Management of a potentially aggressive patient on PCP.

[NYMedic828]

Thanks for the great answers.

Unfortunately I missed the call, but from what u heard benzos really sounded more justified.

Unfortunately we are one of those scared systems. It is a system of mostly inexperienced people and to get something like sedation, which is almost never done, is unfortunately a long shot.


In the city they would give it to me no problem.

 

[DrParasite]

Basically, it came in as a seizure at a local restaurant. When the crew got there, they had an agitated patient who was supposedly trying to smash the urinals in the bathroom off the walls with his bare hands. (and succeeding)

First thing, get everyone away from the bathroom. Second thing, no one goes near the guy until PD gets there with enough resources to contain and restrain the individual. Let him destroy the urinals, the mirrors, and the walls. Either way, it's a violent unsafe scene, and EMS should NOT be getting involved until PD has restrained the guy. EMS should NOT be getting hurt, should not be taking punches or kicks from this guy.

Let the cops do there thing. if they need more people, let them call more cops.

I've dealt with quite a few PCP users, usually they are 250 lbs, naked or nearly naked, and very violent. I've seen 6 city cops restraining a guy who was in handcuffs, and he was still tossing them around like they were rag dolls. These guys are not to be messed with.

Once the cops have him secured, and the scene is made safe, than maybe chemical sedation is an alternative to look for. and make sure security/PD at the receiving hospital is ready to receive him.

 

[Melclin]

You and I exchanged some pms about versed because I was afraid of the very same thing.

Then I watched my partner give a guy 10 mgs and the hospital give 5 mgs of Ativan and 10 mgs of valium to the same pt and he was still kicking *** and taking names.


It's not so intimidating anymore. Although he did have some sort of drugs on board.

Not that I disagree but midaz can be a fraction unpredictable. And comorbities matter. In my short time I've seen 20mg render a 40kg cranky teenager ready for a light nap and 1mg render a 110kg bloke almost tubeable.

I can see why clinical oversight types might wanna scare the lowest common denominator into a little respect for the drug.

 

[Melclin]

First thing, get everyone away from the bathroom. Second thing, no one goes near the guy until PD gets there with enough resources to contain and restrain the individual. Let him destroy the urinals, the mirrors, and the walls. Either way, it's a violent unsafe scene, and EMS should NOT be getting involved until PD has restrained the guy. EMS should NOT be getting hurt, should not be taking punches or kicks from this guy.

Let the cops do there thing. if they need more people, let them call more cops.

I've dealt with quite a few PCP users, usually they are 250 lbs, naked or nearly naked, and very violent. I've seen 6 city cops restraining a guy who was in handcuffs, and he was still tossing them around like they were rag dolls. These guys are not to be messed with.

Once the cops have him secured, and the scene is made safe, than maybe chemical sedation is an alternative to look for. and make sure security/PD at the receiving hospital is ready to receive him.

This ^^^

You'd be flat out trying to get me outa the ambulance.

 

[Cawolf86]

As an aside to the thread topic - say your first line drug was versed. What would your preferred initial route be? IM vs IN? Assuming IV access unobtainable due to the patient's condition. I know in theory IN should have a faster onset but in my personal, non-scientific experience IN versed has not been as effective as IM. Thoughts? Sorry if too OT for thread.

 

[the_negro_puppy]

We carry these to tranquilize any dangerous animals (crocodiles etc) that we come across. We recently had protocols changed to allows us to use them on psychotic/overdose patients.

 

[Akulahawk]

I gave an 8 year old close to 20mgs of it one day (granted he was intubated). His seizure never broke for more than 5 minutes.

I fear hypotension way more than airway loss.

Remember, in the absence of other compounds that activate GABA receptors the effects of benzos are self-limiting by your endogenous GABA.

A few years ago, I ended up giving something like 10 mg (IIRC, it was 2 mg doses) Lorazepam to a seizing patient. It would stop his physical seizure for about 10 min (usually less) and then he'd start right back up again. About the only benzo that worked on him was diazepam - and that was good for about an hour or so. This was about 10 years ago, so the exact doses and amounts I gave are a bit hazy... but what was impressed upon me was the need to have more than one option available, in the event what you're giving isn't working. And yes, the amount of lorazepam we gave him was quite a bit... and surprised all of us that he was still going...

 

[NYMedic828]

As an aside to the thread topic - say your first line drug was versed. What would your preferred initial route be? IM vs IN? Assuming IV access unobtainable due to the patient's condition. I know in theory IN should have a faster onset but in my personal, non-scientific experience IN versed has not been as effective as IM. Thoughts? Sorry if too OT for thread.

I figure that less needles with a combative patient, is a safer approach.

If the guy is that aggressive, and an arm breaks free that needle might end up in you awfully fast.

