# Geodon/Zyprexa for agitation management



## NomadicMedic (Oct 15, 2016)

I'm curious, after reading some articles on the management of agitated and/or combative patients, if any prehospital agencies have started carrying atypical antipsychotics like Geodon or Zyprexa and if so, how has your experience been?


----------



## TransportJockey (Oct 15, 2016)

We carry geodon. For excited delirium (what our protocol calls for it to be used for) it sucks. We actually are going to ketamine to replace geodon. 

Sent from my SM-N920P using Tapatalk


----------



## VentMonkey (Oct 15, 2016)

I had wondered the same about Haldol. I can't recall who, or where, but someone had it in their system for agitated delirium long before Ketamine was so robust.

I'd be curious to know how well this antipsychotic worked in the prehospital environment, and whether or not it was given in conjunction with say, Benadryl.


----------



## TransportJockey (Oct 15, 2016)

We usually pair it with versed, and still have problems with it working. I carried haldol in pecos and had mixed results with it. Now, haldol works very well when given as a b52 (50mg benadryl, 2mg ativan, and 5mg haldol)

Sent from my SM-N920P using Tapatalk


----------



## Carlos Danger (Oct 15, 2016)

VentMonkey said:


> I had wondered the same about Haldol. I can't recall who, or where, but someone had it in their system for agitated delirium long before Ketamine was so robust.



"5 + 5" was fairly common back in the day. Generally works pretty well.

(5mg of haldol and 5mg of versed)

Though personally, I think true indications for this type of "takedown cocktail" are pretty rare.


----------



## Carlos Danger (Oct 15, 2016)

double post


----------



## VentMonkey (Oct 15, 2016)

TransportJockey said:


> Now, haldol works very well when given as a b52 (50mg benadryl, 2mg ativan, and 5mg haldol)
> 
> Sent from my SM-N920P using Tapatalk


Ah, yes! The ol' "Vitamin H Cocktail". I'd seen a patient who was quite literally going psychotic when we got to him, and for the life of us he would not stop screaming, and fighting (this was before agitated delirium was accepted in the prehospital setting, so no sedatives).

It turned out he was a long term alcoholic who had up and quit cold turkey, and was experiencing violent hallucinations.

The first thing that ED doctor ordered was the cocktail, and man did it work like a charm.

@TransportJockey, what was the onset like for Haldol when giving it, and was IV, IM, or both?


----------



## Summit (Oct 15, 2016)

Haldon and Versed! Woo! The versed works until the haldol kicks in. Curious, how much haldol do your protocols call for?

Xyprexa is nice but they have to be more cooperative... and it still takes longer to kick in than most of your transport times.

Watch the benadryl... 5-10% of people have CNS anitcholinergic effects at normal doses and will find it anxiety and agitation inducing.


----------



## EpiEMS (Oct 15, 2016)

Interesting note from the "Gathering of Eagles"* (2010):
Of the 34 largest systems, "33 have something for agitation." 
   Midazolam; 26
   Diazepam: 9
   Lorazepam: 4
   Haloperidol: 5 (and 3 are adding it)
   Droperidol: 2
   Ketamine: 1

*Largest EMS systems medical directors =/= the _best_ systems' medical directors

My guess is more have added Special K, but maybe that's my bias from reading on this board


----------



## NomadicMedic (Oct 15, 2016)

We had a protocol for Haldol and Versed in DE. Only used it once or twice, but it worked well. It was usually a load of Versed. In Washington I used Zyprexa frequently when doing a long distance transport of combative or violent behavioral patients. Usually a dose at the ED and then another dose during the ride. That kept things pretty mellow. 

I also saw a doc jab a fighter in the ED with a load of Etomidate IM. Worked pretty quick, but it might have been a bit of overkill. Wouldn't have been my first choice, but any port in a storm, I guess.


