Haldol

godzilla2

I rank Haldol 24 out of 33 drugs I carry. I would rank it much higher except:

A. I use it only in combination with Ativan, and Ativan may do more of the work than Haldol.

B. One of my prides is my ability to talk to psychs and get them to come peacefully, so it is rare I have to restrain somone.

C. In the town where I work, dispatch commonly calls the commercial service to transport psychiatric patients so I don’t deal with the same volume of agitated patients I used to when I worked more in the city.

Last year I did not use Haldol at all.

But when you need it, it is a great drug. We combine it with Ativan in the same syringe now (we used to have to use two syringes) and can use it after attempts to talk down a patient have failed and physcial restraint will likely result in injury or the patient continuing to fight despite the restraints. (See full guideline below).

***

This is my favorite Haldol story – Sleepy Boy or Fetch My Dart Gun:

We get called for a violent psych at the juvenile school. Wait for PD, our dispatcher tells us.

A violent psych at the juvenile school. The last violent psych I had at a juvenile school was a fifty pound ten-year-old who was standing up on top of the cabinents in the principal’s office jumping up and down screaming at the top of his lungs after already having thrown all the books that were on top of the cabinent down on the floor. I reached up, plucked him off the cabinents, tucked him under my arm, laid him on the stretcher and wrapped him in a blanket, then told him to knock it off, which surprisingly he did.

When we arrive, a staff member meets us in the hall and asks us if we are familiar with Andy.

I am not.

Big kid, thirteen years old, autistic, out of control today. They have six people holding him down, he says.

Six people, I think, right. Talk about overkill.

I enter the room, nod to the cop, who is standing by the door. I look about the room, then look down on the ground, where there are indeed six people holding Andy down. Andy is two hundred fifty pounds minimum, maybe two-seventy. He has the muscled shape of a big bear. There is a grown man on each limb, a large grown man leaning over his torso, and another man holding his head down. He looks up, despite the hold the man has on him, and roars. I swear the room shakes.

“You’re just one crew?” the cop asks. “You have restraints?”

***

Now when I first took my EMT class many years ago, I wasn’t too keen on the section of the course where we practiced restraining patients. I mean I wasn’t certain I wasn’t going to vomit at the first sight of gore, and I wasn’t certain how good I was going to be at wrestling patients. I was as tall as I am now, but not nearly in the shape I am in now. I was sort of skinny and flabby at the same time.

I was lucky that one of my partners when I first stared working was a black belt karate instructor, but other times I worked with tiny women. In the same way I hoped that I never had to deal with the massive chemical hazmat train wreck mutlicasulaty plane crash call, I hoped I wouln’t get called for the big guy who wanted to kick my ass.

I cultivated a calm approach, and learned to rely on my voice and on the trait of patience, which I have in fair abundance, and when faced with being patient or getting pummeled, I am always happy to be patient. But there are always some patients who patience doesn’t work on. That’s why we have cops, but cops don’t like to get worked up any more than paramedics.

In recent years, restraining patients has also gone somewhat out of favor due to some tragedies — patient’s dyig of asphxia. A couple years ago, our protocols were rewriten to address issues of restraint. In the case of Andy, in my mind, I flip through the first two pages of the protocol to half way down the third page, under the title “Chemical Restraint.”

***

“We’re going to sedate him,” I say. (If this was movie, I would have said to my partner, “Fetch my dart gun.”)

2 mg Ativan and 5 mg Haldol IM.

He screams when I stick him in the thigh. He presses against his restrainers, tries to spit, but they quickly put a face shield over him. He calls me nasty names.

Then we sit and wait. He settles down for a moment, but any time anyone moves or tries to talk to him, he starts fighting again.

Ten minutes go by. He is still angry and yelling.

I excuse myself and go out to the ambulance and call medical control. The doctor approves my request for a second dose. “By all means,” he says.

Andy nearly throws everyone off him when I hit him in the other thigh.

I sit back down in a chair and wait.

A staffer asks what the plan is now.

“I’m going to sit here until he’s asleep,” I say.

Five minutes later, he starts to snore.

One by one I have each of the restrainers get up. We nudge Andy, and he opens his eyes, and sleepily gets up and lays down on the stretcher like a little boy who has stayed up past his bedtime.

He snores all the way to the ER.

