How To Draw Up Haldol And Ativan

Permit's start past setting the stage:  Our patient is a 35 year-quondam man who is angry that he has been arrested in a domestic dispute case.  He cooperated with the booking process, merely and then, several hours after, began to repeatedly ram his caput full force into the wall.  There is blood on his face and on the wall.  The word "uncooperative" does non do him justice.  He is agitated and belligerent and wants to fight.  He is screaming offensive obscenities.

Of course, he cannot be allowed to continue to injure himself.  The deputies have him down and strap him to a restraint chair.  A spit mask is required.  Nobody really expected him to calm downward after he is placed in the restraint chair and they are not disappointed.  30 minutes afterward, he is even so screaming.

This patient certainly meets the criteria for chemical sedation.  He is an acute danger to himself.  He is an astute danger to others.  He has refused voluntary sedation.  He is non hypoxic or hypoglycemic (but if at that place is a suspicion of this, it is like shooting fish in a barrel plenty to go a pulse oximetry reading or a finger stick blood saccharide).

What medications should be used to sedate this patient?

Retrieve that our goal is to sedate the patient and so that he tin can be released from physical restraints.  We would like him to exist sedated and drowsy and fifty-fifty go to sleep, but to be easily arousable.  Nosotros practise not desire respiratory low or other serious side effects.

The two main drug classes that accept been traditionally used for this type of chemical sedation are the benzodiazepines and the antipsychotics.  I was taught in my Emergency Medicine residency that the benzos were "pocket-size sedatives" and the antipsychotics were "major sedatives."  However, in that location have been several studies comparing the two when sedating agitated patients, including this 2010 Cochrane Review, and, in fact, both piece of work well.  They may piece of work even ameliorate when given together.  Each has advantages and disadvantages that should exist considered.

 Antipsychotics for Sedation–Haloperidol

The all-time overall antipsychotic for rapid sedation of agitated patients in a correctional setting, in my opinion, is good, sometime haloperidol.  Haldol has been safely used for this indication (probably) millions of times world-broad.  It is "tried and true."  It is Vitamin H.  The Velvet Hammer.

The master advantage of haloperidol is that it is so safe.  It does non crusade respiratory depression so can exist given to intoxicated patients.  Information technology has no dose limit for safety reasons.  This means that information technology can safely be given to patients who are already taking antipsychotics.  The dose is the same whether po or IM, so if a patient changes his listen and accepts oral meds, information technology is easy to change course.  It can be given IV as well as IM (though we would seldom give haloperidol Iv in a correctional facility as is done routinely in ERs).

 "Haloperidol has been evaluated in a large number of clinical trials lone and in combination with benzodiazepines.  These studies demonstrate that intramuscular haloperidol is both prophylactic and effective in the treatment of agitation caused by virtually whatsoever etiology" Roberts: Clinical Procedures in Emergency Medicine,5th ed.

Whatever other antipsychotic that can be given IM can also be used for rapid sedation.  Possibilities include Inapsine (droperidol), Geodon (ziprasidone), and Zyprexa (olanzapine).  There is cipher wrong with any of these agents, and if you already use them and are comfortable with them, that is great.  They offer no advantages to Haldol, notwithstanding.  None are more than effective and none are safer.

The major potential adverse furnishings of acute i-time dose Haldol administration are exceedingly rare.  One of these is Q-T prolongation that can, potentially, crusade dysrythmias.  Another is Neuroleptic Malignant Syndrome. Both of these are very rare, however, and the run a risk is far less than the adventure of prolonged concrete restraint.  Haldol has as well been reported to lower the seizure threshold, only this is controversial.

The i reasonably common agin effect of astute IM Haldol administration is a  dystonic reaction.  Dystonic reactions involve involuntary muscle contractions  usually in the cervix, shoulders or face, simply also elsewhere.  Information technology tin can likewise manifest as akesthesia, which can be thought of as a case of restless legs from hell.  Nosotros are not talking here about Tardive Dyskinesia. Tardive Dyskinesia is as well involuntary muscle contractions simply these occur after years of neuroleptic medication use and are irreversible.  Acute dystonic reactions are easily reversible, using an antihistamine, like Benadryl.  Unlike tardive dyskinesia, dystonic reactions are a nuisance, trivial and easily treated.

