strategy for sedating agitated/demented patient for ct?

[Painter1]

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70yo MR patient, hx of agitation and dementia. s/p mechanical fall with contussion to her scalp.

patient agitated, hitting herself on the face at baseline. she's on risperdal and valium daily.

what approach would you take in sedating the patient for a ct head?

i had a painful time with this case. i'll discuss what i did. i just want to hear some of your replies first.

 

[tkim]

70yo MR patient, hx of agitation and dementia. s/p mechanical fall with contussion to her scalp.

patient agitated, hitting herself on the face at baseline. she's on risperdal and valium daily.

what approach would you take in sedating the patient for a ct head?

i had a painful time with this case. i'll discuss what i did. i just want to hear some of your replies first.

Haldol.

 

[Rendar5]

Is your concern in looking for a fast on-off sedative to continue to assess mental status post-CT? The pt's home valium instructions for prn agitation? If so, I'd try her home dose or something a bit higher. Fast on-off, though active metabolites. I might also consider benadryl.

 

[Apollyon]

I might also consider benadryl.

Oh dear - in an elderly demented? No way.

 

[tkim]

Oh dear - in an elderly demented? No way.

http://www.virginiageriatrics.org/consult/delirium/do7.html

Their dosages are touch light, to me.

Besides, we're not talking about calming her down just to chill her out, we want to have her hold still for the CT head. Different dosages for different reasons.

 

[Apollyon]

http://www.virginiageriatrics.org/consult/delirium/do7.html

Their dosages are touch light, to me.

Besides, we're not talking about calming her down just to chill her out, we want to have her hold still for the CT head. Different dosages for different reasons.

Hey, at least the geri docs (who also will tell any- and everyone to not give quinolones to anyone over 65, but no one listens, even as a normal 67 y/o on Cipro bounces back in one day, delirious) support what I said!

 

[BADMD]

70yo MR patient, hx of agitation and dementia. s/p mechanical fall with contussion to her scalp.

patient agitated, hitting herself on the face at baseline. she's on risperdal and valium daily.

what approach would you take in sedating the patient for a ct head?

i had a painful time with this case. i'll discuss what i did. i just want to hear some of your replies first.

I'd want a little more info. Any other comorbidities, electrolyte issues, normal ECG, seizures, other meds?

In this patient, I would probably just start with a dose or two of a benzo. they are the cleanest, but can cause issues in the elderly. If that didn't do enough, I'd then use serial doses of haloperidol up to about 5 mg in total divided. I'd avoid anything antimuscarinic (understanding that haloperidol has some antimuscarinic effects). Beyond those two, I'd be hesitant to use much more. The patient might need procedural sedation and is likely ASA level III.

 

[BADMD]

oh dear - in an elderly demented? No way.

+1

 

[GeneralVeers]

I've had this come up a number of times. Had an elderly patient with metastatic prostate cancer to C5 and needed to get a STAT MRI. He wouldn't hold still.

Before I sedate the patient, I determine if the patient is going to be admitted or not regardless of the results. If they're going to be admitted then I go ahead and give Ativan in 0.5 mg increments and titrate up to effect.

If they're going home I tend to avoid benzos as they can hang around for a long time. Sometimes you have no choice and have to give a benzo. At most I'd consider Versed, but usually will give a low dose of morphine or Fentanyl if there's a pain issue as well.

I'd avoid Haldol as its effect on the elderly is often not predictable.

 

[Rendar5]

+1

Since I don't seem to have enough experience or knowledge in dealing with geriatric medicine (and will look it up myself later anyway), could someone explain to me the danger of using anticholinergics in the elderly?

 

[Apollyon]

Since I don't seem to have enough experience or knowledge in dealing with geriatric medicine (and will look it up myself later anyway), could someone explain to me the danger of using anticholinergics in the elderly?

Almost guaranteed delirium.