Podcast 060 – On Human Bondage and the Art of the Chemical Takedown

In this episode, I discuss the takedown and restraint of the violent, agitated delirium patient. This is a team sport and requires a coordinated approach for the safety of the patient and staff.

Essentials of EM

See my experience at Essentials of EM 2011.

How to apply restraints in the ED

This video by Gary Marks, DO is the best instructional source for the proper way to restrain a patient in the ED

This image shows good restraint:

how to restrain

If you have ideas of your own and how to accomplish safe takedown of these patients, please put your comments below.

Some Evidence

Haldol vs. Droperidol

  • J Clin Psychiatry. 1984 Jul;45(7):298-9. Droperidol vs. haloperidol in the initial management of acutely agitated patients.
  • Ann Emerg Med. 1992 Apr;21(4):407-13. Droperidol versus haloperidol for chemical restraint of agitated and combative patients.

Droperidol vs. Midazolam

10 mg IM droperidol was not associated with greater QTc prolongation than the midazolam group. The DORM Study. Ann Emerg Med 2010;56:392-401.

Droperidol Safety

Article froms Peds literature looked at safety of high doses in patients aged 15-21 (Peds Emerg Care 2010;26(4):248)

The DORM Study

Randomized Controlled Trial of Intramuscular Droperidol Versus Midazolam for Violence and Acute Behavioral Disturbance: The DORM Study(Annals of Emergency Medicine Volume 56, Issue 4 , Pages 392-401.e1, October 2010)

This study showed that 10mg of IM droperidol was safe and more effective than midazolam or a combination of the two at half does of each.

Now on to the podcast…

Play

You finished the 'cast,
Now get CME credit

Already an EMCrit CME Subscriber?
Click Here to Get CME Credit for the Episode


Not a subcriber yet? Why the heck not?
By subscribing, you can...

  • Get CME hours
  • Support the show
  • Write it off on your taxes or get reimbursed by your department

Sign Up Today!

.

Subscribe Now

If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the ED Critical Care goodness.

This Post was by , MD, published 3 years ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.

Comments

  1. Chris writes:

    I have heard of ‘old skool’ ED guys using sux to restrain patients also and heard the term:
    “No one fucks with a 100 of sux.”

  2. Minh Le Cong says:

    Hi Scott
    great discussion of a neglected EM topic

    Firstly Sux as restraint. What can I say? Why don’t you just use a TASER on theM instead? But really, I think we can do better. We took an oath to.

    Secondly acute sedation is tricky. I agree haldol and ativan can be too slow.
    Midazolam is ok but not always ideal. I am sure you have run into tolerance and paradoxical agitation as I have. I had one speed freak still playing fight club with the police after IV 60 mg midazolam over 20 minutes early in my career
    Midazolam in high bolus dose IMI carries some risks as well. refer to this paper
    http://www.ncbi.nlm.nih.gov/pubmed/18377400

    Droperidol is a good evidence based choice I agree. rapid acting, sedating and safe.
    ketamine is probably the current single best sedation agent for acute agitation in the world. Rapid acting, effective via IMI admin. useful in kids as well as adults. We had a case of a 13 yo brought in handcuffed by police in a remote clinic. Threw the veritable kitchen sink at him: olanzapine, diazepam, midazolam, haloperidol…he got worst…my colleague attending asked the visiting psychiatrist what to do and he said he had been working with me on our ketamine retrieval sedation paper so suggested try that…IV 30 mg ketamine settled the kid down completely.

    If the patient is hypertensive, I just mix the ketamine with more midazolam in the IMI syringe. I usually do not add the midazolam with ketamine in the first IMI shot. But if patietn hypertensive I will add 5 mg midazolam for average adult and more for bigger people in the first IMI cocktail along with the 4mg/kg ketamine dose

    Finally about oxygen supplementation and sedation, I still think giving oxygen is a good idea but you do need to regularly assess sedation level and ensure it is not getting worse. However there is this case report where acute sedation, oxygen therapy and saturation monitoring may have played a role in a sedation mishap
    (refer to page 22)
    http://www.health.wa.gov.au/circularsnew/attachments/468.pdf

    • As usual, we agree on most of this. Unless there is coincident pulmonary pathology, if these patients are desaturating the only reason is hypoventilation. I’m sure in your setting, you are monitoring these folks wonderfully and it would be safe to give them O2. However, in most EDs, if these patients are put in the general mix, or worse an iso room, they will be ignored until they perish. I’d much rather have the sat alarm beeping.

