Emergencia comportamental 2 (contención farmacológica)

Pharmacological Containment in Behavioral Emergencies

Introduction to Pharmacological Containment

• The seminar focuses on pharmacological containment within the context of behavioral emergency patients, emphasizing that all guidelines agree on its necessity.

• Pharmacological containment can refer to sedation or anxiolysis; not all behavioral emergencies require sedation.

Understanding Sedation

• Sedation is defined as bringing a patient to a state of drowsiness while maintaining responsiveness to minor stimuli.

• The goal is for the patient to be able to open their eyes and respond when prompted, indicating a state known as superficial sedation.

• Continuous monitoring of vital signs (heart rate, respiratory rate, oxygen saturation) is essential during sedation.

Indications for Sedation

• Sedation is indicated in cases where physical restraint has been used due to potential complications related to stressors.

• If a patient is immobilized but conscious, they may experience increased agitation; thus, sedation might be necessary.

Special Considerations for Different Patients

• In elderly patients with delirium requiring trunk and pelvis immobilization, sedation may not always be needed unless more extensive restraints are applied.

• High-risk situations such as severe withdrawal symptoms in substance-dependent patients may necessitate sedation even if physical restraint isn't required.

Verbal Containment vs. Pharmacological Intervention

• Verbal containment often fails to address the underlying reasons for behavioral emergencies; resistance to hospitalization is common.

• Relying solely on verbal techniques can lead to repeated calls from staff if the patient's agitation persists after initial intervention.

Recommended Therapeutic Agents

• Benzodiazepines are preferred for both sedation and anxiolysis due to their effectiveness but carry risks like respiratory depression.

• A balance must be struck between respect and caution when using benzodiazepines; understanding the sedative index is crucial for safe administration.

Conclusion: The Art of Medicine

• Medicine requires an understanding of individual responses rather than relying solely on statistical data; this applies particularly in determining dosages for medications like midazolam.

Understanding Sedation in Emergency Medicine

Importance of Sedation Management

• The goal of sedation is to achieve an appropriate level with minimal medication applications, reducing the risk of complications.

• It’s crucial to find the sedation index while avoiding cumulative effects; the drug's half-life differs from its total elimination time.

• Administering multiple doses too close together can lead to over-sedation and respiratory depression, especially if not monitored properly.

Drug Selection and Safety

• Understanding the antagonism of sedatives is vital; for instance, phenobarbital lacks an antagonist, necessitating careful dosage management.

• Benzodiazepines like midazolam are preferred due to their shorter action half-lives, allowing for easier management of over-sedation.

Dosing Guidelines

• The recommended dosing range for midazolam is between 0.04 mg/kg and 0.4 mg/kg; closer doses to 0.04 mg/kg aim for anxiolysis.

• Higher doses may be required based on individual patient responses and specific emergency situations, particularly in behavioral emergencies.

Practical Application in Emergencies

• For behavioral emergencies, starting doses should be around 0.1 to 0.15 mg/kg; this often results in effective sedation without significant adverse effects.

• A typical dose for a 70 kg adult would be approximately 10.4 mg when starting at 0.15 mg/kg, using standard ampoules available in emergency settings.

Monitoring and Adjustments

• Experience shows that initiating treatment at lower doses (e.g., 0.15 mg/kg) rarely leads to respiratory depression if titrated correctly.

• Sedation aims to bring patients into a state of somnolence while managing cumulative dosing risks associated with benzodiazepines effectively.

By following these guidelines and understanding the pharmacological principles behind sedation, healthcare providers can ensure safer practices during emergency interventions.

Sedation Dosing in Psychiatry

Importance of Estimating Patient Weight

• It is crucial for healthcare providers to estimate a patient's weight before administering sedation. This helps ensure accurate dosing and patient safety. For example, estimating a patient’s weight between 70-75 kg allows for better control during the procedure.

Calculating Initial Sedation Doses

• The recommended initial sedation dose in psychiatry typically ranges from 0.1 to 0.15 mg/kg. Most patients respond well to this dosage, which serves as a baseline for further adjustments if necessary.

Evaluating Sedation Effectiveness

• There are two primary outcomes when assessing sedation effectiveness:

• Ineffective Dose: No effect observed.

• Partially Effective Dose: Some calming effects but no full sedation achieved; monitoring is essential to determine the next steps in treatment.

Adjusting Dosage Based on Response

• If a patient remains combative after an initial dose, it may be necessary to increase the dosage significantly rather than making minimal adjustments (e.g., moving from 0.15 mg/kg directly to 0.20 mg/kg). This approach aims to achieve effective sedation more efficiently and safely.

