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Strayerisms - Agitation Mitigation

Reuben Strayer, MD
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15:38
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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01:51

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EM:RAP 2017 June Written Summary 647 KB - PDF

Reuben Strayer’s stepwise pharmacologic approach to managing the agitated patient. Agitated but cooperative - oral benzo or orally dissolving antipsychotic. Agitated but not dangerous - intramuscular haloperidol plus midazolam. Agitated delirium -IM ketamine.

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Abrar W. -

Thank goodness, we still have Droperidol in Australia.

Reuben Strayer (@emupdates) -

https://goo.gl/euycJS

Steve D. -

Some of the studies on the agitated patient that I have reviewed show a higher rate of respiratory depression when multiple agents are used. So would using a combination of haloperidol and midazolam increase the risk profile rather than just repeated doses of one agent?

Reuben Strayer (@emupdates) -

Midazolam has important respiratory depression effects, haldol much less so, but haldol is slow onset and less effective as monotherapy. This is why I recommend using a relatively large dose of haldol and a small dose of midazolam. Keeping the midaz dose small minimizes the likelihood of respiratory depression but gives you rapid onset of sedation and synergistic effects with the haldol.

Darren -

In using ketamine for the undifferentiated patient with agitated delirium (who might have schizophrenia), are you concerned that "known or suspected schizophrenia" is commonly listed (including in ACEP guidelines) as an absolute contraindication to the use of ketamine?

Reuben Strayer (@emupdates) -

this contraindication is basically nonsense. lots of literature in attesting to safety undifferentiated agitation (which includes a high proportion of psychiatric etiologies as you would guess, though more substance than psych) and very compelling evidence in prehospital psychiatric transport:

https://goo.gl/W3rzGu

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Don’t Fear The Stink! Full episode audio for MD edition 245:23 min - 342 MB - M4AEM:RAP 2017 June Canadian Edition Canadian 24:49 min - 34 MB - MP3EM:RAP 2017 June German Edition Deutsche 68:28 min - 94 MB - MP3EM:RAP 2017 June French Français 29:35 min - 41 MB - MP3EMRAP 2017 June Resumen Español Español 94:49 min - 130 MB - MP3EM:RAP 2017 June Board Review Answers 187 KB - PDFEM:RAP 2017 June Board Review Questions 170 KB - PDFEM:RAP 2017 June MP3 328 MB - ZIPEM:RAP 2017 June Written Summary 647 KB - PDF

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