative patients but recently introduced Ketamine as a take-down drug for a combative patient. 2mg/kg IM up to a maximum of 200mg.

[Swe112]

Hey!

Anyone using propfol for combative patients and whats your experince?

Chris

Sweden.

[Vorenus]

Yeah, Propofol can be useful in chemical restraint. It acts pretty fast and you can control it pretty good since the effect wears off pretty fast too (this also means you`ve gotta stock up your propofol reserve if you`ve got a long drive) and most contraindications aren`t found in your usual psych patient, so yeah, it`s pretty handy.

Course you`ve gotta take a close look at their saturation, same as Ketamine.