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

– disturbances in sleep/wake cycle

– generally caused by illness, medication or intoxication

– caused by imbalance of neurotransmitters

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

– Benzos

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