Haldol and Ativan cocktail IV

Trauma Columnist · Aug 19, 2008

We called it a B52: Haldol 5mg and ativan 2mg - given IM seemed to calm most folks - lol.

Thunderwolf, MSN, RN · Aug 19, 2008

Typically, this is what I saw and gave as well...Haldol 5 mg and Ativan 2mg IM mixed in one injection.

If any concern regarding dystonia, a second injection of Cogentin 1 mg IM was given.

aloevera · Aug 19, 2008

We had a pt. one time that was given his B52 X2 and still was not calming down....doc afraid to give any more so we ended up calling police to stun him.....there are a few that just don't seem to wind down!! He was in restraints but still mad as a hatter when the police came....

Mish56, BSN, RN · Aug 20, 2008

we do the 5/2/1 99% of the time. HOWEVER, I had one attending I worked with years ago, who during a really violent episode (the patient, not MD) he ordered versed IM. I bless the floors he walks on! The patient lost it at the nurses station, and we couldn't get him to his room, or in restraints. Obvioisly, this is a fast acting, but short acting med. Stopped the patients forward moving agitation, when he woke up, he had lost his steam. Only saw it that once, but hey, it worked!

Back in the way olden days, we had "rapid tranq" thorazine 100 mg po Q1H until patient asleep. Those were the days my friend.

alfa-sierra, BSN, RN · Aug 20, 2008

aloevera said:
We had a pt. one time that was given his B52 X2 and still was not calming down....doc afraid to give any more so we ended up calling police to stun him.....there are a few that just don't seem to wind down!! He was in restraints but still mad as a hatter when the police came....

Sadism and ignorance can, and often do, go hand in hand. I stopped keeping track of how many times "psychiatric" nurses fail to identify akethisia as a reaction of too much antipsychotics, leading erroneously to a "too much is never enough" mentality when in fact, when it comes to Haldol in particular, less is more. Exception to this could be a patient high on PCP.

Mish56, BSN, RN · Aug 20, 2008

alfa-sierra said:
sadism and ignorance can, and often do, go hand in hand. i stopped keeping track of how many times "psychiatric" nurses fail to identify akethisia as a reaction of too much antipsychotics, leading erroneously to a "too much is never enough" mentality when in fact, when it comes to haldol in particular, less is more. exception to this could be a patient high on pcp.

alpha, i'm not sure how to respond to your post?! mind you i work on an inpatient unit, so we know what medications have been given, and therefore know what adverse effects to look for. severe akathisia and acute psychotic agitation do not (in my humble opinion) have a similiar presentation. akathesic agitation normally has a start/stop/start/stop type driven movement vs. the "full steam ahead" of psychosis. in akathisia 99 times out of 100 you hear the words "i'm coming out of my skin!", vs. "you are the devil spirit of my dead mother" of psychosis. besides which, it only takes a few seconds to do a barnes akathesia rating scale in your head. regardless, both conditions come with severe emotional pain, which is just as real as the pain of a good compound fracture. what i would view as "sadistic" would be to sit by and allow the patient to suffer horribly when treatment is available.

treatment of akathesia is pretty straight forward. 1). remove the offending agent, whether it's haldol, prozac, regalan or whatever 2). usually we use a benzo, such as ativan, once in a rare while inderal. but as this is a thread about the use of haldol and ativan together, one would hope the ativan would counteract the possiblity of akathesia, just as the cogetin would do for dystonia/epse.

as a nurse who as dedicated my entire proffessional career to the care of the of mentally ill people, i resent your choice of words: "ignorant and sadistic". my most developed nursing "skill" is compassion for those whose lives are devastated by an illness that cannot be easily diagnosed with an xray or lab values, an illness that cause many a med-surg nurse to spend as little time as possible caring for the a post op patient that happens to also have schizophrenia. i think most of us use this site to ask or answer questions, share the highs and lows of nursing, vent and rant, but never to be attacked or insulted by our peers.

Thunderwolf, MSN, RN · Aug 20, 2008

Both points of both members well taken....being mindful to diffierentiate between the two syndromes....akathisia vs psychotic agitation. Yet, Alfa does make a valid point about ignorance regarding psychiatric meds among nurses. The words used by Alfa maybe harsh, but I believe they were used to emphasize the point. Nursing ignorance is not bliss...and the patient can suffer unneededly as a result. Critical thinking skills as a nurse are required to differentiate between the two syndromes and should guide our assessments...and as a result....when it is appropriate to give that antipsychotic or something totally different. Thanks to both Mish and Alfa for pointing this out. I am not defending Alfa....but wish to redirect us to the matter at hand on this thread...back to Haldol and Ativan as discussed.

Peace to you both.

alfa-sierra, BSN, RN · Aug 21, 2008

I respond to Mish's red herring posting only out of respect for the learning value of this site. Fallacies, or arguments with flawed logic, detract not only from the truth but from the integrity of learning experiences. For instance this was a fallacy somewhat relevant to the point of differential diagnosis further ahead: so we know what medications have been given, and therefore know what adverse effects to look for. Don't we wish that was always the case but one does not necessarily follow the other! A red herring :devil:is a deliberate attempt to change a subject or divert an argument. How come Mish's posting is a red herring? Because my initial argument was digressed upon and altered in its form, context and purpose to create the impression of a personal, :imbarshameful, attaking, insulting proposition. My purpose here however is to clarify, not to engage in ad hominem arguments:). This was the original posting by Aloevera:

We had a pt. one time that was given his B52 X2 and still was not calming down....doc afraid to give any more so we ended up calling police to stun him.....there are a few that just don't seem to wind down!! He was in restraints but still mad as a hatter when the police came....

