IM injection for out of control inmates

jaycrue · Dec 24, 2004

Hi all, I work in a max county jail. We seem to get all the mental patients who have been off their meds for who knows how long. If the inmate gets out of control and has to be placed in the restraint chair, our Dr. has me use a coctail of sorts: Hadol 5mg and Benedryl 50mg IM. This Tx is reserved for the really nutty ones. I mean, when there's no time to get out your little alcohol wipe and there's six officers holding this pt down, so you do an intradenim, if you know what I mean. I have found that this little coctail doesn't do anything for the real nuts. They will still be up thinking they're spiderman. What do you use for these circumstances. I would really like to deal with this in a more dignified manor with a coctail that actually works. I don't want to knock the pt out but would like to see them get some immediate relief from the psychosis. any suggestions would be great, esp. if it's something with good clinical results that I can present to the Dr. Our mental health provider is noooo.. help. Thanks, T

How old are your dr.s?

We use a variety of antipsychotics, I haven't given much less seen an order for haldol in about two years.

Clopixol-acuphase or zuclopenthixol acetate 50-75 mg.

Olanzapine IM 25mg and ativan IM 2mg

we also have Respirodone IM in use

Interested Party · Dec 25, 2004

Hi all, I work in a max county jail. We seem to get all the mental patients who have been off their meds for who knows how long. If the inmate gets out of control and has to be placed in the restraint chair, our Dr. has me use a coctail of sorts: Hadol 5mg and Benedryl 50mg IM. This Tx is reserved for the really nutty ones. I mean, when there's no time to get out your little alcohol wipe and there's six officers holding this pt down, so you do an intradenim, if you know what I mean. I have found that this little coctail doesn't do anything for the real nuts. They will still be up thinking they're spiderman. What do you use for these circumstances. I would really like to deal with this in a more dignified manor with a coctail that actually works. I don't want to knock the pt out but would like to see them get some immediate relief from the psychosis. any suggestions would be great, esp. if it's something with good clinical results that I can present to the Dr. Our mental health provider is noooo.. help. Thanks, T

Hi

I work in Mental Health in Queensland, Australia. We have a Medium Secure Unit which holds mainly Forensics patients and Psychiatric Intensive Care Unit within each acute inpatient units. We use Acuphase, Olanzapine and Midazolam as these are quick acting IMI.

I also work in the Community and we administer Haldol and Risperdal Consta, Zuclopenthixol, Flupenthixol and minimal Modecate as these are long acting IMI depots.

We hardly do 'intradenim' due to infection control. We rely on really good techniques of take-down and also numbers of persons. So, have nurses ready to administer fast acting IMI and they are usually not involved in the take-down. We do not have restraints such as the 'chair', it's against the law. But patients who have been given fast acting IMI and have been violent and aggressive are usually placed in seclusion under some kind of observation, even if they are a Forensic patient.

I have not heard of Haldol IMI being used in the circumstances you mention for a very, very long time. And yes, how old are your psychiatrists? There have been a lot of research and evidence based practise policies about management of violent, aggressive and basically really unwell patients. And I mean there are lots of research on it. I can recall nurses going to the Union because their doctors would not budge from their usual practise.

I hope my input has helped.

IP

nurseT · Dec 25, 2004

Thank You So Much.

Can You Tell Me Where To Look For The Research On These Meds?

Interested Party · Dec 26, 2004

Thank You So Much.
Can You Tell Me Where To Look For The Research On These Meds?

I discussed your question and predicament with other nurses (NZ, UK, Aust trained & experienced) at work last night. First, we need to clarify Benedryl as this is a cough mixture here. Did you mean cogentin/benztropine? And could Haldol be Haloperidol fast acting? Certainly, I received a united response that there are better IMI that can be used which are more effective. What you can do is ring up the drug companies (such as Eli Lilley, Lundbeck, Sandoz, Janssen Cilag, Pharmalab, Sigma etc) and speak with the drug rep in your area. If they work the same in the US as they do in Aust, then they can come and conduct an inservice for all staff concerned including psychiatrist to introduced their products. Plus they have the most up to date research which their companies have conducted and comparison studies between their product their competitors .......and will willingly share their findings. Expect some degree of biasness from them as they are trying to promote their own products. Ring them & invite them all to 'sell' their products. When the drug rep comes to see us, they usually come with beakfast, lunch or even drug company dinners. Be specific about IMI, when you speak with them.

