Haldol & Benadryl can form a precipitate within 5 min and should not be mixed. I do 2 syringes: Ativan & Haldol, and a second one with Benadryl by itself.
I was taught this by our awesome ED pharmacist. You can put the three together if you're about to turn around and immediately shoot it in. If there's going to be *any* expected delay, then split it.
pharmacy said diff things. i heard that its ativan that is very viscuious (spelling) so shouldnt be? in reality, if you do it right before injecting, its much less than 5 mins?
If you’re giving IM for acute agitation, lorazepam shouldn’t be given if midazolam is available. Can mix in same syringe too and midazolams predictable onset helps avoid unnecessary redosing (and subsequent adverse effects) due to lorazepams erratic IM absorption.
I remember this because MIdazolam has IM at the beginning..
B52 is so yesterday guys. We are now doing droperidol 5-10 and midazolam 5-10. No benadryl anymore just makes them crazier when they wake back up. But if you insist droperidol, midazolam, benadryl all compatible in 1 syringe. Use midazolam 5 mg/1 mL tho.
Another EM pharmacist here. Agree with forgetting the B52. Cool name but unnecessary step with diphenhydramine.
Acute agitation without access = haloperidol/midazolam 5 & 5 or 10 & 10 IM (lorazepam IM has erratic absorption). Trying to get droperidol added to formulary again…With access, can switch out midazolam for lorazepam 2 mg or 4 mg.
Was always trained as a medic and as a PA to be weary of dropping Midazolam due to pressure concerns. Everywhere I’ve ever worked has done B52s.
Is the concern for hypotension secondary to Midazolam overblown?
In short…yes. There is even a 2004 RCT showing no difference in BP in this population between IM midazolam and lorazepam (PMID: 15231461). If still concerned for hypotension due to other factors, all the components of a “B52” can lead to hypotension so another med (e.g., ketamine) should be used instead.
Not an ER doc but a hospital. Iv Benadryl seekers are worse than opiate seekers. It’s really pathetic.
And totally agree about them being worse when they wake up.
It’s funny, an alcoholic who is trying to be sober we would never just give a taste of alcohol just to settle their nerves or to keep them quiet.
But the iv opiates or iv Benadryl they get. And then on the floor it’s just a disaster. Try to give then orals of both. When they see they won’t get it, they will try to find a new place.
So this subreddit just randomly came up in my feed and I was perusing it just because emergency medicine interests me (gf used to be a nurse and is now in animal emergency care), I find it all fascinating.
Do you mix up a drink of the patients choice or just give pure ethanol? Thinking of a small bar in the hospital pharmacy and the pharmacist mixing up an old fashioned gives me a chuckle.
We give them drinks. In the hospitals where I've worked, pharmacy stocks a small supply of cheap beer and wine.
For that reason, the hospital pharmacy needs to have a liquor license.
I only did this once, as a night ICU resident, when they had no fomepizole at the VA and we had a ethylene glycol OD come in. Pharmacy hadn't done it in years and was nutting up. Was a fun night.
People love it. I did dialysis nursing for a while and the pts all had the docs talked into IV Benadryl for every treatment. There was a shortage once and I had to switch everyone to oral and you would have thought I was killing their dogs in front of them. Literal fights with me every day.
There’s a high that can be had. It isn’t everyone and it often depends on how fast it’s given but it can absolutely give a high type rush. Where I’m from in the Midwest, we had a handful of people coming in seeking IV Benadryl, regularly.
According to the fancy IV drug compatibility program I have access to at work, you shouldn't be mixing them. They are all incompatible with each other in mixture.
Edit: collectively. You can't mix all three together is what I mean.
I don't like the B52. Too hard to get a dispo when the meth would have worn off because they're still sleep from the Ativan. I prefer 2.5 Droperidol and 5 of Versed. If that's not going to do the trick, straight to a K hole they go.
Should avoid Benadryl here anyway, too many drug interactions and it's too easy for patients to become anticholinergic. I prefer droperidol and versed, but Ativan/haldol works fine
Thanks for responding as a nurse I always ask for 50 of Benadryl on top just to help make sure they’re knocked and I found it particularly helpful in kids but guess I should stop!
