disruption, danger, and droperidol: emergency management of the agitated patient

disruption, danger, and droperidol: emergency management of the agitated patient

reuben j. strayer emupdates.com

what patient defines emergency medicine?


sickwell


undifferentiated chest pain undifferentiated abdominal pain undifferentiated headache undifferentiated dizzy undifferentiated back pain undifferentiated fever

undifferentiated agitation


an immediate threatrequires use of dangerous maneuversdrunk or dying

simultaneous control, resuscitation, and risk stratification

undifferentiated agitation

3 types of emergency department agitation

agitated but cooperativedisruptive without dangerexcited delirium

agitated but cooperative

responds to suggestionno concern for dangerous condition

have someone sit with themor small dose oral benzo

assessable - low concern for dangerous condition

conversant but disruptive

sleep it off

disruptive without danger

safety prioritized over speed and efficacy

often “observed” in unmonitored bed

very common in many ED’s



haldol 5, lorazepam 2is fine. better than fine:

droperidoldroperidol is the most effective agent for undifferentiated agitation


Chan 2013 Isbister 2010 Martel 2005 Resnick 1984 Richards 1998 Thomas 1992

droperidol is the safest agent for undifferentiated agitation

droperidol


Isbister 2010 Knott 2006 Martel 2009 Spain 2008

is nonsense

droperidol


Calver 2013 Calver 2015 Chase 2002 Chambers 1999 Nuttall 2007 Perkins 2015 Richards 2002 Shale 2003 Szuba 1992

the QT black box

and suspicious

droperidol


is nonsense Bailey 2002 Horowitz 2002 Jackson 2007 Kao 2003 Lenzer 2002 Mullins 2004 Newman 2015 van Zwieten 2004

the QT black box


Clindamycin Clopidogrel Factor VIIa Dihydroergotamine Flumazenil Haloperidol NSAIDs Metformin Methotrexate Metronidazole Midazolam Nitroprusside Procainamide Succinylcholine Warfarin

the QT black boxis nonsense

droperidol

Clindamycin Clopidogrel Factor VIIa Dihydroergotamine Flumazenil Haloperidol NSAIDs Metformin Methotrexate Metronidazole Midazolam Nitroprusside Procainamide Succinylcholine Warfarin

is nonsense

droperidol


the QT black box

is no longer available in the US

long live droperidol

droperidol


5-10droperidol


midazolam


midazolam

disruptive without dangeri

Hung 1996 Nobay 2004 McMullan 2010 Rey 1999

midazolam


hypoventilationparadoxical response benzo resistancevs. droperidolvs. haloperidol

5-10

Spain 2008 Mancuso 2004

monitor

no monitor

haldol 10 versed 2

*

faster than haloperidol*but narrow therapeutic window


re-dosing is okvs. excited delirium

droperidol 5-10 IMmidazolam 5-10 IMhaldol 10 midaz 2 IM

excited delirium

uncommon outside citiesdelirium and danger

to himself to others from dangerous conditions

*except in australia

disruptive vs. delirious

cannot engage / incoherentfluctuating sensoriumabnormal vitals - don’t fight for vitals

screaming and thrashing

err on treating as excited deliriumdrunks exist to embarrass emergency doctors

disregard for futility, pain, fatigue

Vilke 2012

1. adequate forcemake sure it’s safe to approach the patient

code white - partner with hospital security

how to manage excited delirium

2. put face mask oxygen on the patientcontrols spitprovides oxygen

whatever the patient position

[pic of choke hold / neck compression]

[pic of knee on back of face down patient preventing chest excursion]

[pic of pulling the officer’s hand off the face of the patient by holding a face mask]

[pic of pulling the straps tight to the face of the patient, strongly securing the face mask to the face]

3. relieve dangerous restraint holdsneck or chest compression

3. relieve dangerous restraint holdsneck or chest compressionhog tie

prone positionHick 1999

4. chemical restraintNOT physical restraintsclock is ticking danger is unaddressedovercome this unfortunate tradition

focus on sedation

IM not IV

through clothing

SPEEDSAFETY

4. chemical restraint

Calver 2010

speed and efficacy trump concern for over-sedation

(respiratory depression)

intubating the excited delirium patient is good care

4. chemical restraint

rapid single shot success4. chemical restraint

ketamine“but this patient has elevated HR and BP!” NO PROBLEM - ketamine will normalize hyperdynamic vitals in most cases

Isbister 2016 Burnett 2012 Hopper 2015 Iwanicki 2014 Keseg 2015 Melamed 2007 Roberts 2001 Scheppke 2014

this is procedural sedation requires PSA monitoring

500 mg4-6 mg/kg IM

ketaminerapid single shot success4. chemical restraint

do not apply tight restraints, continue to hold the patient

loose restraints are ok but should be unnecessary and should not delay resuscitation

loosen existing tight restraints

head of bed up

as the patient calms

5. vitalstemp fingerstickroom air saturation

or capnography

6. vascular access and crystalloid bolus

7. identify and treat dangerous causes and effects of severe agitation

hypoxia hyperthermia hypoglycemia hypoperfusion

first

hyperkalemia acidemia ICH CNS infection

second

sedative withdrawal serotonin syndrome NMS thyrotoxicosis sepsis seizure/postictal Na, Ca, Cr, NH3

third

CK, trauma

oral whatever5 and 2

droperidol midazolam

k e t a m i n e5 mg 20 mg10 mg

dissociative dose

(haloperidol)

agitationlikelihood of dangerous condition

cooperativedisruptive without danger

excited deliriumuncontrollably

violent

sub-dissociativeolanazapine ziprasidone

concern for dangerous condition?droperidol or midazolam 5-10 mg IM or haldol 10 midazolam 2

ketamine 500 mg IM immediate PSA setup

adequate forceface mask oxygenrelieve dangerous restraint holds

identify/treat dangerous causes/effects of severe agitation

loose restraints prn, no tight restraints, head of bed up

vascular access and crystalloid bolus

yes

no

1. hypoxia, hyperthermia, hypoglycemia, hypoperfusion 2. hyperkalemia, acidemia, ICH, CNS infection 3. withdrawal, thyrotoxicosis, rhabdomyolysis, occult trauma

@emupdates

emergency management

of the agitated patient

vitals esp. temperature, fingerstick, room air pulse oximetryor ETCO2

www.kickstarter.com/bringbackdroperidol

@emupdates

droperidol midazolam

sub-dissociative dose ketamine

dissociative dose ketamine

more danger

excited delirium

uncontrollable violence

analgesia

recreational

partially dissociated

dissociated

less disruptive less danger

PSA Setup

analgesia

recreational


dissociated

10 mg

200 mg (IV)ketamine brain continuum

analgesia

recreational


dissociated

10 mg


?

dissociated


+midazolam+droperidol

10 mg

Le Cong 2011

initial control vs. ongoing care

alcohol withdrawal sympathomimetic intox NMS, SS

psychiatry

benzodiazepines

antipsychotics

thyrotoxicosis beta blockerssepsis antibioticshypoxia oxygenheat stroke ice

disruption, danger, and droperidol: emergency management of the agitated patient

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