chemical restraint

We have 2mg of Ativan and 10mg of Geodon, followed by 10mg of geodon, if needed.
 
Non-intubated
Ativan 0.5-2
Versed 0.5-2
Both can be repeated

Intubated
Ativan 2-4
Versed 2-5
Both can be repeated


If need be, they buy themselves some Roc/Etomidate and a tube.
 
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Linuss said:
Non-intubated
Ativan 0.5-2
Versed 0.5-2
Both can be repeated

Intubated
Ativan 2-4
Versed 2-5
Both can be repeated


If need be, they buy themselves some Roc/Etomidate and a tube.
Click to expand...

Don't forget we can also treat pain as a possible cause of agitation...2 of midaz and 100mcg of fentanyl usually makes for a "comfortable" situation for everyone involved :D.
 
I love me some conscious sedation! Only thing I love more is the look on the nurses face when they realize what I did to the patient.

"That's conscious sedation!"
"Yeah, and?"


Honestly, I'm surprised they don't have Benadryl as a standing chemical sedative for us. Go to some place like Green Oaks, and you won't touch a patient who doesn't have atleast 50mg running through them at any given point.



I love Jimmy's view... "EVERYONE is agitated!"
 
Linuss said:
If need be, they buy themselves some Roc/Etomidate and a tube.
Click to expand...

Are you serious? RSIing a merely uncooperative patient would, at least in my old system, get you QIed and probably a vacation. We knocked down and tubed a lot of patients, but each was medically justifiable. We had 100% review on any RSI.

Let's remember this thread was about chemical restraint, ie: controlling an unruly patient that was dangerous to himself or others, not about sedating and then managing the airway of a medically unstable, possibly combative patient
 
Yes, I'm serious. No, the OP never made a distinction between a combative psych, and a combative head injury... just chemical restraints for combative patients.



You will NOT see me RSIing someone who's simply unruly. Period. And I doubt 99% of the medics at my agency will either. The other 1% need not be Paramedics to begin with. It's the 'use of force' continuum, only for EMS. RSI is to us like a gun is to LEOs... your last step, but if you need it you better have it. Better to start off low like physical restraints, but sometimes that's simply not enough... which apparently our clinical department and med control agree with.




Hell, if someone is already intubated, and you've tried more Etomidate / Fent / Benzos but they're still bucking the tube, guess what? Paralysis... and from what I've seen, that's used in EMS, the ER, OR, ICU, etc etc. Some people simply cannot be sedated enough with normal means.




Shoot, have you ever fought someone high on PCP? They break handcuffs for Gods sake.
 
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n7lxi said:
Are you serious? RSIing a merely uncooperative patient would, at least in my old system, get you QIed and probably a vacation. We knocked down and tubed a lot of patients, but each was medically justifiable. We had 100% review on any RSI.

Let's remember this thread was about chemical restraint, ie: controlling an unruly patient that was dangerous to himself or others, not about sedating and then managing the airway of a medically unstable, possibly combative patient
Click to expand...

The line starts to get blurry with extremely agitated, hypermetabolic patients. I have RSI'd patients who were extremely agitated/combative and unresponsive to benzodiazepines. We have 100% QA of RSI as well, as did the last program I worked for.

That said, where I worked before was an airmedical program and we currently share clinical guidelines with our HEMS program. Airframe safety is paramount and takes precedence.
 
Our protocol is 2-5mg Versed IV or 5mg IN/IM and can only be repeated once.

Like everything else, however, it requires a base hospital order. :rolleyes:
 
Oh, I agree that combative patients need to be sedated for their safety and the safety of the crew transporting or caring for them, and yes, I'd not hesitate to RSI a combative head injury.

That being said, the statement "...they buy themselves...a tube" seems a bit cavalier.

...but that's the internet, isn't it?
 
versed 5mg im for agitation with out an order, i can repeat with an order.
 
Ive heard of RSI in hospital to facilitate CT or other invasive testing. I am not sure I agree with it prehospital, however if the physicians in control of your guidelines believe it to be necessary, then I would assume that the quality control process is in place well enough to make it safe practice.

We carry Ativan/Valium(lol), Versed, Haldol...

4mg/20mg/10mg/10mg respectively
 
ADULT BEHAVIORAL EMERGENCIES
Standing Orders
A. Assess the severity of the patient’s agitation.
B. Consider manpower necessary to adequately and safely restrain the patient.