      • Minh Le Cong says:

        acute sedation should be practised to the same standard as any other ED procedural sedation. Nursing should be one to one and oxygen should be provided.
        I appreciate in a busy ED that is not always a priority but it is best practice. the key as you point out is maintaining a safe sedation level. This is in the unintubated patient of course..but even in the intubated you need to be careful about sedation level monitoring. We have had two cases of reported awareness during intubation when it was used for restraint.

    • As to ketamine, I agree I think it is probably the ideal agent. I need someone to either publish or show me some numbers on what happens to hyperdynamic vitals (and I mean scary high) when we give the drug. Until then, I can’t publicly say it is a good idea on the podcast regardless of what I may do in my own personal practice.

      • Pik Mukherji says:

        Ketamine’s 2011 ACEP Clinical practice guidelines: Absolute contraindications (risk essentially always outweighs benefits) = age < 3mo and known or suspected schizophrenia. Wait, what now? (sighs) No idea what this is about.

  3. Minh Le Cong says:

    Oh and about martial arts and trying to pull moves on agitated patients..I totally agree with Scott on this one. No place for heroics and yes I have seen people bitten, spat at, all kinds of nasty stuff.
    You don’t train for that in your air conditioned dojo.
    even in UFC you are not allowed to bite!
    the key to safety is numbers . bring your gang..its a team effort as Scott says.
    I talked to Master Cliff Reid about this when I met him ( we both have a Wing Chun background)..he retells the story of when the agitated ED patient took a swing at him in the waiting room, he ducked and put him in a choke hold retraint and put the guy to sleep before security got there. He further tells how it cleared the ED waiting room quicker than a dropped grenade!

    • Amazing! If you didn’t know better, you might tried to mug Bruce Lee as well–just looks like a scrawny dude. But that mugger would have been in for a big surprise.

  4. Hi Scott
    Thanks for your podcast on sedation / restraint – this is one of those areas that is done very poorly and never talked about. Couldn’t agree more re: psych ward strategy in ED – this is a highway to nowhere but failure.

    I have posted a lot of stuff on this topic and have some resources that I have created myself at the Broome Docs site. I would like to hear your take on my “matrix” of care.
    Check out:
    http://wacdocs.csp.uwa.edu.au/2011/08/clinical-case-024-livin-the-ketamine-dream/
    http://wacdocs.csp.uwa.edu.au/2011/06/psych-sedation-and-transfer-update/

    As you can read – I am very passionate about this topic. Way too many unnecessary deaths and staff injuries in my shop. I have completely changed strategy / plans in the last 5 years and it is going very well.

    My main criticism of your podcast is this:
    You cannot apply a single sedation recipe to every patient, I have seen this go wrong so often it scares me. That is what they pay us for – not to jump on angry people, but to safely sedate them – to get the mix right.
    Maybe it is the semi-anaesthetist in me, but ask yourself this question: you have a 200 lb man with sweat coming off his brow and steam from his ears, a neck like a tractor tube – with a #dislocated ankle… are you gonna give him the same mix you give a skinny woman, or an old lady – and you are not going to sedate him in the main ED – you want to do it in an “airway-ready bay”.

    Anyway – that is my way of doing it.
    Casey.
    PS: if I were a superhero, my super power would be getting IV access in agitated patients – it changes the plan and allows titration if you can get one.

    • Casey, As Minh alludes this is specifically a podcast on the take-down of the acutely violent, agitated patient. I have yet to see old ladies in this scenario, though I am certainly not ruling it out.

      I don’t have a single sedation recipe as the previous podcasts have gone through and I think are matrices would probably overlap in this regard.

      However the takedown recipe is pretty much pt independent as it is titrated, safe and effective to start with a reasonable dose of drop/midaz in any patient exhibiting agitated delirium.

