So here is how I reckon you should manage / sedate each of the groups (colours) in the SAFE Sedation matrix. Some of tis is not new – there are a few strategies that are not routine practice – let me know what you think:
WHITE: low-risk in both ways – if you are admitting these patients then you may need a sleeper, or mild anxiolysis only – easy, do your usual thing.
VIOLET: in this group I would advocate restraint, monotherapy, longer-acting agents and good nursing are all that is required.
INDIGO: Step away from the drug cabinet! You have little to gain from sedating a high-risk medical patient who is not too agitated. Good nurse care, orientation, reassurance and minimal stimulation are best – enlist family where possible
BLUE: This group need some sedation. The strategy I like with the healthy / thin patient is a decent dose of sedation – then see what happens – either you are good or you add a bit more – I like a combo of antipsychotic and benzo (eg, Olanzapine + Clonazepam). The mistake I see often is trying a little dose of x, then swapping to y, then z – suddenly the patient has subtherapeutic doses of 3 agents on board and it is hard to decide what to do next wen they don’t work!
GREEN: This group is the same management as BLUE – except you might want to do it in an environment where you can do airway stuff if needed whilst you are titrating. If you have time then titrate the sedation (something longer-acting), try and achieve fasting, maybe some metoclopramide and PPI for the reflux?
YELLOW: This group is tiger territory – their safety risk is either unknown or volatile – but you know they are likely to be an airway problem. I think here you should use non-pharmacological means first, try a small dose of shorter agent (eg midaz) and then a tincture of time. Two things might happen – either they settle and become “INDIGO” or they don’t – then you are looking at BLACK – see below.
ORANGE: This is the controversial bit. Thin, healthy, easy airway BUT very dangerous / violent punter – traditionally we have used big doses of all sorts to get them under control…. and then intubated them as there is no way the RFDS will fly this guy unless he in in a coma (quite sensibly). So my PROPOFOL as first line comes in here – why put the patient at risk with a day or two of heavy sedation / airway unprotected, urinary retention, staff being punched wen you can just jump in with what you are going to have to do eventually anyway? Sure talk to the RFDS team, arrange a transport, keep the Police in the department / handcuffs on etc until you are ready then – RSI, Propofol / fentanyl drip. Off to ICU for wake up then into a secure facility – minimise the risk to all parties.
RED: Same as ORANGE – but you might want to optimise your situation – await fasting if you can, have the best airway team you can get there. Keep the patient in the critical area / Resus bay with Police etc nearby. You might try a bit of sedation, but only if you are prepared to “go all the way” if the need arises
BLACK : “Damned if you do, damned if you don’t”. I am gonna post a case that falls into this category to illustrate the disasters that can occur in this area. Needless to say it ended very badly. My suggestion is to use the minimum drugs you can and have both a good airway setup / cric kit etc all there. DO not let the Police leave – handcuffs might be nasty but they are better than being dead. This is tough – there is no good answer – I will put up my case for comment soon. All I will say is I would rather be pulled up by the Mental Health Advocate legal team for being cruel with physical restraint of a live patient; than face the coroner about the sedation that resulted in the death of my patient….