The security guard and physician escorted the patient to bed while he yelled loudly. He then pushed the security guard, was placed in physical restraints and was then given intravenous haloperidol and lorazepam. Roughly 15 minutes later, the patient stopped breathing. ACLS was performed and when the patient was attached to the monitor, he was found to be in torsades de pointes.
He received cardioversion and a normal rhythm was restored. He was admitted to the intensive care unit. As a health law attorney, Dr.
Sullivan represents medical providers and has published many articles on legal issues in medicine. If you are having trouble with this kind of patient in this manner, you are trying to protect both him and staff.
Were the two drugs given in similar doses to the prior events, or was the dose increased? The usual reason for dosing drugs IV as opposed to IM is for quicker onset of action, better control of effect and side effects; also the presence of an IV makes it easier to reverse drugs, at least the ones that are reversible.
A better question might be this: if the patient was physically restrained, did he require IV restraint as well? One or the other might be more advisable. I do have another comment. In many of these writeups, the patient is a deliberately unsympathetic individual who suffers a bad outcome and then of course files a suit. This is possibly deceitful and biased; most med mal suits are not filed by plaintiffs who might be charitably described as unsympathetic individuals.
That said, SOC was met in my opinion. IV Haldol is part of emergency medicine practice. However, there will be many who will testify to its dangers real or imagined. In the true alcoholic who is in mutritional jeopardy, using Haldol and other QT prolonging drugs is more dangerous due to the magnesium depletion that accompanies the nutritional depletion and diuresis of alcoholism.
Thank you for the great comments so far. To address Dr. I believe they paint patients in a fair light. That said, we appreciate readers continuing to hold us to the highest standard. Keep it coming! The question of if off label use of a medication constitutes a breach of standard of care I feel the answer is no, especially not in a drug as well studied in the geriatric and alcoholic population as Haldol.
There is a statement that concerns me that there may have been a breach in the standard of care. If the patient had been restrained and sedated and not monitored with a cardiac monitor and pulse ox, then the standard of care was breached as the likelihood of arrhythmia was not addressed. If the patient was on a monitor and an arrhythmia was missed then the standard of care was breached. If the patient was appropriately sedated and monitored and checked upon, then any complication is a complication from neccessary care and not a breach of the standard of care.
I agree with Dr Kraemer. Persons who are given IV sedation which could depress respiration ought to be on a monitor and it is a good question. Was the patient in fact on a monitor? In each of these cases, this fellow could have slept off his drunk in the jail. Do not pass go! I feel Routine of Care was met, as well as Standard of Care.
Torsades is a class effect of the atypicals. Torsades also occurs in many other circumstances, like anoxia and electrolyte disorders. Presence of EPS is a common occurrence with cerebral anoxia. Conclusion: exemplary care on the part of the EP in getting tranquilizers in, cuffs off and cops out.
It is an unfortunate fact of life, I guess, that the ED has become the defacto drunk tank. Same at my shop. I suspect it happened do to diabetics dying in drunk tanks before the advent of glucometers. We tried to change EMS protocol to allow the medics to not bring them. Cumbler adds that alternative treatments for delirium-related agitation should be the first-line therapy.
When an antipsychotic is still needed, Dr. Cumbler says, a better choice may be an oral dose or an IM injection. The obvious next intervention, he adds, is the kind of alert that Dr. Pell has helped implement. You instead need to build safety into the system. Building the right alert According to Dr. Pell, having the alert in place is certainly a good start. For one, physicians on the clinical decision-support committee working on the project are still debating whether the alert needs to be a hard stop or if doctors should be able to continue to click their way through an IV haloperidol order.
At the same time, Dr. Sunday, November 14, Today's Hospitalist. Ferreting out delirium in the hospital setting. A hospital takes charge of antibody infusions. Recent articles. Tips for negotiating compensation May Dying after leaving AMA September Tough choices: the right diuretic for heart failure and the best July Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: an executive summary.
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Torsade de pointes, which generally occurs in patients with prolonged QT intervals, is characterized by QRS complexes that change amplitude and direction, or "twist. To sign up for updates or to access your subscriber preferences, please enter your email address below. We want to hear from our users about how we can improve the PSNet experience. Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest.
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