  5. Minh Le Cong says:

    Casey, I think Scott is talking about that situation before you have IV access..in those cases, you have little choice but to go IMI. I agree when you need to give rapid IMI sedation that is risky and you have to pretty much set it up like as for procedural sedation…if you got the time. As Scott cites, these cases you often got no time. I understand why some have gone to the extreme of IMI Sux.
    The coroner up here has recently finished an inquiry into the sedation death last year of a mental health patient in a psychiatric unit. He had been admitted to the unit and then became agitated. He was taken down by staff and held down whilst he was given IMI olanzapine 10mg. he kept struggling so they gave him a second dose within 10 minutes. he arrested soon afterwards and eventually died despite efforts.
    This follows a TASER related death a couple of years ago in an intoxicated man resisting arrest in our region. we can do better I believe.

    Its usually possible if you got the staff to hold someone down, then usually you can get IV access. I have no issue with a once off IMI sedation, establish control and IV access.
    The problem as you point out is that best practice has not been established yet. Common mistakes are usually underdosing the patient with an ineffective agent and this risks subsequent overdosing the patient with repeated doses.
    I totally agree with Casey on doing a risk assessment prior to sedation. It is the basis for safe sedation. The other is targetting a safe sedation level. The goal is a calm cooperative patient, not an unconscious unresponsive one.

  6. Hi Scott — great podcast! Just out of curiosity, is there any reason for your preference of droperidol over haloperidol (or any other typical antipsychotic)? Is it an evidence-based reason, or simply a formulary consideration?

  7. Mike Jasumback says:

    Ok guys, here’s my take:
    A patient that is so agitated to require this degree of intervention is in the class of “Excited Delirium”. This is a medical EMERGENCY! And in my opinion, requires rapid, complete sedation. We have two drugs that work well in this situation. Propofol and Ketamine.
    In my shop, these folks get the team approach. Two people on each extremity, RT at the bedside with the RSI box, nurse with RSI meds and IV start kit. Doc with syringe full of 100mg of propofol. Ready…….GO!
    Pt restrained, Doc at groin, femoral vessel ID’d and 50mg propofol as direct IV push. Nurse moves in for real vascular access. Doc moves to head of bed for intubation. IV access, paralytics and heavy sedation applied. Pt airway controlled.
    An alternative is IM ketamine in big doses ie 5-7mg/kg. I mean what are they gonna do, get sedated?
    This may seem extreme, but having watched a few people die of excited delirium, I think this approach is reasonable. I would disagree that the goal is a calm cooperative patient in this situation. The goal is a very sedate patient until the source of their excited delirium resolves. Sure the less agitated pt doesn’t need this, but they don’t usually require the team approach.

    Mike J

    • Minh Le Cong says:

      Hi Mike
      I half agree with you! At least you choose more effective sedation agents and have a total control approach. Scott’s approach is evidence based..a couple of RCT comparing droperidol vs midazolam demonstrate greater safety and faster control
      http://www.ncbi.nlm.nih.gov/pubmed/20868907
      http://onlinelibrary.wiley.com/doi/10.1197/j.aem.2005.07.017/abstract

      Of Course some agitated patients who are at one end of the spectrum and lives are in danger, do require urgent sedation and airway control. Your approach is valid in them.
      Many do not.
      The goal should always be a calm cooperative patient. We do not need to intubate everyone with delirium. BUt yes some we do.
      OUr current retrieval medicine record in my service for ketamine sedation is 400mg IV/hr…this guy was still awake but dissociated and responding to questions..in restraints still but actually smiling to my questions. Did he need to be rendered comatose? No.
      As Casey alludes to , if you are aiming to comatose your patients as standard care in these cases, some will die of oversedation. I have a list of cases from Australia. I think you have a famous case in the US from propofol sedation? I know your approach is rapid total control for severe cases, which is good. You address the main problems of sedation in this group which is usually ineffective agents at ineffective doses with ineffective monitoring

      • Mike Jasumback says:

        Minh and Scott,
        I agree that there are probably two populations to deal with.

        Excited Delirium=Rapid and total control

        Agitation alone=more measured response.

