Emergency management of agitation: Reuben Strayer
1 likes
views
Rueben Strayer provides a masterclass in droperidol for emergency management of agitation. He discusses sedation in three patient groups. Agitated but cooperative If the patient is agitated but cooperative there is no concern for a dangerous condition. They respond well to some company and a sandwich. Drug therapy in this group is relatively straightforward. Disruptive without danger You can converse and engage with this group; however, they are not responsive to suggestion. They are loud and disruptive and need to be sedated. You can do a history and exam and be fairly confident that there is no dangerous underlying condition. There is no threat to themselves or others. They can be managed by observation in an unmonitored bed. So, you can sacrifice speed of sedation to ensure safety. Simple and well worn, tried and tested methods of mixed medical sedation are fine in this situation. And Reuben stresses this… it is fine. To be better than fine, consider a single agent - droperidol. Droperidol is the most effective and safest agent for undifferentiated agitation. If droperidol is unavailable the next best choice is midazolam intramuscularly. Be careful. Dosage is trickier in this situation. You need to monitor for respiratory depression and ne prepared to manage it. It works quickly but has a narrow therapeutic window. As such, for unmonitored patients, Reuben combines drugs to get away with smaller doses. Listen in to learn how! Excited delirium This patient is rare. But this is a dangerous situation. A few clues are the patients who are thrashing, angry, incoherent, un-engageable. They may have a fluctuating level of consciousness. Have a low threshold if you are not sure – err on the side of caution and treat as excited delirium. How do you treat this person? Five strong people are needed (not including those administering care), one for each limb plus one at the head. Administer high flow oxygen via a mask immediately. Do not wait for sats or vitals. This stops spit and provides oxygen! Get the patient out of dangerous positions such as the “hogtie” position and ensure no one is applying pressure to the chest or neck. Next chemical restraint – IM shot as soon as possible. This is as opposed to any mechanical restraints. The priority is immediate control. This allows you time to properly assess and treat the patient whilst ensuring their safety and the safety of the treating team. Join Reuben for a no nonsense run through of managing the agitated patient.
Emergency management of agitation: Reuben Strayer
- disruption, danger, and droperidol: emergency management of the agitated patient reuben j. strayer emupdates.com
- what patient defines emergency medicine?
- what patient defines emergency medicine?
- what patient defines emergency medicine? sick well
- what patient defines emergency medicine? undifferentiated chest pain undifferentiated abdominal pain undifferentiated headache undifferentiated dizzy undifferentiated back pain undifferentiated fever undifferentiated agitation
- what patient defines emergency medicine? an immediate threat requires use of dangerous maneuvers drunk or dying simultaneous control, resuscitation, and risk stratification undifferentiated agitation
- 3 types of emergency department agitation agitated but cooperative disruptive without danger excited delirium
- agitated but cooperative responds to suggestion no concern for dangerous condition have someone sit with them or small dose oral benzo
- assessable - low concern for dangerous condition conversant but disruptive sleep it off disruptive without danger
- safety prioritized over speed and efficacy often “observed” in unmonitored bed very common in many ED’s disruptive without danger
- disruptive without danger haldol 5, lorazepam 2 is fine. better than fine:
- droperidol droperidol is the most effective agent for undifferentiated agitation disruptive without danger Chan 2013 Isbister 2010 Martel 2005 Resnick 1984 Richards 1998 Thomas 1992
- droperidol is the safest agent for undifferentiated agitation droperidol disruptive without danger Isbister 2010 Knott 2006 Martel 2009 Spain 2008
- is nonsense droperidol disruptive without danger Calver 2013 Calver 2015 Chase 2002 Chambers 1999 Nuttall 2007 Perkins 2015 Richards 2002 Shale 2003 Szuba 1992 the QT black box
- and suspicious droperidol disruptive without danger is nonsense Bailey 2002 Horowitz 2002 Jackson 2007 Kao 2003 Lenzer 2002 Mullins 2004 Newman 2015 van Zwieten 2004 the QT black box
- disruptive without danger Clindamycin Clopidogrel Factor VIIa Dihydroergotamine Flumazenil Haloperidol NSAIDs Metformin Methotrexate Metronidazole Midazolam Nitroprusside Procainamide Succinylcholine Warfarin the QT black box is nonsense droperidol
- Clindamycin Clopidogrel Factor VIIa Dihydroergotamine Flumazenil Haloperidol NSAIDs Metformin Methotrexate Metronidazole Midazolam Nitroprusside Procainamide Succinylcholine Warfarin is nonsense droperidol disruptive without danger the QT black box
