PS63 2019: Use of drugs for acute behavioural disturbance

 

List:

·         Premise

·         Goals

·         Assessment

·         Preparation

·         Management

·         Other

·         Drug doses

 

Premise: why this statement?

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

 

Goals:

·         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)

 

Assessment:

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

 

Preparation:

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

 

Management:

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

 

Other:

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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