B-52

[alphaholic06]

How many of you guys and girls use this for your agitated patients? Do you use benadryl when you do, and do you mix all 3 in the same syringe?

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[Tiger26]

I've actually never used the B-52 during residency.

My preferred agitation regimen is the following:

1) Known or suspected psychosis: 5mg Droperidol +/- 5-10 mg Versed, generally IM pending IV access--takes 5-10 min. Typically lasts 1.5-3 hrs.

2) Undifferentiated but routine drunk agitation: 5-10 mg Versed, also usually IM pending IV access--takes about 8-10 min. Benefit is that this lasts 45-60 min and allows you to get most of the tests you need and IV access--can either dispo to the floor, detox, or re-sedate at this time.

3) The unable to hold down by 6 security guards and tearing up the ED guy: 5 mg/kg IM ketamine

The last regimen is my favorite--down in 2 min, typically 400-500 mg total, still breathing, often end up getting intubated for airway protection and to facilitate the rest of the workup


At this point, I get my labs, EKG, head CT, other indicated tests. Also do continuous cardiac monitoring and end-tidal CO2

 

[Birdstrike]

How many of you guys and girls use this for your agitated patients? Do you use benadryl when you do, and do you mix all 3 in the same syringe?

The "B-52" just like the B-52 bomber.

5 mg haldol IM
2 mg Ativan IM

Old school, but gets the job done.

 

[Mighty Mouse]

i don't particularly like the polypharmacy involved. i'm an overwhelming show of force by security, 10mg versed IM, guy. hit 'em, put on pulse ox, elevate head of bed, and walk away. once physical stimulus is gone, out they go.

most important thing -- i don't try to talk them down or reason with them. they are irrational and dangerous. i never negotiate with drunks, psychotics, terrorists or otherwise irrational people. sedate, insure safety of you and your crew, and ask questions later.

 

[dotcb]

At my shop, B52 most commonly means:

Benadryl 50mg
5mg Haldol
2mg Lorazepam or Midazolam
IM (of course)

My favorite: droperidol - not allowed to use it at my ED.

I most commonly use 2mg midaz, +/- 5mg haldol as initial sedative meds.

 

[Arcan57]

20 mg of IM geodon buys a lot of "shut the hell up". I'm leery on versed because its so unpredictable what its going to take to knock someone down.

 

[TrumpetDoc]

Love it. Works great. IM, never had any problems.

 

[Bostonredsox]

20 mg of IM geodon buys a lot of "shut the hell up". I'm leery on versed because its so unpredictable what its going to take to knock someone down.

although I have used quite a bit of B52......this... is my fav. It is much simpler and easier for the floor nurses when the same crazyness manifests on the floor. "20 of geodon IM now, im going to get a sandwich, Ill be back in a bit. make sure he's on remote tele and has a pulse on on him".

 

[joeDO2]

anyone have experience using intranasal midazolam? i've had decent results using it this way in status and for light procedural sedation but have not tried it with agitated/combative pts. always looking for ways to minimize use of needles in these cases.

 

[Arcan57]

anyone have experience using intranasal midazolam? i've had decent results using it this way in status and for light procedural sedation but have not tried it with agitated/combative pts. always looking for ways to minimize use of needles in these cases.

If you are close enough to reliably squirt it in the nose, then your fingers are awfully close to their mouth FWIW.

 

[la gringa]

How many of you guys and girls use this for your agitated patients? Do you use benadryl when you do, and do you mix all 3 in the same syringe?

i do not use benadryl

usually ativan/haldol is my go-to for routine put 'em down drunk and disorderly types

geodon for the more psych types and it lasts a bit longer

haven't tried IM versed or ketamine as mentioned above

 

[Apollyon]

anyone have experience using intranasal midazolam? i've had decent results using it this way in status and for light procedural sedation but have not tried it with agitated/combative pts. always looking for ways to minimize use of needles in these cases.

Are you a second year medical student? Where are you doing moderate sedation?

 

[UnderwaterDoc]

I've actually never used the B-52 during residency.

My preferred agitation regimen is the following:

1) Known or suspected psychosis: 5mg Droperidol +/- 5-10 mg Versed, generally IM pending IV access--takes 5-10 min. Typically lasts 1.5-3 hrs.

2) Undifferentiated but routine drunk agitation: 5-10 mg Versed, also usually IM pending IV access--takes about 8-10 min. Benefit is that this lasts 45-60 min and allows you to get most of the tests you need and IV access--can either dispo to the floor, detox, or re-sedate at this time.

