Pyschotic Trauma Patients

[maranara]

Hello!

I'm looking for some information on how other trauma facilities deal with pyschotic(either chronically diagnosed or acute pyschotic episodes) patient populations. Our unit needs an effective treatment plan for these folks. Currently, our trauma surgeons tend to bypass consulting psychiatrists & instead treat these patients by intubating &/or sedating. It's obviously not working! Our vent days & LOS days are sky-high. Any advice is appreciated!

[PAERRN20]

Sadly we do the same thing. If they are combative, psychotic, or any other way a threat they get tubed . Wish I had an answer for you.

[Whispera, MSN, RN]

are they tubed because they're too knocked out to breathe without being tubed? this strikes me as so inappropriate and possibly even illegal...

our protocol was Haldol, Ativan, restraints, and someone watching at all times

[JulieCVICURN, BSN, RN]

We also intubate if they can't be calmed with other methods. It's necessary to keep them from injuring themselves. Sad that it comes to this, but sometimes it's the only way.

[alem-tsahai]

Wow I've never heard of that, that sounds kinda nuts!! We put our active psychotics in 4-point restraints, give them ativan/haldol and keep them on 1:1 watch.

We get some seriously psychotic peeps too- they are usually brought in thrashing and screaming and escorted by a team of police officers as well as EMS. Never has intubation been considered. Then again, I don't work in a trauma facility.

I'm very curious to learn more about this. The concept of intubating a psychotic patient just strikes me as completely bizarre, but I'm assuming that these facilities have very good reasons for doing this. What is usually the presentation of these patients? I really want to understand.

thx

[meandragonbrett]

We often times intubate for their safety.

[RNperdiem, RN]

Often the patients come in from the field intubated.

Weaning them off the vent is really difficult. If you wean their sedation even a little bit, they wig out.

I am curious if other places do things differently.

[maranara]

Our patients typically come in due to MVC's & shooting/stabbings. Granted, this population is no stranger to drugs; street or pharmaceuticals. A lot of times they do come in intubated. We work hard to extubate patients who don't have a respiratory reason to be vented. A lot of these patients do have mental health disorders. When they have a psychotic episode in our unit, we may or may not try a little Haldol or a little Geodon; but typically our trauma docs intubate & sedate. We don't feel as if this is a solution. Of course, starting these patients on antipyschotics would be appropriate but that is not our culture. I'm wondering if any one has advice or an example of a delirum/pyschosis protocol. We actually haven't thought of making these patients strict 1:1's, probably because our staffing wouldn't allow this.

[maranara]

How do you wean from the vent when they seem to be in a manic state for weeks? We have had people in our trauma unit for weeks on end, trach'd & peg'd; on & off the vent when they get crazy. Sure, it's easier to take care of them when they are vented/sedated/restrained, but we are craving another way for our patients.

[Whispera, MSN, RN]

Antipsychotic meds (haldol, thorazine, geodon) aren't just for calming a patient down. The calming effect is a side effect that's quite helpful however. What they're for in the long run, is they take away the hallucinations, paranoia, and other things that make the person out of control. Just sedating a person only puts off dealing with the underlying problem of the mental illness. As soon as the difficult weaning process is begun, the psychosis/mania will be back in full force. He might also go through withdrawal symptoms from whatever medication has been used to sedate him, if it's one that one can build dependence on (Ativan, other benzodiazepines, and others), and he's been on it long enough.

I think it's incredibly cruel to sedate a person so much that he will need ventilator weaning, because it's easier on staff, if he doesn't need sedation for a medical purpose. It's setting the facility and the patient up for so many future problems.

Your facility needs restraints....for arms, legs, waist, wrists, ankles, etc. There's an item called the "net" that is a full body restraint thing. You also need a protocol for what people need to do to protect the patient and themselves during times restraining is required. Once anti-psychosis medications kick in, the restraints won't be needed so much. I'm not saying it is easy--I know it's NOT.

How about calling a local psych hospital or getting input from the psych unit where you work, if there is one, on what should be done?

[Da_Milk_of_Amnesia, MSN]

I work at a Level 2a trauma/stroke center. I have personally tubed 2 patients who were suffering from the DTs and they was just no way to keep them calm or safe. It's usually short term and just to get them through the withdrawal and then we work hard to get them extubated.

[Whispera, MSN, RN]

Intubating for DTs is different than intubating for other psychosis/mania. I support that intubation.