March 29, 2024

Welcome back to UH EMS-I’s Pharmacy Phriday. In our last installment, we reviewed Olanzapine. As the Prehospital Paradigm series monthly focus on psychiatric emergencies concludes, we will look at one more medication within the “Behavioral/Agitation/Combative” protocol.

Several options exist in the protocol for the provider to use when sedating the agitated patient. The choice of medications used can be based on many factors, including the specifics of the situation, the severity or degree of agitation, the possible cause of the agitation, the expectations and/or preferences of your individual medical director, and the level of certification of the provider to name just a few. 

Haloperidol, a medication that only the paramedic provider may administer, is recommended in cases of moderate agitation and would include patients who are a risk to themselves or others but are not necessarily violent (not in Hulk mode). Haloperidol is also the recommended sedative when the primary cause of the agitation is or a history of psychiatric psychosis exists.

Haloperidol is a first-generation antipsychotic medication that dates to the 1950s. The medication is believed to work by blocking dopamine receptors in the brain that control mood and behavior. It also provides a major tranquilizing effect for the treatment of the combative patient, and the use of the drug is considered a form of chemical restraint.

Prior to the use of Haloperidol, be sure that the criteria established within your protocol for chemical restraint are met. These considerations include an adult patient who cannot be calmed, who is out of control, a danger, and that the medication can be administered safely. It is worth noting that in cases where a patient poses a “significant” risk (Hulk mode) to the provider, Ketamine is the preferred choice for chemical restraint. Ketamine was reviewed in an earlier installment that is archived on the Prehospital Paradigm site and can be viewed by clicking here.

Though protocol indicates Haloperidol may be used as the single medication in these cases, it is often suggested that the agent be used in conjunction with a benzodiazepine, Midazolam being our first-line choice. Haloperidol has a longer onset time (some resources suggest 30-45 minutes), while Midazolam will most likely work quicker (15 minutes if given IM), calming the patient sooner and until Haloperidol takes effect. Another consideration is the use of physical restraints along with chemical restraint. Chemical and physical restraints should generally be used in combination with each other.  

Older providers may recall the “B-52” used for behavioral patients, which combined Haloperidol, Lorazepam, and Diphenhydramine (used for potential side effects discussed shortly) in one syringe. Current protocol and thought permit the use of these drugs together but does not permit the mixing of these medications in one syringe due to compatibility issues. 

Dosing of Haloperidol is 5 mg IM (preferably in the anterolateral thigh), given just once in the prehospital setting. In patients over 65 years of age, the dose is reduced to 2.5 mg. 

Haloperidol is not used in the pediatric patient within the UH protocols and should only be used in the pregnant or breastfeeding patient after a careful risk-benefit assessment. Haloperidol is not approved for dementia-related psychosis and is contraindicated in cases of Parkinson’s, CNS depression, severe cardiac disease, or liver disease. Care should be exercised in patients with a seizure history or disorder.

Haloperidol does have some notable side effects. Some of the more common side effects include extrapyramidal effects (EPS). Symptoms of EPS include an inability to sit still, involuntary muscle contraction, tremors, stiff muscles, and involuntary facial movements. Treatment of these adverse effects is managed with the use of Diphenhydramine. 

Other side effects such as Parkinsonism, Tardive Dyskinesia, Neuroleptic Malignant Syndrome, and even cardiac symptoms such as QTc prolongation or hypotension can occur from higher doses or long-term use of Haloperidol. But again, the most common side effects in the prehospital use and dose of Haloperidol are the EPS symptoms mentioned above.

The use of Haloperidol is considered sedation and thus requires thorough monitoring of the patient and transport by EMS. If we can monitor it, we should! These should include heart rate, EKG, blood pressure, Spo2, ETCO2, Glucose, GCS, MSPs, etc. And as you are monitoring the patient, be sure to look for possible causes of the agitation and treat appropriately during transport to a medical facility.

Most behavioral emergencies do not require medication administration in the prehospital setting. However, when the use of non-pharmacological measures such as de-escalation, removing the patient from the stressful environment or situation, and/or establishing a good rapport with the patient does not assure their safety or your crew’s safety, sedation with medications can provide a medical benefit and result in better patient care. 

With proper training, decision-making, and patient monitoring, sedation can be very effective and advantageous in treating the agitated patient. And Haloperidol is just one of the agents to consider. For further materials on this topic, seek out advice from your local medical director and check out the Prehospital Paradigm site for archived articles.