3) The unable to hold down by 6 security guards and tearing up the ED guy: 5 mg/kg IM ketamine

The last regimen is my favorite--down in 2 min, typically 400-500 mg total, still breathing, often end up getting intubated for airway protection and to facilitate the rest of the workup


At this point, I get my labs, EKG, head CT, other indicated tests. Also do continuous cardiac monitoring and end-tidal CO2

I ask for Droperidol all the time and no attending has let me give it yet, and holy wow that is a lot of Ketamine, again nobody would let me do that here. You are lucky where you are.

So far versed has been my friend, if they are still fighting after a sufficiently large dose they usually get tubed.

 

[docB]

I use B52 daily.

I do it a little different. I give 2.5 of Haldol, 25 of Banadryl and 2 of Ativan. So I guess it's technically a B2.52. I like this because it's less sedating so they don't wind up asleep for 12 hours and so you're less likely to overshoot and get into trouble. I give the Ativan full dose because it's the cleanest of the drugs involved. If that's not enough I just repeat it so the wind up with a B54.

 

[glorfindel]

I'm a physical-restraint kind of guy.

j/k.

I like the B-52.

I like droperidol even more. To any resident who's attendings won't let them use this medication in residency, my condolences. I like droperidol better than haldol for sedation, so my preferred B-52 is really a B-52(D).

I like ketamine. Provided, of course, that my nurse likes ketamine. If we're both on board, it's a great drug.

For the big out-of control guys, I like ketamine even more.

I haven't used geodon much, but on Arcan57s recommendation I'm going to try it.

I've found that similar formulations (apart from ketamine) are also highly effective for cyclic vomiting patients.

 

[Arcan57]

For those that use ketamine for agitation NOS, does the contraindication in schizophrenics give you pause? If not, what is your rationale (I'd love to be able to justify using it for the lab and radiology portion of the eval).

 

[joeDO2]

Are you a second year medical student? Where are you doing moderate sedation?

used it as a paramedic for cardioversion and pacing

 

[goodoldalky]

People are really still using diphenhydramine for the acutely agitated patient? Surprised... In my opinion there's not any evidence to support that, can be anticholinergic, I don't believe anecdotally that it adds anything to a benzo + antipsychotic. I tend to default to 2 mg of lorazepam and 5 of haldol but that's based on just doing what I was taught. Literature probably suggests you are best off with some type of combo of that sort. The best evidence may be for midazolam as it is a bit faster on/off than lorazepam. As for the antipsychotic, it seems to me you just want to pick the thing that is less-likely to have you medicolegally associated with an arrhythmia, whether it's related to the QTc effect or not. I love that patients wake up from Geodon faster but there is some solid evidence that the QT effect is more significant than with haloperidol. Seems to me you are best off sitting with haloperidol or droperidol plus a benzo.
There's really not one proven right way in the literature... I've heard a lot of different arguments.
Does anyone just go with whopping doses of benzos solo?
Anyone use Zyprexa or something else?

 

[Tiger26]

For those that use ketamine for agitation NOS, does the contraindication in schizophrenics give you pause? If not, what is your rationale (I'd love to be able to justify using it for the lab and radiology portion of the eval).

Regarding Ketamine, it's really weighing the risk to the patient of exacerbating their schizophrenia vs the risk to themselves and staff while ripping up the ED.

Overall, I think of it as procedural sedation for control of agitated delirium. If interested, there's some good podcasts from Weingart and some of the Life in the Fast Lane guys on it's use for retreival medicine. In addition, there's a lot of stuff from Minneapolis EMS, as it's in their protocol there.

As for droperidol, I feel like it's a magic elixir--a sort of nectar of the gods. For the poster above who's attendings won't use it, show them the evidence. It's an incredibly safe drug with no more QT prolongation than zofran. There was initially a lot of hesitation at our shop until one of the other senior residents and I pushed the issue and got a few influential attendings on board.

 

[Xerxes1729]

Some anesthesiologists use IM ketamine for large uncooperative patients (i.e., 6'4" 400# developmentally disabled) in order to facilitate getting the IV and getting the patient on the table. I've used it once so far in residency for an extremely agitated psych patient, and it worked great. She went to sleep for a few hours, then woke up and was much calmer for the rest of the day.

 

[dchristismi]

I'm a 20-of-Geodon kind of girl. Ok, so 10 if it's a small-ish person.

Done the ketamine thing once, and it was in a violent hypoglycemic pt, of all things. Worked well, and would use it again for that. But for the psychotic/drunk/combative I'm all about the Geodon.

 

[RustedFox]

20 Geodon IM here as well. I even love the name. "Down to Earth" in a sense.

 

[e30ftw]

another vote for Geodon.