----------



## VentMonkey (Oct 15, 2016)




----------



## TransportJockey (Oct 15, 2016)

VentMonkey said:


> @TransportJockey, what was the onset like for Haldol when giving it, and was IV, IM, or both?


Five to ten minutes it seemed for IM. I never actually have given it IV.


----------



## NomadicMedic (Oct 15, 2016)

TransportJockey said:


> Five to ten minutes it seemed for IM. I never actually have given it IV.



It is just such a dangerous thing. Nothing like a wildly flailing guy, with superhuman strength (or what seems like it) and a hapless paramedic, standing there with a sharp syringe loaded with sedative, trying to get close enough to jab and depress that plunger. Tell me again why we can't have dart guns?


----------



## VentMonkey (Oct 15, 2016)




----------



## Summit (Oct 15, 2016)




----------



## VentMonkey (Oct 15, 2016)

[QUOTE="Summit said:


>


...said every parent ever.


----------



## Tigger (Oct 15, 2016)

We carry Haldol here and I have not had much luck with it, which considering it's onset is not surprising. By the time we get to the hospital it's usually helping, but it hardly has much effect during the "takedown" phase, even with the 50 of Benadryl we give "prophylactically." Both times I gave it interning I ended having to hit them with Versed too, I think in the future I will start with Versed instead. 

We also have Ketamine for excited delirium as well as Inapsine, though no one can get their hands on the latter.


----------



## Summit (Oct 15, 2016)

Those giving haldol, how much are you giving?


----------



## Tigger (Oct 15, 2016)

Summit said:


> Those giving haldol, how much are you giving?


5mg, IM only.


----------



## VentMonkey (Oct 15, 2016)

Tigger said:


> 5mg, IM only.


Do you, or @TransportJockey know why it is/ was IM only? Are the side effects IVP in the prehospital setting too risky?


----------



## Carlos Danger (Oct 15, 2016)

VentMonkey said:


> Do you, or @TransportJockey know why it is/ was IM only? Are the side effects IVP in the prehospital setting too risky?



I obviously can't speak for everyone's protocols, but I imagine it's only IM because the assumption is you don't have an IV in these patients. If you did have an IV, some plain 'ole versed would be the way to go, IMO. To be honest, I'm not sure haldol is all that great of an idea. I've had good luck with 5+5 a couple times in the past, but I think the versed was doing much more than the haldol.

In the pre-op area, for uncooperative (MR or autistic) patients I have a co-worker who a couple times has darted them with about 1mg/kg of ketamine and 0.1mg/kg of versed, and it works really well. I haven't had to do it yet myself, but I'd probably use the same thing.

If I were in the field and they were being violent I'd probably not fool around drawing up multiple drugs and just use a large dose of ketamine. Like 200-300mg IM for an average sized adult. Once they fall asleep manage the airway prn, start an IV, and give some ativan or valium before the K starts to wear off. K.I.S.S. Easy peasy.


----------



## VentMonkey (Oct 15, 2016)

Remi said:


> I obviously can't speak for everyone's protocols, but I imagine it's only IM because the assumption is you don't have an IV in these patients. If you did have an IV, some plain 'ole versed would be the way to go, IMO. To be honest, I'm not sure haldol is all that great of an idea. I've had good luck with 5+5 a couple times in the past, but I think the versed was doing much more than the haldol.
> 
> In the pre-op area, for uncooperative (MR or autistic) patients I have a co-worker who a couple times has darted them with about 1mg/kg of ketamine and 0.1mg/kg of versed. I haven't had to do it yet myself, but I'd probably use the same thing.
> 
> If I were in the field and they were being violent I'd probably not fool around drawing up multiple drugs and just use a large dose of ketamine. Like 200-300mg IM for an average sized adult. Once they fall asleep manage the airway prn, start an IV, and give some ativan or valium before the K starts to wear off. K.I.S.S. Easy peasy.