Get back to me if you need anything else ......................... I try to help as much as possible

nurseT · Dec 26, 2004

Thank you for your reply and information. The benedryl is an antihistamine that comes in an injectable form. The purpose for the benedryl is to cause drowsiness. The Haldol is Haloperidol. It is considered a good antipsychotic here in the states. The Haldol dose can be increased every 30 minutes until tranquility is achieved. Then the total dose is divided in two and half is given BID to maintain. This is my first experience with psych patients and I am unfamiliar with some of the meds used. The laws here are a little different than in Australia. And a county jail is not a healthcare facility, so some things I can't do. I have an inmate now who is Bipolar. The reason he is there is because he quit taking his meds and is really kooky. He went into the local police station and ripped off his shirt and said " come on you mother ****ers, I'll kick all your asses". And he did. He is very aggressive, can be violent without warning and is a danger to others. We have him in isolation because he would harm another inmate. He has been taking his lithium for me for 10 days now but has literally been awake for 2 weeks that I know of. We tried to add Zyprexa but it made him sleepy and he doesn't want to sleep so he refuses to take it. Our mental health facilities are overcrowded and they will let him stay in jail until they have a bed because they think he's safer in jail than on the street, but this puts the jail at risk.

I discussed your question and predicament with other nurses (NZ, UK, Aust trained & experienced) at work last night. First, we need to clarify Benedryl as this is a cough mixture here. Did you mean cogentin/benztropine? And could Haldol be Haloperidol fast acting? Certainly, I received a united response that there are better IMI that can be used which are more effective. What you can do is ring up the drug companies (such as Eli Lilley, Lundbeck, Sandoz, Janssen Cilag, Pharmalab, Sigma etc) and speak with the drug rep in your area. If they work the same in the US as they do in Aust, then they can come and conduct an inservice for all staff concerned including psychiatrist to introduced their products. Plus they have the most up to date research which their companies have conducted and comparison studies between their product their competitors .......and will willingly share their findings. Expect some degree of biasness from them as they are trying to promote their own products. Ring them & invite them all to 'sell' their products. When the drug rep comes to see us, they usually come with beakfast, lunch or even drug company dinners. Be specific about IMI, when you speak with them.
Get back to me if you need anything else ......................... I try to help as much as possible

Interested Party · Dec 26, 2004

The main thing that you want to achieve for this person is to have him sleep. For as long as he resist sleep and does not sleep, he will remain unpredictable and aggressive. Is his condition drug induced? How long has he been in custody and behaving like this? Were you giving him oral zyprexa? Was he more settled when he was complaint with Zyprexa? If he was more settled then perhaps you ought to consider the fast acting Zyprexa IMI, which I think can be prescribed 10mg TDS as required. Perhaps you can liaise with the mental health facility to have him reviewed by their psychiatrist. It is unfair that you have to nurse some one who has a condition which you are unfamiliar with. Do they have a consultation liaison nurse or mobile assessment team who can come out and assess this person properly? Is the Lithium making much difference at all in his presentation?

Try to negotiate with him (I am assuming that he was given an IMI when he first arrived) ........... Educate him on importance of sleep, how it impairs one's judgement etc, then tell him that you are aware that Zyprexa will make him sleepy and that is what the treating team is trying to achieve eg sleep. If he is still resistant then you would have to offer him a choice, have oral Zyprexa or you would have to get the team in, restrained him and IMI ( Zyprexa) him. And if he is still resistive you have to act on your 'threat'. If you have to do this, he is not going to like you but you don't really have much choice.

But then again, I hope the MH facility can come up with a bed soon. Then, of course, you will need to think about safety in transferring him to that facility.

