What about the dangerously agitated patient due to use of sympathetic agonists -the speed drugs crystal methamphetamine -with a possible high blood pressure 200/100 plus -midazolam will not cause sympathetic surge and the hypo ventilation can be treated with a bag valve mask or an extra glottic device like i gel -there is little laryngospasm ;
midaz is a great agent for agitation, and if you're prepared to provide rescue ventilation, go for a huge dose in hyperadrenergic patient, I've done it many times.
but if you're really nervous, dissociative dose ketamine is more reliable than midazolam. and in these patients, despite the effect that ketamine has on calm patients getting PSA (hypertension tachycarida), you will see normalization of vitals.
If the only concentration is 50mg/mL, a 100kg person requires 10 mL IM. Do you give it all as one injection or split the dose? We have trouble getting nursing to go above 3 mLs for IM injections and I've convinced them (literature supports) that 5 mL is safe but giving two injections in a dangerously agitated patient can be challenging. We eliminated the 100mg/mL because dosing errors (lower conc looks exactly the same) and I think Canada doesn't make the 100mg/dL conc.
but nursing protocols often don't respond to literature. the best solution is to stock the 100mg/mL concentration in special vials that have "FOR IM USE ONLY" or some similar warning on them. Otherwise, you'll have to divide the dose, which, as you mention, does put staff at risk.
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Ian L., Dr - April 1, 2020 3:14 PM
What about the dangerously agitated patient due to use of sympathetic agonists -the speed drugs crystal methamphetamine -with a possible high blood pressure 200/100 plus -midazolam will not cause sympathetic surge and the hypo ventilation can be treated with a bag valve mask or an extra glottic device like i gel -there is little laryngospasm ;
Reuben Strayer (@emupdates) - April 1, 2020 9:03 PM
midaz is a great agent for agitation, and if you're prepared to provide rescue ventilation, go for a huge dose in hyperadrenergic patient, I've done it many times.
but if you're really nervous, dissociative dose ketamine is more reliable than midazolam. and in these patients, despite the effect that ketamine has on calm patients getting PSA (hypertension tachycarida), you will see normalization of vitals.
Mike D. - April 9, 2020 1:40 PM
If the only concentration is 50mg/mL, a 100kg person requires 10 mL IM. Do you give it all as one injection or split the dose? We have trouble getting nursing to go above 3 mLs for IM injections and I've convinced them (literature supports) that 5 mL is safe but giving two injections in a dangerously agitated patient can be challenging. We eliminated the 100mg/mL because dosing errors (lower conc looks exactly the same) and I think Canada doesn't make the 100mg/dL conc.
Reuben Strayer (@emupdates) - April 17, 2020 5:28 PM
this is a persistent problem. it is safe to give 10 mL IM.
https://www.dropbox.com/sh/plbqgdk4xey445m/AACz6_AMzaoFb3d--fi02Sa_a?dl=0
but nursing protocols often don't respond to literature. the best solution is to stock the 100mg/mL concentration in special vials that have "FOR IM USE ONLY" or some similar warning on them. Otherwise, you'll have to divide the dose, which, as you mention, does put staff at risk.