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The B52

You may be familiar with the cocktail famously known as the “B52,” made up of haloperidol 5 mg, lorazepam 2 mg, and diphenhydramine 50 mg (Urban Dictionary n.d.). In truth, we have rarely seen this mixture of medications fail to achieve its desired effect. It has been shown that haloperidol given with lorazepam has been more effective than lorazepam given alone (Bieniek et al. 1998). The problem is that you have likely now created a patient that will be so sedated as to be unable to participate in directing their care or giving the medical team important information about their history. The “B52” is well named because, just like the B52 bomber, it will get the job done but will likely cause a great deal of collateral damage.

Other Medication Classes

There is no evidence to support usage of mood stabilizers or antidepressants in the acute setting.

Special Situations

While a complete list of special cases where one should choose one agent over another, or one class over another, would be infinitely long, here are the most common situations you will face and how to proceed most safely:

  • ? Pregnancy: Avoid benzodiazepines because of the risk of teratogenicity. Stick with an antipsychotic, like haloperidol, that has a long track record of success treating agitation and a scant record of negatively impacting the fetus (Diav-Citrin et al. 2005). Of course, if medications can be avoided in the pregnant patient, this is always preferred.
  • ? Lewy body dementia/Parkinson’s: These patients are in a hypodopaminergic state at baseline and giving them a D2 blocker (antipsychotic) will exacerbate this problem. Use benzodiazepines.
  • ? Alcohol or benzodiazepine withdrawal: The treatment of choice in these patients is benzodiazepines and the outcome that one is trying to avoid is withdrawal seizures. Giving antipsy- chotics will do nothing to lower the risk of seizures and may in fact make them more likely.
  • ? Phencyclidine (PCP) intoxication: Patients are at increased risk of rhabdomyolysis and the combination of this with antipsychotics can put the patient at cumulatively more risk of this feared outcome.
  • ? Prolonged QTc: Studies have shown that aripiprazole has a relatively safe cardiac profile (Polcwiartek et al. 2015). It has been shown to be effective in delirium (Boettger and Breitbart 2011; Boettger et al. 2011). It is available in PO, IM, oral disintegrating tablet, and liquid form, but not all are readily available in all hospital systems. The evidence on death secondary to QTc prolongation caused by antipsychotics ranges from sparse to nonexistent. It our practice, however, when QTc is greater than 500 msec, we prefer to give benzodiazepines for agitation.
 
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