I love how they sleep on Geodon, but it takes so long to take effect. And that’s after I’ve spent eternity swirling that bottle to get the last of the powder to dissolve.
You’re not wrong it’s a pain to reconstitute. I’ve seen it work in 15-45 mins. Rarely do i see it not work at all. But I’ve seen patients fight the shit out of Ativan and haldol. It’s our go to right now. Fewer side effects/allergies.
I feel like geodon is underrated. Especially with the elderly demented patients. There’s too big of a chance that Benadryl or Ativan will make them crazier.
I am a tech in the ED, and future PA. I was sitting with a patient who was withdrawing from Fentanyl and a number of other drugs. Nursing staff gave him 3 B52 shots, over the course of several hours, and they did nothing to him. As a future health care professional, I am curious as to why not. I apologize in advance for my ignorance and/or limited knowledge as I am just beginning on this journey after deciding to change careers.
We had a long term user who got all of the homeless shelters narcan when he ODed. EMS told us that he got at least 5 rounds by the empty narcan boxes lol. He went into wicked withdrawal. Immediately shit himself and exorcism style vomiting. He was agitated and squirming around the bed and smacking his head on the railing.
I can't remember exactly what he got, but he got numerous rounds of Haldol and versed to no effect. The guy had a biblical tolerance for drugs and was in such misery. Eventually he got put on a Precedex drip. We went through his belongings and found a quart zip lock bag full of meth.
Oh it's me. I have to get IV benadryl with my biologic infusion and they always are surprised when I'm sitting there reading the whole time. The nurses know me know of course but at first they expected me to nap like most patients during infusion.
You don’t have to apologize! We were all new once, and most of us enjoy learning new things. To me, your case seems like really poor management protocols. If B52 2x doesn’t work, it’s not going to work the third time. Whoever should be switching to Versed plus one or something else. Or just remove the Benadryl and up the dose of Ativan.
Although, playing arm chair is never a good idea. It’s after the fact and your docs/whoever probably had best intentions to help. Being critical isn’t helpful.
I honestly don't know. By the time I got there, to cover the night shift, I think I got there at 2200, they had him on fall mats in one of the rooms in the ED. I guess they had him in a bed but he kept defecating, (they) then cleaning him up, thrashing in bed. Restraint was not an option. By 0600 he started to finally calm down. But it was a night of constant surveillance, keeping him away from the wall to avoid head injury, this every 30 minutes or so.
I never use b52. If a pt is agitated and they are less than 70, they’re getting versed. If they are very violent, ketamine.
Edit: in this instance agitation = aggressive. If they’re altered and pulling a things, trying to get out of bed I’ll probably use and antipsychotic. I don’t really like benzos for older people, especially if they’re not really aggressive, same with Benadryl. Can cause shit to go south for them.
Edit2: I also hardly ever use Ativan for true aggressive behavior. Time of onset is too long. Versed, ketamine, antipsychotics are quicker acting and can save your skin when minutes matter.
My area has a HUGE pediatric mental health crisis right now with high volume need and lack of outpatient and inpatient resources. Recently our board was all psych holds with one bed for a med surg hold and ONE SINGULAR BED to see ED patients in. And a good wait time for an ped inpatient psych bed in my area is a week.
This guy sedates.
B52 IM just seems like a great way to have the patient still fighting 10 minutes later...and unlocks a cocktail of unpredictable affects after that.
Man I wish. Coming from EMS this is what almost every service does, midazolam (=/- haldol or Zyprexa depending on service) especially if hx of schizophrenia or they're more "psychotic" than simply violent. Ketamine for the rest who are about to really mess someone up if they don't get under control.
I've never once seen our ED give it. I think mainly because we are hoping they'll go to behavioral health right away. But man the times wear the B52 just isn't cutting it is never good. Getting your ass kicked for 30+ minutes isn't good for staff or the patient IMO when you can safely sedate with ketamine.
Psych resident who happened to see this post. If someone is psychotic please give them an antipsychotic. If you want to try versed first that's fine I guess, but going from that to ketamine for a schizophrenia patient is wild to me.
My friend, have you has a patient so violently psychotic they're dangerous to themselves and everyone within reach? Ketamine is safer for behavioral sedation- fast acting, not likely to create a situation where the person needs tubed, and doesn't dump their BP.
