Sedation of the Violent Patient

 

Droperidol

0.625 im or iv: nausea

1.25  im or iv, nausea

2.5 im or iv, migraine

5.0 im or iv, psychosis and agitation

10.0 im or iv, psychosis, extreme violence

Droperidol can cause sedation by lack of the ability to act on volition. This may result in inner turmoil.

 

The IM doses are great in that an IV is not needed with droperidol for rapid action.

 

A large study shows no change in rates of sedation related death or TdP despite no use of droperidol (Anesth 2007;107:531)

Another demonstrates the safety of the 0.625 mg dose (Anesth 2013;118(2):382)

derailing-the-myth-of-droperidol-dangers

ANother review showing safety (ACAD EMERG MED • December 2002, Vol. 9, No. 12:1402)

IM midazolam has a quicker onset and offset than IM haloperidol or IM lorazepam alone.

Nobay F, Simon BC, Levitt MA, Dresden GM. A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Acad Emerg Med. 2004 Jul;11(7):744-9.                                 Time to onset                      Time to arousal Lorazepam (2 mg IM) 32.2 min                             217.2 min Haloperidol (5 mg IM) 28.3 min                              126.5 min Midazolam (5 mg IM) 18.3 min                              81.9 min

 

 

Battaglia, J. et al. “Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study.” Am.J.Emerg.Med. 15.4 (1997): 335-40. This is the classic article that compared haloperidol, lorazepam and the combination of the two in agitated patients in the ED. All three treatment groups showed a decrease in agitation as measured by the Agitated Behavior Scale, Brief Psychiatric Rating Scale and the Clinical Global Impressions scale. The combination of haloperidol and lorazepam was more effective at decreasing agitation when compared with haloperidol alone or lorazepam alone. The only negative side effect noted with this combination of medications is an increased length of time that patients were asleep. Hill, S. and J. Petit. “The violent patient.” Emerg.Med.Clin.North Am. 18.2 (2000): 301-15, x. This is an excellent review article by an emergency physician about the overall care of the violent patient in the ED. It provides a comprehensive algorithm for assessing violent behavior and providing interventions in a stepwise manner. The review includes a discussion of patient’s rights and the various methods of restraints. Currier, G. W. “Atypical antipsychotic medications in the psychiatric emergency service.” J.Clin.Psychiatry 61 Suppl 14 (2000): 21-26. This article provides a brief review of the atypical antipsychotics. It concentrates on the comparison between haloperidol and risperidone. The author concludes that risperidone is as efficacious at treating psychosis as haloperidol with significantly less side effects, particularly EPS. Miller, C. H. et al. “The prevalence of acute extrapyramidal signs and symptoms in patients treated with clozapine, risperidone, and conventional antipsychotics.” J.Clin.Psychiatry 59.2 (1998): 69-75. This article provides a comparison of the EPS effects of two atypical antipsychotics, clozapine and risperidone, and conventional antipsychotics. 106 patients were treated for at least 3 months. The prevalence of akathisia in the clozapine group was 7.3%, 13% in the risperidone group and 23.8% in the group treated with conventional antipsychotics. There is a very good explanation about how the ratio of 5-HT2 receptor blockade to D2 receptor blockade may determine the incidence of the EPS side effects in the atypical antipsychotics. Head to head randomized study of 5-10 mg Haldol vs. 7.5-15 mg versed given IM.  Both effective Midazolam was quicker to work.  Low side effects. (BMJ 327:27, Sept 2003)

 

(Annals 2004 43:1) 3 cases of droperidol death at normal doses:

1.  48 hrs after 5 mg drop while on many other drugs

2.  .625 mg drop on numerous card meds c other PMH

3.  5 mg in an illicit drug user

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 Ketamine

Case report of extremely violent agitated patient getting 4.5 mg IM with sedation and no resp depression (PREHOSPITAL EMERGENCY CARE 2005;9:85–89)

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Fatalities in the Acutely Agitated Patient

Review by James Roberts (Emerg Med News Sept 2007)

 

(Can Med J 1998;158(12):1603)

21 deaths

all were in prone/hogtie or with pressure applied to neck

patients die a bradycardic, hyperthermic, acidotic death

? administer large amounts of bicarb if they code?

Am J Emerg Med 2001;19:187

18 cases

all were in prone/hobble, all had excited delerium, all were struggling against their restraints

Am J Forensic Med Pathol 1998;19(3):201)

body position alone is not enough to cause death, though frc and hypoxia is certainly worse in this position

 

 

 

 

 

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