Geodon/Zyprexa for agitation management

[Carlos Danger]

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]

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]

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]

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]

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]

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]

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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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]

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]

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]

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]

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]

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]

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.


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[StCEMT]

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

 

[VentMonkey]

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]

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]

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]

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]

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]

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".


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