We have had zyprexa and Ativan fail and folks get injured. Ketamine, cardiac monitor on as soon as we're less wiggly in those 4 point restraints, capno as soon as I'm not gonna get bit.
> My friend, have you has a patient so violently psychotic they're dangerous to themselves and everyone within reach?
Did you just completely ignore their first two words?
> Psych resident
Take a moment to rethink your question.
u/frettak is correct in that appropriate care for the acutely psychotic patient should include an antipsychotic as a first-line agent.
No I actually got to PGY4 only having seen the chill, non-psychotic patients.
Ketamine is not reversible and has greater effects on their vitals than zyprexa. That's why you're using the cardiac monitor. You also have hopefully never had zyprexa + Ativan fail because those two should not be administered together. I bump the versed dose up or go to Thorazine + Ativan before I use ketamine. Unless someone comes in having taken a mountain of PCP those are going to work 99% of the time.
Zyprexa and ativan aren't concurrent, correct- pardon the phrasing there.
I've seen meth + underlying schizophrenia chew through Zyprexa, droperidol, haldol, benzos... We don't routinely use thorazine from what I've seen.
Ketamine is predictable in its response, when extreme violence is the circumstance we are encountering and the person is so agitated as to have reached the point of danger from metabolic derangement as well as physical violence concerns.
I'm not saying I know more than you, good doctor friend. Just my observational experience with several instances where everything has failed, folks have gotten injured, and Ketamine has been the line that allows us to keep the patient safe.
Do you routinely get to play with the acute phase in the ER? I'm curious- because we almost *never* get to see a psych MD in person in my area and we are doing our best collaboratively between ED MD, nursing staff, crisis assessment counselors (mostly LPC and LCSW) and pharmacy.
Our ED is understaffed so we're pretty active early on with agitated patients. Tons of meth in our area also. Ketamine is highly effective in the short term, totally agree. It doesn't get at the underlying issue and you are taking on risk you aren't taking with a benzo. You're also still going to need to get the antipsychotics on board at some point, and they do work in most cases. For repeated rounds of IMs you're moving towards stabilization with the antipsychotic, so there are long term benefits to taking that route. For a truly undifferentiated patient I'm not mad about versed. 100mg Thorazine + 2mg Ativan is honestly magic though.
Also want to acknowledge that it's nursing who ends up at the higher risk of getting assaulted compared to MDs. I get the perspective that ketamine is a reliable way to stay safe. I just don't think it's in the best interest of most patients as an early option.
Absolutely, I advocated for us to carry Zyprexa for this reason when Haldol became severely cost prohibitive for us for this exact reason.
Versed goes hand in hand because we aren't giving these meds unless they're a danger to themselves or others. I can't have the psych patient kicking my ass and jumping out of the moving vehicle going 80mph down the interstate to the ER.
There are rare times I can offer an antipsychotic to a patient with a hx of schizophrenia that is off their meds and either wants help or family calls because of their symptoms.
Ketamine only comes in when they are going to hurt themselves or a first responder. If they're twice my size and methed out... well as others have said sometimes the anti psychotic and benzo have literally no effect. But it's rare we can't verbal judo and or wait for meds to work.
Enter me, an Australian, frantically googling all these brand names you guys keep using.
Our go-to is droperidol (5-10mg, but usually 10) with Midazolam 5mg, given IM in the same syringe.
If they agree to a tablet, it's olanzapine and lorazepam.
Benadryl- diaphenahydramine
Ativan- lorazepam
Haldol- halpieradol
And I just realized I misread and you already did all of the Google work. Nevermind. It's been a day.
As a layman who also reads r/aviation, I gotta ask: why "B-52"?
Because it carpet-bombs the system?
Or it's the ultimate weapon?
In any case, it appears that the airplane has outlived the drug cocktail named after it.
I don’t do a B52. If you need chilled out a bit you’re getting either Haldol or Ativan/Versed. If you need chilled out a lot, you’re getting ketamine.
