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Cocktails to control Psychomotor Aggitation, ETOH, Cocaine


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I work in a ER that sees a good share of patients which every ER sees, then we have a special group  who fall into either

 

1) Drunk, ETOH, Cocaine, Meth user who is agitated and aggressive.

 

2) Psychotic, angry and combative.

 

 

My question is what medications, dosages, route, are best to help control these patients, i don't not necessary want to sedate them, overall goal is to protect the patient from himself and from staff members.

 

Our hospital does not stock Droperidol.

 

 

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If it's a straight cocaine ingestion, I usually have a preference for benzo's (ativan or versed); haldol can theoretically lower the seizure threshold which isn't great in a hyper-stimulated patient like a cocaine overdose.  We have our medics do midazolam 5mg IV/IM/IN for sedation, along with 5mg of haldol in the right patient population.

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What about using Geodon?  I do know from what I have seen to not use paralytics in these patients when intubating as it can cause a hypermetabolic state even without predisposition of genetic evidence, I.e. MH.  Actually saw a 16 y/o kid on a drug called "Molly" and nothing touched him.  I mean he was powering through Versed from ems, Ativan, Haldol, and even the damn iron hammer....and kept on fighting and going nuts.  They decided to intubate, hit him with etomidate, fentanyl, and even a faciculating dose of vec...then sux...then bam...MH.  First time and I am sure the only time I might ever see it, was crazy to say the least.

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MH is a genetic condition of the ryanodine receptor and would have occurred no matter what drug they were on when given sux or volatile anesthestic. Nondepolarizer paralytics are fine. I've never seen evidence to show that it can occur without the condition. If you have some studies I would love to see it. Very interesting.

 

Also, I'm sure it could be a typo, but I think you mean defasiculating dose of vec, which more recent literature shows doesn't prevent myalgia (the only reason to give it).

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Okie-

 

Just went through a nice educaitonal course put on by one of our docs regarding Molly (MDMA variant).  We had a 22 year old fellow die after he took it a rave concert, presented with a temp of about 107F towards the end.  So I would attribute the hyperthermia more to the ingestion than I would the RSI.  Just a thought!

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I just like benzos.  Cheap, easy to use and when given IV are very titratable.  

 

In along the same lines as EMEDPA, during my psych rotation I became familiar with the "10-2-50" (Haldol-Ativan-Benadryl).  No matter in what state of acute psychosis they were in or what substance they were on, it always did the trick.  I've never used that combination as a PA though.  I've also yet to see a pt on bath salts personally.

 

(now that I say that, tomorrow night at work I'm going to get an entire rave party of naked, sweating face-eating psychos descend upon my ER)

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My experience is quite limited in comparison to EMED, TrueAnomaly, medic, et al, but here's my thoughts.

 

Drunk and agitated = haldol.  Start 10, and then repeat with 5mg every 10 minutes until they chill.  I try to avoid benzo's in these guys because ETOH + Benzo = apnea.  I would rather them sleep it off as I sew them up so they can go home in a few hours and not spend the night in the ICU on the vent. 

 

Meth = ativan, push 4 mg q 10 minutes until they chill and their numbers get better.  Watch for hyperthermia.  In past 2 months I've had a few meth overdoses, including a huge meth overdose AND a 2 yo the other night with a huge methylphenidate overdose that presented, and I treated, the same as a meth overdose.  Haven't had to intubate one yet.    Not sure if haldol would help me out with this.

 

Haven't had a cocaine OD yet (knock on wood), but expect I would do the same thing. 

 

Psychotic with no hx of ETOH or meth?  B-52 as described above. 

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http://onlinelibrary.wiley.com/store/10.1197/j.aem.2003.06.015/asset/j.aem.2003.06.015.pdf?v=1&t=ho3zkex5&s=84527ec528a4035e0033d50d39cfd8c21309416b

 

Check out Nobey et al. for an interesting article on ED sedation; midazolam was significantly better for rapid sedation that either lorazepam or haloperidol.  I also like the fact that it's got a shorter half-life than the other two drugs.  I'd rather have to re-dose a patient who is safely restrained than  tie up a bed all night with a patient who is lost to the world after multiple ativan doses.