Considerations for Tolerance and Resistance

• Patients who do not respond adequately to initial doses may have developed tolerance due to prior benzodiazepine use, necessitating careful consideration of alternative medications or higher dosages while being mindful of potential respiratory depression risks associated with increased sedative use.

Emergency Management of Behavioral Emergencies

Use of Antihistamines in Emergencies

• The discussion begins with the recommendation to use hydroxyzine and diphenhydramine for effective management, focusing on their impact on histamine receptors.

• Emphasizes that these medications are safe with minimal risk of respiratory depression, making them suitable for patients who do not respond to initial treatments.

Indications for Antipsychotics

• Clarifies that haloperidol is not a true sedative; it acts as an antagonist without significant sedative effects, which can lead to bradycardia in some patients.

• Antipsychotics should only be used in behavioral emergencies when there is a psychotic origin or high violence potential, requiring careful assessment before administration.

Identifying High-Risk Situations

• Highlights the importance of recognizing individuals from military backgrounds or those with violent histories during behavioral emergencies.

• Advises against using antipsychotics unless specific indicators are present; benzodiazepines may be preferred otherwise.

Dosage Guidelines for Haloperidol

• Discusses appropriate dosing ranges for haloperidol (1 to 10 mg per day), stressing the need to avoid outdated mega doses.

• Recommends starting doses between 2.5 mg and 5 mg within 24 hours, adjusting based on patient response and route of administration.

Alternatives and Risks in Treatment

• Suggests considering alternatives like injectable medications over haloperidol due to lower risks associated with neuroleptic malignant syndrome.

• Concludes that if haloperidol is necessary, dosages should remain low (up to 7.5 mg per day), ensuring safety while managing behavioral control effectively.

Patient History Considerations

• Stresses the importance of interviewing patients about previous experiences with antipsychotics before administering haloperidol.

• Warns against using metoclopramide as it may induce anxiety symptoms similar to those caused by potent dopamine antagonists like haloperidol.

Medication Dosing and Management in Behavioral Emergencies

Initial Dosing Considerations

• The importance of calculating the initial dose carefully is emphasized, with a recommended starting range of 0.1 to 0.15 mg/kg for effective management.

• The necessity of titrating the dose based on effectiveness is discussed, particularly in cases where psychosis contributes to behavioral emergencies.

Administration Routes and Dosage Adjustments

• In situations where oral administration isn't possible, intramuscular dosing is suggested, with a maximum of 5 mg over 24 hours being highlighted as a safe limit.

• If patients are cooperative but still agitated, oral sedation options like clonazepam or lorazepam can be considered, depending on their risk level.

Sedation Options and Guidelines

• Clonazepam is available in various forms including tablets and drops; dosage calculations should consider the concentration (2.5 mg/mL).

• Typical adult sedation doses are around 2 mg for lorazepam and approximately 11.5 mg for clonazepam, calculated at about 0.3 mg/kg.

Alternative Medications for Sedation

• Antipsychotics such as olanzapine and quetiapine may provide additional sedative effects; however, caution is advised regarding their dosages.

• Additional doses of antipsychotics can be administered without exceeding daily limits (20 mg/day for olanzapine).

Anxiolytic Dosing Strategies

• For anxiety management during behavioral emergencies, lower doses (0.04 to 0.09 mg/kg) are recommended before escalating to sedation levels.

• Maximum dosing limits for lorazepam (up to 6 mg per dose) and clonazepam (up to 4 mg per dose), with a total daily cap of 12 mg across both medications, must be adhered to ensure patient safety.

Pharmacological Management of Behavioral Emergencies

Dosage Considerations for Clonazepam and Lorazepam

• The speaker discusses administering less than 0.3 mg/kg of clonazepam, emphasizing the importance of dosage in managing anxiety.

• They suggest that lorazepam can be given at doses ranging from 0.5 mg to 1.5 mg in adults, highlighting its effectiveness in treating anxiety-related symptoms.

Managing Behavioral Emergencies

• The speaker reflects on a behavioral emergency (grade 2), noting that collaboration from the patient is crucial despite ongoing anxiety.

• They recommend conducting thorough assessments, such as 3D analyses, to understand pharmacological effects during emergencies.

Importance of Initial Dosing

• Emphasizing the need for appropriate initial dosing, the speaker advises against being overly cautious with medication to prevent cumulative effects.

• They stress that if a second or third dose is required without response, alternative strategies like antihistamines should be considered.

Guidelines and Resources for Decision-Making

• The speaker encourages reviewing various guidelines (Spanish guidelines, NICE guidelines, etc.) to prepare for decision-making during patient management.

• They highlight the necessity of being well-informed so healthcare professionals can confidently respond when asked about medication dosages by colleagues.