your regimen for severely agitated young patients

[Painter1]

i had a young guy in his 30s brought in by EMS after witnessed ground level fall. patient has a hx of sz. on arrival, the patient is diaphoretic, tachycardiac and stronger than Superman fighting off staff and talking jiberish. he has abrasions to his head and knees. fingerstick was normal.

though only ground level, considering his evidence of head trauma and AMS would any one call a trauma activation for this guy? i knew if i called them they would request an intubation however my impression was that this guy was intoxicated with either pcp or smoked a ton of crack.

next question, how would you sedate this guy?

i hit him with haldol 5mg IM and ativan 2mg IM with zero affect after about 8 minutes. he's still thrashing around. how would you proceed with his agitation from there?

anyone using geodon as first agent?

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[tkim]

i had a young guy in his 30s brought in by EMS after witnessed ground level fall. patient has a hx of sz. on arrival, the patient is diaphoretic, tachycardiac and stronger than Superman fighting off staff and talking jiberish. he has abrasions to his head and knees. fingerstick was normal.

though only ground level, considering his evidence of head trauma and AMS would any one call a trauma activation for this guy? i knew if i called them they would request an intubation however my impression was that this guy was intoxicated with either pcp or smoked a ton of crack.

next question, how would you sedate this guy?

i hit him with haldol 5mg IM and ativan 2mg IM with zero affect after about 8 minutes. he's still thrashing around. how would you proceed with his agitation from there?

anyone using geodon as first agent?

I'd hit with another 5 / 2, and maybe benedryl 50 mg.

If you were truly worried about a head injury, I'd RSI and scan as fast as possible, and not dick around with haldol.

 

[WilcoWorld]

This is very much an "it depends" situation.

Do I think the patient is agitated because of head injury? Then my preferred sedation is usually Roc & Etomidate with an ET tube chaser (+/- fentanyl/lidocaine appetizer).

Do I think it's a drunk jerk? I'll give verbal deescalation a try but quickly convert to haldol, because that's the antipsychotic we have available quickly and I don't like giving lots of benzos to people who are already drunk.

Do I think it's alcohol withdrawl? Benzos, benzos, benzos.

Do I think it's acute non-toxicologic psychosis? Then I'll try to get 'em to take something orally but will do haldol here, whereas I used to use Geodon until we had to start waiting for the pharmacy to send it up.

Do I think it's meth or coke? Back to benzos baby.
And the beat goes on, and the beat goes on...

 

[WilcoWorld]

P.S.: When I had Geodon readily available I preferred it to Haldol for acute non-tox psychosis, because it seemed that patients were usually more "interviewable" after Geodon than after Haldol.

 

[deleted65604]

I've had good luck with zyprexa/ativan combo (I guess versed would be the best if you wanted to get him over to the CT scanner and wanted sedation to last a minimum amount of time). I agree with CT ASAP and RSI if he isn't cooperative despite one (or possibly two doses) of reasonable sedation.

I had a kid a couple months ago who reportedly fell out of the truck, hitting his head and losing consciousness. He too was intoxicated with a BA of around 210. He was alert and oriented times three and answered questions appropriately. However, his short term memory was terrible and he just would not sit still to maintain c-spine precautions. After 4 of versed just made him slightly worse, I just intubated him and got him to the CT. He had a couple of mild brain-bleeds and spent a few days in the trauma center down the road.

My point is that you've got to assume the worst, that he has a brain bleed that is expanding and the sooner you find it, the more brain-tissue survives.

 

[njac]

I've had good luck with zyprexa/ativan combo

what about the "zOMG!!! Benzos + IM Zyprexa = cardiovascular collapse!!! zOMG!!!111!!!eleven!!!"

 

[docB]

I like Haldol 2.5, Ativan 2 and Benadryl 25 IM or IV. The nice thing about that regimen is that it's lower than the full B52 and you can repeat the whole thing if you need to without piecemealing which always seems to create confusion.

 

[dchristismi]

This is very much an "it depends" situation.

Do I think the patient is agitated because of head injury? Then my preferred sedation is usually Roc & Etomidate with an ET tube chaser (+/- fentanyl/lidocaine appetizer).

Do I think it's a drunk jerk? I'll give verbal deescalation a try but quickly convert to haldol, because that's the antipsychotic we have available quickly and I don't like giving lots of benzos to people who are already drunk.

Do I think it's alcohol withdrawl? Benzos, benzos, benzos.

Do I think it's acute non-toxicologic psychosis? Then I'll try to get 'em to take something orally but will do haldol here, whereas I used to use Geodon until we had to start waiting for the pharmacy to send it up.

Do I think it's meth or coke? Back to benzos baby.
And the beat goes on, and the beat goes on...

This sums up my practice pretty well, although I go for the IM geodon pretty quickly. I do have it readily available, and find it works very well.

I did have a case with a violent hypoglycemic patient - couldn't get a line and he was endangering both himself and staff. Ended up slugging him with IM Ketamine just to get control of the situation. Then got the line. Then fixed him. (No, the glucagon wasn't cutting it)

I had a violent head injury case in residency where we went straight to propofol (at the behest of the attending.) She was the closest to the line, so just yelled for it. It worked. Guy managed to smash up the portable XR machine - with his head - in the interim. That's how violent he was.

 

[substanceP]

i had a young guy in his 30s brought in by EMS after witnessed ground level fall. patient has a hx of sz. on arrival, the patient is diaphoretic, tachycardiac and stronger than Superman fighting off staff and talking jiberish. he has abrasions to his head and knees. fingerstick was normal.

though only ground level, considering his evidence of head trauma and AMS would any one call a trauma activation for this guy? i knew if i called them they would request an intubation however my impression was that this guy was intoxicated with either pcp or smoked a ton of crack.

next question, how would you sedate this guy?

i hit him with haldol 5mg IM and ativan 2mg IM with zero affect after about 8 minutes. he's still thrashing around. how would you proceed with his agitation from there?

anyone using geodon as first agent?

i'll address your second question first. with a known seizure hx i would've avoided the haldol b/c it lowers the seizure threshold. over the past year or two i've used a "two and two" (two of versed and two of ativan) with pretty decent results. the versed is faster acting and the ativan lasts longer so you get relatively quick sedation that lasts.

as far as your first question is concerned, yes i would've called it a trauma activation with that clinical picture, and yes i would've intubated this guy. jarabacoa said it right. you have to assume the worst (brain bleed) so he needs the scan asap.

as far as geodon, i've never used it so i have no opinion.

--sp

 

[PharmaTope]

what about the "zOMG!!! Benzos + IM Zyprexa = cardiovascular collapse!!! zOMG!!!111!!!eleven!!!"

what is the zOMG and the 111!!!! eleven!!!! ?

 

[GeneralVeers]

If the patient is particularly sociopathic in their behavior I find that a dose of Inapsine IV or IM gets the job done rather quickly.

 

[Apollyon]

what is the zOMG and the 111!!!! eleven!!!! ?

Internet slang. Check out Google and the Urban Dictionary.

(And I will not lmgtfy.)

 

[njac]

now how do you feel about the various atypical antipsychotics - we've got IM Geodon, Zyprexa and Abilify.

A couple people have mentioned Geodon - it's been pounded into me that this one is the most likely to cause QT prolongation, etc, and that the other two would be preferable agents.

While on paper Zyprexa has the shortest onset, I've heard it has a great sedation profile as well - but when we tried to add it at our last hospital, the trauma attending was quite underwhelmed by it.

Experiences?

 

[njac]

what is the zOMG and the 111!!!! eleven!!!! ?

I was demonstrating the overreaction and hysteria of people using internet hyperbole.