Have you ever had those patients that are agitated? In a Zombie-like frenzy they rip out all their lines and extubate themselves in the CT scanner agitated? I think we’ve all been there (hopefully with something for sedation in hand!).
Dr. Reuben Strayer highlighted how to handle these patients well in his 2016 SMACC talk.
- Agitated but cooperative:
- Redirection
- 1:1
- reduce external stimuli
- 1-2mg lorazepam PO
- The OTHERS (Dr. Strayer splits this into 2 groups- disruptive without danger and excited delirium but for my simplicity they are one group on a continuum)
- First establish IV!
- ‘Oh you don’t have one’
- First give IM Meds! Good Ol’ 5+2: haldol 5mg IM, and lorazepam 2mg IM or midazolam 5-10mg IM (faster on/off)
- Lorazepam onset 1-3min IV, 15-30min IM; 1/2 life: 14-42 hours
- Midazolam onset 1-3min IV, 15-20min IM/PO; 1/2 life: 1.5-2.5hrs; can see hypoventilation and hypotension
- Haldol can see QT prolongation so get EKG first! has extrapyramidal side effects and may lower seizure threshold; can you give it IV? yes! but not FDA approved
- Try Zebras?
- Ketamine: The Original Kings of County reviewed the use of Ketamine for rapid sedation–>They found a number of studies where ketamine offered rapid sedation but was associated with increased side effects such as: laryngospasm, emergence reaction, apnea…=more intubations
- Droperidol (I don’t think we use this here)…
- Atypical Antipsychotics such as Olanzapine
- Some studies have shown shows that atypical antipsychotics may have similar efficacy as haldol and limited side effects (Skrobik et al 2004)
- First establish IV!
- Get the Bodies on the floor
- Get help and support with restraints
- Reevaluate; if a patient is struggling against restraints may need more chemical sedation
Example of a Sedation timeline [adapted from The Original Kings of County]
| 5 min | 15 min | 20 min | 35 min | 90 min | Next… |
| 5-10mg IM Midazolam and/or Haldol 5mg | 0.5-1 mg IV Midazolam | 0.5-1mg IV Midazolam +/- restraints; Haldol 5mg | 1-2mg (not to exceed 2.5mg) IV Midazolam; +/- restraints; Haldol 5mg | STOP (Hammer Time) reeval patient may be getting alot of Haldol and may need to consider: Ketamine 140mg IV (push slow!) | Rocuronium and intubate; Propofol drip |
Sources:
- Strayer, R. 2016. SMACC. http://www.smacc.net.au/2016/09/disruption-danger-droperidol-emergency-management-agitated-patient/
- deSouza,I. 2016. The Original Kings of County. http://blog.clinicalmonster.com/2016/08/em-critical-care-sedation-agitated-patient/
- Skrobik, Y., Bergeron, N., Dumont, M., & Gottfried, S. (2004). Olanzapine vs haloperidol: treating delirium in a critical care setting. Intensive care medicine, 30(3), 444-449.