        How you differentiate those is challenging in the heat of battle. I would disagree with the sentiment that “some will die of oversedation”. This is usually a well planned and coordinated management strategy. RT at the bedside, enough hands to make it safe (by enough I mean at least 2 people per extremity, one at the head and 2-3 on the torso). The plan is immediate control, intubation, IV Access and continued heavy sedation. Given the adrenergic drive we see, excess sedation is rarely a problem.

        The other group is a tougher nut to crack, I, personally am not a fan of droperidol and versed, but it does work. As does Geodon. I think the best choice is real doses of IM Ketamine, the problem as Scott alludes to, is what is the effect in the face of adrenergic crisis?

        • Minh Le Cong says:

          Hi Mike
          I appreciate the concern regarding adrenergic crisis and ketamine making things worse. There is little evidence base to guide us here. The case reports from mainly the US and my own case series is that there are no obvious adverse outcomes apart from transiennt worsening of hypertension, that requires generally observation only.
          The Hennepin county case report was in someone with cocaine intoxication and a hefty dose of ketamine did not lead to cardiovascular adverse events.
          I have found this to be the case in my own series. What we know from other published literature such as the Spain article on high dose midazolam in psychostimulant presentations is that it was deemed unacceptable due to significant adverse events.
          as like many things when there is a poor level of evidence to guide practice , you gotta make a call depending on the case.
          My practice is to blunt the adrenergic response with adjunctive IMI midazolam along with the ketamine. You could reasonably do scotts approach first with the droperidol and midazolam to get some control and blunting of adrenergic crisis and then follow it with IMI ketamine if needed..hopefully you get iv access then you can do your approach or a range of others.
          the mainlining of propofol has not been reported in the literature as far as I know in this situation. If you have a case series you should publish it for peer review.
          crash anaesthesia/intubation is high risk and I agree with scott that its best to get secure IV access before giving an intravenous induction agent.

          • I think Minh will turn out to be right about hemodynamics not being a bid deal with ketamine in these players> I just need someone to put a nice case series in the lit demonstrating this fact.

    • Mike-
      I never condemn anything that works, but mainlining propofol would seem very scary to me. I wouldn’t want to have to maintain a needle in the femoral vessel while a patient is thrashing around. Just judging by how femoral art or vein placements go during cpr, I’m not sure how much of the prop is actually getting in the vessel and how much in the sub-q. I’d also think that the degree of sedation without resp depression is lower with prop than the benzo class.

      I think your IM ketamine is fine for the takedown and then hefty doses of benzos. If that is failing, intubation and propofol.

      Reason I can’t rec ketamine is not that the patient will be sedated but that the patient will be even more sympathomimetic.

      • Minh Le Cong says:

        yeah Scott thats a fair point about mainlining propofol being risky.
        if your intention is to rapidly intubate them, you might as well go old school and give them IMI SUX plus IMI ketamine…prob safer than mainlining propofol
        you can mix in one syringe but depending upon size of patient that might be 8mls worth..less for smaller people. Or you can divide into two syringes

        but I think that is rarely necessary

  8. Just to be clear with the 5 & 5 method, you are using the 5 mg/ml midazolam for a total volume of 3 ml, correct? Sorry just the pharmacist in me, in the heat of the moment I would hate for somebody to give a 7 ml IMI. Silly to point out, but just a med safety point. Thanks for the great podcast, I spread your gospel whenever/where ever possible.

  9. Kane Guthrie says:

    Great discussion here guys.
    Some of you have discussed the difficulties of getting and IV in these patients, would any of you consider going down the intraosseous path?
    Be interested in your thoughts.

    Kane

    • Minh Le Cong says:

      doing an IO in a struggling patient is only slightly easier than doing an IV in a combative patient.

      firstly restraining someone safely to expose an IO site is challenging. tibial site I haeve seen people kneed in the groin or kicked in the face
      humeral site I have seen people bitten.
      IMI into the buttocks is safer if you hold someone down..not ideal restraint position but ok for a IMI shot then get them onto side whilt awaiting effect.
      IMI into thigh is also safer but you are exposed to being punched

      • Minh as usual took the words right out of my mouth. I see no reason not to give all these folks their first round IM and then work on the IV or IO. It can only make your life easier. If you are worried about excess sedation and think you can get a line then just give the droperidol and then try your IV. Save the benzos for when you get the line.