Considering of the possibility of a dystonic reaction to IM Haldol, some practitioners give Benadryl 50mg IM at the same time every bit the Haldol.  I practice not exercise this for the following reasons:

1. The dystonic reactions from Haldol tend to occur the 24-hour interval following the IM injection.  Benadryl is then short acting that it is gone by and so.  Theoretically, then, it may not be effective in reducing dystonic reactions.  This has never been studied, as far as I know.
2. Only 1 in 6 or 7 patients who receive a unmarried Haldol injection will develop dystonia.  If you give Benadryl to everyone, y'all are treating the bulk of patients needlessly.  Benadryl has its ain set up of ill furnishings and side effects.
3. If a patient does develop dystonia the next day, 50mg of Benadryl given orally volition solve the problem quickly at that time.  That is when I prefer to treat these nuisance reactions.

The standard adult dose of Haldol for rapid sedation is 5-20 mg IM.

Benzodiazepines for Sedation–Lorazepam

Any benzodiazepine that can be given IM can exist used for chemic sedation.  I like to use Ativan (lorazepam), myself.  Valium can be used but is not equally good because it is not well absorbed from an IM injection.  Versed (midazolam) is an acceptable culling to Ativan.

The main disadvantage of Ativan as a chemical allaying is that it tin can cause respiratory depression, especially when combined with other sedating drugs.  For case, it should be used cautiously in the obnoxious drunkard.  Haldol lonely is a better choice for him.  It also reportedly tin can cause hypotension, though I have never seen this.

On the other mitt, lorazepam is an excellent choice for stimulant overdoses.  Information technology almost tin be thought of equally an "antidote" to stimulant "poisoning."  And so the patient who is agitated while "tweaking" on meth would do well receiving lorazepam.

The standard dose of lorazepam for chemical sedation is 1-4mg IM.

Combination Therapy

One absurd thing about Haldol and Ativan is that they play well together.  The medical term for this is that they are synergistic—they increment each other'due south effectiveness.  In applied terms, this means that if they are combined, you can use a smaller total dose of each agent.  Instead of needing 4mg of lorazepam IM to sedate a patient, if you combine it with Haldol, you just may demand ane or 2 mg  and vice versa. The two drugs are so compatible that you lot tin can mix them together in the same syringe.

The standard dose of the combination used for chemical sedation of the agitated patient is "ten and 2" pregnant 10mg of Haldol and 2mg of Ativan.  Y'all can reduce this to "five and one" or increase it depending on the circumstances.  You can too vary the ratio or employ but Haldol or but lorazepam depending on a particular case.  For instance, what would you use in these cases?

1. The Standard Jerk.  This is the patient who is agitated and belligerent not because of drugs or booze,  but considering of frustration, manipulation or any.  Chemic Sedation:  "Ten and Ii" (Haldol 10mg and lorazepam 2mg IM).
2. The "Mean Drunk." This patient is yet intoxicated, so y'all might not want to use lorazepam since it potentially could cause respiratory depression in combination with the alcohol.  Chemical Sedation:  Haldol 10mg IM.  It will not cause respiratory sedation and can be used safely in an intoxicated patient.
3. The Acutely Psychotic or Manic Patient.  Chemical Sedation?  "10 and two."  Sometimes these patients need a 2nd dose in an hour.  Should nosotros be worried that the patient is already taking antipsychotics (let'south say Abilify, for example)?  The answer is no.  You tin still safely give Haldol.
4. Methamphetamine Intoxication.  Lorazepam is the "antitoxin" for the patient who is tweaking on meth or cocaine.  Chemical Sedation?  Lorezepam 4mg IM.  Yous tin add 5mg of Haldol, as well if you desire.
5. "Undifferentiated."  If you merely do not know why the patient is agitated and belligerent, remember that "intramuscular haloperidol is both safe and effective in the handling of agitation caused by most any etiology" Roberts: Clinical Procedures in Emergency Medicine,5th ed. If you are reasonably certain the patient is non drunk, add the lorazepam, as well.

 Next installment in the series:  Chemical Sedation:  Right Documentation and Right Follow –Up.

What medications do you use for Involuntary Chemical Sedation at your facility?  Please annotate!

Source: https://www.jailmedicine.com/involuntary-chemical-sedation-the-right-medications/

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