From EMCRIT with Reuben Strayer in August 2020

1. Agitated, but Cooperative

Not a problem in the ED. Oral medications or non-pharm techniques.

2. Disruptive without Danger

Use standard anti-psychotics and sedatives, with the understanding that haloperidol 5mg and lorazepam 2 mg given IM will take a long time for full effect, have inconsistent absorption of IM lorazepam (midazolam much better) and even then, may not provide adequate sedation. There are better choices for this group:

Strayer choices:

1. Droperidol monotherapy 5-10 mg IM or 5 mg IV
2. Droperidol 5 mg + Midazolam 2mg IM or IV in the same syringe
3. Olanzapine 10 mg IM (Needs Resp Monitoring).
4. Olanzapine 5 mg + Midazolam 2 mg IM or IV  (Needs Resp Monitoring)
5. Haldol 5 mg + Midazolam 2 mg IM or IV (will be slower than the other choices)

Farkas choices:

1. IV/IM Olanzapine 5-10mg

Farkas post

If using standard 5/2 (haldol and lorazepam IM), too much time for effect and impatience leads to the wrong subsequent choice, i.e. giving ketamine to this group.

DROPERIDOL review on EMRAP with Reuben Strayer

3. Disruptive and Dangerous

• dangerous to staff, dangerous to self
• danger is relative to the resources of the location
• Dividing Line Question: Would you consider intubation to control the situation if ketamine was not available? Reub calls this the Ketamine Litmus Test.

Proper Physical Restraint:

• One person on each limb
• One person holding the head
• No compression of neck, face or chest
• Nonrebreather on the face

Drug of choice:

Ketamine Dose: 4-6mg/kg IM (300-500mg, 6-10ml of 50mg/ml ketamine).

Ketamine takedown must be treated as Procedural Sedation (1:1 nursing observation)

• Reference is the SMACC Slideshow of Strayer’s lecture

Intramuscular Medication Administration:

• Can go through clothes if you need to [Fleming et al.]
• Reub states maximum volume of up to 20 mls per injection
• Deltoid or lateral thigh
  • Harrington 2005 Administer Single Site 30mL Injection Fosphenytoin – Medsurg Nursing
  • Hopkins 2013 Large Volume IM Injections Review of Best Practices (Oncology) – Onc Nurse Advisor
  • Ramsay 1997 IM Fosphenytoin Loading High Volumes – Epilepsy Research

Ketamine Brain Continuum

• See the EMUpdates post by Reub

Selected References

• Cole, Jon B., Johanna C. Moore, Benjamin J. Dolan, Alex O’Brien-Lambert, Brandon J. Fryza, James R. Miner, and Marc L. Martel. “A Prospective Observational Study of Patients Receiving Intravenous and Intramuscular Olanzapine in the Emergency Department.” Annals of Emergency Medicine 69, no. 3 (March 2017): 327-336.e2. https://doi.org/10.1016/j.annemergmed.2016.08.008.
• “Intravenous Midazolam-Droperidol Combination, Droperidol or Olanzapine Monotherapy for Methamphetamine-Related Acute Agitation: Subgroup Analysis of a Randomized Controlled Trial – PubMed.” Accessed August 30, 2020. https://pubmed-ncbi-nlm-nih-gov.eresources.mssm.edu/28160494/.
• Khorassani, Farah, and Maha Saad. “Intravenous Olanzapine for the Management of Agitation: Review of the Literature.” The Annals of Pharmacotherapy 53, no. 8 (2019): 853–59. https://doi.org/10.1177/1060028019831634.
• Martel, Marc L., Lauren R. Klein, Robert L. Rivard, and Jon B. Cole. “A Large Retrospective Cohort of Patients Receiving Intravenous Olanzapine in the Emergency Department.” Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine 23, no. 1 (January 2016): 29–35. https://doi.org/10.1111/acem.12842.