We're given Versed for our "chemical restraint" protocol, and I wholeheartedly agree this is sufficient; though it may take a bit more with patients depending on their particular chosen "stimulant(s)" for that particular evening.

Bath salts anyone?...


----------



## NomadicMedic (Oct 15, 2016)

Versed is what most people are/we're using here, but even backwards ole Georgia is getting K for these patients. 

Also, anecdotally, I've had 50/50 results with IN versed in these cases too. It's safer than a sharp, but if you've got a couple of struggling cops holding some guy in a headlock, it's just as easy to jab 'em.


----------



## VentMonkey (Oct 15, 2016)

DEmedic said:


> Versed is what most people are/we're using here, but even backwards ole Georgia is getting K for these patients.
> 
> Also, anecdotally, I've had 50/50 results with IN versed in these cases too. It's safer than a sharp, but if you've got a couple of struggling cops holding some guy in a headlock, it's just as easy to jab 'em.


Tried IN Versed only a handful of times. Worked great for a stat ep febrile sz, not so much the bath salts patient who flung a snot rocket across the back of the ambulance though...


----------



## EpiEMS (Oct 15, 2016)

DEmedic said:


> We had a protocol for Haldol and Versed in DE. Only used it once or twice, but it worked well. It was usually a load of Versed.



I was under the impression that the Haldol and Ativan cocktail was generally standard practice in the ED. That being said, I haven't seen it used outside the ED.

I like the IN versed idea - seems nice and safe, relatively speaking.

Has anybody used droperidol pre-hospitally?


----------



## SpecialK (Oct 16, 2016)

Oral olanzapine is being introduced for mildly agitated pts.  The "goal" is for them to respond well to it and be able to be left in the community.


----------



## ParamedicStudent (Oct 16, 2016)

TransportJockey said:


> We usually pair it with versed, and still have problems with it working. I carried haldol in pecos and had mixed results with it. Now, haldol works very well when given as a b52 (50mg benadryl, 2mg ativan, and 5mg haldol)
> 
> Sent from my SM-N920P using Tapatalk


Why benadryl? Is it for the drowsiness effect?

And I thought a lot of protocols for agitation or combative patients was to give a benzo.


----------



## cruiseforever (Oct 16, 2016)

EpiEMS said:


> Has anybody used droperidol pre-hospitally?



Droperidol was a wonderful drug until the black box thing.  We have tried to put it back on the trucks, but it's been a tough med to find.


----------



## Summit (Oct 16, 2016)

SpecialK said:


> Oral olanzapine is being introduced for mildly agitated pts.  The "goal" is for them to respond well to it and be able to be left in the community.


That is really awesome and progressive care right there. Does the system really allow for you to go on scene for an hour+ to let things simmer down and the meds kick in?


----------



## Tigger (Oct 16, 2016)

VentMonkey said:


> Do you, or @TransportJockey know why it is/ was IM only? Are the side effects IVP in the prehospital setting too risky?


It is known to lower the seizure threshold and potentially cause prolonged QT. As to how that is prevented with administration...I do not know.


----------



## Tigger (Oct 16, 2016)

Remi said:


> I obviously can't speak for everyone's protocols, but I imagine it's only IM because the assumption is you don't have an IV in these patients. If you did have an IV, some plain 'ole versed would be the way to go, IMO. To be honest, I'm not sure haldol is all that great of an idea. I've had good luck with 5+5 a couple times in the past, but I think the versed was doing much more than the haldol.
> 
> In the pre-op area, for uncooperative (MR or autistic) patients I have a co-worker who a couple times has darted them with about 1mg/kg of ketamine and 0.1mg/kg of versed, and it works really well. I haven't had to do it yet myself, but I'd probably use the same thing.
> 
> If I were in the field and they were being violent I'd probably not fool around drawing up multiple drugs and just use a large dose of ketamine. Like 200-300mg IM for an average sized adult. Once they fall asleep manage the airway prn, start an IV, and give some ativan or valium before the K starts to wear off. K.I.S.S. Easy peasy.