  10. Mike Jasumback says:

    Scott,

    Thanks for the great exposure of this issue! I look forward to your discussion of agitated delirium as this needs a fuller discussion than it has had in the past. As I said earlier I am a firm believer in rapid, complete sedation in these folks. Death in this situation is not as uncommon as we would like and rapid sedation is paramount.

    Mike

  11. Minh Le Cong says:

    just to pay respect where its due
    this was the original case report that sparked my interest into researching ketamine as chemical restraint
    kudos to the Hennepin County EM dept folks!
    http://www.ncbi.nlm.nih.gov/m/pubmed/16036834/

  12. DR SCOTT,
    Thanx for covering such a neglected area that was quite informative,just two days we had faced similar kind of situation in our ED.Patient presented with complaints of respiratory distress,severe body ache and started shouting suddenly.Vitals were absolutely normal,Spo2 100% on air,when we started digging into history and medical records it was found he was taking injections of pentozacine and promethazine at least 20 times a month meaning he was addicted to it.We tried to convince him and when we said no to his request he started shouting,abusing and what not.Lot of medazolam toatal 10mg in intermittent doses was given with no effect at all ultimately after struggling for long,only short dose of propofol worked and he was than transferred to Rehab.

  13. The Hypocritic Corpus

    As I stand over this
    Screaming
    (human?)
    Patchwork
    Scarred
    Scared
    Amphetamine fuelled
    Pulsing rage
    With a syringe of midazolam
    (fantazaslam!)
    Invoking the Mental Health Act
    (the gospel according to psychiatry!)
    As if I believe in it

    I realise this does not rest easy
    With the mumbled Greek of Hippocrates,
    Sworn in a marbled hall in another life

    When I believed in it

  14. Mike Sherriff says:

    We have intranasal midazolam with a mucosal atomization device, as an option. 10 mg doses.

    No needles, but watch out for teeth :)

    Mike

    • yep, I’m not going anywhere near the face without my demo gloves on

    • Minh Le Cong says:

      believe it or not, at some point in recent years the US military researched the use of ketamine nasal spray for soldiers in lieu of other prehospital analgesics
      So you can give ketamine intranasally as well!
      but in this case of severely agitated patient I am not confident it is best approach due to risk of being bitten as cited already.
      choosing between a needle stick vs a human bite injury is challenging decision.

    • Minh Le Cong says:

      Mike , I have to ask. Have you ever used intranasal midazolam this way to sedate an agitated patient?

      • Mike Sherriff says:

        Minh,

        I’ve used IN midazolam on pediatric and adult patients with seizures and have found it very effective. However, as I was lamenting recently, since we added the IN midazolam for adults I have not had the chance to use it on a combative patient. I suspect it would be best to have both a needle and an atomizier available, and use the appropriate technique based on what part of the body you end up having access to.

        I work prehospital, so likely there will either be a taser or significant brutane applied prior to my attempting to sedate the patient (I worked for 5 years on a psychiatric unit and in the ED, so I know settings vary). Prior to the IN/IM midazolam, we had IV diazepam. I’ve started IV’s on combative patients, and that is no fun.

        Mostly though, I just use my Canadian charm–these Yanks love it :)

  15. Minh, Scott,

    I frequently use the MAD atomizer on these patients. I still use the 5+5 technique you mentioned with the nurse pushing 5 mg of IM droperidol, the guards securing the extremities, and myself pushing the midazolam in the nares. We usually have one guard on the head which makes the process a lot smoother. Just make sure to use the 5mg/mL solution if you can because you don’t want to push more than 2-2.5 mL per nare.

    Thanks for the great post. The strapping method makes complete sense having tried it just last night. We’ll have to retrain security but the patients are much less able to buck themselves to the bottom of the bed.

