How often should you check EKG/QTc with IM Haldol?

[Blitz2006]

Recently started CL/ER Psych gig, been a couple years since doing ER psych.

Wondering about IM Haldol, 5-10 mg for agitation/psychosis. After how many doses/quantity of Haldol, should I check/be concerned for QTc Prolongation?

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[TheRightMedication]

I think the most important thing is to get a family and personal medical history, to know what the a priori risk is. After that, I worry more about med interactions than the absolute dose of haldol.

Edit - also note the K and Mg, QT is a good excuse to replete even a mild deficit. Especially Mg.

Then, a baseline EKG, and a judgement call after that.

Or just use a monitored bed if available.

 

[Stagg737]

I don't really ever worry about it unless patient has a h/o significant cardiac issues or their initial QTc is really high (as in well over 500). Keep in mind that Bazette's formula isn't going to be accurate for heart rates significantly different than 60bpm, so I pretty much always recalculate using another formula if their HR is over 80 unless QT and QTc are basically identical.

IM haldol isn't a major concern for me and I'm fairly comfortable with them getting 2-3 doses of 5mg in a day with minimal concern aside from patients mentioned above. IV Haldol is the real offender, which should be monitored more closely. If you're legit concerned about an arrhythmia, repeat EKG daily or just put them on tele in an ER or medical floor. Or just use something else like Olanzapine or benzos.

 

[comp1]

Yeah, this is mostly about IV, not IM.

 

[forchinet121]

If I remember correctly, they’ve done studies with haldol 100 mg and higher before, 5 mg is nothing

 

[Blitz2006]

Thanks for helpful answers.

Yeah, I guess I meant, patients who get relatively high doses of IM Haldol (like 20-30 mg/day, over 2-3 days).

But it appears I might be overthinking this....

And I've never Rxed IV Haldol, but maybe there might be a time....

 

[TheRightMedication]

You're not overthinking it -

If you're gonna do CL, you're the QT guy.

Not saying you have to freak out every time someone's QT is north of 500 (indeed do not), but you oughtta give it some thought and documentation.

Look at the 'lytes, review the med list and history, and comment on the risk and benefit. Ideally with patient or family conversations.

Also - read, there's decent literature out there.

 

[shoomer]

Thanks for helpful answers.

Yeah, I guess I meant, patients who get relatively high doses of IM Haldol (like 20-30 mg/day, over 2-3 days).

But it appears I might be overthinking this....

And I've never Rxed IV Haldol, but maybe there might be a time....

IV Haldol definitely has its place, ICU setting in particular you'll encounter it. The IV route (if lines will stay in place) can often be less disturbing than an IM injection for the agitated, delirious patient.

I'll echo the sentiments above of familiarizing yourself with other confounding QT prolongers, and the different formulas for calculating QTc (Bazzett being the standard across ECG machines while being the biggest culprit of overcorrecting as the HR increases).

 

[ObsequiousAplomb]

If someone has an IV in place already, there are relatively few good reasons to go with an IM administration. Why inflict pain on someone who's already agitated? If you're worried about the risks of a particular medication IV, then consider giving an IV med you are less concerned about.

While QT and arrhythmia in general is a risk of IV Haldol, the other risks are much less than they are with IM. Patients are less likely to be snowed, less likely to have dystonia, and IV does work more quickly than IM. People tend to tolerate much higher doses IV than IM for Haldol. Mass Gen CL book talks about routinely going over 100 mg IV in a day. While 100 mg of Haldol IM was rather routine 50 years ago, it's much less common than 100 mg of IV in the modern era.

 

[ObsequiousAplomb]

Thanks for helpful answers.

Yeah, I guess I meant, patients who get relatively high doses of IM Haldol (like 20-30 mg/day, over 2-3 days).

But it appears I might be overthinking this....

And I've never Rxed IV Haldol, but maybe there might be a time....

There's also a question of why they need 30 mg / day of IM Haldol for 3 days. 30 mg IM is roughly equivalent to 40 mg PO. I would generally avoid giving Haldol lactate in doses above 10 mg IM as a single administration, and in most cases I would also avoid giving more than 5 mg IM in a single administration. Higher doses can certainly be given in IV administration, as mentioned above.

If it's for agitation, three administrations of 10 mg or six of 5 mg for three days in a row would tell me that Haldol IM is not the correct treatment. I would much rather be giving someone higher doses of Ativan or switching to a different (more sedating) antipsychotic if I needed to give them Haldol IM 3-6 times per day for three consecutive days if the indication is agitation.

If it's delirium, I generally wouldn't be giving an IM, as I said in my earlier post.

If you're treating psychosis/schizophrenia: studies are pretty clear that 95% of patients that respond to Haldol respond at total daily doses less than the equivalent of 10 mg PO. Unless you have clear evidence that this person is responding to the equivalent of 40 mg / day PO but not 5, 7.5, 10, 15, 20, 25, 30, or 35 mg PO, there are relatively few reasons to go as high as 30 mg / day IM for three consecutive days if all you are treating is psychosis in the setting of PO refusal. If you're treating psychosis using a med refusal override process then the patient would be better served by an accelerated loading schedule of Haldol decanoate (50-100 mg IM day 1, 100 mg IM day 3, day 7, and day 14) than if you are planning to give them Haldol lactate 10 mg IM TID until the more relaxed loading schedule of Haldol decanoate kicks in or the patient decides to accept PO.

 

[Stagg737]

If it's for agitation, three administrations of 10 mg or six of 5 mg for three days in a row would tell me that Haldol IM is not the correct treatment.

This is the bottom line. If you're requiring Haldol that frequently then it either just needs to be scheduled at higher doses or you need to use something else. There are plenty of other options for agitation and there's no reason a patient should be getting that amount of Haldol as a PRN for more than a day. If a patient is that agitated, is dangerous, and nothing is working then you need to start seriously considering calling anesthesia to put them under.

 

[forchinet121]

This is the bottom line. If you're requiring Haldol that frequently then it either just needs to be scheduled at higher doses or you need to use something else. There are plenty of other options for agitation and there's no reason a patient should be getting that amount of Haldol as a PRN for more than a day. If a patient is that agitated, is dangerous, and nothing is working then you need to start seriously considering calling anesthesia to put them under.

You call anesthesia on your inpatient psychiatric unit to put the patient into a coma?

 

[Stagg737]

You call anesthesia on your inpatient psychiatric unit to put the patient into a coma?

Not on the inpatient unit. I have had one or two patients in residency whom we did discuss transferring to our medical unit to be put on a precedex drip.

I wasn't talking about the inpatient psych unit though, since it sounds like OP is talking about an ER setting. Where I'm at, we occasionally do this with patients who come through our ER who are completely out of control for more than a day or who are on the medical floor. Obviously, we never want to snow anyone, but when the patient has gotten significant amounts of multiple antipsychotics and benzos and is still assaulting staff and harming themselves it can be necessary.