The true excited delirium patient gets 5mg/kg IM here. But given the lack of consensus about what constitutes excited delirium plenty of patients experiencing a violent behavioral crisis have gotten it too. Seems to work pretty good.


----------



## EpiEMS (Oct 16, 2016)

SpecialK said:


> Oral olanzapine is being introduced for mildly agitated pts.  The "goal" is for them to respond well to it and be able to be left in the community.



That's awesome, and such an effective use of resources! Where is this? UK, Australia?


----------



## Handsome Robb (Oct 16, 2016)

Remi said:


> I obviously can't speak for everyone's protocols, but I imagine it's only IM because the assumption is you don't have an IV in these patients. If you did have an IV, some plain 'ole versed would be the way to go, IMO. To be honest, I'm not sure haldol is all that great of an idea. I've had good luck with 5+5 a couple times in the past, but I think the versed was doing much more than the haldol.
> 
> In the pre-op area, for uncooperative (MR or autistic) patients I have a co-worker who a couple times has darted them with about 1mg/kg of ketamine and 0.1mg/kg of versed, and it works really well. I haven't had to do it yet myself, but I'd probably use the same thing.
> 
> If I were in the field and they were being violent I'd probably not fool around drawing up multiple drugs and just use a large dose of ketamine. Like 200-300mg IM for an average sized adult. Once they fall asleep manage the airway prn, start an IV, and give some ativan or valium before the K starts to wear off. K.I.S.S. Easy peasy.



Our chemical restraint protocol for violent patients is 5mg/kg IM of ketamine. Only issue we have is having to split the dose up between two injection sites due to the volume. 

We also carry haldol and versed. Only use versed for anxiety though. "Resistant" patients get haldol. I've always had decent results with it, just takes a little while to kick in but we're not using it for patients who are hostile either. We give 5mg IV or IM.


Sent from my iPhone using Tapatalk


----------



## StCEMT (Oct 16, 2016)

I don't have anything like that. If someone wants to get testy, they get a trip down the k hole.


----------



## VentMonkey (Oct 16, 2016)

Handsome Robb said:


> We also carry haldol and versed. Only use versed for anxiety though. "Resistant" patients get haldol. I've always had decent results with it, just takes a little while to kick in but we're not using it for patients who are hostile either. We give 5mg IV or IM.


What's the typical onset time you, or others in your system are seeing for IV vs. IM Haldol administration?

Also, do you, or anyone on this forum, have a protocol worked in for sedative administration of cardiac chest pain precipitated by suspected stimulant overdose?


----------



## mttbdtd (Oct 16, 2016)

I have used Haldol/Versed a few times. Most notably on a young guy that had just dropped acid his first time. He was extremely agitated and violent. When I go there a pile of people were holding him down. 5/5 and about 10 minutes later he started to have increasingly long "moments of clarity". He would relax, appeared to stop hallucinationing, and talk normally. He would then suddenly return to his previous screaming and fighting state. This continued all the way to the hospital. In the ER he finally started to nap. The time from admin to actually sedated was 30+ minutes.


----------



## SpecialK (Oct 16, 2016)

The idea of oral olanzapine is for people who are mildly agitated.  Currently, the only option for these people is nothing.  As many of these people as possible should be managed in the community by the existing mental health services.  The last (worst) place for patients who do not require it is an emergency department.  An emergency department is bright, loud, noisy and not a very dignified place.

It will be for mental health patients who do not have moderate or severe agitation, but just need something a bit more than "nice words" for them to settle and be able to remain in the community once they've been referred to (and accepted by) mental health services; e.g. their GP, community team, etc.


