Behavioral Emergencies

1. BehavioralEmergencies EMS 230 Pharmacology II for EMS

2. Objectives Define the term behavioral emergency List the intrapsychic causes of altered behavior Explain interpersonal and environmental causes of behavioral emergencies Describe and list the indications, contraindications, and dosages for medications used in the management of behavioral emergencies in the prehospital setting

3. Behavioral Emergencies A behavioral emergency is an intrapsychic, environmental, situational, or organic alteration that results in behavior that cannot be tolerated by the patient or other members of society It usually requires immediate attention

4. Intrapsychic Causes Intrapsychic causes of altered behavior arise from problems within the person. Behavior usually results from an acute underlying psychiatric condition A wide range of behaviors can be manifested

5. Intrapsychic Causes cont. Behavior manifestations include: Depression Withdrawal Catatonia Violence Suicidal acts Homicidal acts Paranoid reactions Phobias Hysterical conversions Disorientation Disorganization

6. Interpersonal & Environmental Causes Interpersonal & environmental causes of behavioral emergencies result from reactions to stimuli outside the person. Usually result from overwhelming and stressful incidents Examples include: Death of loved one Rape Natural & manmade disasters

7. Organic Causes Organic causes of altered behavior results from a disturbance in the patient’s physical or biochemical state Examples include: Drug/alcohol or substance abuse Trauma Medical illness Dementia

8. Organic Causes cont. It is important to consider an organic cause in dealing with any patient presenting with behavior emergency

9. Haloperidol (Haldol) Class Antipsychotic & narcoleptic Description Frequently used as a major tranquilizer MOA Major tranquilizer of the butyrophenone class Pharmacological properties similar phenothiazine class Appears to block dopamine receptors in the brain associated with mood & behavior

10. Haloperidol (Haldol) Pharmacokinetics Onset 30 – 45 min Peak effects 10 – 20 min Duration Varies T ½ 3 – 35 hours Contraindications Should not be given if other sedatives are present Should not be administered for altered behavior is a result of Talwin Sedation and anesthesia may ensue

11. Haloperidol (Haldol) Precautions May impair mental & physical abilities Orthostatic hypotension may result if other sedatives are used in conjunction Administer with caution when patients are taking anticoagulants Extrapyramidal or dystonic reactions may occur following administration Side effects EPS Insomnia Restlessness Drowsiness Seizures Respiratory depression Dry mouth Constipation Hypotension tachycardia

12. Haloperidol (Haldol) Interactions Antihypertensive drugs may increase the likelihood of developing hypotension Should be used with extreme when patients are taking lithium Irreversible brain damage (encephalopathic syndrome) has been reported Dosage 2 – 5 mg IM ONLY

13. Droperidol (Inapsine) Class Antiemetic & antipsychotic Description Butyropenone derivative that is structurally and pharmacological related to haloperidol MOA Antagonizes the emetic effects of morphine-like analgesics & other drugs that act on the chemoreceptor trigger zone (CTZ) Mild alpha-adrenergic blocking properties & direct vasodilation effects may cause hypotension Acts at the subcortical layer to produce sedation & reduce anxiety without producing sleep

14. Droperidol (Inapsine) Pharmacokinetics Onset 3 – 10 min Peak effects 30 min Duration 2 – 4 hours T ½ 2 hours Indications Indicated in the management of nausea & vomiting in patients refractory to first-line antiemetics Can be used to produce a tranquilizing effect and as an antipsychotic

15. Droperidol (Inapsine) Contraindications Known hypersensitivity Safe use during pregnancy and in children under 2-y/o has not been established Precautions Prolonged QT/QTc intervals are possible Torsades de pointes has been associated with administration Side effects CNS & CV side effects are consistent with those of haloperidol Other reported side effects include: Chills Shivering Laryngospasm Bronchospasm Interactions None reported

16. Droperidol (Inapsine) Dosage 2.5 – 10 mg IV or IM

17. Chloropromazine (Thorazine/Largactil) Class Antipsychotic & neuroleptic Description Antipsychotic of the phenothiazine type & neuroleptic used in the management of severe psychotic episodes MOA Thought to block dopamine receptors in the brain that are associated with behavior & mood Also effective in the management of mild alcohol withdrawal & intractable hiccups

18. Chloropromazine (Thorazine/Largactil) Pharmacokinetics Onset 3 – 5 min Peak effects 30 – 60 min Duration 4 – 6 hours T ½ 6 hours Indications Acute psychotic episodes Mild alcohol withdrawal Intractable hiccups Nausea & vomiting

19. Chloropromazine (Thorazine/Largactil) Contraindications Should not be administered to patients in a comatose state or who have recently ingested large amounts of sedatives Should not be administered to patients that have recently taken hallucinogenics because it tends to promote seizures Precautions Same as haloperidol Side effects Dry mouth, constipation, blurred vision, dry eyes, sedation, headache, drowsiness, hypotension, & tachycardia

20. Chloropromazine (Thorazine/Largactil) Interactions May increase the likelihood of a patient developing hypotension Dosage Acute psychotic episodes 25 – 50 mg IM Intractable hiccups 25 mg IM Paramedics should only administer IM

21. Ziprasidone (Geodon) Class Antipsychotic Description Unrelated to phenothiazines or butyrophenone Known to bind serotonin, dopamine, histamine, and alpha1 adrenergic receptors MOA Unknown Probably related to inhibition of synaptic uptake of serotonin and norepinephrine Pharmacokinetics Onset Not yet determined for IM route Peak effects Not yet determined for IM route Duration Not yet determined for IM route T ½ 7 hours

