Versed for agitation

[Cytarabine]

On psych rotation right now. A depressed/anxious patient on our inpatient service presented from the ED a while back after "freaking out". The documentation was kind of sparse as to what exactly happened, but the pt ended up getting versed in the ED. The psych team hadn't seen midaz used for this purpose before, and there was no documentation regarding need for chemical restraints (which kind of contributed to flagging this as potentially poor practice). On searching a bit, it seems like it does have some use for agitation and maybe outperforms lorazepam and antipsychotics, which was surprising given that we hadn't seen it used for that purpose previously. Do you all commonly use it for agitation? If not, what's your agitation go to / algorithm?

---

Members don't see this ad.

 

[Caesar]

On psych rotation right now. A depressed/anxious patient on our inpatient service presented from the ED a while back after "freaking out". The documentation was kind of sparse as to what exactly happened, but the pt ended up getting versed in the ED. The psych team hadn't seen midaz used for this purpose before, and there was no documentation regarding need for chemical restraints (which kind of contributed to flagging this as potentially poor practice). On searching a bit, it seems like it does have some use for agitation and maybe outperforms lorazepam and antipsychotics, which was surprising given that we hadn't seen it used for that purpose previously. Do you all commonly use it for agitation? If not, what's your agitation go to / algorithm?

Geodon PO if they will take it IM if not or Haldol plus Ativan if I think there are substances on board.

 

[Rendar5]

of course it has use for agitation. It's a benzo 🙂 That's what it's designed for, It just happens be a shorter lasting one than Ativan which is why it's not used as often for psych patients who need longer-term sedation.

 

[RustedFox]

Versed FTW when you need to put someone down 5 minutes ago. Its great in the MRDD crowd as well if they get all riled up.

Then, once they're calmer than a Hindu cow, sedate ad litem.

 

[WilcoWorld]

On psych rotation right now. A depressed/anxious patient on our inpatient service presented from the ED a while back after "freaking out". The documentation was kind of sparse as to what exactly happened, but the pt ended up getting versed in the ED. The psych team hadn't seen midaz used for this purpose before, and there was no documentation regarding need for chemical restraints (which kind of contributed to flagging this as potentially poor practice). On searching a bit, it seems like it does have some use for agitation and maybe outperforms lorazepam and antipsychotics, which was surprising given that we hadn't seen it used for that purpose previously. Do you all commonly use it for agitation? If not, what's your agitation go to / algorithm?

ED nurses and ED docs (including myself) like antipsychotics like haloperidol or Geodon because they work very well. However most toxicologists I have discussed this with strongly prefer benzodiazepines for undifferentiated agitation. "Don't use an antipsychotic if they're not psychotic" is the refrain I recall. While there are some conditions that antipsychotics won't help or can harm (neuroleptic malignant syndrome being one example), benzodiazepines are safe for just about everything except benzodiazepine allergy.

I don't mean to suggest that I always use benzos, as I use antipsychotics quite often. However, using versed for undifferentiated agitation is not at all a "poor practice". In fact, it's probably best practice.

 

[Arcan57]

Some anti-psychotics lower seizure threshold and I'd say it's about a 10:1 ratio of agitated due to substance abuse vs. agitated due to psychiatric disease without substances on board. While it's contraindicated in schizophrenia, I think ketamine is a great drug for the agitated patient that you need to put down immediately. I've seen too many people that chewed through 20-25 mg of midazolam because of the cross-tolerance from years of heavy ETOH and sedative abuse. Anecdotally I haven't seen the hemodynamic effects from ketamine be important clinically in pts with agitated delirium and it does buy time to get the line in and titrate up the benzos if needed.

 

[GeneralVeers]

Ketamine for the drunk, agitated patient who needs a head CT. You can put them down for a good 30-60 minutes, do whatever tests/procedures you need, and you don't have to worry about synergistic respiratory depression with the alcohol.

 

[Birdstrike]

Any benzo can be used for agitation. Versed is pretty short acting, but there's no reason you can't use it initially, then follow up with something longer acting. There's many different ways to accomplish the same thing, often times in Medicine. It's called the "art" of Medicine that many conveniently have chosen to forget exists. There's much arrogance, condescension and stone throwing from inside glass houses in our profession. This is partly why the medical malpractice situation is what it is. There's no shortage of these self-professed "geniuses" with their patented retrospectoscopes, that are more than happy to take money from plaintiff's attorneys to fuel frivolous lawsuits and voice criticism against their own colleges.