Although if you give 20 might wanna snag an EKG when they're calmed down if you have any suspicion of cardiac rx factors.

it also works great for procedures on drunk, agitated patients who don't need a sedation but need to be calmed down for suturing, etc.

 

[Rendar5]

Never saw the need for geodon unless I got a Vitamin H allergic pt, though luckily our drunks aren't usually violent enough to plow through the haldol.

 

[WilcoWorld]

In residency, we had Geodon in the pyxis, so I used 20mg IM and never ordered haldol in 3 years.

At my 1st shop out of residency Geodon had to come from pharmacy, the patients were more volatile, and I swear the nurses could get an IV in an obese dialysis patient from atop a horse at a full gallop. So for the 3 years I was there we gave a lot of doses of 5mg haldol IV, and only rarely had to give anything more. I never had a complication with the IV haldodl.

Now I'm at a shop with far fewer agitated patients, and the nurses here have much stronger opinions about which meds to use. So, I'll run my various med options past the RN and go with whichever one he or she is most comfortable with (and it seems that preferences are quite variable, and non-scientific, but I can always get them to agree to one effective measure or another). Here we love droperidol so much we've run out of it twice in the last year.

So, I guess what I'm saying is that there are a number of effective options. While I suspect that ketamine is the safest option (but I've never gone as big as 5mg/kg!), my choice is more influenced by my practice environment than it is by pharmacology.

 

[Pharmavixen]

In the jail we use 2 mg Ativan + 10 mg Zyprexa Zydis po. We can't force meds on anybody, so no vitamin H, but our psych nurse is brilliant at coaxing violent nasty psychotics into taking a Zydis. Works great.

Do you worry about QT prolongation from Geodon if the person is psychotic from crack, or is this more of a textbook thing?

 

[njac]

At my 1st shop out of residency Geodon had to come from pharmacy, the patients were more volatile, and I swear the nurses could get an IV in an obese dialysis patient from atop a horse at a full gallop.

Imagine my surprise when I went across the country to learn that "we can't get access" is a problem in the real world...

 

[WilcoWorld]

Imagine my surprise when I went across the country to learn that "we can't get access" is a problem in the real world...

Yesterday a patient was transferred to us for a CT scan, because the sending facility couldn't get IV access! Linda would've had an IV in this patient before he had time to ask for ice chips.

 

[docB]

Yesterday a patient was transferred to us for a CT scan, because the sending facility couldn't get IV access! Linda would've had an IV in this patient before he had time to ask for ice chips.

I get about one of these a month. I'd get more but in general for our nursing home population there's no such thing as an outpatient CT anyway. So they get sent not for no access but to get the scan. The orders are hilarious:

T.O. from Dr. Lazy, tansfer to ER non-emergent for CT of chest, and, pelvis, legs and spirit, endocrine consult.

In my area all dialysis access issues are just dumped into the ER. Nothing gets done outpatient.

 

[UnderwaterDoc]

As for droperidol, I feel like it's a magic elixir--a sort of nectar of the gods. For the poster above who's attendings won't use it, show them the evidence. It's an incredibly safe drug with no more QT prolongation than zofran. There was initially a lot of hesitation at our shop until one of the other senior residents and I pushed the issue and got a few influential attendings on board.

Did that already, didn't work. Best part was when I showed them that Haldol is worse than Droperidol as far as QT prolongation, yet they still give it like water.

Oh well, another thing to add to the list of "things I will do when I am an attending", for now it's versed till they drop.

 

[docB]

Did that already, didn't work. Best part was when I showed them that Haldol is worse than Droperidol as far as QT prolongation, yet they still give it like water.

Oh well, another thing to add to the list of "things I will do when I am an attending", for now it's versed till they drop.

Remember that a lot of these issues arise not because docs are ignorant of the actual science but because following the EBM has been made so difficult. Many of us are barred by policy from giving droperidol IV or without an EKG first. It doesn't matter how I want to practice if I try to give it I'll get a policy tossed in my face and a lecture about "my nursing license."

 

[glorfindel]

Remember that a lot of these issues arise not because docs are ignorant of the actual science but because following the EBM has been made so difficult. Many of us are barred by policy from giving droperidol IV or without an EKG first. It doesn't matter how I want to practice if I try to give it I'll get a policy tossed in my face and a lecture about "my nursing license."

[bold mine]

Here's the problem: hospital credentialing policies that lag decades behind the evidence (see, e.g., propofol for (deep) procedural sedation in the ER), and hospital pharmacy and therapeutics committees that are overly intrusive and restrictive.

Fix those two problems and our practice of EM gets a whole lot better.