    • Minh Le Cong says:

      Rob, I agree, the restraint video is excellent. big thankyou to Scott for posting it.
      I am unclear why you give droperidol IMI and midazolam IN, Rob. Why not both IMI as Scott suggests?
      Do you think the INmidazolam works faster?

      • Not to put words in Rob’s mouth, but I think IN midaz would be markedly quicker…but I’m still not going there. Nebulized midaz wouldn’t be the worst idea as an augmentation to the IM meds and to keep the team from being spit upon at the same time.

        • IN is very fast. I had one patient calmly sedated in about 60 seconds. It helped that the patient snorted the midazolam as I was administering it. I suppose they thought I was giving them something else they’d enjoy. . . As mentioned, you need one person on the head as the patient tend to flail. We have a decent security force and when the police bring us a patient, they often stay and help too, so there is a lot of manpower available to restrain the patient.

          • Minh Le Cong says:

            thanks mate for the tip. I am aware IN is faster than IM midaz but just was not sure why you gave one IN and the other IM..but it seems to make sense. IN works for rapid onset whilst IM starts to kick in for added sedation.

            yes that sounds sensible now.
            Despite the problems with biting, spitting and holding someones head still for IN, you at least dont have to inject through clothes or try to get some clothing off…that was one thing I was wondering about Mike J’s suggestion of mainlining propofol via the fem vein…how do you get their pants off to do that easily? at least IM you can do it into the arm or if desperate through their pants into their thigh or buttock.
            but Rob’s tip of IN is a clever strategy…just need enough people to restrain them safely to do this…and make sure they do not have a runny nose..or epistaxis from the initial brutane restraint that may have been used. …the thing I like about IMI is there are less variables to worry about and once its in, you know its in.

  16. Interesting conversation.

    I’m currently working at the Mater Hospital Newcastle which is the main centre here for both toxicology and mental health. Our practice is largely based on a study of 90 patients (http://www.ncbi.nlm.nih.gov/pubmed/20868907) completed at the hospital in 2010.

    Conclusion: Intramuscular droperidol and midazolam resulted in a similar duration of violent and acute behavioral disturbance, but more additional sedation was required with midazolam. Midazolam caused more adverse effects because of oversedation, and there was no evidence of QT prolongation associated with droperidol compared with midazolam.

    Our procedure is, in a step wise fashion, the patient is ‘code blacked’, offerred oral diazepam, security provides physical restraint with limb restraints to a bed, 10mg IM droperidol repeat x 1-2, discussion with toxicologist, dexmedetomidine, then RSI. Fortunately most people are pretty chilled after 1 dose of droperidol.

    Oxygen is not used unless co-existing disease. They have CO2/sats monitoring and if active airway management if needed.

    It’s unusual for us to use ketamine but probably would be a useful adjunct.

    • Minh Le Cong says:

      thanks Dan
      I read a recent study from your department on dexmedetomidine sedation in ED
      http://emj.bmj.com/content/early/2011/12/08/emermed-2011-200849.short?rss=1
      sounds like it has been stopped due to safety concerns?
      time to do that ketamine sedation in ED study?

    • Dan, great study to add to the list. We used to use droperidol 110 mg at a time until the black box warning (a warning which all of us in the States know is ridiculous). 10 mg worked very, very well as you say. I imagine if I was able to repeat the 10 mg a second time, most anyone could be chilled out. I’m surprised Dex is in the protocol. I have been using it extensively for proc sedation and I am unimpressed with its ability to blunt agitation.

  17. First; Scott, you are redefining my residency experience and appreciation thereof. Your lectures are game-changers here and our generation of docs is implementing the kind of interventions that are saving lives. Awesome. Keep it coming.

    Second: Anything I should know about giving it IV vs. IM? Had to put down a combo cocaine and tylenol OD with 5 droperidol IM, but when I ordered it we already had an IV so that’s how I gave it. Pharmacy was nonplussed. Quicker to the fabled QT elongation (which I did not see)? Worked like a charm.

    • Thanks, Gabriel! Nope IV and IM are the same gig.

