SEDATION OF THE AGITATED PATIENT WITH MEDICATION
Introduction
This Guideline brings together the various elements of the sedation of patients from other Guidelines in this document. Medication-assisted sedation of the severely agitated, delirious, combative, drug impaired, and impaired violent patient who poses a risk of harm to themselves and others is safer and more effective than physical restraint. Patients in these hypermetabolic states are at risk for disability or death, and using physical restraints places them at heightened risk for a poor outcome. Sedation is only undertaken under the following conditions. The individual has been turned over to EMS as a patient, a medical indication for sedation is established, and transport to an appropriate medical facility is available within a reasonable amount of time.
As noted, the treating paramedic and team make the decision to sedate a patient with medications. Medication-assisted sedation is not a law enforcement decision. However, officers may be the source of the referral and may be needed to assist in restraining the patient during medication administration. Always act to ensure the patient's safety and well-being.
Guideline
1. The patient may be the subject of a 911 call, a referral from the MIH/LIGHT team, or law enforcement. In all cases the subject must be turned over to EMS as a patient to determine the needs of the patient and whether sedation is indicated.
2. All patients need to be assessed to the extent that the patient’s condition allows including a history and a physical examination.
3. Sedation has significant risks and should only be done for the safety and well-being of the patient and care providers.
4. Once it is determined that sedation is indicated it is paramount that all equipment, manpower, and medications are prepared before an attempt to sedate is made. Personnel will be prepared to administer the medication, monitor the patient, and manage any adverse events. Adverse events are rare but need to be anticipated.
5. The following medications are approved for medication assisted sedation:
A. KETAMINE is a NM Special Skill medication. The dose is 2-4 mg./kg. IM. It is generally effective within five minutes. Limited to patients 13 years and older.
B. MIDAZOLAM is a benzodiazepine. The dose is 5-10 mg. IM. It may take up to 20 minutes to become effective.
C. The choice of medication is up to the treating paramedic. In general, pure cases of psychosis from schizophrenia, manic psychosis, or other isolated psychoses without drug involvement can be managed best with MIDAZOLAM. Ketamine can aggravate psychosis. If psychoactive drugs may be involved KETAMINE may be the preferred agent.
D. Once sedation appears effective and the patient is calm and able to cooperate all physical restraint and restraints should be removed including “The WRAP”. The patient must be kept in a comfortable position that facilitates breathing and hemodynamic stability.
E. The patient should be closely monitored by a paramedic. Vital signs, pulse oximetry, and end tidal CO2 will be monitored as well as the patient’s airway and ventilation. Transport to a medical facility should be undertaken when it is safe to do so.
6. In unusual situations where KETAMINE appears to be ineffective or even aggravates the patient’s agitated state it is safe to administer MIDAZOLAM. Again, it is necessary to monitor the patient for compromised breathing with two sedating medications in their system.
7. For the MIH/LIGHT team it is important that a transporting unit be available within a reasonable period of time in order to safely sedate and transport the patient.
8. For MINOR patients there is the opportunity to obtain informed consent from parents or guardians. This opportunity may be taken and a good faith effort made to obtain consent before any medication administration. If no opportunity exists to get informed consent on behalf of the minor patient exercise clinical judgement in determining the appropriateness of sedation in an emergency situation.
9. PEDIATRIC patients represent an unusual and vulnerable population. Nevertheless, the need for sedation in select severely agitated patients does arise. Again, the opportunity for informed consent is present and should be pursued with the patient’s parents or guardians. KETAMINE has not been extensively studied in pediatric patients and is not recommended below the age of 13. MIDAZOLAM is the preferred medication for sedation. The dose is 0.2 mg./kg. given IM. Maximum dose is 10 mg.
10. Patients being transported from a facility should be sedated by the facility staff at the facility. No one should be placed in an ambulance unit who is not safe and comfortable in a gurney.
a. Thorough history and understanding of medication used to sedate a patient by a facility will be obtained.
b. Contact medical control for direction on continuing sedation if necessary, during transport.
c. Collaboration with the facility is necessary to ensure safety of the patient and responders.
