Geodon/Zyprexa for agitation management

[NomadicMedic]

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]

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.

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[VentMonkey]

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]

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)

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[Carlos Danger]

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]

double post

 

[VentMonkey]

Now, haldol works very well when given as a b52 (50mg benadryl, 2mg ativan, and 5mg haldol)

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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]

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]

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]

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]

 

[TransportJockey]

@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]

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]

 

[Summit]

 

[VentMonkey]

...said every parent ever.

 

[Tigger]

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]

Those giving haldol, how much are you giving?

 

[Tigger]

Those giving haldol, how much are you giving?

5mg, IM only.

 

[VentMonkey]

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?