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It’s a hot summer day.  A 40s M with a hx of psychiatric illness smokes crack and becomes agitated and incoherent in the street.  EMS and the cops are called.  In order to bring the EDP to medical attention, PD subdues the pt physically and cuffs him.  The patient is transported on his stomach to the hospital.  On arrival to the hospital, he is violent and uncooperative.  How do we proceed?

10 Comments

  • Michael Jones

    Verbal de-escalation–not likely to work.

    4-5 mg/kg IM ketamine. Split up into two shots, one for each buttock.

    Safest option for all. Rapid control of the event. Then look for usual suspects of excited delirium.

  • himynameisvince

    I think the first concerning thing is to get him off his stomach and onto his back. The cases of ExDS are often described this way, with a patient having taken a sympathomimetic, tied up or on his stomach (or chokehold). They struggle, sweat profusely, then suddenly die.
    What we know is early chemical sedation is best. Which agent to use is up for debate. As it stands right now, the Clinical Practice Guideline put out by Annals (and adopted by ACEP) has ketamine use as an absolute contraindication in patients with known or SUSPECTED schizophrenia. That’s not a real concern of mine if I drive a schizoprenic into florid schizophrenia, but that’s something to consider…
    The major thing to consider is the high rate of intubation – paradoxically – that we see when using ketamine in an agitated patient. It’s not like using ketamine in grandma with a Colles or toddler with a lac. The intubation rate was 63% in one study (Olives 2016) and about 1/2 dozen other papers show similar findings. Think of it like the taser guns that police use. The studies on healthy volunteers show perfect safety – use it on a guy selling loosie’s outside a bodega and some die…
    Isbister writes the best study on this, called the DORM study where ketamine is used as a rescue agent after droperidol (or haloperidol in our case) and midazolam have failed. They recommend it’s use as a 2nd or 3rd line agent…
    And we don’t have the concentrated ketamine formulation, so you’d have to 500cc to a fat guy IM. Even Mike Jones buttocks aren’t big enough to take that…
    Be patient. Start with haloperidol and midazolam. Tie him down, turn off the lights, go have a cigarette. Repeat if necessary. But usually not…

  • Michael Jones

    Appreciate the discussion, and comments about my rear size. One of these days, I’ll publish my case series on ketamine use — zero intubations. My general opinion is that the studies with higher intubation rates reflect a general lack of provider familiarity with the immediate, normal and expected side effects of ketamine, as well as a slightly increased sphincter tone in trying something new. Ketamine vs. haloperidol vs. benzos probably won’t be agreed upon in this forum — just understand that there are options, that I’m right, and Vince is a weenie toxicologist (remember that whole haloperidol and arrhythmia thing?). Figure out what your go to is and know what to do when it goes awry or you need to consider an alternative option.

    Lets pose a better question — IM or IV? This gets to the heart of why I’m a proponent of ketamine for excited delirium. The situation is inherently unsafe and in these cases, our Jacobi hold him down and place an IV mentality truly needs to be re-examined. We should be using IM medications routinely in this sub-set of cases for staff safety (avoiding needle sticks and other injuries). I would rather have this patient controlled and sedated rapidly by using IM ketamine as opposed to waiting for the IM haldol and benzo to kick in while getting swung at. (Cue Vince with data on onset of action or just take my word, IM ketamine is consistently faster!)

    Enjoying the discussion — keep it coming!

  • Tonynap

    Agree with Jonesy. Pick your poison (literally) and go. Too much analysis leads to paralysis. Get control of this guy with whatever means necessary including intubation) and move on. Whether you hold him down and I’m him or IV him to do it overlooks a more common error in these patients…….walking away! Giving thes guys meds and then throwing them in a room or 4 pointing them in a bed without revitalizing them has killed more of these patients than the meds and has gotten wonderful drugs removed from our Pyxis (droperidol; a wonderful sedative antiemetic and intubation adjunct) and worse has the JCAHO breathing down our necks about how we use chemical and physical restraints.
    Don’t leave this guy until he is safely sleeping in a bed unrestrained with a running IV and labs sent

  • himynameisvince

    Not all agitations are the same…
    There are different causes and different levels of agitation. And the goals of sedation differs from case to case – you want a patient deeply sedated for 12hrs? deeply sedated for 4hrs? or calm enough for psych transfer? That’s why I have slight issue with some of what has been written above: you shouldn’t have an always “go-to” medication, a secret sauce… IM or IV should be determined case by case…
    For example, take this guy below… How would you want to sedate him?
    Try this link if pic doesn’t show up: http://bit.ly/2vYPuk4

  • himynameisvince

    Not all agitations are the same…
    There are different causes and different levels of agitation. And the goals of sedation differs from case to case – you want a patient deeply sedated for 12hrs? deeply sedated for 4hrs? or calm enough for psych transfer? That’s why I have slight issue with some of what has been written above: you shouldn’t have an always “go-to” medication, a secret sauce… IM or IV should be determined case by case…
    For example, take this guy below… How would you want to sedate him?
    Try this link if pic doesn’t show up: http://bit.ly/2vYPuk4

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