 

[flanaganj]

I would have PD restrain the patient, then 5mg haldol and 2mg ativan in the same syringe im. Then 50mg benadryl im. If after ten minutes he is still a danger to ME and himself, another 5 and 2. All standing order. If that doesn't work call medcon and get orders for versed on top of that.

Sent from my Nexus S 4G using Tapatalk

 

[NYMedic828]

I would have PD restrain the patient, then 5mg haldol and 2mg ativan in the same syringe im. Then 50mg benadryl im. If after ten minutes he is still a danger to ME and himself, another 5 and 2. All standing order. If that doesn't work call medcon and get orders for versed on top of that.

Sent from my Nexus S 4G using Tapatalk

We don't carry Haldol or Lorazepam.

Some agencies carry Ativan instead of Versed, very rarely do they have both

 

[abckidsmom]

Because the Versed demon will come take your airway away!!!
/sarcasm

lol, I was talking to medical control not long ago and wanted to give Versed for a patient who had overdosed on something and was fighting and agitated. (We have to get orders to use benzos for anything other than seizures.)

The physician said, "I'm just worried about her airway if we end up oversedating her."

I replied, "I am prepared to manage her airway, I stayed in a holiday inn express last night."

She said, "Oh, well, in that case...go ahead and give her the Versed."

The guys in the communications center met me at the back door of the ER with a high five. They are sick of patients not getting the treatment they need because of worried doctors.

 

[mycrofft]

PCP warriors will get drugs IM (backhanded into a thigh or buttock) or not at all, unless you can trap then in a closet and neb the entire volume.
Side issues with this sort of case:
1. Paradoxic effects to benzos: seen them. Ativan or Valium are like champagne to them.
2. Count MACE or pepper spray to list of chemicals likely on board. Now YOU can get a second-hand topical application as well, plus oily pper spray can make things like the floor get slick.
4. Valium is good. Less resp effects than some other drugs, works faster than some other benzos IM, does not have as short a half-life as some. However, I am not sure if it is doing anything but wallpapering the issue, it could make the pt simply more purposeful (a calm monster versus a panicked monster).
5. DOCUMENT! No matter what, you will be investigated for every booboo and death associated with this sort of pt and they are really subject to positional asphyxia, hyperthermia, and being trashed with batons.

Scene safety first and whatever you do, coordinate it.

 

[usalsfyre]

I figure that less needles with a combative patient, is a safer approach.

If the guy is that aggressive, and an arm breaks free that needle might end up in you awfully fast.

Yeah, but trapping a nostril in this patient can be pretty darn difficult.

 

[mycrofft]

Just to be a wisearse, tell him it will get him high..?

 

[NomadicMedic]

I had one of these the other night. I hate to fight, but there I was... me and two firefighters, rolling around on the floor with this whacked out dude. I'm a big guy, about 250, and the other two guys were also larger than the average bear and it took all three of us to get him to a position where I could atomize 5mg of Versed up his snout...

Then we jumped off and let him writhe around for a bit.

Shortly after that he became calm enough for us to wrap him up in a reeves and lug him out to the truck.

I always vote for Versed in a MAD rather than IM. I would have wound up sticking one of the firefighters and that would have been no bueno.

 

[Handsome Robb]

I had one of these the other night. I hate to fight, but there I was... me and two firefighters, rolling around on the floor with this whacked out dude. I'm a big guy, about 250, and the other two guys were also larger than the average bear and it took all three of us to get him to a position where I could atomize 5mg of Versed up his snout....

This is what scares me a bit. I'm 155 and 5'8'' on a good day... I have no problem strength wise but in something like this leverage comes into play.

 

[Cawolf86]

So you would say the effect of 5mg Versed IN is similar to it's effects IM - with faster onset? Maybe it has just been the patient's I have used it on but I have found IN to not be as effective so far in my limited experience.

 

[NomadicMedic]

So you would say the effect of 5mg Versed IN is similar to it's effects IM - with faster onset? Maybe it has just been the patient's I have used it on but I have found IN to not be as effective so far in my limited experience.

I've only had limited experience with IN Versed. In the past I've been forced to use Droperidol or Haldol to manage this kind of stuff. However, I will say that the 5mg/1ml blasted up the nose of the guy who was fighting and trying to eat me worked pretty well in this case. I certainly didn't want to get anywhere near him with a needle.

 

[usalsfyre]

Sometimes a quick "juke in, jab the thigh and head bob out" with the IM syringe and big (think 18ga through the clothes) can be safer and easier than the dog pile that ensues trying to get a nostril. The most effective way I found to get the node nose required at least one person per limb, one for the head, a "squirter" and possibly someone to lay on the torso.

Either way once the meds in it's time to back off and let sleepy time kick in.

 

[fast65]

Consult for "as much as it takes". 10mgs may not touch this guy, I've heard of 30 and up being used.

It's times like this that I enjoy having orders for Versed at 0.3 mg/kg...or "titrate to desired effect".