Haldol IV?

[RelleyRN]

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.

[JER006, MSN, APRN, NP]

We give 5mg IV all the time.

[michlynn, BSN, RN]

We give it IV more times than not, usually in a 50cc IV piggyback. All of our patients are on tele monitors.

[macawake, MSN]

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.

OP, this is something that I was wondering about when I read your post but I forgot to ask you about it in my previous post. Did the physician (or you) have any theories of what happened to the patient to cause this change in status? There are a few possibilities that come to mind and need to be ruled out.

Why was the patient in the ED in the first place (chief complaint)?

Medical history? Other medications?

[Oh'Ello, BSN, RN]

EPS-dystonia. We give IV haldol all the time. Its a part of our chemotherapy anti-emetic regimen and these EPS pop up from time to time when we first start giving the drug. Combat it with a Benzo or Benzotropine (anticholinergic). That usually fixes the problem.

[canigraduate]

There's not really enough information for me in the OP. What was the pt's problem? Did they have comorbidities? What do you mean by contracted? Full body, limb, specific muscle group? Where there any other s/sx that it was the Haldol that was the problem and not the pt's original dx?

I agree with another poster that if there was an underlying seizure disorder, the Haldol could have reduce the seizure threshold enough to trigger an episode. I also think the poster that brought up EPS has a point.

As far as the commonality of IV Haldol, I've given it multiple times to multiple demographics. 2mg is not a high dose, especially several hours apart. If you were giving 5mg every time and on schedule (rather than spaced out as you did), then I would be much more worried about side effects.

[Twinmom06, ASN, APN]

I've given it IV more often than IM although the other night I gave IM ativan because the pt went ballistic after awaking from an OD on Elavil. He'd pulled out his IV in the time I went to the med room and came back - it was fairly effective at calming him enough to put him in restraints so the 7 security guards could let him go so they could intubate him.

[Anna Flaxis, BSN, RN]

Yes, you can give Haldol IV- it is an off label use, but it's not uncommon. 2mg over two hours is not a huge dose. It sounds like a possible dystonic reaction, but it's hard to say. I have had patients "play possum" with me on a few occasions, where their apparent unresponsiveness was behavioral. I'm glad the patient is okay. Did you notify the physician?

[toomuchbaloney]

There's not really enough information for me in the OP. What was the pt's problem? Did they have comorbidities? What do you mean by contracted? Full body, limb, specific muscle group? Where there any other s/sx that it was the Haldol that was the problem and not the pt's original dx?

I agree with another poster that if there was an underlying seizure disorder, the Haldol could have reduce the seizure threshold enough to trigger an episode. I also think the poster that brought up EPS has a point.

As far as the commonality of IV Haldol, I've given it multiple times to multiple demographics. 2mg is not a high dose, especially several hours apart. If you were giving 5mg every time and on schedule (rather than spaced out as you did), then I would be much more worried about side effects.

I agree.

My first thought when reading about the change in LOC and "contracted" limbs was that the fellow seized.

the dose is not too high and IV Haldol is an acceptable route.

[RelleyRN]

Hi all thanks for your responses. The background is the patient developed SOB after dialysis at a SNF. Admit dx COPD/CHF exac. He was on tele, sinus brady in the high 50s throughout the night. During the sternal rub it was reading vtach but unsure that was accurate. It was his arms and fingers that were contracted. The physician was notified but by the time he got to the floor the pt was waking to verbal stimuli, although his speech initially was unintelligible. He questioned possible seizures. I'm wondering if NMS was starting DT pts renal failure.

[RelleyRN]

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.

The patient did not receive any benzos, opiates, or antipsychotic in the ED. RR & sa02 were wnl

[CelticGoddess, BSN, RN]

We give IV haldol all the time. IF the dose is 5mg or greater or if the patient will get 10mg or more in a 24hour period, hospital policy is the patient must be on tele. (Because of QT segment prolongation issues).

I have found that haldol is worthless most of the time. Not sure how everyone else finds it but We'll give 2mg Haldol x 3 doses (Over 5 to 8 hours) and the patient is still smacking the nurses across the face with the plate covers. (yes that happened to me, nearly broke my nose)

[MunoRN, RN]

FDA approval doesn't determine how a medication can be used, it determines how it can be marketed. Once it's on the market it's use is basically a free-for-all legally speaking. Like many drugs, haldol did not seek approval as IV and IM separately, it was approved as "for injection" or IV/IM.

IV is often preferred because it considered safer (the initial dose can be more easily titrated to the optimal dose, whereas with IM it's more common to give a larger initial dose).

The need for continuous telemetry monitoring for a patient receiving haldol is controversial. There really isn't any evidence that it's significantly different than any other QTc prolonger, which typically aren't recommended to be on continuous telemetry monitoring. There is evidence that a single 12 lead when levels would be at their highest is not only sufficient but more accurate.