Drugs for agitated patients?

[systemet]

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.

[croaker260]

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)

[Bieber]

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.

[ERDoc]

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.

[Doczilla]

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 January 30, 2012 by Doczilla

[systemet]

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?

[Doczilla]

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.

[triemal04]

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?

[croaker260]

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?)

[Kiwiology]

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?"

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

Edited February 15, 2012 by kiwimedic