· Premise
· Goals
· Assessment
· Preparation
· Management
· Other
· Drug doses
Psych drug side effects |
· CNS: often narrow therapeutic index between sedation and GA, EPSE, seizure · Resp side effects: apnoea, airway obstruction · CVS side effects: ↓HR, ↓BP, arrest · Allergy/anaphylaxis |
Psych drug unpredictability |
· Variable kinetic + dynamics · Hence variable onset and duration · Hence variable peak effect and toxicity |
Difficult to monitor |
· Violence · Seclusion · Transport |
· Avoid physical harm to bystanders
· Avoid physical harm to patient
· Treat acute behavioural disturbance (NOT sedate)
· Treat underlying cause
· Use minimum necessary force (words before drugs, PO before IM)
Aim |
· Nature of disturbance · Severity of disturbance · Cause of disturbance · Competence of patient · Risk of drug complications |
Aetiology |
· Mental illness · Physiological derangement · Drug intoxication |
Red flags |
· Full stomach · Obese · Severe comorbidity · Extremes of age · Pregnant |
History |
· From patient · From others: relative, doctor, nurse, medical record · HOPC · PHx cvs, resp · PHx anaesthesia, sedation · Medications, drugs, alcohol · Allergies, fasting status |
Examination |
· Airway and teeth · CVS · Resp · Toxidrome |
Place |
· Space · Lighting · Means of calling for help · Equipped for ABC disaster |
Stuff |
· 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 · If violent: five others (4 limbs + 1 head) · Security guards probably a good idea |
Minimum necessary force |
· Words before drugs · PO before IM |
Specific treatment |
· Words · Drugs · Restraint · Seclusion |
Supportive treatment |
· 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 |
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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