    • Gabriel,

      The QT effect isn’t a fable, plenty of literature out there demonstrating the effect. It’s just not as clinically significant as the FDA would have you believe. Theres a great Annals of EM article that does a nice deep dive that I read before I jumped in with both feet and began happily using droperidol. Problem is, I’m pretty much the only faculty member at our shop that uses it and many of my residents are still afraid of it. The nurses however, have become big fans.

      Check out the Annals article here: http://www.annemergmed.com/article/S0196-0644(03)00059-3/fulltext

      • Rob, much obliged for the reminder and reference; I’ve read it and printed it to pass around our droperidol-hungry residents. I didn’t mean to imply a disbelief in the existence of prolongation, just a recognition that we’re unlikely to hit it with these take-down doses. Pharmacy is in the process of re-writing some of our sedation caresets to include droperidol and I do appreciate the cautious approach, as my favorite method is still the verbal de-escalation. As impressed (relieved) as I am with the efficacy of droperidol, I think that any of these chemical approaches need to be applied with care on a case-by-case basis. Thanks your time, Rob.

  18. Dean Burns says:

    Hi Scott

    I’ve just revisited this podcast and was wondering what your current thoughts are on the management of the agitated ICU patient; ICU delirium. I managed a lady on my last night shift with 5mg Haldol IV who has OSA and obesity hypoventilation syndrome. I think her delirium was exacerbated by her problems sleeping ( she’d desaturate on falling asleep ) and the nursing staff were waking her. She lost it and went crazy, speaking in tongues and needed to be restrained.

    She became unresponsive after the Haldol and tolerated BiPAP well.

    Any thoughts on the latest best meds for this scary entity and whether Dexmetetomidine is a feasible option?

    Thanks

    Dean

  19. Patrick Burkhardt says:

    Sometimes it´s worth it to look over the fence and see what veterinarians do. I use Ketamine mainly to position patients with hip fractures for spinal anesthesia. A lot of them are hypertensive and tachycardic, often in AF. Ketofol (which I call Ketacolada) sometimes leads to respiratory depression in patients > 80 y. So I started mixing Ketamine with Clonidine, to counteract the sympathomimetic effects and for additional sedation and analgesia. When I researched this idea, guess what I found? It´s called the “Hellabrunn Mixture” (after the Munich Zoo) and it´s a favorite to bring down animals via blow gun.
    http://www.eazwv.org/php/uploads/downloads/ss08_Immobilisation_Primates.pdf
    (Xylazine is basically Clonidine, (Dex)medotomidine should also work)
    I haven´t used it yet to chemically restrain large primates. But with Clonidine being more or less the mainstay for treating delirium in our ICU, it should work just fine.
    Cheers, Patrick

    • Patrick, I always love to hear what the vets are doing, they are usually a decade or so ahead of the curve. Ketamine/dexmed combo has been in the adult literature as well. When it comes off patent, it should get some play.

  20. HASSAN ALMAATEEQ says:

    great discussion… I had patient with postictal agitation who received total of midazolam 20mg iv with increasing agitation… finally we tried diazepam increments of 5mg, he regain full consciousness within two hours and asked to leave hospital :) .. in seizure/postictal, the choices are limited (avoiding antipsychotics)… then you play with sedation trying to avoid intubation due to lack of ICU beds and high rate of infection related outbreaks. One friend suggested Thiopental 50mg!! what do you think ?

    • After an adequate dose of benzos, I’d have no problem giving droperidol in these cases. Theoretical seizure threshold stuff doesn’t worry me so much. Ketamine is always an option and will lower recurrent seizure risk, but they may wake up even more agitiated, though doubtful if benzos are on board.

  21. Kandie Desell says:

    Hi. I found this site while looking for info on alternatives to tasers being used in the ER In Maine we have two hospitals who are now using them. I am hoping to get this policy changed. I understand that staff needs to be kept safe, so I am looking for other alternatives than just the normal ones usually used. If any of you have ideas for me I would appreciate it.
    Currently ,I am including faster triage time, changing the color and atmosphere of the ER ,possibly offering a wait room with out as many people and calming music.. And adding a peer specialist to their staff. Thank you for any help you can give. Kandie