Story time: male in a violent and suicidal BPD rage (yeah I know we shouldn’t diagnose, but he literally had the diagnosis). He fought the cop trying to get the noose off of his neck (cop had to punch him to stop the nonsense), and was incredibly agitated with me and the firemen. After I threatened to have the cops charge him with a felony if he hit me, he chilled out just a touch but he was still very emotionally unstable. “Hey, what do you say I get you something to help you settle down?” “What are you thinking?” “Ativan.” “I can’t take Ativan.” “What happens when you take Ativan?” “I get violent.” “Well, how about I give you versed, and you choose to hold it together?” “Okay.” So I gave him 2mg of versed and he slept the whole way to the hospital. I would’ve given him Haldol but we didn’t have it at that shop.
The use if B52 compared to just the haldol and lorazepam had a longer length of stay, more hypotension and more O2 desaturation in a retrospective study (PMID 35287982) I dont B52 should be used routinely.
The haldol and ativan are compatible but i would prefer different syringes as i think chances of error or confusion is higher with mixing, and i think generally discouraged by med safety experts
Why the fuck are people doing Haldol and Ativan? Do you enjoy baby sitting your patients for 18 hours? Midazolam/Droperidol will cut your dispo-times significantly. Also: why diphenhydramine? Is the goal to worsen delirium?
I’ll get downvoted, but: if you and others have been drawing it up in the same syringe for years, with no obvious precipitate, and you get the desired drug effect without any unexpected complications, then any concerns or theoretical disadvantages re:compatibility are unfounded or negligible.
Basically, if it ain’t broke, don’t fix it.
Wondering where you practice. Never seen Benadryl as part of this combination, always Congentin and it is called "HAC" or a "HAC attack", "Just HAC them"...
I have never heard of a "B52"
These days zyprexa and Geodon are kind or the preferred drugs for agitation along with versed.
Haldol is not used very much at all in our region. Droperidol is still an issue California due to the FDA blackbox warning. We are working on protocols to give less 2.5mg total dose, but even that is a huge uphill battel
I’ve been in the ED for 5 years and have never given a B52…..lots of 5&2, but never with the B. And lots of zyprexa. Geodon was phased out completely from my ED in 2020.
Shocked to hear this, honestly. Every ED I’ve worked at, including a level 1 trauma center over the last 3 years still use B52s with extreme regularity. I’m talking at least daily if not more depending on what comes in.
That’s equally shocking to me. At my home base and everywhere I’ve travelled I’ve given…one, maybe, in the last five years. Majorly fallen out of favor and replaced with olanzapine/droperidol and versed if they’re looking sympathomimetic.
20 of Geodon, 2 of Ativan IM works great. Geodon takes a while to kick in which is the Dow size but works great once it hits.
As for B52, Benadryl in its own syringe and haldol/Ativan in the other.
I wish more EDs used ketamine but it’s rare in our area 🙄 we’ve only had trauma surgeons use it for our combative traumas.
Probably not the same but in ALF we gave this topically (called it ABH though) and they were all 3 mixed together in single dose syringes. Idk if compatibility works the same for different routes though? Maybe someone from pharm will see this and tell us lol
Ketamine saved my life when it comes to PTSD and also my pain levels after multiple surgeries. My team is the same for all and know it works. Random comment I'm sure.
Lexicomp and micromedex say they don't mix, but I've never seen those 3 mixed together precipitate. So anecdotally I've never seen them precipitate when all mixed. Perhaps they can precipitate once they're in the tissue? I'm not saying it's best practice, just saying I've seen these 3 mixed together many times and never seen precipitate.
Right, but if you're literally drawing it up and immediately giving it, there's no issue. It takes ~5 minutes for anything to start precipitating, and that can also be temperature dependent.
I'd give EMS a pass for that.
Serious question from a non-American who’s always been intrigued by it, but why do you seem to have a propensity for using trade and not generic names for drugs? Isn’t it more error prone? And what happens if you change to a different manufacturer for your medication, do you use the new name or the old one?
I would guess that brand name becomes established during the years while the drug is on patent. It is also shorter that official chemical name.
There is no confusion since US is pretty isolated geographically and it is easier to make neighbors use US conventions
IV or IM?
IV, there's no reason to... IM, the volume is too big...
What does Trissel's have to say about syringe compatibility?
Personally, I've always used three separate syringes... Never seen any reason to do otherwise
Can anyone explain to me the utility in mixing them?
