PS63 2019: Use of drugs for acute behavioural disturbance

 

List:

·        Premise

·        Goals

·        Assessment

·        Preparation

·        Management

·        Drug doses

 

Premise:

Side effects

·     Neurological: unconsciousness, EPSE, seizure

·     Respiratory: apnoea, airway obstruction

·     Cardiovascular: ↓HR, ↓BP, arrest

·     Allergy/anaphylaxis

Unpredictability

·     Variable kinetic + dynamics

·     Hence variable onset and duration

·     Hence variable peak effect and toxicity

Difficult to monitor

·     Violence

·     Seclusion

·     Transport

 

Goals:

Safety

·     Avoid harm to staff

·     Avoid harm to patient

Treatment

·     Treat the underlying cause

·     Treat the disturbance (cf. sedation)

·     Minimum necessary force

 

Assessment:

Aim

·     Nature of disturbance

·     Severity of disturbance

·     Cause of disturbance (psych, phys, pharm)

·     Competence of patient

·     Risk of drug complications

Red flags

·     Full stomach

·     Obese

·     Severe comorbidity

·     Extremes of age

·     Pregnant

History

·     HOPC

·     PMHx: comorbidities, previous anaesthesia

·     Meds: prescription, illicit

·     Allergies

·     Fasting status

Examination

·     Airway and teeth

·     Respiratory

·     Cardiovascular

·     Toxidrome

 

Preparation:

Location

·     Space

·     Lighting

·     Means of calling for help

·     Equipped for ABC disaster

Equipment

·     Oxygen

·     Suction

·     Bag + mask

·     Airway equipment

·     IV equipment

·     Emergency drugs

·     Monitoring including ECG and CO2

·     Defibrillator

Staff

·     Doctor trained in ALS/airway/drugs/complications

·     Nurse trained in CPR

·     If compliant: one other person

·     If violent: five other people (4 limbs + 1 head)

·     Security guards recommended

 

Management:

Specific

·     Words

·     Drugs

·     Restraint

·     Seclusion

Supportive

·     IV access

·     Oxygen

·     Hydration

·     Pressure care

·     VTE prophylaxis

Monitoring

·     Visual observation of ABC

·     Sedation score

·     SpO2 and HR

·     NIBP

·     ECG

·     CO2

Documentation

·     Assessment

·     Treatment

·     Monitoring

Instructions

·     Eating and drinking

·     Normal activities

·     Driving

·     Legally-binding decisions

 

Drug doses:

Olanzapine

·     5mg PO or IM

Quetiapine

·     50mg PO

Haloperidol

·     2mg PO or IV

Droperidol

·     2.5mg IV

Midazolam

·     2.5mg IV

 

 

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