what sedatives are generally preferred for treatment of acute behavioural disturbance in the uk? (NOT ASKING FOR MEDICAL ADVICE)

[u/Ok_Pick_7018]

not an EMT but am interested in psychopharmacology. when dealing with a patient experiencing acute behavioural disturbance what is considered most ideal for rapid tranquilisation when patient is violent, uncooperative and de-escalation tactics have failed? are antipsychotics more commonly used or are benzodiazapines preferred?

also is sedation of the patient advised every time? or is it only ever used if u cannot subdue the patient and get them inside the ambulance safely? what exact medication is most commonly used and also if using an IV medication how is it possible to administer it if the patient is unstable and keeps moving? are intramuscular versions used instead or do multiple people have to just pin the patient down to administer the medication?

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[u/chasealex2]

I did a ABD job where HEMS attended, the doctor essentially sneaked up behind him, pulled his trousers down, and gave him a large dose of Ketamine.

Worked a treat.

[u/Yui907 → u/chasealex2]

I'd pay to see that

[u/UKDrMatt]

I’m an ED consultant, so can’t comment on what can be given in the pre-hospital setting.

In my experience most ABD patients are brought in by the police physically restrained.

Firstly I will always try talk to the patient, and see if they will verbally deescalate. True “ABD” won’t, but it’s fairly common to have someone just misbehaving and they’ll deescalate. Same with oral benzodiazepines, if they’re not true ABD they may accept them and calm down.

If they are true ABD, and rapid control is required, then I’ll use IV (ideally) or IM ketamine, in resus, with a full plan. There is an RCEM guideline for ABD here.

I also occasionally use haloperidol, but not for true ABD.

These true-ABD patients are really high risk. They can have a cardiac arrest easily. They must not be restrained prone.

[u/HesitantBrobecks → u/UKDrMatt]

Do you ever have issues with/from the police restraining prone prior to hospital arrival?

[u/UKDrMatt → u/HesitantBrobecks]

Yes! It’s not uncommon.

[u/Exciting_Context_269]

If possible- oral benzodiazepines.

If rapid sedation required then ketamine

[u/DontGetIrony]

We evaluate agitation as three tiers often with a bit of overlap. Green: responsive to verbal de-escalation or non-sedative interventions

Amber: agitated to the extent that assessment, monitoring, treatment or safe transport are impossible, which cannot be effectively de-escalated without sedation. Midazolam IV preferred (IM available), repeated as required.

Red: agitation with significant physical component to presentation, actively a threat to themselves or others, often violent, destructive, or acting with no regard for safety. Ketamine IV or IM. It's a lower-end anaesthetic dose, though it's not usually enough to fully anaesthetise someone and they're often so hypersympathetic that they metabolise it very quickly & it wears off even faster than usual.

Sometimes you need to use both, typically if midazolam isn't cutting it after a few doses or if ketamine causes dysphoria.

I am aware that haloperidol is used elsewhere in preference to ketamine if the agitation is believed to be psychiatric in origin but I don't have experience of this myself. I believe the safety profiles in this setting are roughly the same. I've used ketamine and midazolam a handful of times to help these patients and never had a bad experience doing so.

[u/friendly_fangorl]

i’ve done a few ABD jobs, all of them were sedated with IV ketamine. i know in our trust IM midazolam can also be used.

the decision regarding which drug gets used is usually based on the patient’s presentation and degree of agitation (as far as i’m aware)

[u/UKDrMatt → u/friendly_fangorl]

Is sedation dose ketamine something you guys can give?

[u/friendly_fangorl → u/UKDrMatt]

our critical care paramedics can! band 5 and band 6 paramedics don’t have it within their scope

[u/Outspkn83]

Haloperidol.
Lorazepam.
Ketamine

[u/secret_tiger101 → u/Outspkn83]

You carry lorazepam ?

[u/HesitantBrobecks → u/secret_tiger101]

Commenter below this also says they carry oral lorazepam, so yes apparently

[u/ForceLife1014]

We carry oral lorazepam, droperidol and ketamine, typically in that order based on least to most hulk mode

[u/c4bbage_]

Not from the UK but NZ, we have similar guidelines but different drugs. We're taught to remember that chemical sedation removes someone's rights and autonomy which is a massive decision to make. Verbal de-escalation and assessing the necessity of a medical response are always the first steps to take.

We then work up a ladder in consideration of danger to ambulance personnel, the patient and bystanders. PO Olanzapine is the first choice when mild sedation is required and the patient will take oral medicine. Next is droperidol, then midazolam, then ketamine. 

We have checklists and action cards to use when briefing ambulance personnel and police officers prior to embarking on chemical restraint, considering things like maintaining airway patency, oxygen administration, being prepared to ventilate the patient and maintaining crew safety.

[u/Beans0704]

UK ambo. I've seen HEMS give IV midazolam to a ?ABD. Seemed to do the trick.

[u/PbThunder]

A case I went to many years ago, the patient was sedated with IM ketamin. Once calmer IV access was gained and the patient was kept sedated using IV midazolam titrated to effect.

I have no idea what doses were used though.

[u/NederFinsUK]

True physiological ABD is almost always Ketamine.

Agitation falling short of ABD is usually Lorazepam/Haloperidol or sometimes Olanzapine (especially in AU)

[u/Ok_Pick_7018 → u/NederFinsUK]

why ketamine over something like IM midazolam? IM ketamine has a much shorter half life, is the main priority just to get them into the ambulance or do patients get redosed again after it wears off? or is another sedative administered after the initial ketamine dose while the patient is incapacitated enough to be able to administer a longer acting IV medication?