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ativan 4 mg q 10 is pretty stiff. I generally do 2 Q 10-15. someone benzo-naive who gets 4 of ativan IV push is basically getting valium 20 mg iv push...

Yes it is.  I was referring to the meth overdose who is gorked out while thier pulse is swinging 180-200.  Ran the hospital out of ativan on one guy last month.  Gave the 2 yo 1.5 mg q 8 min X2, then 1 mg q 10 min.

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MH is a genetic condition of the ryanodine receptor and would have occurred no matter what drug they were on when given sux or volatile anesthestic. Nondepolarizer paralytics are fine. I've never seen evidence to show that it can occur without the condition. If you have some studies I would love to see it. Very interesting. Also, I'm sure it could be a typo, but I think you mean defasiculating dose of vec, which more recent literature shows doesn't prevent myalgia (the only reason to give it).

I meant to say a defasciculating dose, thank for the correction.  I have only seen the MH/hypermetabolic state just once as described above.  I have given TONS of paralytics on the helicopter and never had one adverse reaction other than maybe some tachycardia or flushing, we were always taught about it, just never expected to encounter it as we did in the ED.  

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We have about 60 psychs a day come through ER, not all require sedation but 90% of the docs and PAs/NPs do nothing for EtOH intoxication exept monitor and protect airway for aspiration, (this is in a party city so lots and lots of out of town EtOH ODs come in. Oy-vey the number of eye brows ive sewn back together on vacationers! (just a little trivia) For straight psychotic gets B52 (we start at haldol 5 then go up as needed) i personally use B51, easier to add than remove! We often hold ativan in the gero psych population as it hits them hard, the drug crazy usually get B52 and rarely, once in a while one gets intubated as they fight for quite a while, and then the higher dose meds hit them like a wall. Geodon used by a few newer Docs. Works pretty fast.

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"The B52 is tried and true!"  And to tag on to the comment about the BP elevation and tachycardia with cocaine intoxication - I've found in more than a few cases that if you just get them settled down with some benzos that the sympathomimetic stuff follows and you may not have to resort to the β-blockers.

 

Straight EtOH intoxication and agitated (a mean drunk), haldol or droperidol work well as Boatswain2PA noted.  Best not to throw a sedative-hypnotic at someone who's already overdosed on a sedative-hypnotic.  But overall Haldol is a great drug for acute undifferentiated agitation but it does take a bit longer than the fast-acting benzos to get 'em sedated.

 

Wish I could upload a couple of good articles: "The Violent or Agitated Patient" by Rossi & Swan in EM Clinics of North America 2010 and a study by Martel, et al in Academic Emergency Medicine in 2005 titled "Management of Acute Undifferentiated Agitation in the Emergency Department: A Randomized Double-Blind Trial of Droperidol, Ziprasidone, and Midazolam".  PM me if you want a copy.

 

Also Billy Mallon at USC+LAC had a great lecture a few years back titled "Punks and Drunks".  It may still be on EMedHome, but I've got a copy of the video lecture if anyone would like that too.

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I second (or maybe 5th) the B52 combo.  It works well in most of my agitated patients. I'm also a fan of versed or geodon depending on the circumstances.  I haven't had the pleasure of any Molly patients yet (though I'm sure it's bound to happen soon). Some of my bath salts patients were the most difficult, and I've had several that we have had to completely sedate and intubate because they were so combative. Thankfully, it's been a while since I've had to do this.  Does it bother anyone else that we have to snow someone, breathe for them, admit them to the ICU, all so they can then sober up?!?

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I've so far had one bath salts case only, and yeah, I had to intubate him. It was freaky how jacked up this dude was! Completely altered, combative, and very out of it.

 

When I thought ingestion, I was thinking PCP, he was that crazed. And he didn't fit the drug user profile, either. A clean cut guy in his 40's with a wife and kids.

 

I went barking up a bunch of weird metabolic and infectious trees before his buddy took me aside and confessed their predilection for bath salts. Thanks for the wasted million-dollar workup, dude!

 

B52 didn't even touch this guy. We had 6 men restraining him, and I still got a nice big bruise on my arm from him grabbing me. The man was 6'4" and weighed about 300 lbs. For the sake of his future medical providers, I hope he switches to downers as his recreational drug of choice!

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