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PED-EM-L  August 2009

PED-EM-L August 2009

Subject:

Re: Sedation of the Agitated/Violent/Psychotic Patient

From:

Amy Baxter <[log in to unmask]>

Reply-To:

Amy Baxter <[log in to unmask]>

Date:

Fri, 21 Aug 2009 15:59:54 -0400

Content-Type:

text/plain

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Parts/Attachments

text/plain (128 lines)

Hello, Erica-

I don't know that we specifically have a protocol beyond the one for
restraints, but here are a few references that might help.  I haven't
looked at the last two years of literature, though, so there may be better
stuff out there now.

Pre-diagnosed psychiatric illness:  orally dissolving tablets of atypical
antipsychotics have been shown to be more effective than haloperidol, with
less risk of extrapyramidal side effects.1 Repeating a dose of something
they already take is an option.

Garden variety dangerous violent person:  IM midazolam more effective and
safer than IM haloperidol.2  

Already on some kind of antipsychotic but you don't know what: 
ziprasidone IM sedated adults in 15 minutes.3, 4  

I am pretty sure risperdal is the only antipsychotic with an indication
for autism, and while I don't have first hand experience with it
dexmedetomidine is new-ish alpha-2 agonist.  One series of 122 patients,
many with diagnoses of delay, autism, or psychiatric illness, found onset
of sedation in a meant time of 27 minutes using 5μg/kg of  buccal
dexmedetomidine. 5

1.         Allen MH, Currier GW, Carpenter D, Ross RW, Docherty
JP. The expert consensus guideline series. Treatment of behavioral
emergencies 2005. J Psychiatr Pract. Nov 2005;11 Suppl 1:5-108; quiz
110-102.

2.         Rapid tranquillisation for agitated patients in
emergency psychiatric rooms: a randomised trial of midazolam versus
haloperidol plus promethazine. Bmj. Sep 27 2003;327(7417):708-713.

3.         Mendelowitz AJ. The utility of intramuscular
ziprasidone in the management of acute psychotic agitation. Ann Clin
Psychiatry. Jul-Sep 2004;16(3):145-154.

4.         Daniel DG, Potkin SG, Reeves KR, Swift RH, Harrigan EP.
Intramuscular (IM) ziprasidone 20 mg is effective in reducing acute
agitation associated with psychosis: a double-blind, randomized trial.
Psychopharmacology (Berl). May 2001;155(2):128-134.

5.         Lubisch N, Tordella T, Roskos R. Buccal Dexmedetomidine
is an Effective Alternative for Procedural Sedations in Pediatric
Patients. American Academy of Pediatrics. San Francisco; 2007.

 

"Erica Liebelt, M.D." <[log in to unmask]> writes:
>Dear Colleagues,
>
> 
>
>Has anyone developed/implemented  standardized guidelines/order sets for
>sedating the agitated/violent/psychotic/ patient and/or "behavioral
>emergencies" in the pediatric emergency department-specifically
>indications for pharmacologic sedation, pharmacologic options, doses,
>routes of administration, and patient monitoring. We are starting to
>look at these issues from a medication safety perspective and am
>interested in what others are doing/have done.
>
> 
>
>Thank you in advance.
>
> 
>
>Erica
>
> 
>
> 
>
> 
>
> 
>
> 
>
>Erica L. Liebelt MD FACMT
>
>Professor of Pediatrics and Emergency Medicine
>
>Medical Director of Medication Safety, The Children's Hospital
>
>Director, Medical Toxicology Services
>
>UAB and Children's Hospital
>
>1600 7th Ave South, CPP Suite 210
>
>Birmingham, AL  35233
>
> 
>
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>For more information, send mail to [log in to unmask] with the
>message: info PED-EM-L
>The URL for the PED-EM-L Web Page is:
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>
>



Amy Baxter MD
Pediatric Emergency Medicine Associates
404 371-1190


For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html

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