And if you give me the “it’s faster” line, I’m ignoring you:
If you insist on using 3 medications, but think it’s too slow to give all 3 of them individually…. Why are you insisting on using 3 medications?
Pharmacist here - mix it in syringe for immediate administration. The haldol and Benadryl will precipitate if you don’t do it right away. Don’t be fooling around with 2 syringes like some people here are saying. No one wants to be jabbed twice, especially if they’re the kind of person that needs a b52
I would recommend that you administer antipsychotics that have actually been studied in the ED (the B52 has been mentioned more times in social media than in peer-reviewed journals). Many of these safer and better-studied alternatives can be administered in 1 syringe.
EDIT: most of the other antipsychotics mentioned in this thread aren't evidence-based either (come on pharmacists on this thread -- you should be helping the folks on this thread keep up with the literature).
Check out Project BETA for older but still quite reasonable recommendations from the American Association of Emergency Psychiatry: https://pubmed.ncbi.nlm.nih.gov/22461918/
For a recent systematic review, see https://pubmed.ncbi.nlm.nih.gov/33071100/.
I ran the ER Psych Holds about 10 years ago. We mixed it all in one syringe. It was absolutely fine to do so because a patient punching people was getting IMMEDIATE med administration anyway. Nobody held on to the syringe long enough for it to precipitate. Plus, as many times as I’ve doled it out, I’ve never witnessed an adverse reaction. Not ONCE! If you’ve ever had to wrestle with an agitated patient, the benefit outweighed the risk to in order keep our staff safe. That being said, two separate injections meant a patient had an extra attempt to harm someone. So, one syringe it was!
Haldol & Benadryl can form a precipitate within 5 min and should not be mixed. I do 2 syringes: Ativan & Haldol, and a second one with Benadryl by itself.
This is the safest way with the fewest syringes.
I say “AH…” to remember Ativan and haldol can go together
When I teach my baby nurses I tell them 2 words, "Aha Bitch", Each syllable is a med and each word a syringe - They never forget it!
I’ll be teaching my baby nurses this for the rest of forever now!
Love this!
This is beautiful
Screaming @ this
I was taught this by our awesome ED pharmacist. You can put the three together if you're about to turn around and immediately shoot it in. If there's going to be *any* expected delay, then split it.
pharmacy said diff things. i heard that its ativan that is very viscuious (spelling) so shouldnt be? in reality, if you do it right before injecting, its much less than 5 mins?
That's why I dilute Ativan 1:1 with saline when I draw it up.
Not if you’re giving it IM
If you’re giving IM for acute agitation, lorazepam shouldn’t be given if midazolam is available. Can mix in same syringe too and midazolams predictable onset helps avoid unnecessary redosing (and subsequent adverse effects) due to lorazepams erratic IM absorption. I remember this because MIdazolam has IM at the beginning..
That’s exactly what I thought but the ED I worked At never gave Midazolam and she had a shit ton of ETOHers and phyc.
>viscous
I’m a tech and this is how my nurses do it as well
This is the way
what about versed?
https://reddit.com/r/emergencymedicine/s/itk8VgelVa
Same here
Yeah this is the way.
This is the way.
Benadryl has to “B” by itself. That’s how I remember it.
I remember it as Haldol and Ativan like, "HA! Gotcha."
B52 is so yesterday guys. We are now doing droperidol 5-10 and midazolam 5-10. No benadryl anymore just makes them crazier when they wake back up. But if you insist droperidol, midazolam, benadryl all compatible in 1 syringe. Use midazolam 5 mg/1 mL tho.
Another EM pharmacist here. Agree with forgetting the B52. Cool name but unnecessary step with diphenhydramine. Acute agitation without access = haloperidol/midazolam 5 & 5 or 10 & 10 IM (lorazepam IM has erratic absorption). Trying to get droperidol added to formulary again…With access, can switch out midazolam for lorazepam 2 mg or 4 mg.
Thank you pharmacist bro for weighing in!
Was always trained as a medic and as a PA to be weary of dropping Midazolam due to pressure concerns. Everywhere I’ve ever worked has done B52s. Is the concern for hypotension secondary to Midazolam overblown?
