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)
  • 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.