***

Haloperidol (Haldol)

Class: Tranquilizer, antipsychotic

Action: Inhibits CNS catecholamine receptors, strong anti-dopaminergic and weak anticholinergic.
Acts on CNS to depress subcortical areas, mid-brain and ascending Reticular Activating System

Indication: Chemical restraint for violent, agitated, and aggressive patients who present a danger to themselves or to others and who cannot be safely managed otherwise.

Contraindications: Agitation secondary to shock or hypoxia
Hypersensitivity
Parkinsonís Disease
CNS Depression
Relative contraindication if has seizure history

Side effects: Extrapyramidal symptoms (dystonic reaction), restlessness, spasms
Lowers seizure threshold
Hypotension
Tachycardia
Vomiting
Blurred vision

Dose: 5 mg IM

Route: IM

***

Here is our restraint guideline:

North Central EMS Behavioral Emergency Guidelines

EMS providers may use physical and/or chemical restraints on patients who pose a danger to themselves or others.

Providers should make every effort to ensure that law enforcement and adequate assistance are present when attempting to restrain a violent or combative patient.

Only the minimum amount of restraint necessary to protect providers and the patient should be used.

Providers should first attempt to verbally calm the patient down. If the patient does not comply, physical restraint may be attempted.

Providers should assess the patient for medical conditions that could be contributing to the patientís behavior. If an assessment cannot be performed prior to physical restraint, it should occur as soon as possible after restraint is applied when it is safe and feasible.

Physical restraints must be soft in nature and pose no threat to the patientís safety.

Only the extremities shall be restrained and these restraints must be assessed every five minutes.

Patients must never be hog-tied, restrained in a prone position with hands tied behind their backs or placed between backboards or mattresses. No restraint shall ever be tied around the head, neck or chest. A surgical mask, spit shield, or an oxygen mask may be placed loosely on the patient to prevent spitting.

Handcuffs may only be used by law enforcement or correction officials on patients in their custody. If the law enforcement officer insists that the patient remain handcuffed during transport, they must either accompany the patient or provide a key to EMS personnel.

Chemical restraint may be used per guideline following unsuccessful attempts at verbal and/or physical restraint or when a patient continues to forcibly struggle against physical restraints.

All restrained patients must have continual reassessment of vital signs and neurovascular status of distal extremities. In chemically restrained patients (safety permitting) this should include ECG, pulse oximetry, and capnography if the patient is no longer alert.

Documentation must include justification for restraint, type of restraint used, restraint procedure, results of continual reassessment, medications administered, the indications for the administration, and any other care rendered.

Do not hesitate to involve medical direction in any call involving restraint.

2 Comments

  • Matt says:

    Have you used any other neurolyptics? We had droperidol for a while, which is kinda-sorta-maybe-actually-not better than haldol… for some reason. I think it was supposed to be faster-acting. Worked great, but it was felt that QT prolongation was too much of risk.

  • medicscribe says:

    We considered this, but then the FDA issued one of their black box warnings on the drug and that put an end to it.

    Thanks for the comment,

    Peter

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Peter Canning

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  • Comments
    Casey
    Intranasal Medication
    Agreed Steve. Love IN Versed for combative/ictal patients. Also IN versed is used in ED for kids. Helps with pain relief and as an amnesic and wears off fairly quick- not sure that directly applies to prehospital but food for thought nonetheless
    2015-05-07 00:36:28
    Chris
    AHA 2015 Guidelines: A Preview
    I am a 25 year veteran firefighter/medic, and 9 year veteran critial care fixed wing medic. I work in Northeast Ohio. In this region, we have all but abandoned endotrachal intubation for the intent of ease of a superglottic airway. AHA de-emphasizing ETI and we have seen this coming for a while. We either bag…
    2015-05-05 20:54:08
    Steve
    Intranasal Medication
    "either because they are seizing or are violent, then the better and quicker route would be IM. " I'm quite hesitant about bring a needle against someone fighting me or shaking... those are the perfect times to be needleless.
    2015-04-27 18:34:14
    bill
    The Ideal Medic
    very well put! aggression can be a good in moderation but over aggression can do harm. 1 year to 30 years no medic will know it all epically with our ever changing job description. thank you for your input!
    2015-04-26 11:46:50
    Ben Leighton
    Adenosine
    Hi. Im a UK Student Paramedic and I have a few questions regarding adenosine (we currently dont carry it) and I was wondering if any of you guys could e-mail me at ben-leighton@hotmail.co.uk and start some correspondance. Im aiming to set a proposal to my service in order to carry this drug and wanted some…
    2015-04-20 13:36:03

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