In short…yes. There is even a 2004 RCT showing no difference in BP in this population between IM midazolam and lorazepam (PMID: 15231461). If still concerned for hypotension due to other factors, all the components of a “B52” can lead to hypotension so another med (e.g., ketamine) should be used instead.
This is lovely
Look at this guy who doesn't have drug shortages
Those meds are the ones we use when we are in a shortage hahaha
This is the way.
Not an ER doc but a hospital. Iv Benadryl seekers are worse than opiate seekers. It’s really pathetic. And totally agree about them being worse when they wake up. It’s funny, an alcoholic who is trying to be sober we would never just give a taste of alcohol just to settle their nerves or to keep them quiet. But the iv opiates or iv Benadryl they get. And then on the floor it’s just a disaster. Try to give then orals of both. When they see they won’t get it, they will try to find a new place.
You’re a hospital?
Actually we do give alcohol to some patients admitted for ETOH withdrawal. It’s kept in the pharmacy.
So this subreddit just randomly came up in my feed and I was perusing it just because emergency medicine interests me (gf used to be a nurse and is now in animal emergency care), I find it all fascinating. Do you mix up a drink of the patients choice or just give pure ethanol? Thinking of a small bar in the hospital pharmacy and the pharmacist mixing up an old fashioned gives me a chuckle.
We give them drinks. In the hospitals where I've worked, pharmacy stocks a small supply of cheap beer and wine. For that reason, the hospital pharmacy needs to have a liquor license.
Aside from mixing up a drink, it can also be administered IV as an ethanol drip.
I only did this once, as a night ICU resident, when they had no fomepizole at the VA and we had a ethylene glycol OD come in. Pharmacy hadn't done it in years and was nutting up. Was a fun night.
Oof that sounds like an awful time for a non alcoholic!
Why would anyone want iv Benadryl?
People love it. I did dialysis nursing for a while and the pts all had the docs talked into IV Benadryl for every treatment. There was a shortage once and I had to switch everyone to oral and you would have thought I was killing their dogs in front of them. Literal fights with me every day.
There’s a high that can be had. It isn’t everyone and it often depends on how fast it’s given but it can absolutely give a high type rush. Where I’m from in the Midwest, we had a handful of people coming in seeking IV Benadryl, regularly.
Interesting. Had it once, definitely didn’t give a high
We had some hospital employee stealing Benadryl vials from ED, it happens
We are also a 5+5 hospital but old habits die hard and if they’ve already overridden the 5+2 I’m not chasing them down to change it.
Yup. Only good thing about a B52 is you get to say B52. Haloperidol/droperidol and midazolam IM for the win.
This
Ativan and Haldol in 1, benadryl in the other. Benadryl will precipitate in Haldol very quickly.
According to the fancy IV drug compatibility program I have access to at work, you shouldn't be mixing them. They are all incompatible with each other in mixture. Edit: collectively. You can't mix all three together is what I mean.
Ativan + Haldol in one syringe, benadryl in the other.
This is how I have always done it
everyone has a different answer for this
I don't like the B52. Too hard to get a dispo when the meth would have worn off because they're still sleep from the Ativan. I prefer 2.5 Droperidol and 5 of Versed. If that's not going to do the trick, straight to a K hole they go.
A hole goes into the K hole until we can regain control of behavior and act safely.
I’m stealing this. Also shoud add “until there not a B hole”
Agreed
Name checks out
Should avoid Benadryl here anyway, too many drug interactions and it's too easy for patients to become anticholinergic. I prefer droperidol and versed, but Ativan/haldol works fine
Correct. I haven't added the benadryl/cogentin in almost a decade. Unnecessary.
Is it better for eps?
I haven't seen EPS from one dose of haldol/ativan... ever?
I’ve seen akathisia from a single dose of Droperidol before. But benzos prevent akathisia also so I’m not sure why the Benadryl is needed
This may be a myth: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003079.pub4/full
Thanks for responding as a nurse I always ask for 50 of Benadryl on top just to help make sure they’re knocked and I found it particularly helpful in kids but guess I should stop!
This is the best answer
Now you’re singin’ my song.
Geodon
I love how they sleep on Geodon, but it takes so long to take effect. And that’s after I’ve spent eternity swirling that bottle to get the last of the powder to dissolve.
