Pharm of Acute Agitation Flashcards
What are the non-antipsychotic options to manage acute agitation?
Benzos and ketamine
Pros and cons of benzos for agitation
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
What are the different benzos used for agitation and the differences between them?
Midazolam: faster on/off
Lorazepam: slower on, but longer lasting
Diazepam: has active metabolites making oversedation a risk with repeat doses
What is the dosing for midazolam and the routes of administration and onset of action?
2-5mg
IV 3-5min
IM 10-20min
PO 10-30min
What is the dosing, routes of administration and onset for lorazepam?
0.5-4mg
IV 5-10 min
IM 15-30 min
PO 20-30 min
How do the half lives compare between lorazepam and midazolam?
Ativan: 10-14 hours
Versed: 1-4hrs
When should ketamine be avoided?
schizophrenia and primary psychosis
What is the dosing and routes and time of onset for ketamine in agitation?
IV/IO 1-2mg/kg, onset <30sec
IM 4-5mg/kg, onset 3-5min
What are the pros and cons of haloperidol in agitation?
Low sedation/hypotension
Sedation only at 2 hrs
Increased QTc and dystonic reactions requiring co-administration of other drugs
What drugs can be given to mediate the dystonic reaction of haloperidol?
Promethazine
Benztropine
Diphenhydramine
What is the onset of action for haloperidol?
20-40 minutes IM
What is the dosing for haloperidol?
2-5mg IM q4-8hrs PRN, but may need q1Hr administration
What patients should not be given haloperidol for agitation?
Dementia-related psychosis
Increased risk of death
Contraindicated in parkinsons
Should IV haloperidol be given?
IV administration carries higher risk of QT prolongation and must be monitored by EKG
2nd generation anti-psychotics are drugs of choice for what patients?
Underlying psychiatric illness now experiencing agitation
How do second generation anti-psychotics compare to first generation?
Same efficacy with less side-effects
Still cause prolonged QTc, but less likely to be greater than 500
How do the 2nd gen anti psych drugs compare with QTc?
Ziprasidone is worst for QTc and Olanzapine is best
What is the dosing for Geodon and route?
10-20mg IM
Q2h if 10mg
Q4h if 20mg
What is the dosing and route for Zyprexa?
5-10mg IM/PO q2-4h
How does onset of action compare between 1st and second gen anti psychotics?
1st gen: onset 30-60 minutes IM
2nd gen: onset 15-45 min IM
How does duration of action compare between haloperidol, geodon and zyprexa?
Haldol: 18hr t1/2
Geodon: 2-5hr
Zyprexa: 21-54hr
What is the drug of choice for agitation and ETOH intoxication?
Haldol
Which anti-psychotic works the most often to decrease psychosis and agitation?
Ziprasidone
When is onset for haldol faster than olanzapine?
Haldol + promethazine is faster onset
How does midazolam compare to haldol overall?
Versed is faster and has the same long-term outcomes overall
What caution should be considered when treating elderly agitated patient?
Rapid respiratory depression and decompensation is possible in the elderly and they are easily over sedated
Increase risk of CVA with anti-psychotics
What caution should be remembered with combining olanzapine with other agitation medications?
zyprexa + benzos leads to excessive sedation and cardiorespiratory depression making monitoring required and use in elderly contraindicated
Which anti-psychotic is ok in elderly with dementia and parkinsons?
Ziprasidone
What are first-line agents in elderly agitated patients? Second line?
Geodon, then haldol but at a reduced dose and with more gradual adjustments
What drugs should be avoided in elderly?
Benzos, diphenhydramine, cogentin and anti-cholinergics which can cause extra-pyramidal symptoms.
