Drugs for agitated patients?

[BushyFromOz]

Hey!

Anyone using propfol for combative patients and whats your experince?

Chris

Sweden.

conrad murray......

Midazo-slam is our drug oif choice. 100mcg/kg to a max of 10mg and a total of 4 doses..... generally make for a compliant patient

[dandanthemedicineman]

conrad murray......

Zing.

[craig]

bushy....dont think MJ was the agitated one...maybe the little boys that were 'sleeping' over were......

we use Midaz and morphine mix here as well as midaz

[Bieber]

Midazolam and Haldol. Haven't used either yet, but I hear Haldol has quite a kick to it!

[Sequel]

I've used Haldol once. It's a real pain to draw it up from the vials though, so I've never been able to administer a full dose (if anyone has any tips for drawing up from those vials I'm all ears). I administered it about 10-15 minutes prior to arrival at the hospital and as I understand the time of onset for Haldol is typically 30 minutes so I didn't notice much of a change in my patient except that she was less excited and didn't speak as much (or quite as crazy).

[Bieber]

Sequel, did you just give Haldol or Haldol + a benzodiazepine?

[croaker260]

I've used Haldol once. It's a real pain to draw it up from the vials though, so I've never been able to administer a full dose (if anyone has any tips for drawing up from those vials I'm all ears). I administered it about 10-15 minutes prior to arrival at the hospital and as I understand the time of onset for Haldol is typically 30 minutes so I didn't notice much of a change in my patient except that she was less excited and didn't speak as much (or quite as crazy).

In the old days we had a "coctail" on standing order for 5 mg of Haldol, 25 mg of Benadryl, and 10 mg of valium IM for the extreemely comabtive patients. It was used quite often to good effect...sometimes too much effect...but this was pre-versed days.

This is our current protocol:

http://www.adaweb.net/LinkClick.aspx?fileticket=j79mqGaMLDc%3d&tabid=798

ALS SPECIFIC CARE: See adult General Medical Care Protocol M-1

Sedation

- Diazepam (Valium)

ƒ IV: 2-5 mg every 5-10 min PRN.

ƒ IM: 5-10 mg repeated once in 20 minutes PRN.

ƒ Max of 20 mg

- Midazolam (Versed)

ƒ IV/IM: 0.5-2.5 mg every 5-10 min repeated PRN to a max of

5 mg

- Haloperidol (Haldol)

ƒ IV/IM: 2.0-5.0 mg IVP PRN to a max of 10 mg

ƒ Strongly consider co-administration of Benadryl

ƒ Caution with Hyperthermia, seizure risks, and Hyperdynamic

drug use

If removal of noxious stimulus fails to resolve episode, pharmacologic therapy

is indicated.

Adjunctive medications: These medications are given for their potentiation of

other drugs effects or for the prevention/treatment of certain side effects

(nausea, EPS, etc) of drugs used in sedation.

- Benadryl (Diphenhydramine)

ƒ IV/IM: 25-50 mg

[Doczilla]

We are adding Ketamine this year to the regional protocol for agitated delirium/combative patient. 100mg IV/IN or 500mg IM.

We are also allowing its use in the RSI and sedate to intubate protocols. 100mg IV/IN

A couple of local services (mine) will be using it for pain control in trauma, 0.5mg/kg IV.

'zilla

[Kiwiology]

We are adding Ketamine this year to the regional protocol for agitated delirium/combative patient. 100mg IV/IN or 500mg IM.

We are also allowing its use in the RSI and sedate to intubate protocols. 100mg IV/IN

A couple of local services (mine) will be using it for pain control in trauma, 0.5mg/kg IV.

'zilla

The win in this cannot be overstated for realz ...

Why fixed bolus dosages for combative pt/RSI rather than a weight based dosing as you have done in trauma?

In saying that, New Zed is using fixed bolus dosages for pain (10-40 mg IV as required) and weight based dosing for combative patients and anaesthesia for RSI (1 mg and 1.5 mg/kg respectively)

Like all our analgesia, the aetiology of the pain is not important, so ketamine can be used in a patient who has physiologic pain say from gallstones or a headache (if cranial haemmorhage can be confidently excluded)

[DartmouthDave]

Hello,

Excelelnt discussion.

Back to Swe112 comments on Propofol and the agitated patient. It use is gaining popularity for non-intubated patients with delerium and agitation. Typically, a low dose infusion is hung until standard PO medications have time to take effect (Clonadine/Seraquil ect...) In fact, are published case now of low dose Propofol used in palative acre as well.

However, as most poster here will quickly point out this can not be generalized to the pre-hospital environment.

But, what is interesting is the use of Propofol in transporting (fixed wing/HEMS) psychotic patients to Regional Medical Centers from small communities. As well as Ketamine gtts. Dr. Minh Le Cong blog has lots of good information on it. There was even a case of a very dangerious psychotic patient (in New Zealand) that was sedated with Remifentinal/Ketamine and the inserted an LAM and connected it to a t-piece.

Interesting stuff. We covered this in great depth at my service recently. I just wish I had a copy of the power point to put up.

We tried a Propofol gtts once for an non-intubated agitated patient. It worked well. However, in the end, we have decidied to go with standard therapy (Haldol/Zyprexa/Benzo) because the services in these case studies are Physician based and can not be generalized to a non-physician based team.

Cheers,

My rambling post in done.....too many Starbucks coffee today!

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