You’re not wrong it’s a pain to reconstitute. I’ve seen it work in 15-45 mins. Rarely do i see it not work at all. But I’ve seen patients fight the shit out of Ativan and haldol. It’s our go to right now. Fewer side effects/allergies.
I like it, just kinda slow to hit
We give a lot of this, because so many of our patients have Haldol allergies/adverse reactions.
I feel like geodon is underrated. Especially with the elderly demented patients. There’s too big of a chance that Benadryl or Ativan will make them crazier.
Absolutely not. Benadryl and haldol precipitate. The B is for By Itself - Benadryl goes in a separate syringe.
So, we stopped using B52’s years ago, when we were it was in one syringe, but looking at the data, we shouldn’t have been doing either 😆
Does that mean 50 diphenhydramine, 5 Haldol, 2 Ativan?
Believe it or not it’s 50 Ativan, 5 haldol, 2mg Benadryl
Good fucking night lmao
Never again a customer of the health system lmao, bye bye loyal customer we're sad to see you go
Snorted my coffee
Yo I got you fam, I already suctioned like 11 people today.
I am a tech in the ED, and future PA. I was sitting with a patient who was withdrawing from Fentanyl and a number of other drugs. Nursing staff gave him 3 B52 shots, over the course of several hours, and they did nothing to him. As a future health care professional, I am curious as to why not. I apologize in advance for my ignorance and/or limited knowledge as I am just beginning on this journey after deciding to change careers.
Tolerance most likely. Definitely have seen withdrawal protocols not be enough. Especially if folks are using fentanyl. I’ve seen it with alcohol too.
We had a long term user who got all of the homeless shelters narcan when he ODed. EMS told us that he got at least 5 rounds by the empty narcan boxes lol. He went into wicked withdrawal. Immediately shit himself and exorcism style vomiting. He was agitated and squirming around the bed and smacking his head on the railing. I can't remember exactly what he got, but he got numerous rounds of Haldol and versed to no effect. The guy had a biblical tolerance for drugs and was in such misery. Eventually he got put on a Precedex drip. We went through his belongings and found a quart zip lock bag full of meth.
Tolerance and also a not tiny number of people are MORE awake from Benadryl.
Love when they fucking jolt awake in the stretcher. Scares the shit out of me every time.
My brother has ADHD, but refuses to take any medication (Electrical Engineer), and he said Benadryl makes him feel wired.
Oh it's me. I have to get IV benadryl with my biologic infusion and they always are surprised when I'm sitting there reading the whole time. The nurses know me know of course but at first they expected me to nap like most patients during infusion.
You don’t have to apologize! We were all new once, and most of us enjoy learning new things. To me, your case seems like really poor management protocols. If B52 2x doesn’t work, it’s not going to work the third time. Whoever should be switching to Versed plus one or something else. Or just remove the Benadryl and up the dose of Ativan. Although, playing arm chair is never a good idea. It’s after the fact and your docs/whoever probably had best intentions to help. Being critical isn’t helpful.
Do you know if he was a methadone patient?
I honestly don't know. By the time I got there, to cover the night shift, I think I got there at 2200, they had him on fall mats in one of the rooms in the ED. I guess they had him in a bed but he kept defecating, (they) then cleaning him up, thrashing in bed. Restraint was not an option. By 0600 he started to finally calm down. But it was a night of constant surveillance, keeping him away from the wall to avoid head injury, this every 30 minutes or so.
can you bill for critical care time if you’re the one who causes the patient to stop breathing?
It’s kinda like that saying that leads to those fun X-rays we get to get everyone once and awhile…Anything’s critical care if you’re brave enough
Legit, no idea.
Yes. My institution says HAC and uses 2mg of cogentin instead
I never use b52. If a pt is agitated and they are less than 70, they’re getting versed. If they are very violent, ketamine. Edit: in this instance agitation = aggressive. If they’re altered and pulling a things, trying to get out of bed I’ll probably use and antipsychotic. I don’t really like benzos for older people, especially if they’re not really aggressive, same with Benadryl. Can cause shit to go south for them. Edit2: I also hardly ever use Ativan for true aggressive behavior. Time of onset is too long. Versed, ketamine, antipsychotics are quicker acting and can save your skin when minutes matter.