C. SEVERE AGITATION
1. If the patient is severely agitated and poses an immediate threat to himself/herself
or others, consider giving one or both medications (may be mixed together in one
syringe):
Versed 5 mg IV/IM/IO; AND/OR
Haldol 5-10 mg, IV/IM/IO (dosage based on the patient’s age and/or
weight).
OR
Ativan 2 mg IV/IM/IO; AND/OR
Haldol 5-10 mg, IV/IM/IO (dosage based on the patient’s age and/or
weight).
2. For continued agitation, contact a medical control physician for further orders
After Obtaining Verbal Orders
3. Consider additional Versed 1-5 mg IV/IM/IO OR Ativan 1-2 mg IV/IM/IO.

D. PROFOUND AGITATION
1. If the patient is profoundly agitated with active physical violence to
himself/herself or others evident, and usual chemical or physical restraints
(section C) may not be appropriate or safely used, consider:
Ketamine 5 mg/kg IM (If IV already established, may give 2 mg/kg
IV/IO).
DO NOT attempt to place an IV in a severely combative patient.
2. If Ketamine is administered, rapidly move the patient to the ambulance and be
prepared to provide:
a. Respiratory support including suctioning, oxygen, and intubation.
b. Monitoring of the airway for laryngospasm (presents as stridor, abrupt
cyanosis/hypoxia early in sedation period). If laryngospasm occurs perform
the following in sequence until the patient is ventilating, then support as
needed:
i. Provide jaw thrust and oxygen.
ii. Attempt Bag Valve Mask (BVM) ventilation.
iii. Intubate over gum bougie/tracheal tube introducer with appropriate RSI
medications as needed (per applicable service protocols). Cords likely to
be closed if not paralyzed thus the need for introducer.
If hypersecretion is present, consider Atropine IV/IO 0.1-0.3 mg IV or 0.5 mg
IM.
If emergence of hallucinations/agitation after administration of Ketamine,
consider Midazolam 2-5 mg IM/IV/IO.
3. Consider IV access once sedation occurs (if no IV access previously established
and Ketamine given IM) then administer Normal Saline wide open up to 1 liters.
4. Consider Sodium Bicarbonate 1 amp IV/IO push.
5. Rapid transport at earliest opportunity.
 
We have midazolam and haloperidol for sedation, both only used IM. 10mg of each if required, more available with phonecall approval.
 
SEDATION/CHEMICAL RESTRAINT
PARAMEDIC
MILD SEDATION (i.e. Anxiety)
• Versed 1-2 mg IV/IN, or
• Ativan 0.5-2 mg IV/IM
MODERATE SEDATION (Cardioversion, painful procedures, potential harm to self or others without
psychiatric history)
• Versed 2-5 mg IV/IN
CHEMICAL RESTRAINT (Potental harm to self or others, psychiatric history) except Excited Delirium)
IV (Must be administered in separate syringes)
• Haldol 5 mg
• Versed 2-5 mg and/or Ativan 2 mg
IM (Must be administered in separate syringes)
• Haldol 5-10 mg
• Versed 5 mg and/or Ativan 2 mg

EXCITED DELIRIUM
ALL KETAMINE USAGE MUST HAVE PRIOR
MEDICAL CONTROL APPROVAL
INDICATIONS
• Sedation of combative or violent patients
SYMPTOMS
• Agitation
• Aggressive, threatening, or combative behavior
• Amazing feats of strength
• Presured, loud, incoherent speech
• Sweating (or loss of sweating late)
• Dilated pupils/less reactive to light
• Rapid breathing
• Stripping of clothes
FIRST-LINE TREATMENT MAY BE MEDICATION ADMINISTRATION
MEDICAL CONTROL CONSULT (Only Paramedic In-Charge Can Perform this Guideline)
• CABCs, Oxygen
• Vital signs including temperature – With hyperthermia perform immediate cooling
• NS 250 mL may repeat 4-8 times if no evidence of pulmonary edema
• ECG, SpO2, ETCO2
Options
• Ketamine 1-2 mg/kg IV over 1 minute or 4-5 mg/kg IM
• Versed 2-5 mg IV/IN (to prevent emergence) and/or
• Ativan 2 mg IV/IM (to prevent emergence)
• Zofran 4-8 mg IV (to prevent emesis)
 
ZOMG somebody in the US is using ketamine woohoo :D

*Brown jumps around doing the very happy dance
 
Mr. Brown -- our medical director absolutely loves Ketamine and encourages its use when appropriate, of course.
 
Ketamine if given in sufficient doses (and chased with either a drip or some form of benzo to avoid the emergence reaction) is a good drug for putting someone out.
 
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