Introduction
This Guideline brings together the various elements of the sedation of patients from other Guidelines in this document. Medication-assisted sedation of the severely agitated, delirious, combative, drug impaired, and impaired violent patient who poses a risk of harm to themselves and others is safer and more effective than physical restraint. Patients in these hypermetabolic states are at risk for disability or death, and using physical restraints places them at heightened risk for a poor outcome. Sedation is only undertaken under the following conditions. The individual has been turned over to EMS as a patient, a medical indication for sedation is established, and transport to an appropriate medical facility is available within a reasonable amount of time.
As noted, the treating paramedic and team make the decision to sedate a patient with medications. Medication-assisted sedation is not a law enforcement decision. However, officers may be the source of the referral and may be needed to assist in restraining the patient during medication administration. Always act to ensure the patient's safety and well-being.
Guideline
1. The patient may be the subject of a 911 call, a referral from the MIH/LIGHT team, or law enforcement. In all cases the subject must be turned over to EMS as a patient to determine the needs of the patient and whether sedation is indicated.
2. All patients need to be assessed to the extent that the patient’s condition allows including a history and a physical examination.
3. Sedation has significant risks and should only be done for the safety and well-being of the patient and care providers.
4. Once it is determined that sedation is indicated it is paramount that all equipment, manpower, and medications are prepared before an attempt to sedate is made. Personnel will be prepared to administer the medication, monitor the patient, and manage any adverse events. Adverse events are rare but need to be anticipated.
5. The following medications are approved for medication assisted sedation:
A. KETAMINE is a NM Special Skill medication. The dose is 2-4 mg./kg. IM. It is generally effective within five minutes. Limited to patients 13 years and older.
B. MIDAZOLAM is a benzodiazepine. The dose is 5-10 mg. IM. It may take up to 20 minutes to become effective.
C. The choice of medication is up to the treating paramedic. In general, pure cases of psychosis from schizophrenia, manic psychosis, or other isolated psychoses without drug involvement can be managed best with MIDAZOLAM. Ketamine can aggravate psychosis. If psychoactive drugs may be involved KETAMINE may be the preferred agent.
D. Once sedation appears effective and the patient is calm and able to cooperate all physical restraint and restraints should be removed including “The WRAP”. The patient must be kept in a comfortable position that facilitates breathing and hemodynamic stability.
E. The patient should be closely monitored by a paramedic. Vital signs, pulse oximetry, and end tidal CO2 will be monitored as well as the patient’s airway and ventilation. Transport to a medical facility should be undertaken when it is safe to do so.
6. In unusual situations where KETAMINE appears to be ineffective or even aggravates the patient’s agitated state it is safe to administer MIDAZOLAM. Again, it is necessary to monitor the patient for compromised breathing with two sedating medications in their system.
7. For the MIH/LIGHT team it is important that a transporting unit be available within a reasonable period of time in order to safely sedate and transport the patient.
8. For MINOR patients there is the opportunity to obtain informed consent from parents or guardians. This opportunity may be taken and a good faith effort made to obtain consent before any medication administration. If no opportunity exists to get informed consent on behalf of the minor patient exercise clinical judgement in determining the appropriateness of sedation in an emergency situation.
9. PEDIATRIC patients represent an unusual and vulnerable population. Nevertheless, the need for sedation in select severely agitated patients does arise. Again, the opportunity for informed consent is present and should be pursued with the patient’s parents or guardians. KETAMINE has not been extensively studied in pediatric patients and is not recommended below the age of 13. MIDAZOLAM is the preferred medication for sedation. The dose is 0.2 mg./kg. given IM. Maximum dose is 10 mg.
10. Patients being transported from a facility should be sedated by the facility staff at the facility. No one should be placed in an ambulance unit who is not safe and comfortable in a gurney.
a. Thorough history and understanding of medication used to sedate a patient by a facility will be obtained.
b. Contact medical control for direction on continuing sedation if necessary, during transport.
c. Collaboration with the facility is necessary to ensure safety of the patient and responders.