Morning Report: 10/26/2012

Today’s Morning Report is courtesy of Dr. DiMare!

Sedation and the Agitated Patient

 

What are the hallmarks of delirium?

       altered level of consciousness

  • either increased or decreased

       disturbances in sleep/wake cycle

       generally caused by illness, medication or intoxication

       caused by imbalance of neurotransmitters

  • dopamine, seratonin, acetylcholine, GABA

 

What should our focus be?

       diagnosing the underlying cause may be the final solution

       safety of patient and staff while finding the underlying cause

       don’t make things worse

 

What do we generally use?

       High potency Typical Antipsychotics

  • Haloperidol
  • Droperidol

       Benzos

  • Midazolam
  • Lorazepam

 

Who needs to be sedated? And how?

       Intoxicated and crazy

  • Actively intoxicated
    • ETOH – haldol/droperidol
      • Droperidol is quicker acting than haldol
      • Less chance of respiratory depression
      • EKG once sedated since EtOH puts you at risk for hypomagesemia and long QTc
      • Sympathimomimetics (cocaine/PCP) – Benzos
        • Less of a concern for respiratory suppression
  • EtOH withdrawal – Benzos
    • Treat withdrawal and you will treat the agitation
    • Generally not Midazolam – may need to be re-dosed, documented instances of respiratory depression requiring BVM or intubation after multiple rounds of re-dosing
  • Combo therapy
    • Considered safe in the generally young, intoxicated population, allows shorter onset and longer duration and minimizes side effects of both drug classes

       Old and crazy

  • Typical teaching has been that haldol is better than benzos
  • Best treatment is to treat the cause but sedation is often necessary to allow full evaluation
  • Haldol
    • Cochrane Review – decreases aggression, doesn’t decrease agitation
  • Droperidol – typically avoided because of “black box” warning
  • Benzos
    • May be better if patient has Parkinsons
      • Less of a chance of EPS
      • Avoid in a hypotensive patient or a patient who may be on their way to being hypotensive (ie delirium secondary to infection)
  • All of these patients should be admitted

       Just crazy

  • Longer periods of agitation lead to more violent outbursts, often unprovoked
  • American Psychiatrists Assoc recommends Haldol as first line medication
  • Droperidol may be superior because of shorter time to onset, longer half life, increased potency
    • Review of 12,000 patients who received droperidol for primary psychotic behavior showed no dysrhythmias

 

After sedating:

       VS including FSG

       put the patient on a monitor

       get an EKG

       try not to physically as well as chemically restrain

       examine the patient for signs of trauma

       if things don’t make sense do more tests

  • CT head, LP, chemistry etc.

 

Thanks Dr. DiMare!

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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