Pharm of Acute Agitation

Question 1

What are the non-antipsychotic options to manage acute agitation?

Answer 1

Benzos and ketamine

Question 2

Pros and cons of benzos for agitation

Answer 2

Good for patient’s with no known medical history, or if intoxicated (except for ETOH)
No cardiotoxic effects
Don’t decrease seizure threshhold
Must monitor for cardio/respiratory depression

Question 3

What are the different benzos used for agitation and the differences between them?

Answer 3

Midazolam: faster on/off
Lorazepam: slower on, but longer lasting
Diazepam: has active metabolites making oversedation a risk with repeat doses

Question 4

What is the dosing for midazolam and the routes of administration and onset of action?

Answer 4

2-5mg
IV 3-5min
IM 10-20min
PO 10-30min

Question 5

What is the dosing, routes of administration and onset for lorazepam?

Answer 5

0.5-4mg
IV 5-10 min
IM 15-30 min
PO 20-30 min

Question 6

How do the half lives compare between lorazepam and midazolam?

Answer 6

Ativan: 10-14 hours
Versed: 1-4hrs

Question 7

When should ketamine be avoided?

Answer 7

schizophrenia and primary psychosis

Question 8

What is the dosing and routes and time of onset for ketamine in agitation?

Answer 8

IV/IO 1-2mg/kg, onset <30sec

IM 4-5mg/kg, onset 3-5min

Question 9

What are the pros and cons of haloperidol in agitation?

Answer 9

Low sedation/hypotension
Sedation only at 2 hrs
Increased QTc and dystonic reactions requiring co-administration of other drugs

Question 10

What drugs can be given to mediate the dystonic reaction of haloperidol?

Answer 10

Promethazine
Benztropine
Diphenhydramine

Question 11

What is the onset of action for haloperidol?

Answer 11

20-40 minutes IM

Question 12

What is the dosing for haloperidol?

Answer 12

2-5mg IM q4-8hrs PRN, but may need q1Hr administration

Question 13

What patients should not be given haloperidol for agitation?

Answer 13

Dementia-related psychosis
Increased risk of death
Contraindicated in parkinsons

Question 14

Should IV haloperidol be given?

Answer 14

IV administration carries higher risk of QT prolongation and must be monitored by EKG

Question 15

2nd generation anti-psychotics are drugs of choice for what patients?

Answer 15

Underlying psychiatric illness now experiencing agitation

Question 16

How do second generation anti-psychotics compare to first generation?

Answer 16

Same efficacy with less side-effects

Still cause prolonged QTc, but less likely to be greater than 500

Question 17

How do the 2nd gen anti psych drugs compare with QTc?

Answer 17

Ziprasidone is worst for QTc and Olanzapine is best

Question 18

What is the dosing for Geodon and route?

Answer 18

10-20mg IM
Q2h if 10mg
Q4h if 20mg

Question 19

What is the dosing and route for Zyprexa?

Answer 19

5-10mg IM/PO q2-4h

Question 20

How does onset of action compare between 1st and second gen anti psychotics?

Answer 20

1st gen: onset 30-60 minutes IM

2nd gen: onset 15-45 min IM

Question 21

How does duration of action compare between haloperidol, geodon and zyprexa?

Answer 21

Haldol: 18hr t1/2
Geodon: 2-5hr
Zyprexa: 21-54hr

Question 22

What is the drug of choice for agitation and ETOH intoxication?

Answer 22

Haldol

Question 23

Which anti-psychotic works the most often to decrease psychosis and agitation?

Answer 23

Ziprasidone

Question 24

When is onset for haldol faster than olanzapine?

Answer 24

Haldol + promethazine is faster onset

Question 25

How does midazolam compare to haldol overall?

Answer 25

Versed is faster and has the same long-term outcomes overall

Question 26

What caution should be considered when treating elderly agitated patient?

Answer 26

Rapid respiratory depression and decompensation is possible in the elderly and they are easily over sedated Increase risk of CVA with anti-psychotics

Question 27

What caution should be remembered with combining olanzapine with other agitation medications?

Answer 27

zyprexa + benzos leads to excessive sedation and cardiorespiratory depression making monitoring required and use in elderly contraindicated

Question 28

Which anti-psychotic is ok in elderly with dementia and parkinsons?

Answer 28

Ziprasidone

Question 29

What are first-line agents in elderly agitated patients? Second line?

Answer 29

Geodon, then haldol but at a reduced dose and with more gradual adjustments

Question 30

What drugs should be avoided in elderly?

Answer 30

Benzos, diphenhydramine, cogentin and anti-cholinergics which can cause extra-pyramidal symptoms.