My response to the subject of Aloevera's posting (it can be seen in Mish's posting) reflected my reaction to the use of a stunning gun on a patient already in mechanical restraints and after a repeated dose of chemical restraints in an unspecified timeframe. Even though that was not the thread, the circumstances around it were to me of a higher magnitude and relevance. Restraints used in ER and psych units are not the same as soft restraints used somewhere else. A pt in those restraints won't go anywhere or strike anyone. If images of the stunning of a pt already in such a powerless position were captured by live TV or video it would certainly be perceived by the public opinion if not as sadism then as unnecessary violence, the kind that elicits repulsion, anger and distrust in the viewers. And with good reason. Public opinion trusts professionals to deal with crises professionally. Taser or stun guns are not sanctioned methods of intervention by clinical staff in clinical settings, above all when the pt is already restrained. I was not there, so I'm not privy to what could have been exceptionally extenuating circumstances. On the other hand, I don't know either if other more sophisticated considerations would have entered the clinicians' minds. Could the pt's altered perceptions make him believe the staff was going to kill him? Could the sustained combativeness be his way of fighting for dear life? Whenever feasible, exploring and implementing alternative strategies beyond, or preferably before, the most restrictive ones, is what makes a practice holistic. Could the reassuring intervention of a trusted family member have restored some balance? All practicioners are, at one time or another, consumers too. So, let's be careful because as the saying goes, what is good for the goose today may be good for the gander or her family tomorrow.

I agree with the description of the treatment for akathesia and that agitation is a common, and only, denominator to both akathesia and some psychotic exacerbations. Unfortunately, agitation without a differential diagnosis is too often, for some, a good enough criteria to administer more and more antipsychotic prns. Unrecognized akathesia symptoms are common and important enough occurrences to have been documented in the literature. Mish posting stated: I resent your choice of words: "ignorant and sadistic" I can swear under the Bible and no fear of perjury that I never wrote such words. ? I will let the readers be my witnesses. The posting concluded with the paragraph I think most of us use this site to ask or answer questions, share the highs and lows of nursing, vent and rant, but never to be attacked or insulted by our peers. I couldn't agree any more. Yet, those words misattributed to me are qualifiers that I never used to qualify any person in my posting. I can not, in all fairness, accept authorship and responsibility for the implied connections made between those words and any sort of personally perceived attack or insult. I regret any room for misinterpretation that the conciseness or perhaps lack of clarity of my initial posting may have contributed to. This is not the same as to say that I retract in any way my initial intended assertion. Why? Because all the following are on my side. Historical facts, statistical records of mental ill fatalities attributed to police, nurses and doctors's inappropriate communication and interventions (eg.:too high or frequent med dosages, improper use of restraints, incorrect, fear-driven :argue:

assessments and crisis intervention protocols). Plus records of federal investigations of numerous state and county psychiatric hospitals, informal testimonies from nurses, social workers, patients and families. They all corroborate the past and present existence and correlation of ignorance and sadism in too many psychiatric milieus. No denial, rationalizations or misallocated loyalties should ever cause patients advocates to mince their words. I trust that someone with the self described, highly commendable qualities of compassion and a humble opinion atop 30 yrs of experience, can only be on the same, brighter side of the humanistic fence.

Thunderwolf, MSN, RN · Aug 21, 2008

Alfa, your points are noted...and thanks for sharing and clarifying your position further. Your post also emphasizes the importance in evaluating the patient's bigger picture and needs...as well as nurses needing to evaluate their own professionalism, especially in the public eye (and even when not in the public eye).

Quote
Public opinion trusts professionals to deal with crises professionally. Taser or stun guns are not sanctioned methods of intervention by clinical staff in clinical settings, above all when the pt is already restrained. I was not there, so I’m not privy to what could have been exceptionally extenuating circumstances. On the other hand, I don’t know either if other more sophisticated considerations would have entered the clinicians’ minds. Could the pt’s altered perceptions make him believe the staff was going to kill him? Could the sustained combativeness be his way of fighting for dear life? Whenever feasible, exploring and implementing alternative strategies beyond, or preferably before, the most restrictive ones, is what makes a practice holistic. Could the reassuring intervention of a trusted family member have restored some balance? All practicioners are, at one time or another, consumers too.

Totally agree.

Now,

Moving us all forward...encouraging members to shake hands, extending professionalism to each other in order for others to learn from our example.

OP initial post reads:

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Okay have been working in small ER over one year. I cannot remember How often and the maximum dose you can give of H and A. The larger ER I used to work 2 years ago that saw quite a bit of psych, used to start with 10mg Haldol and 2mg Ativan, then every so ofter till patient was calm. I had an out of control patient the other night and ther ER doc would not give more than 10 and 2, patient ended up in four point restraints and was still able to cause some minimal harm to staff and self. Any suggestions would be greatly appreciated.

Thanks all.

Wolfie

wonderbee, BSN, RN · Aug 21, 2008

In response to the original post, when working in a neuro trauma ICU setting, I've seen as much as Haldol 10/Ativan 5 IV push q2h for head injury combined with detoxing, a very common occurrence, which is something which might be seen in the ER setting. Of course in that setting, the patient is monitored 24/7. In the psych setting, I've seen Haldol 10/Ativan 2 for a forced med patient with paranoid schizophrenia. It was moderately effective. Never seen more than Ativan 2 in the psych setting.

motyandproudofit · Sep 9, 2008

I am a second semester nursing student. Tomorrow is my first clinical and my very first patient's dx: drug overdose, medications are Ativan 2mg and Haldol 5mg. I simply googled the two meds and found this discussion. It is has been very interesting. Thanks.