 

[Cytarabine]

Thank you all for the information, I appreciate it. As far as benzo use for sedation, I can definitely see the favorable side effect profile relative to antipsychotics, and on the psych ward we do use ativan for nonpsychotic agitation. I guess I'm just curious about the use of versed in particular out of naivety / lack of experience. I've only seen it used in the cath lab and for scopes. For agitation, is the intent with versed to essentially go straight to moderate sedation? Or is it able to used in a similar fashion to ativan where it tends to more so settle them down than knock them out?

 

[Cytarabine]

Any benzo can be used for agitation. Versed is pretty short acting, but there's no reason you can't use it initially, then follow up with something longer acting. There's many different ways to accomplish the same thing, often times in Medicine. It's called the "art" of Medicine that many conveniently have chosen to forget exists. There's much arrogance, condescension and stone throwing from inside glass houses in our profession. This is partly why the medical malpractice situation is what it is. There's no shortage of these self-professed "geniuses" with their patented retrospectoscopes, that are more than happy to take money from plaintiff's attorneys to fuel frivolous lawsuits and voice criticism against their own colleges.

I agree and think the infighting in medicine is a great detriment to the field. I tend to air on the side of deferring to the judgment of another clinician (particularly given my stage of training), but the combination of the unfamiliarity with the concurrent lack of documentation made me raise an eyebrow

 

[Vandalia]

Any benzo can be used for agitation. Versed is pretty short acting, but there's no reason you can't use it initially, then follow up with something longer acting. There's many different ways to accomplish the same thing, often times in Medicine. It's called the "art" of Medicine that many conveniently have chosen to forget exists. There's much arrogance, condescension and stone throwing from inside glass houses in our profession. This is partly why the medical malpractice situation is what it is. There's no shortage of these self-professed "geniuses" with their patented retrospectoscopes, that are more than happy to take money from plaintiff's attorneys to fuel frivolous lawsuits and voice criticism against their own colleges.

We are all formed to some extent by our practice environment. A lot of the psychiatrists I know are so tapped out detoxing and rehabbing patients who had benzos handed out like candy that they have developed a knee-jerk reaction against them in general.

 

[Arcan57]

Thank you all for the information, I appreciate it. As far as benzo use for sedation, I can definitely see the favorable side effect profile relative to antipsychotics, and on the psych ward we do use ativan for nonpsychotic agitation. I guess I'm just curious about the use of versed in particular out of naivety / lack of experience. I've only seen it used in the cath lab and for scopes. For agitation, is the intent with versed to essentially go straight to moderate sedation? Or is it able to used in a similar fashion to ativan where it tends to more so settle them down than knock them out?

It's a benzo like any other benzo. It's frequently used in procedural sedation due to its shorter duration of action but the level of sedation achieved is going to depend on dose and pt's tolerance and other drugs on board. Geodon, et al have done a good job of being marketed in the US so we tend to use injectable anti-psychotics as our go to agitation but there are other Western countries (Austalia for one) where high-dose IM benzos are the treatment of choice. The papers looking benzos for agitation show a decent rate of respiratory depression, but part of that is going to be practice setting. If I have 2 nurses, 3 techs, and 4 security guards to restrain a patient then I can take the time to titrate up. If I'm a single coverage doc in a 10 bed ED then I'll take a 10% chance of needing to tube someone over the potential for multiple injured staff members.

 

[Birdstrike]

We are all formed to some extent by our practice environment. A lot of the psychiatrists I know are so tapped out detoxing and rehabbing patients who had benzos handed out like candy that they have developed a knee-jerk reaction against them in general.

To equate an acute one or two time dose of a sedative with the inappropriate overprescribing of chronic outpatient benzos, seems like a great, great stretch. It's an agitated patient who won't likely ever remember getting the benzo dose, and certainly won't be getting a prescription for it, from the ED doctor who gave a one time IV or IM benzo dose. That seems more like an emotional reaction, than a clinical one a physician should make. I suppose if a physician wants to treat their patients and judge their colleagues based on emotional knee-jerk reactions, without any rational oversight then I cannot stop them. It would be similar to concluding that IV opiates should not be used acutely for patients with broken limbs, because the outpatient version of the same are overprescribed in completely incomparable situations. It sounds more like garden-variety, uninformed ER-doctor bashing to me, but hey... that would be nothing new.