22. Ziprasidone (Geodon) Indications Acute psychosis and Tourette’s syndrome Contraindications Should not be used in patient’s with known hypersensitivity Should not be used in patients with prolonged QT/QTc interval Precautions Used with caution in patient with: Seizure disorders Stroke Alzheimer’s disease CAD

23. Ziprasidone (Geodon) Side effects Myalgias Somnolence Dizziness Tremors Dyskinesia Dystonia Tachycardia Postural hypotension Nausea Dry mouth Interactions Carbazepine (Tegretol) may decrease Geodon levels Interactions may occur with: Antihypertensives Antidepressants Ethanol Dosage 10 – 20 mg IM up to 40 mg max

24. Olanzapine (Zyprexa, Zyprexa Zydis) Class Antipsychotic Description Rapidly acting oral antipsychotic chemically related to clozapine Zyprexa Zydis is a rapidly dissolving water that can be administered orally or placed in a drink Pharmacokinetics Onset < 30 min Peak effects 6 hours Duration Varies T ½ 21 – 54 hours

25. Olanzapine (Zyprexa, Zyprexa ZYDIS) Indications Acute psychosis Alzheimer’s disease Contraindications Hypersensitivity to the drug Precautions Should be avoided in patients with cardiovascular disease or conditions that predispose the patient to hypotension Do not push through the blister pack Pull the foil back

26. Olanzapine (Zyprexa, Zyprexa ZYDIS) Side effects Myalgias Somnolence Dizziness Tremors Tachycardia Postural hypotension Nausea Dry mouth Interactions may enhance hypotensive effects of antihypertensives Dosage 5 – 15 mg PO

27. Benzodiazepines All medications in this class share the same indications, contraindications, & side effects MOA: Bind to specific sites on the gamma-aminobutyric acid (GABA) Type-A receptors the brain GABA is a major inhibitory neurotransmitter of the CNS Benzodiazepines have no direct effect on GABA – but do potentiate the effects of GABA in the brain.

28. Benzodiazepines Medications in this class are considered, based on the dosage administered: Anticonvulsants Antianxiety Sedatives Hypnotics

29. Benzodiazepines Drugs include: Diazepam (Valium) Lorazepam (Ativan) Midazolam (Versed)

30. Diazepam (Valium) Pharmacokinetics Onset 1 – 5 min IV 15 – 30 min IM Peak effects 10 min IV 30 – 45 min IM Duration 15 – 60 min T ½ 20 – 50 hours Indications Acute anxiety states Premedication for cardioversion Skeletal muscle relaxant Major motor seizures Status epilepticus Contraindications Hypersensitivity to the drug

31. Diazepam (Valium) Precautions Short acting drug, in cases of seizures – seizures may return Injectable diazepam can cause local venous irritation Should be administered in larger veins no more than 1 ml/min Side effects Hypotension Tachycardia Drowsiness Headache Amnesia Hallucinations Respiratory depression Blurred vision Nausea Vomiting

32. Diazepam (Valium) Interactions Diazepam is incompatible with many other drugs When give IV, the line should be adequately flushed The effects of diazepam can be additive when used with other CNS depressants and alcohol Dosage Acute anxiety 2 – 5 mg IM or IV Amnesia effects 5 – 15 mg IV Seizures 5 – 10 mg IV

33. Lorazepam (Ativan) Pharmacokinetics Onset 1 – 5 min IV 15 – 30 min IM Peak effects 15 – 20 min IV 2 hours IM Duration 6 – 8 hours T ½ 10 – 20 hours Indications Major motor seizures Status epilepticus Premedication prior to cardioversion Acute anxiety Contraindications Hypersensitivity to the drug

34. Lorazepam (Ativan) Precautions Should be diluted with NS or D5W prior to IV administration Short acting, when used for seizures – seizures may return Side effects Same as Valium Interactions Same as Valium Dosage 0.5 – 2.0 mg IV 1.0 – 4.0 mg IM

35. Midazolam (Versed) Pharmacokinetics Onset 3 – 5 min IV 15 min IM Peak effects 20 – 60 min Duration <2 hours IV 1 – 6 hours IM T ½ 1 – 4 hours Indications Premedication for painful medical procedures Can be used as an anticonvulsant Contraindications Hypersensitivity to the drug Narrow-angle glaucoma Patients in shock Alcoholic coma

36. Midazolam (Versed) Precautions Emergency resuscitation equipment must be present Vitals must be constantly monitored Respiratory depression/arrest is possible Side effects In addition to those of Valium Laryngospasm Bronchospasm Dyspnea Respiratory arrest Premature ventricular contractions Retching

37. Midazolam (Versed) Interactions Same as Valium Dosage Sedation 1 – 2.5 mg slow IV 0.07 – 0.08 mg/kg IM

38. Hydroxyzine (Vistaril, Atarax) Class Antihistamine Description Antihistamine with antianxiety and sedative effects Also has anticholenergic properties MOA Because of its anticholenergic properties it has been shown to exert a calming effect during acute psychotic episodes Pharmacokinetics Onset 15 – 30 min Peak effects 1 – 2 hours Duration 4 – 6 hours T ½ 20 hours

39. Hydroxyzine (Vistaril, Atarax) Indications Used to potentiate the effects of narcotics and synthetic narcotics Nausea Vomiting Anxiety reactions Contraindications Hypersensitivity to the drug Precautions Administered by IM injection ONLY Side effects Sedation Dizziness Headache Dry mouth Seizures

40. Hydroxyzine (Vistaril, Atarax) Interactions Potentiate the effects of CNS depressants Dosage Acute anxiety 50 – 100 mg IM Antiemetic 25 – 50 mg IM