Art of the Chemical Takedown

An unruly, intoxicated and violent patient rolls into the ED. The situation and the patient are both in need of control. How do you go about it? Redirection? Calming words? Sometimes those things aren’t quite enough and chemical sedation is in order. When it comes to choice of sedating agent, everyone seems to have their secret formula. We canvassed the planet to see how chemical takedowns are done across the globe.


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Our Panel

ZdoggMD Art of the chemical takedown FOAMed World Premier

Scott Weingart  5mg of droperidol and 2mg of midazolam mixed together in a syringe with 11⁄2 inch needle and jabbed into whatever large muscle is available. Wait a few minutes. If necessary, will repeat once. Then establish IV

Minh Le Cong Ketamine  IV, IM, or IO.

Cliff Reid Ketamine

Chris Nickson Benzo, olanzipine or droperidol

Sean Nordt The B-52.  5mg Haldol, 2mg Ativan and 50mg of benadryl mixed together in a single syringe and given IM

Katrin Hruska abusive patients are asked to leave the emergency department

Amit Maini 5mg of IM droperidol. Repeat in 5-10 minutes if needed

Sa’ad Lahri: lorazepam (4 to 8 mg IV) and haloperidol (5mg IV)

Yosef Leibman midazolam, droperidol. Starting to use clotiapine –  a dibenzothiazepine anti-psychotic and a phenothiazine with anti-anxiety properties.

Gerry O’Malley Burly security guards and a show of force. If that doesn’t work- benzodiazepine

Ray Moreno:  Toxin related or sympathomimetic: midazolam 5 – 10mg IM. Psychiatric related- olanzipine. No idea what’s causing the agitation- midazolam

Chris Richards- The B-52.  5mg Haldol, 2mg Ativan and 50mg of benadryl mixed together in a single syringe and given IM

Bonus section:

Droperidol,  QTc prolongation, and the Black Box with toxicologist Sean Nordt….

When droperidol was ‘black boxed’ in the US, it sent shockwaves across the emergency medicine community because this drug was, for many of us, the go to agent for sedation of combative and agitated patients. Over the past several years, the pendulum has swung away from the black box and toward increasing use of droperidol. Why is that? Have we all gone mad? Are we putting patients in danger?

The history (or the conspiracy, depending on how you look at it) is expertly explained in the below article. It involves big pharma, outlier case reports of patients given much higher doses than are used in the ED for either nausea or sedation, and suspicious timing. There is no doubt that butyrophenones can influence the QTc, but so can a lot of other meds we use (that are not black boxed).

Sean Nordt’s approach to giving droperidol in the agitated patient

  1. Give the med
  2. When the patient has calmed, get an EKG.
  3. If the QTc is prolonged, put the patient on a cardiac monitor

Horowitz, B. Zane, Kenneth Bizovi, and Raymond Moreno. “Droperidol—behind the black box warning.” Academic Emergency Medicine 9.6 (2002): 615-618.


Interested in checking out the best emergency medicine CME and CNE on the planet?


EM:RAP RN Edition





Psychology of the Difficult Airway

Rich Levitan, pioneer in airway management, talks about operator stress response in the difficult airway. Referenced in this discussion: The laryngeal handshake,  books On Combat and Warrior Mindset. Rich offers several courses including the one of a kind Practical Emergency Airway Management Course and the Advanced Airway Endoscopy Course in Yellowstone.

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Psychology of Intubation: The Fourth Plane (

Interested in a truly unique CME experience? Join Rich Levitan, Scott Weingart, Matt Dawson, Mike Mallin, Andy Sloas and me December 6-8, 2014 for a 5 star, all inclusive vacation in Cabo San Lucas and earn your CME credits in style. The 2014 Cabo CME Retreat will focus on the newest emergency medical practices and technologies in the areas of ultrasound and airway medicine. Our lineup of leading emergency doctors and medical speakers will present at Secret’s Resort, the newest all inclusive luxury resort in San Jose del Cabo. Secrets Puerto Los Cabos Golf & Spa Resort boasts five gourmet restaurants, incredible views, infinity pools, and world renowned golf courses designed by Greg Norman and Jack Nicklaus. At this limited-access retreat, you will experience a CME conference unlike any other.

To register and/or find out more, go to the Cabo CME homepage

How to run a code

Cardiac arrest. It seems so easy. Just follow the algorithm on the reference card, and all cardiac arrest issues will be solved. The truth is that codes can be messy, chaotic and scattered. On this episode of ERcast, we hear from the RAGE podcast  experts on how to take control of the room and run an effective resuscitation.