Till next time, stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals

September 29, 2023

Welcome back to UH EMS-I’s Pharmacy Phriday.  October 1st through the 7th is Mental Illness Awareness week, so in the next two issues of this column, we will look at two medications used in the “Behavioral/Psychiatric Emergencies” protocol, Haldol and Zyprexa. Both medications are also discussed in this month’s continuing education lecture written by Dr. Jordan Singer. In this issue, we will focus on Haldol.

Several options exist in the protocol for the provider to use when sedating the patient experiencing a behavioral emergency. The choice of medications used is often specific to the situation and severity or degree of agitation, as well as the cause of the agitation. Haldol is recommended for the combative, non-violent patient (not in Hulk mode) but is still a risk to self or others. Haldol is also the recommended sedative when the primary cause of the agitation is or a history of psychiatric psychosis exists.

Haldol is a first-generation antipsychotic medication that dates to the 1950s. The medication is believed to work by blocking dopamine receptors in the brain that control mood and behavior. It also provides a major tranquilizing effect for the treatment of the combative patient, and the use of the drug is considered a form of chemical restraint.

Prior to the use of Haldol, the paramedic provider should be sure to consider other treatable causes of the behavior and be sure that the criteria established within the UH protocol for chemical restraint are met. These considerations include an adult patient who cannot be calmed, who is out of control, a danger, and that the medication can be administered safely. It is worth noting that in cases where a patient poses a “significant” risk (Hulk mode) to the provider, Ketamine is the preferred choice for chemical restraint.

Though protocol indicates Haldol may be used as the single medication in a behavioral emergency, it is often suggested that the agent be used in conjunction with a Benzo, Versed being our first-line choice. Haldol has a longer onset time (some resources suggest 30-45 minutes) while Versed will most likely work quicker (15 minutes if given IM) calming the patient sooner and until Haldol takes effect. 

Older providers may recall the “B-52” used for behavioral patients that combined Haldol, Ativan, and Benadryl (used for potential side effects discussed shortly) in one syringe. Current protocol and thought permit the use of these drugs but does not permit the mixing of these medications in one syringe due to compatibility issues. 

Dosing of Haldol is 5 mg IM (preferably in the anterolateral thigh), given just once in the prehospital setting. In patients over 65 years of age, the dose is reduced to 2.5 mg. Haldol is not used in the pediatric patient within the UH protocols and should only be used in the pregnant or breast-feeding patient after a careful risk-benefit assessment. Haldol is not approved for dementia-related psychosis and is contraindicated in cases of Parkinson's, use with other antipsychotics, CNS depression, severe cardiac disease, or liver disease. Care should be exercised in patients with a seizure history or disorder.

Haldol does have some notable side effects. Some of the more common side effects include extrapyramidal effects (EPS). Symptoms of EPS include an inability to sit still, involuntary muscle contraction, tremors, stiff muscles, and involuntary facial movements. Treatment of these adverse effects is managed with the use of Benadryl. Other side effects such as Parkinsonism, Tardive Dyskinesia, Neuroleptic Malignant Syndrome, and even cardiac symptoms such as QTc prolongation or hypotension can occur from higher doses or long-term use of Haldol. But again, the most common side effects in the prehospital use of Haldol are the EPS symptoms mentioned above.

Besides monitoring for these possible adverse effects and being ready to administer Benadryl as needed, the provider should plan for the use of physical restraints. Monitoring the patient’s respiratory system via capnography, the patient’s EKG, and all vital signs will also be needed. 

Finally, be sure to consider crew safety when administering Haldol. As mentioned, administration is only approved for IM administration, and doing so with a combative patient can be a challenge. Assure that adequate personnel are available for the procedure and a clear plan is understood by all! 

Look for the October 2023 CE lecture “Psychiatric Emergencies” coming soon to a station near you for more on the sedation and restraint of agitated behavioral patients. The presentation will be archived HERE at the end of the month. 

You should also look for the Monday Morning Medical Director articles related to this topic. These weekly articles are written by our Medical Directors and focus on the various CE topics every month. Sign up to be on the mailing list HERE or access the archived articles at the pre-hospital paradigm site.

Thanks for all you do and have a great week!!

Sincerely,



The UH EMS-I Team

University Hospital