It’s a hot summer day. A 40s M with a hx of psychiatric illness smokes crack and becomes agitated and incoherent in the street. EMS and the cops are called. In order to bring the EDP to medical attention, PD subdues the pt physically and cuffs him. The patient is transported on his stomach to the hospital. On arrival to the hospital, he is violent and uncooperative. How do we proceed?
IM ketamine 400mg. airway equipment bedside.
Call HP, get a show of force, attempt verbal deescalation. If/when that fails and if the patient is a threat, restrain, give haldol/ativan IM, get vitals/FS, place on monitor, ECG, basic labs/EtOH/[APAP]/[ASA].
Verbal deescalation unlikely to work in this scenario and if it does, it may give a false sense of reassurance leading to an unsafe environment once EMS and cops leave. Make sure there is a person for each limb and if you can get a line safely and quickly (on posterior forearm), can give 5 & 2. If not, Ketamine 3-5mg/kg IM (even though he has a psych history) and be ready to intubate if needed. He will also need to be laid supine.
Be wary of excited delirium (cocaine use, psych history, agitation, incoherence). Rapid sedation with 5mg of haldol, 2mg of ativan if able to get IV access vs IM ketamine 3-5mg/kg (shorter onset of action) or IM olanzapine 10mg (less concern for QTc prolongation compared to haldol since pt has psych history). Supportive care with cooling if pt is hyperthermic and IVF for acidosis/rhabdo. Would closely monitor and have airway equipment ready as pt’s in excited delirium are at high risk for cardiopulmonary arrest
Agree with rapid tranquilization for excited delirium.. Whisper de-escalation techniques via IM Ketamine. Be prepared to intubate especially if planning on scanning head.. Not as cause of delirium but 2/2 PD takedown. Flip panda off his belly or it’ll worsen respiratory drive.