The medicine isn’t always the hard part. Being an effective leader, communicating well,  and making things happen are often the bigger challenges. And speaking of Making things happen. Click that link for one of the greatest medical lectures. Ever.

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Bonus section: Adenosine vs Verapamil Articles

Adenosine versus Verapamil for termination of SVT (AVNRT)

Comparison of adenosine and verapamil for termination of paroxysmal junctional tachycardia

Adenosine versus verapamil in the treatment of supraventricular tachycardia: A randomized double-crossover trial

Comparative clinical and electrophysiologic effects of adenosine and verapamil on termination of paroxysmal supraventricular tachycardia.

Contemporary management of paroxysmal supraventricular tachycardia.




Acetaminophen vs Ibuprofen. Which works better?

Which is more effective for pain and fever control: Acetaminophen or Ibuprofen? Should a patient in the emergency department with upper GI pain be started on an H2 blocker or a proton pump inhibitor? Special guest Anand ‘The Swami’ Swaminathan from EM Lyceum joins ERCast to explore these and many more medical quagmires.


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Bonus Segment: How can a medical students present themselves well during critical rotations? In this case, we are talking about emergency medicine rotations.

Rob Says

  1. Work hard, always be curious, donʼt stress getting out right on time
  2. Presenting patients is one of your critical skills as a medical student
  3. Get the Emergency Medicine Secrets book so you know a rational approach to common medical emergencies, and keep the EMRA ddx card/ book in your pocket
  4. Present to the attendings but don’t be a kiss ass
  5. Present patients the same way each time. Be concise with pertinent positives and negatives. When you give your differential diagnosis,, ALWAYS starting with the life threats based on the chief complaint. Even itʼs a typical migraine, emergency medicine is in the business of ruling out the life threats. As one of my internal medicine colleagues says, EM is in the business  of ‘not to lose’
  6. As attendings, we want to know that the student ʻgetsʼ emergency medicine

Swami Says

  1. Show up to work on time. By on time, I mean the Joe Lex on time – 15 minutes early
  2. Recognize when it’s too busy and go into helper mode. This means not taking patients primarily (which is more work for us). Starting IVs, do EKGs, draw blood, sew lacerations, etc.
  3. Work hard. It’s as simple as that. When I work, I rarely sit, I keep moving all time. I should see the same from the students.
  4. There are three unforgivable sins in emergency medicine – laziness, stupidity and arrogance. It’s preferable to have none of these. If you have one, you may be able to squeak by. If you have two, you are a waste of space.

Acetaminophen versus Ibuprofen

Perrott DA et al. Efficacy and safety of acetaminophen vs ibuprofen for treating children’s pain and fever: a meta-analysis. Arch Pediatr Adolesc Med 2004; 158(6): 521-6.

2004 meta-analysis – summarized the findings from 17 randomized, controlled trials comparing the two drugs in children <18 years of age. Three studies involved pain, 10 involved fever, and all 17 involved safety.


1. Pain – no difference between ibuprofen 4-10 mg/kg vs. APAP 7-15 mg/kg

2. Fever – ibuprofen 5-10 mg/kg superior to APAP 10-15 mg/kg (at 2 hours and more pronounced at 4-6 hours)

15% more children were likely to have reduced fever with ibuprofen compared to acetaminophen.

When selecting for studies using only the 10mg/kg dose of ibuprofen, there was a doubling of the effect in support of ibuprofen.

Safety: there was no evidence that one drug was less safe than the other (or placebo). The authors determined that this data was inconclusive and that more large studies would be needed to identify small differences in safety

Pierce CA et al. Efficacy and safety of ibuprofen and acetaminophen in children and adults: a meta-analysis and qualitative review. Ann Pharmacother 2010; 44(3): 489-506.

First meta-analysis looking at the question in adults.

Qualitative review revealed that ibuprofen was more effective than acetaminophen for pain and fever reduction, and that the two were equally safe.

From the quantitative data, the authors found that for pain, ibuprofen was superior in children and adults. For fever, ibuprofen was superior in children, but conclusions could not be made for adults due to insufficient data.

What about alternating acetaminophen and ibuprofen?

Malya RR. Does combination treatment with ibuprofen and acetaminophen improve fever control? Ann Emerg Med 2013; 61(5): 569-70.

1. Identified 4 studies that the author deemed high-quality and relevant to emergency practitioners.

2. Three of the four studies found that the combination was more effective at reducing fever than either alone.

One study that looked at alternating regimens over 24 hours found that 6-13% of parents exceeded the maximum number of recommended doses (Hay, 2008).