- is no longer available in the US long live droperidol droperidol disruptive without danger
- 5-10droperidol disruptive without danger
- midazolam disruptive without danger
- midazolam disruptive without danger i Hung 1996 Nobay 2004 McMullan 2010 Rey 1999
- midazolam disruptive without danger hypoventilation paradoxical response benzo resistance vs. droperidol vs. haloperidol 5-10 Spain 2008 Mancuso 2004 monitor no monitor haldol 10 versed 2 * faster than haloperidol *but narrow therapeutic window
- disruptive without danger re-dosing is ok vs. excited delirium droperidol 5-10 IM midazolam 5-10 IM haldol 10 midaz 2 IM
- excited delirium uncommon outside cities delirium and danger to himself to others from dangerous conditions *except in australia
- disruptive vs. delirious cannot engage / incoherent fluctuating sensorium abnormal vitals - don’t fight for vitals screaming and thrashing err on treating as excited delirium drunks exist to embarrass emergency doctors disregard for futility, pain, fatigue Vilke 2012
- 1. adequate force make sure it’s safe to approach the patient code white - partner with hospital security how to manage excited delirium
- 2. put face mask oxygen on the patient controls spit provides oxygen whatever the patient position
- [pic of choke hold / neck compression]
- [pic of knee on back of face down patient preventing chest excursion]
- [pic of pulling the officer’s hand off the face of the patient by holding a face mask]
- [pic of pulling the straps tight to the face of the patient, strongly securing the face mask to the face]
- 3. relieve dangerous restraint holds neck or chest compression
- 3. relieve dangerous restraint holds neck or chest compression hog tie prone position Hick 1999
- 4. chemical restraint NOT physical restraints clock is ticking danger is unaddressed overcome this unfortunate tradition focus on sedation
- IM not IV through clothing SPEED SAFETY 4. chemical restraint Calver 2010
- speed and efficacy trump concern for over-sedation (respiratory depression) intubating the excited delirium patient is good care 4. chemical restraint
- rapid single shot success 4. chemical restraint ketamine “but this patient has elevated HR and BP!” NO PROBLEM - ketamine will normalize hyperdynamic vitals in most cases Isbister 2016 Burnett 2012 Hopper 2015 Iwanicki 2014 Keseg 2015 Melamed 2007 Roberts 2001 Scheppke 2014 this is procedural sedation requires PSA monitoring
- 500 mg 4-6 mg/kg IM ketamine rapid single shot success 4. chemical restraint
- do not apply tight restraints, continue to hold the patient loose restraints are ok but should be unnecessary and should not delay resuscitation loosen existing tight restraints head of bed up as the patient calms
- 5. vitals temp fingerstick room air saturationor capnography
- 6. vascular access and crystalloid bolus
- 7. identify and treat dangerous causes and effects of severe agitation
- hypoxia hyperthermia hypoglycemia hypoperfusion first
- hyperkalemia acidemia ICH CNS infection second
- sedative withdrawal serotonin syndrome NMS thyrotoxicosis sepsis seizure/postictal Na, Ca, Cr, NH3 third CK, trauma
- oral whatever 5 and 2 droperidol midazolam k e t a m i n e 5 mg 20 mg10 mg dissociative dose (haloperidol) agitation likelihood of dangerous condition cooperative disruptive without danger excited delirium uncontrollably violent sub-dissociative olanazapine ziprasidone
- concern for dangerous condition? droperidol or midazolam 5-10 mg IM or haldol 10 midazolam 2 ketamine 500 mg IM immediate PSA setup adequate force face mask oxygen relieve dangerous restraint holds identify/treat dangerous causes/effects of severe agitation loose restraints prn, no tight restraints, head of bed up vascular access and crystalloid bolus yes no 1. hypoxia, hyperthermia, hypoglycemia, hypoperfusion 2. hyperkalemia, acidemia, ICH, CNS infection 3. withdrawal, thyrotoxicosis, rhabdomyolysis, occult trauma @emupdates emergency management of the agitated patient vitals esp. temperature, fingerstick, room air pulse oximetry or ETCO2
- www.kickstarter.com/bringbackdroperidol
- @emupdates
- droperidol midazolam sub-dissociative dose ketamine dissociative dose ketamine more danger excited delirium uncontrollable violence analgesia recreational partially dissociated dissociated less disruptive less danger PSA Setup
- analgesia recreational partially dissociated dissociated 10 mg 200 mg (IV)ketamine brain continuum
- analgesia recreational partially dissociated dissociated 10 mg 200 mg (IV)ketamine brain continuum ?
- dissociated 200 mg (IV)ketamine brain continuum +midazolam +droperidol 10 mg Le Cong 2011
- initial control vs. ongoing care alcohol withdrawal sympathomimetic intox NMS, SS psychiatry benzodiazepines antipsychotics thyrotoxicosis beta blockers sepsis antibiotics hypoxia oxygen heat stroke ice