----------



## VentMonkey (Oct 16, 2016)

SpecialK said:


> The idea of oral olanzapine is for people who are mildly agitated.  Currently, the only option for these people is nothing.  As many of these people as possible should be managed in the community by the existing mental health services.  The last (worst) place for patients who do not require it is an emergency department.  An emergency department is bright, loud, noisy and not a very dignified place.
> 
> It will be for mental health patients who do not have moderate or severe agitation, but just need something a bit more than "nice words" for them to settle and be able to remain in the community once they've been referred to (and accepted by) mental health services; e.g. their GP, community team, etc.


Is this something being doled out to all prehospital providers in your neck of the woods/ pond, or is this more so for folks at your service trained in CP (community paramedicine)/ APP's?


----------



## SpecialK (Oct 16, 2016)

It will be initially for Paramedic and Intensive Care Paramedic (the majority of the workforce).  In two years' time when the CPGs are next reviewed (in two years' time) if all things go well it'll be reduced to EMT level.

This is not current practice - it is _coming _from January.


----------



## Handsome Robb (Oct 16, 2016)

VentMonkey said:


> What's the typical onset time you, or others in your system are seeing for IV vs. IM Haldol administration?
> 
> Also, do you, or anyone on this forum, have a protocol worked in for sedative administration of cardiac chest pain precipitated by suspected stimulant overdose?



In my experience it's usually 5-10 and 10-15 respectively. 

We can and do give versed for "stimulant toxicity". 


Sent from my iPhone using Tapatalk


----------



## Mantis Toboggan (Oct 17, 2016)

IV Haldol is generally prohibited because the FDA does not approve its use for intravenous administration.  Adverse effects of Haloperidol include: Torsades, elongated QT, tardive dyskinesia, neuroleptic malignant syndrome, et. al.  The frequency and/or severity of such complications are increased following IV administration, thus the FDA has deemed the route ‘unsafe’ as a routine therapy.  Although Haloperidol is only manufactured as an IM injectable preparation, I have heard of some Docs ordering IV Haldol as an off-label Tx.  Often, I’ll see IM Haldol and IV Versed administered concomitantly in the ER; this may be puzzling to some as IV is generally considered to be the preferred and most effective route.  I would be very surprised if any state board of physicians allowed paramedics an off-label use Haldol in their protocols.


----------



## Summit (Oct 17, 2016)

Mantis Toboggan said:


> IV Haldol is generally prohibited because the FDA does not approve its use for intravenous administration.  Adverse effects of Haloperidol include: Torsades, elongated QT, tardive dyskinesia, neuroleptic malignant syndrome, et. al.  The frequency and/or severity of such complications are increased following IV administration, thus the FDA has deemed the route ‘unsafe’ as a routine therapy.  Although Haloperidol is only manufactured as an IM injectable preparation, I have heard of some Docs ordering IV Haldol as an off-label Tx.  Often, I’ll see IM Haldol and IV Versed administered concomitantly in the ER; this may be puzzling to some as IV is generally considered to be the preferred and most effective route.  I would be very surprised if any state board of physicians allowed paramedics an off-label use Haldol in their protocols.


Most of the Haldol I've given has been IVP. I haven't encountered an adverse reaction yet in the over 100 patients I've pushed it and we watch the QTc closely.

That said, first gen antispychotics and later gen are usually regarded with caution in patients where extended QTc is a concern. However, near as I can tell, haloperidol is not nearly as bad as something like Thorazine and the adverse effects are generated by case reports or case controlled studies.

Unfortunately my institution doesn't have access to this journal: The use of low-dose IV haloperidol is not associated with QTc prolongation: post hoc analysis of a randomized, placebo-controlled trial

This 2001 paper was a small case controlled study 
This 2004 paper shows about 7.1ms increase in QTc for patients on 15mg/day of haldol 
Good Summary

In ICU we are looking for ways to reduce and control delirium. This is a complex problem and could span many threads. One of the adjuncts heavily considered/favored and under research right now is Haloperidol as we do know we want to avoid/minimize benzos on our ICU patients for sedation, agitation, and delirium (note not eliminate because benzos are appropriate at times, even first line). Some of the research is coming out now but there are some big multicenter trials. There is a small study showing it is not a useful prophylaxis.