There is suggestion that the two drugs could act synergistically to cause renal tubular injury; however, acetaminophen and ibuprofen have different pathways of metabolism, and adverse effects in patients taking both have only been described in rare case reports.

EM Lyceum Review of APAP (acetaminophen) vs NSAIDS (ibuprofen). This review also includes a breakdown of PPIs vs H2 blockers, medical treatment for vertigo, and calcium channel blockers versus beta blockers for atrial fibrillation with rapid ventricular response (RVR)

Check out the RAGE podcast. In this episode of ercast, we discuss a recent round table on managing SVT (AVNRT) with verapamil versus adenosine.

Fever Friend or Foe review and lecture from SMACC 

Superficial Thrombophlebitis and other clotting quagmires

Interview with hematologist Dr. Tom Deloughery about a smattering of clotting quagmires…Superficial Thrombophlebitis, Recurrent Pulmonary Embolism, Calf Vein DVT, Clotted PICC Lines, Starting (loading) dose of warfarin, low molecular weight heparin, widowmaker clots.

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Quandary 1. Recurrent pulmonary embolism

Your patient is on warfarin, INR is therapeutic and has another PE. What do you do?

Make sure it’s truly recurrent. If it is…

  1. How long have they been on anticoagulation? If it’s only a week, then the warfarin may not have had time to provide any benefit.
  2. If longer than a week and their INR has been therapeutic the whole time, consider that a warfarin failure. Start LMWH. This is a worrisome sign for an underlying malignancy or coagulopathy. LMWH is superior to warfarin for recurrent thromboembolic disease.
  3. On warfarin for years and has a recurrent PE. Do they get life long LMWH? Give LMWH for 3-6 months and, if they’re stable, restart the oral anticoagulant.

First dose of warfarin

1. How long to you need to wait to start warfarin after the first shot of LMWH? You can start both meds at the same time.

2. Is there a need for a loading dose of warfarin? Sort of….Dosing and effect are unpredictable. As a general rule, Tom gives young and otherwise healthy patients 10mg as a first dose. Over 65 or young and frail, first dose 5mg.

3. If your patient needs to restart warfarin after being off it for a while, do you need to bridge with LMWH until the INR is therapeutic?  In the setting of DVT and PE, yes. In atrial fibrillation, you probably don’t .

Superficial thrombophlebitis

Can  clot in the saphenous vein progress to DVT? Yes. 5-10%. Non saphenous vein clots progress to DVT at a rate of about 1%. As saphenous vein clot gets closer to the femoral vein, risk rises of it becoming a deep clot, but there are also perforator veins all along the saphenous vein that connect it to the deep system. Clot can connect from  the superficial (saphenous) vein to deep vein through a perforator at any point, but it’s less of a worry than deep propagation directly into the femoral vein near the groin.

Treating superficial thrombophlebitis needs to take into account the ‘thrombo’ (clot) and ‘itis’ (inflammation)

Tom’s approach

NSAIDS decrease rate of inflammation and clot extension

Therapeutic vs prophylactic LMWH: both decrease rate of inflammation and clot extension - outcomes are equal, so prophylactic LMWH is preferred (once a day, lower dose)

Small, under 5-7cm and not proximal (not upper half of thigh) NSAIDS

Larger than 5- 7cm or proximal, prophylactic dose of LMWH or fondaparinux (40mg daily)

Duration of therapy

There is uncertainty as to the optimal duration of therapy. Tom treats for two weeks. If patients are still symptomatic, treat for another two weeks.

Upper extremity thrombophlebitis

It is thought that upper extremity superficial thrombophlebitis has a more benign course. Treat with NSAIDS and hot packs. If this isn’t working, transition to LMWH.

What should you do with a PICC line clot?

Anticoagulation does not help with recannalization. Pull the line.

Putting in a new PICC right away – high rethrombosis rate.

Calf vein DVT

15-30% will grown and cause PE. Follow up ultrasound to check for extension is an option.

Unless there is a contraindication, treat with anticoagulation. ACCP recommends 3 months of treatment, Tom treats for 6 weeks.

Factor V Leiden mutation

9% prevalence in Portland, OR. Mostly a caucasion disease. Raises risk of first clot 3 fold (more DVTs than PE). Having this mutation does not increase risk of DVT recurrence.

Bonus point of the day

The SUPERFICIAL femoral vein is a DEEP vein. Perhaps the worst anatomic name ever. If you get a report that your patient has clot in the superficial femoral vein, that is a DVT, not superficial thrombophlebitis.