Haldol IV?

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I was working on a med surg unit and rec'd an admission through the ED. I was told the patient was alert and oriented. When the patient came to me he was agitated, confused, combative, refusing care, and disoriented. The physician ordered IV haldol 1mg q20. I gave it twice a couple hours apart. When I came in an hour later to give medal, the patient was contracted and not responding to sternal rubs for about 5min, all VS completely normal. Has this ever happened to anyone? The patient was fine, but now that I'm researching I'm seeing several things about Haldol not approved for IV use. I'm a new med surg nurse (background pedi and oncology), but my preceptor and other nurses did not flinch when I mentioned the order. I also noticed the bottle today said for IM use only.

Specializes in Geriatrics, Transplant, Education.

Hmm...I don't have much to offer except to say I have seen it given iv as well. What was the pts history? Will be interested to see what others have to say.

Specializes in Hospice & Palliative Care, Oncology, M/S.

We require patients to be tele monitored for IV haldol.

Jules A, MSN

8,864 Posts

Specializes in Family Nurse Practitioner.

My understanding is that while it isn't approved for IV it is often used off label. The FDA recommends constant ekg monitoring if giving it IV. The concern is prolonged QTc but I think the incidents are more likely associated with comorbidities. That said in my opinion IM is a much better route of administration because it not only is the approved route but it also seems to last longer. I get resistance on the medical floors when I order IM because its easier to do IV but I feel the above reasons make IM a better option in most cases. FWIW I also feel benzos being administered IM is preferable over IV when PO isn't an option.

VANurse2010

1,526 Posts

I've seen it ordered IV quite a bit. Keep in mind that just because something is not "FDA approved" doesn't mean it cannot be ordered. The FDA does not regulate the practice of medicine and has no control over off label uses, although the MD is obviously putting himself at more risk of liability if using medications off label.

RNKPCE

1,170 Posts

It can only be given IV in our ICU, not even on telemetry.

Specializes in orthopedic/trauma, Informatics, diabetes.

We give it IV all the time when pts are violent and a danger to themselves or us. We are an intermediate floor. Ours is usually ordered 0.5 mg Q6H prn. We use more ativan than haldol, but it is not uncommon. I say this with the caveat that it is not often we have a combative pt, but if we do, we use it IV. Never had an issue like OP describe. I think in the ED, you can never be sure what they have ad before coming (?)

Guest219794

2,453 Posts

2 mg iv haldol given that far apart isn't likely to cause that level of consciousness. That is a small dose Not saying it's impossible, just that I might be looking for other explanations- Either other causes, or the possibility that the pt is playing possum, so to speak. For frame of reference, it is not unusual to give 10 mg haldol with 2 mg ativan both IM to truly dangerous PTs. The fact that the symptoms resolved spontaneously in 5 minutes would up my suspicions.

A sternal rub can be helpful in determining LOC for truly altered PTs. Not responding to voice, but rousing with painful stimulus tells you something. But, if I was choosing to appear unresponsive, I could do so despite a pretty aggressive sternal rub. I could easily not flinch through most of the sternal rubs I have seen nurses do.

In some instances, this can be more helpful.

Not evidenced based, not taught in nursing school, and no facility policy to guide you.

Done frequently in the ER.

annie.rn

546 Posts

Is it possible he may have had a seizure? Haldol can lower the seizure threshold.

Haldol has so many side effects. I don't like giving it and would not want to give it IV w/o monitoring.

Though it doesn't appear to be the case here, with anti-psychotics there is a risk of Neuroleptic Malignant Syndrome. It's hard to detect b/c it can mimic a lot of other diseases. It can be fatal so if you are giving anti-psychotics it's good to know what the symptoms are so it can be spotted quickly and treated.

Here's a link to learn about Neuroleptic Malignant Syndrome:

Medscape: Medscape Access

Jules A, MSN

8,864 Posts

Specializes in Family Nurse Practitioner.
I think in the ED, you can never be sure what they have ad before coming (?)

This is an excellent point and unfortunately I have heard of more than one story where patients actually died from depression of respirations which was likely the combination of medications administered in the ED and then prn medications administered after being transferred to the mental health unit. Make sure you know what they have received before you pile more on.

macawake, MSN

2,141 Posts

The physician ordered IV haldol 1mg q20. I gave it twice a couple hours apart. When I came in an hour later to give medal, the patient was contracted and not responding to sternal rubs for about 5min, all VS completely normal. Has this ever happened to anyone? The patient was fine, but now that I'm researching I'm seeing several things about Haldol not approved for IV use.

As I understand it higher doses or intravenous administration of haloperidol seem to be associated with higher risk for QT prolongation and Torsades de pointes and that's the reason why it's not approved for iv use.

OP, you wrote that the patient was "contracted". Which part of the patient's body?

First-generation (also known as typical) antipsychotic medications like haloperidol have a strong EPS (extrapyramidal symtoms/side effects) tendency. This means that possible side effects are dystonic reactions like intermittent or sustained involuntary contractions of the muscles of face, neck (can include the larynx), and somtimes the extremities, trunk or pelvis. Symtoms may begin immediately or be delayed (hours/days). These are of course frightening and uncomfortable for the patient, but they are generally reversible.

(One other possible extrapyramidal side effect is tardive dyskinesia which normally occurs after long-term treatment with typical antipsycotic medications and is usually irreversible).

Second-generation (atypical) antipsycotic medications have a lower incidence of extrapyramidal side effects.

The mechanism behind the extrapyramidal side effects caused by antipsycotic drugs is blockade of D2 (dopamine) receptors in the nigrostriatal pathway.

You say that the patient was fine. I guess that by this you mean that they recovered after the episode of contractions? What was done during the five minutes that the patient didn't respond to sternal rubs? Was the physician/provider notified and what did he or she say?

Specializes in Hospice.

I've given it IV as well, however, it is usually IM because by the time I get an order the pt. has ripped out the IV.:mad:

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