  22. As a retired cop and not a Doc this site was very informative though at times a little hard to follow. (not knowing all your lingo) I have been teaching a class in arrest related deaths (ExDS) and preaching the gospel (field sedation for the extremely aggitated) to law enforcement and EMS for years. Of course there is considerable resistance from some medical directors to allow ALS the flexability to do so in the field, but the numbers speak for themselves. Many lives saved due to early sedation. I agree the trick is to give enough. The big difference is we must first get them captured (safely onto the ground) and how we must position the patient for the initial control. Prone is the only workable position out in the field. I do stress recovery position as soon as possible along with what I call prepackaging for the ambulance ride. That involves multiple handcuffs and a backboard but in the long run is much faster than the traditional method of using one set of cuffs which must then be removed prior to transport. Again, lots of good info. here I can add to the class.

    • Jerry,

      Thanks so much for the comments! One thing they have done in NYC is to use what they call the “burrito bag” for EDP in addition to the handcuffs. Completely wraps the body, but allows the patients to be transported supine with safety to crew and officers.

      • Is that an official product or just a name you have given to the procedure? If it is a product I will include it on my list of restraints that agencies need to look at when preparing to deal with this issue. I now suggest looking at the Body Cuff and The Wrap. Both specifically designed to handle extremely aggtitated patients in the field.

  23. Rob McDonald says:

    These pt’s Absolutely need constant monitoring if we physically or chemically restrain the agitated patient. I think it is essential to have a plan of how to care for these patients before hand so it can be implemented quickly.
    If chemical restraint is to be used (my preference would be droperadol and Midazolam) it should be delivered quickly.
    Important to note that physical restraints used in conjunction with chemical restraint is a dangerous combination. Physical restraint should be removed (be that manpower of devices) after the pt is restrained chemically.
    I feel the physical restraints are sometimes used because we are not yet sure what Rx to prescribe. I do not think this is an acceptable level of care for our pts and a plan of care should be devised like we would for any other critical pt.

Trackbacks

  1. [...] last but definitely not least, EMCrit talks about Human Bondage and the Art of Chemical Takedown. Brilliant podcast, listen to this episode – much of the stuff he talks about can be adapted [...]

  2. [...] last but definitely not least, EMCrit talks about Human Bondage and the Art of Chemical Takedown. Brilliant podcast, listen to this episode – much of the stuff he talks about can be adapted [...]

  3. [...] Go listen to the podcast and read the comments. [...]

  4. [...] on managing and restraining the patient suffering from an acute behavioural emergency in: On Human Bondage and the Art of the Chemical Takedown.Also if you’re  depressed enough like me because you couldn’t [...]

  5. [...] [4] On Human Bondage and the Art of the Chemical Takedown EMCrit November 13, 2011 Page with podcast and supplemental information [...]

  6. [...] the Fast Lane  has an excellent discussion of excited delirium. EMCrit podcast has a episode on how to take down a violent, agitated delirium patient. The show notes for that episode link to the following video on the proper safe way to apply [...]

  7. [...] Emerg Med J. 2011 May 12. [Epub ahead of print] PMID: 21565879.Weingart S. EMCrit Podcast 60 — On Human Bondage and the Art of Chemical Takedown.Related posts:Baby Tim's CriesMotherhood Reproduction IntercourseYuletide EuphoriaShare:Filed Under: [...]

  8. [...] mg) (evidence based review of droperidol safety). The background:  From EMCrit's podcast on chemical restraints to EM Lit of Note reviews of ondansetron, FOAM teams with support for [...]

  9. [...] post and a great PV card on drug choices and Scott Weingart of EMCrit dedicated to the art of the chemical takedown. Some pearls from his [...]

  10. […] Drogen etc. Die Diskussion ist lesenswert! Verweisen an dieser Stelle möchte ich auch auf einen Post bei Steve Weingart (unbedingt den Video über die Fixierung eines gewalttätigen Patienten anschauen!): In den […]

  11. […] “Der Patient den niemand mag“) oder im angloamerikanischen Raum (“The Art of Chemical Takedown“)  – studiert, gibt es zahlreiche Konzepte, intramuskuläres Midazolam allein ist nicht mehr […]

Speak Your Mind (Along with your name, job, and affiliation)