From the Guidelines
I strongly recommend against using haloperidol or atypical antipsychotics in this patient due to the risk of torsades de pointes associated with QT prolongation, as suggested by the guidelines 1. Given the patient's history of prolonged QT interval, the use of antipsychotics could further increase the risk of torsades de pointes, a potentially life-threatening arrhythmia. Instead, I recommend a comprehensive evaluation for this patient who fell and is now confused and combative, including:
- Obtaining vital signs, including orthostatics
- Performing a neurological exam
- Assessing for injuries from the fall
- Ordering a head CT to rule out traumatic brain injury
- Checking blood work, including CBC, CMP, magnesium, phosphorus, and cardiac enzymes
- Getting an ECG to evaluate the prolonged QT interval
- Considering toxicology screening and blood cultures if infection is suspected
- Checking blood glucose immediately given the patient's diabetes For the combativeness, I suggest using gentle verbal de-escalation techniques first, and considering alternative sedation options, such as dexmedetomidine, which may be safer in patients with QT prolongation, as suggested by the guidelines 1. The patient's confusion could stem from multiple causes, including traumatic injury, metabolic derangements from diabetes, medication effects, or an acute infection, so a systematic approach is essential to determine the underlying cause while ensuring patient safety. It is also important to note that the patient's history of spinal stenosis, asthma, hypertension, and osteomyelitis may also be relevant to their current condition, and should be taken into consideration when developing a treatment plan. Overall, the goal should be to prioritize the patient's safety and well-being, while also addressing their underlying medical conditions and preventing further complications.
From the Research
Patient Assessment and Treatment
The patient has a history of prolonged QT, nausea and vomiting (NV), colitis, spinal stenosis, asthma, hypertension (HTN), diabetes mellitus type 2 (DM2), and osteomyelitis. The patient recently had a fall, landing on their knees without hitting their head, and is now confused and combative.
ABCDE Approach
Given the patient's critical condition, the ABCDE approach 2 can be applied to facilitate immediate life-saving treatment. This systematic approach breaks down complex clinical situations into manageable parts, focusing on airway, breathing, circulation, disability, and exposure.
QT Prolongation and Medication
The patient's history of prolonged QT is a concern, especially when considering medications that may exacerbate this condition. Studies have shown that haloperidol, a common medication for agitation, can prolong the QT interval 3. However, the effect of haloperidol on QT prolongation may be minimal in most patients 3, and the risk of torsades de pointes (TdP) appears to be low 4.
Management of Agitation
For the patient's agitation, the addition of lorazepam to haloperidol may be considered, as it has been shown to result in a significantly greater reduction in agitation compared to haloperidol alone 5. However, the use of benzodiazepines in delirium is controversial, and further research is needed to assess generalizability and adverse effects.
Monitoring and Treatment
Electrocardiogram (ECG) monitoring may be necessary, especially if high doses of haloperidol are used 4. The patient's confusion and combativeness should be addressed promptly, and the ABCDE approach should be continued to ensure the patient's airway, breathing, and circulation are stable.
- Consider ECG monitoring due to the patient's history of prolonged QT and potential use of QT-prolonging medications 6, 4
- Apply the ABCDE approach to ensure immediate life-saving treatment 2
- Manage agitation with haloperidol and consider adding lorazepam 5
- Monitor for adverse effects, such as extrapyramidal symptoms and QT prolongation 3, 4