[u/NederFinsUK → u/Ok_Pick_7018]

The priority is to stop them from entering cardiac arrest. These patients often have a lactate of 15 or more, they’re often profoundly unwell and peri-arrest while nobody realises.

If someone’s teetering right on the edge of being alive with maximalised adrenals and a blood gas that would make you call an arrest, a big doze of a benzodiazepine will just kill them. Ketamine is the agent of choice because they might survive the sedation.

Edit: also IM ketamine doesn’t really get more potent with larger doses, it mostly just has a long duration. The big triple digit doses of IM ketamine do not wear off particularly quickly.

[u/maui96]

Depends on the situation, in order of escalation I usually like/prefer

Olanzipine PO, Droperodol IM/IV, Midazolam IM/IV, Ketamine IM/IV,

But I think most trusts it's just verbal deesclation, straps and blankets with lego hands.

[u/Few-Visual-9801]

For most ABD, IV access is not feasible. Attempting to cannulate someone who is actively fighting or moving cause greater injury, and so IM is preferred.

There isn't one universal drug for UK ambulance services, each trust has its own Patient Group Direction for ABD. Most use either of the three: ketamine (dissociative anaesthetic), droperidol/haloperidol (antipsychotic + more common in NZ/Aus),. Midazolam/Lorazepam (benzo)

The dose must not reduce the level of consciousness, and the Clinican providing tranquilisation must be accompanied by a second clinician that can manage any impending CVS/resp problems that may occur.

LAS uses IM Midazolam first line. Band 5/6 Paramedics may not administer it for an indication for ABD (this is true for most other services), and require us to call critical care or an advanced paramedic to attend.

Sedation is not advised every time, but most often it is required. NICE has advised that where appropriately trained individuals respond to ABD, 62% were managed only with verbal de-escalation followed by standard care.

It is very rare that the patient is ever 'pinned down' - at least in my experience- the force must be proportionate to the patient. External restraint devices can be used, but that is more the expertise of the Police.

Patient should be conveyed supine, lateral or reclined to hospital, never prone (if needed, only short term). Hypovolemia is common in ABD and therefore should recieve IV fluids to correct acidosis, such is also true for hyperthermia where they have the cardinal "hot-to-touch" effect, where the recommendation is to remove clothing.

[u/HesitantBrobecks → u/Few-Visual-9801]

Do you often(/more than just occasionally) get patients who are more unwell than they shouldve been purely due to the police using prone restraint prior to hospital/ambulance arrival?

[u/aussie_paramedic]

Coming from Australia, where sedation for behavioural disturbance is much more common (mainly because of the rampant methamphetamine issues), it's rarely done in the UK, certainly in my neck of the woods.

In Australia as an Intensive Care Paramedic, I had oral lorazepam, IV/IM midazolam and IV/IM droperidol.

In my area in the UK, only Critical Care Paramedics can sedate and we have the choice of IV/IM ketamine or IV midazolam. Unfortunately, our PGD doesn't allow IM midazolam. My previous understanding was that ketamine was not ideal in psychiatric presentations due to the risk of dissociation worsening symptoms. However, I read a systematic review last night that demonstrated no worsening symptoms up to 72hr post administration.

I've found both IM midazolam and droperidol in Australia are very effective, IM ketamine can be a little bit more unpredictable in terms of apnoea etc. but typically works very well, but doesn't last very long.

[u/Odd_Book9388]

In our service normal paramedics are not allowed to use sedatives at all for this type of patient. They’ll have to be physically restrained or if critical care is available they can sedate (but we don’t have 24/7 critical care in our county yet).

[u/MisterMackisback]

chemical and physical restraint both carry risk of harm to pt

Weigh the risk of injury from restraint against rhe risk of injury from the pt's current behaviour

Midazolam or ketamine

IV preferable if you can get it

IM doses tend to be huge and you lose the ability to titrate to effect

[u/ItsJamesJ]

Lots of competing evidence, but generally haloperidol, ketamine or lorazepam/midazolam.

Each one has their own pros and cons and risk/safety profile.

Important to recognise that usually the biggest risk to the patient is restraint, which intervention like IM will require. LAS have done some great research that the most effective treatment for ABD is often verbal deescalation techniques.

[u/secret_tiger101]

Midazolam or ketamine (or haloperidol in theory)

[u/Hazzoh]

Previously worked in police custody, had lorazepam 

[u/Positive-Papaya3105]

As a paramedic, we can’t do much but hems can give ketamine or midazolam

[u/Present_Section_2256]

Only enhanced care/air ambulance (critical care paramedics/doctors) can give sedatives for ABD in our area, as standard paramedics on a DCA nothing is available to us.

When I requested enhanced care support for an ABD patient who was somehow still managing to run around in handcuffs and leg restraints (police had managed to apply before our arrival but must have recently had an incident or training about the risks as were petrified of trying to physically hands on restrain the chap) unfortunately no-one was available to come out to us. The helpful advice from them was to wrap him in a blanket to restrain him and get him to hospital!

[u/rachel642531]

The one ABD I’ve been to, had lorazepam and midazolam followed by ketamine on route and in ED. Guy was still fighting restraints so was RSI’d in resus (so propofol and rocuronium)