That shouldn't be a construed as a suggesting that benzos are inappropriate for excited delirium in the prehospital patient.

*Prehospital Agitation and Sedation Trial (PhAST): A Randomized Control Trial of Intramuscular Haloperidol versus Intramuscular Midazolam for the Sedation of the Agitated or Violent Patient in the Prehospital Environment.*
unfortunately my open athens account is expired... 

*RESULTS:*
Five patients were enrolled in each study group. In the haloperidol group, the mean time to achieve a RASS score of less than +1 was 24.8 minutes (95% CI, 8-49 minutes), and the mean time for the return of a normal mental status was 84 minutes (95% CI, 0-202 minutes). Two patients required additional prehospital doses for adequate sedation. There were no adverse events recorded in the patients administered haloperidol. In the midazolam group, the mean time to achieve a RASS score of less than +1 was 13.5 minutes (95% CI, 8-19 minutes) and the mean time for the return of normal mental status was 105 minutes (95% CI, 0-178 minutes). One patient required additional sedation in the ED. There were no adverse events recorded among the patients administered midazolam.


----------



## VentMonkey (Oct 17, 2016)

Summit said:


> In ICU we are looking for ways to reduce and control delirium. This is a complex problem and could span many threads. One of the adjuncts heavily considered/favored and under research right now is Haloperidol as we do know we want to avoid/minimize benzos on our ICU patients for sedation, agitation, and delirium (note not eliminate because benzos are appropriate at times, even first line). Some of the research is coming out now but there are some big multicenter trials. There is a small study showing it is not a useful prophylaxis.


Like @Summit said, not to deter further from the prehospital angle of this thread, but this did seem to be thing pretty heavily emphasized the last time I was in, and around and ICU setting.

I believe they call(ed) them "sedation vacations":

http://www.aacn.org/wd/nti/nti2012/...n-article-daily-interruptions-of-sedation.pdf


----------



## Summit (Oct 17, 2016)

VentMonkey said:


> Like @Summit said, not to deter further from the prehospital angle of this thread, but this did seem to be thing pretty heavily emphasized the last time I was in, and around and ICU setting.
> 
> I believe they call(ed) them "sedation vacations":
> 
> http://www.aacn.org/wd/nti/nti2012/docs/pearl/awakening and breathing trial coordination/ccn-article-daily-interruptions-of-sedation.pdf


Sedation vacations serve mulitple purposes ranging from evaluating patient mental status, reducing ICU delirium, and most importantly they are coordinated with SBT (spontaneous breathing trial, aka vent wean)... as dumb as it sounds, for decades patients have failed their ventilator weans because nobody turned down the sedation  or coordinated sedation vacation ahead of the SBT. Getting people off the vent sooner gets you lower delirium, fewer VAPs, shorter stays, and better outcomes.

Benzos are an independent risk factor for ICU Delirium in critically ill patients. Worth a thought in CCT, of course, agitated patients in a CCT rig are far worse. But maybe you've noticed more fent/propofol and precedex hung on your CCT patients instead of fent/midaz?

Good references:
Medication Risk Factors of ICU Delirium
Sedation and Delirium in the ICU
Choice of Sedation
Propofol is associated with favorable outcomes compared with benzodiazepines in ventilated intensive care unit patients.


----------



## VentMonkey (Oct 17, 2016)

Summit said:


> Benzos are an independent risk factor for ICU Delirium in critically ill patients. Worth a thought in CCT, of course, agitated patients in a CCT rig are far worse. But maybe you've noticed more fent/propofol and precedex hung on your CCT patients instead of fent/midaz?


Yes, and thanks for the follow up post. There very much is relevance to my post above yours in the prehospital arena.

