What is the appropriate treatment for an injured patient with altered level of consciousness and combative behavior?

Management of Injured, Combative Patients with Altered Consciousness

For injured patients with altered consciousness who are agitated or combative, use medication-assisted sedation with ketamine (1 mg/kg initial dose) to facilitate preoxygenation and airway management, followed by haloperidol (0.5-1 mg IM/IV) or atypical antipsychotics (risperidone 0.25-2 mg) for ongoing agitation control once airway is secured. 1, 2

Immediate Priorities: Airway and Hemodynamic Stabilization

Before addressing agitation pharmacologically, you must first assess and secure the ABCs:

• Ensure patent airway immediately - altered consciousness with combative behavior creates high risk for airway compromise and aspiration 3, 4
• Assess for hemodynamic instability using ATLS criteria: systolic BP <90 mmHg, heart rate >120 bpm, cool/clammy skin, or altered consciousness itself may indicate shock 5
• Administer high-flow oxygen at 10 L/min and prepare for potential intubation if the patient cannot protect their airway 6

Medication-Assisted Preoxygenation for Combative Patients

When the patient is too agitated to tolerate oxygen delivery devices or assessment:

• Ketamine is the preferred agent for medication-assisted preoxygenation in combative trauma patients, starting with 1 mg/kg IV bolus, followed by 0.5 mg/kg doses until dissociative state achieved (mean total dose 1.4 mg/kg) 1
• This approach increases oxygen saturation by mean of 8.9% and allows for adequate preoxygenation before definitive airway management 1
• Equipment for airway management must be immediately available before administering any sedative medication 7

Ongoing Agitation Management After Airway Secured

First-Line: Atypical Antipsychotics

Once airway is secured and hemodynamic stability confirmed, use atypical antipsychotics for ongoing agitation:

• Risperidone: Start 0.25 mg, maximum 2-3 mg/day in divided doses; monitor for extrapyramidal symptoms at doses ≥2 mg 2
• Quetiapine: Start 12.5 mg twice daily, maximum 200 mg twice daily; more sedating with lower extrapyramidal risk but watch for orthostatic hypotension 2
• Olanzapine: Start 2.5 mg at bedtime, maximum 10 mg/day; monitor for drowsiness and orthostatic hypotension 2

Second-Line: Typical Antipsychotics

• Haloperidol 0.5-1 mg IM/IV for severe agitation when atypicals are insufficient or unavailable 1, 8
• Critical contraindication: Never use haloperidol in suspected Parkinson's disease or Lewy body dementia due to severe neurotoxicity risk 2, 8
• Monitor for extrapyramidal symptoms, QT prolongation, and hypotension requiring vasopressor support (use norepinephrine or phenylephrine, NOT epinephrine as haloperidol blocks its vasopressor activity) 8

Avoid Benzodiazepines

• Do not use benzodiazepines (including lorazepam) as first-line for agitation in altered consciousness - they worsen delirium and cause paradoxical agitation 2
• Lorazepam is reserved specifically for status epilepticus (4 mg IV at 2 mg/min), not general agitation management 7

Identify and Treat Underlying Causes

While managing agitation, simultaneously investigate reversible causes:

• Rule out hypoglycemia immediately - check bedside glucose as neuroglycopenia causes altered consciousness and agitation within 2 hours 1
• Assess for traumatic brain injury - if suspected, maintain MAP ≥80 mmHg (permissive hypotension is contraindicated) 6
• Evaluate for delirium triggers: infections, metabolic disturbances, medication effects, or substance withdrawal 1, 2
• Consider medication-induced causes: review opioids, anti-Parkinsonian drugs, antidepressants, stimulants - opioid rotation has 80-90% response rate for opioid-induced agitation 1, 2

Critical Monitoring Parameters

• Continuous vital signs: HR, BP, respiratory rate, oxygen saturation 5, 6
• Serial neurological assessments: Glasgow Coma Scale, pupillary response, focal deficits 1, 9
• Capillary refill time: prolonged CRT >2 seconds indicates inadequate perfusion 6
• Urine output: target >1 mL/kg/hour as indicator of adequate organ perfusion 6
• Lactate/base deficit: serial measurements guide resuscitation adequacy in trauma patients 6

Common Pitfalls to Avoid

• Never delay airway management to "calm the patient down first" - combative behavior with altered consciousness is an airway emergency 1, 3
• Do not rely solely on blood pressure - patients may maintain normal BP despite significant injury through compensatory mechanisms 5
• Avoid excessive sedation before securing airway - this increases aspiration risk without addressing the underlying airway threat 7
• Do not use epinephrine for hypotension in haloperidol-treated patients - it causes paradoxical further BP drop; use norepinephrine instead 8
• Never assume agitation is purely behavioral - altered consciousness with combativeness indicates organic pathology until proven otherwise 1, 10