 

[link2swim06]

Nimbex works pretty well. Kidding....


But versed is great, although it isn't used as often as ativan or valium where I'm at because it wears off too fast. Versed is the only benzo our EMS carries which is good because it does the job quick and wears off in a reasonable time for us to evaluate them too.

The only problem with versed is sometimes peds patients will have a paradoxical reaction and get more agitated. Although that's more for procedural sedation though.

 

[Cytarabine]

It's a benzo like any other benzo. It's frequently used in procedural sedation due to its shorter duration of action but the level of sedation achieved is going to depend on dose and pt's tolerance and other drugs on board. Geodon, et al have done a good job of being marketed in the US so we tend to use injectable anti-psychotics as our go to agitation but there are other Western countries (Austalia for one) where high-dose IM benzos are the treatment of choice. The papers looking benzos for agitation show a decent rate of respiratory depression, but part of that is going to be practice setting. If I have 2 nurses, 3 techs, and 4 security guards to restrain a patient then I can take the time to titrate up. If I'm a single coverage doc in a 10 bed ED then I'll take a 10% chance of needing to tube someone over the potential for multiple injured staff members.

Gotcha, thanks!

 

[Vandalia]

That seems more like an emotional reaction, than a clinical one a physician should make.

Exactly. We are not nearly as objective as we like to think. If you look at the preferences of experienced physicians, I would wager you will find they are based far more on a few extreme experiences rather than on a careful analysis of objective evidence. That is true even when the evidence would support the decision. EM physicians have drastically cut down on prescribing opioids for home use compared with 20-30 years ago. How much of that is based on evidence-based analysis, and how much is based on the experience of dealing with drug seekers and overdoses?

Whenever I see a patient come in on Soma I cringe. That does not come from reading a journal article.

Look at most of our threads. Take the headache cocktail thread for one example. Some say no toradol ever for any headache patient. How much of that decision is based on evidence-based medicine, and how much is based on "my attending told me that once his best friend's wife had a patient who presented with what he said was his usual migraine and they gave toradol and...."

Example: One of my part-time, soon to be retired partners, breaks out dilaudid for anything requiring analgesia. The rest of us use it as a last resort. Is that philosophical difference due to the difference in morbidity and mortality as reported in a double-blind, multi-center trial, or from frustration with the opioid abuse epidemic? So I can certainly see a psychiatrist preferring not to see a benzo used when there are other viable options.

 

[shookwell]

Versed is the best benzo for sedation in the ED. I use versed or ketamine depending on how long I think I'm going to want them to be sedated. Valium may be better but loses out to versed because of its poor and erratic IM absorption; I'll use it over versed if there is already vascular access.

Ativan and anti-psychotics don't really make much sense in the undifferentiated psychotic patient in the ED.

 

[Arcan57]

Versed is the best benzo for sedation in the ED. I use versed or ketamine depending on how long I think I'm going to want them to be sedated. Valium may be better but loses out to versed because of its poor and erratic IM absorption; I'll use it over versed if there is already vascular access.

Ativan and anti-psychotics don't really make much sense in the undifferentiated psychotic patient in the ED.

I'm going to disagree with your last sentence, although only slightly. Depending on what the turn-around time on cross-sectional imaging, etc. is and how quickly psych comes to assess your patients , Ativan may be a reasonable choice for it's longer duration of action. And while everyone (including myself a couple of posts prior) loves to talk about undifferentiated psychosis, it's actually pretty damn rare that you're going to see a psychotic patient and not have at least an 80% chance of guessing correctly on the cause of their agitation. Axis I based psychosis looks and "feels" different enough from sympathomimetic/anticholinergic agitated delirium which looks different from artificial cannabinoid/hallucinogen "disassociation" that you're usually going to be running down a path that's adjacent but not the same as "undifferentiated" psychosis. There are some weird epilepsy/encephalopathies that are stupidly difficult to diagnose but fortunately they're pretty rare.