Particularly, as you've mentioned with weaning trials, etc. I think too often we as prehospital providers forget that treatment doesn't end once these patients are off-loaded.

In my area it typically is the Fentanyl/ Versed combo, or Diprivan alone. Seldom are patients being paralyzed for the trip, unless they're completely unmanageable (e.g., in the helicopter), but even then it isn't as encouraged as it was, say 5-10 years ago.

So, yeah, the relevance is again, definitely there. Also, unfortunately I don't see much Precedex even in the ICU's around here, though, again I did get a taste of it at one recently and the nurses seemed to favor it.

Have you, or any other ICU felt it's a better choice than Versed given it's less likely to result in deleterious effects on their hemodynamic status?


----------



## Handsome Robb (Oct 17, 2016)

Mantis Toboggan said:


> I would be very surprised if any state board of physicians allowed paramedics an off-label use Haldol in their protocols.



Both the systems I have worked in allowed IV haldol on standing orders. 


Sent from my iPhone using Tapatalk


----------



## VentMonkey (Oct 17, 2016)

Handsome Robb said:


> Both the systems I have worked in allowed IV haldol on standing orders.
> 
> 
> Sent from my iPhone using Tapatalk


What _doesn't _your system do??!- said the jealous paramedic from California.


----------



## Summit (Oct 17, 2016)

VentMonkey said:


> Yes, and thanks for the follow up post. There very much is relevance to my post above yours in the prehospital arena.
> 
> Particularly, as you've mentioned with weaning trials, etc. I think too often we as prehospital providers forget that treatment doesn't end once these patients are off-loaded.
> 
> ...


You know I think it depends on the patient, but anyone at risk for delirium or who is appropriate for precedex or propofol I'd rather have that drip than (or in addition to) a midazolam drip unless it is very short term. Precedex (dexmedotamine) has very little respiratory depression (it's an alpha 2 so it isn't hitting the opiiod and GABA receptors that fent and midaz hit), but you can get hypotension/bradycardia on a bolus dose. You can literally wean someone on precedex which is awesome. But it might not have the punch to do the job on its own and you might not want to bolus it so having another agent for changes in agitation is useful.

Propofol (diprivan) is nice. AKA Milk of Amnesia. You can bolus that. but careful it can give you hypotension/bradycardia as well. Run it at high rates for a long time and it can cause lactic acidosis. The thing I like about propofol is it has a short halflife, like fentanyl short.

Even Precedex has a shorter halflife than midazolam (versed). There is a nice comparison in the NEJM link in my previous post.

ETOH w/d delerium / DT patients I love mixing precedex and midazolam (lets me use significantly less midazolam). This is my favorite Precedex article for AWS


----------



## VentMonkey (Oct 17, 2016)

Summit said:


> *Getting people off the vent sooner gets you lower delirium, fewer VAPs, shorter stays, and better outcomes.*


I just had to go back, and reiterate this to any, and *all* paramedics, both old and new. I find this to be an extremely enlightening statement from an experienced in-hospital provider that will hopefully help even just some, realize that when we intubate patients in the field, there is *waaay* more to their care long-term.

This is what drew me to critical care, learning *all* facets of airway management, from beginning to end, and with that in mind, our* end goal* even in the prehospital setting should be this right here, exactly. So, thank you, @Summit, you've summed it up quite well.


----------



## Rialaigh (Oct 19, 2016)

Ketamine, no haldol or geodon here. 3mg/kg IM for aggressive, agitated, violent patients. Usually does the trick....no complaints from me about Ketamine.

As a note about Haldol I have read several very good articles about some possible reasoning behind the black box warning....the only route I have ever seen it given btw is IV and I see it used regularly in the ER. I believe there were less then 10 (possibly less then 5) reported cases of Torsades after hundreds of thousands of uses over the years. From the literature I have read it is in actuality a very safe drug that is used frequently with good effect in many ER's


----------