I hope this helps, it is frustrating for me, being unfamiliar with your laws, MH legislation etc. Which part of the US are you in anyway? One other thing, I usually pray heaps when I have to deal with non compliant patients who are so unwell .........................................

Get back to me OK...........................

nurseT · Dec 26, 2004

The main thing that you want to achieve for this person is to have him sleep. For as long as he resist sleep and does not sleep, he will remain unpredictable and aggressive. Is his condition drug induced? How long has he been in custody and behaving like this? Were you giving him oral zyprexa? Was he more settled when he was complaint with Zyprexa? If he was more settled then perhaps you ought to consider the fast acting Zyprexa IMI, which I think can be prescribed 10mg TDS as required. Perhaps you can liaise with the mental health facility to have him reviewed by their psychiatrist. It is unfair that you have to nurse some one who has a condition which you are unfamiliar with. Do they have a consultation liaison nurse or mobile assessment team who can come out and assess this person properly? Is the Lithium making much difference at all in his presentation?
Try to negotiate with him (I am assuming that he was given an IMI when he first arrived) ........... Educate him on importance of sleep, how it impairs one's judgement etc, then tell him that you are aware that Zyprexa will make him sleepy and that is what the treating team is trying to achieve eg sleep. If he is still resistant then you would have to offer him a choice, have oral Zyprexa or you would have to get the team in, restrained him and IMI ( Zyprexa) him. And if he is still resistive you have to act on your 'threat'. If you have to do this, he is not going to like you but you don't really have much choice.
But then again, I hope the MH facility can come up with a bed soon. Then, of course, you will need to think about safety in transferring him to that facility.
I hope this helps, it is frustrating for me, being unfamiliar with your laws, MH legislation etc. Which part of the US are you in anyway? One other thing, I usually pray heaps when I have to deal with non compliant patients who are so unwell .........................................
Get back to me OK...........................

Thanks, I did not know Zyprexa came in an injectable form. He thinks he has passed through some physical barrier an no longer requires sleep. He cannot be reasoned with. You are right on offering him the oral or IM. I will run it by the Doctor. I called the MH we use. They came out to do an evaluation and since he refused to talk to them due to some other goofy delusion he has, they just left and have not offered to come back nor offer any medication suggestions. The Lithium has made some difference. He did think he was a kung fu fighter or spider man. He is at least eating and toileting his self. We were able to send him to the lab for a lithium level which was 0.9. Our average theraputic levels here are 0.5 to 1.5.

Nurse Ratched, RN · Dec 26, 2004

Sounds like someone needs an order for "may force meds" - then lots of people to make that happen. It's wonderful how many antipsychotics are coming in injectable form now :).

wam79 · Dec 26, 2004

Zyprexa also comes as a sl "disc" called Zydisc that can be used oraly. It will disolve when taken to assure that the patient is getting the med. We prefer to use this with patients that are acutely ill to be sure they don't cheek the meds, and to get the patient his meds as quick as possible. The primary goal is to get the patient to sleep.

Here it is illegeal to keep someone in jail if they are deemed mentaly ill. The person would be transfered to the state hospital immediately by the corrections dept.

nurseT · Dec 26, 2004

I wish it was illegal here.

Interested Party · Dec 27, 2004

Zyprexa also comes as a sl "disc" called Zydisc that can be used oraly. It will disolve when taken to assure that the patient is getting the med. We prefer to use this with patients that are acutely ill to be sure they don't cheek the meds, and to get the patient his meds as quick as possible. The primary goal is to get the patient to sleep.
Here it is illegeal to keep someone in jail if they are deemed mentaly ill. The person would be transfered to the state hospital immediately by the corrections dept.

Yes, you can get the 'wafer' Zyprexa and they work well also if they are willing to take it. The 'wafer' tend to lose it's potency/effectiveness if left exposed to air or handled by hand because it starts dissolving when in contact with any kind of 'watery' surface. We have had occassions where patients have spat it out quickly enough. Well, I hope that Zyprexa 'wafer' & IMI is available where you are. And sorry that you are not supported well by the MH institution.