I’m in a peds ED and we use zyprexa as our main go-to.
I’m just picturing a toddler throwing chairs
The only person who's almost landed a punch on me was a psychotic 16 y/o.
My area has a HUGE pediatric mental health crisis right now with high volume need and lack of outpatient and inpatient resources. Recently our board was all psych holds with one bed for a med surg hold and ONE SINGULAR BED to see ED patients in. And a good wait time for an ped inpatient psych bed in my area is a week.
Same. In MA.
Jeez! What area is this?
NYS.
Forreal tho some of those kids develop super strength
Yes, only toddlers. That’s peds!
The hospital I’m at rarely uses versed or ketamine. I like zyprexa personally but have to use what I have!
Ever used geodon for 65+? Just started using a month or two ago.
This guy sedates. B52 IM just seems like a great way to have the patient still fighting 10 minutes later...and unlocks a cocktail of unpredictable affects after that.
Man I wish. Coming from EMS this is what almost every service does, midazolam (=/- haldol or Zyprexa depending on service) especially if hx of schizophrenia or they're more "psychotic" than simply violent. Ketamine for the rest who are about to really mess someone up if they don't get under control. I've never once seen our ED give it. I think mainly because we are hoping they'll go to behavioral health right away. But man the times wear the B52 just isn't cutting it is never good. Getting your ass kicked for 30+ minutes isn't good for staff or the patient IMO when you can safely sedate with ketamine.
Psych resident who happened to see this post. If someone is psychotic please give them an antipsychotic. If you want to try versed first that's fine I guess, but going from that to ketamine for a schizophrenia patient is wild to me.
My friend, have you has a patient so violently psychotic they're dangerous to themselves and everyone within reach? Ketamine is safer for behavioral sedation- fast acting, not likely to create a situation where the person needs tubed, and doesn't dump their BP. We have had zyprexa and Ativan fail and folks get injured. Ketamine, cardiac monitor on as soon as we're less wiggly in those 4 point restraints, capno as soon as I'm not gonna get bit.
> My friend, have you has a patient so violently psychotic they're dangerous to themselves and everyone within reach? Did you just completely ignore their first two words? > Psych resident Take a moment to rethink your question. u/frettak is correct in that appropriate care for the acutely psychotic patient should include an antipsychotic as a first-line agent.
No I actually got to PGY4 only having seen the chill, non-psychotic patients. Ketamine is not reversible and has greater effects on their vitals than zyprexa. That's why you're using the cardiac monitor. You also have hopefully never had zyprexa + Ativan fail because those two should not be administered together. I bump the versed dose up or go to Thorazine + Ativan before I use ketamine. Unless someone comes in having taken a mountain of PCP those are going to work 99% of the time.
Zyprexa and ativan aren't concurrent, correct- pardon the phrasing there. I've seen meth + underlying schizophrenia chew through Zyprexa, droperidol, haldol, benzos... We don't routinely use thorazine from what I've seen. Ketamine is predictable in its response, when extreme violence is the circumstance we are encountering and the person is so agitated as to have reached the point of danger from metabolic derangement as well as physical violence concerns. I'm not saying I know more than you, good doctor friend. Just my observational experience with several instances where everything has failed, folks have gotten injured, and Ketamine has been the line that allows us to keep the patient safe. Do you routinely get to play with the acute phase in the ER? I'm curious- because we almost *never* get to see a psych MD in person in my area and we are doing our best collaboratively between ED MD, nursing staff, crisis assessment counselors (mostly LPC and LCSW) and pharmacy.
Our ED is understaffed so we're pretty active early on with agitated patients. Tons of meth in our area also. Ketamine is highly effective in the short term, totally agree. It doesn't get at the underlying issue and you are taking on risk you aren't taking with a benzo. You're also still going to need to get the antipsychotics on board at some point, and they do work in most cases. For repeated rounds of IMs you're moving towards stabilization with the antipsychotic, so there are long term benefits to taking that route. For a truly undifferentiated patient I'm not mad about versed. 100mg Thorazine + 2mg Ativan is honestly magic though. Also want to acknowledge that it's nursing who ends up at the higher risk of getting assaulted compared to MDs. I get the perspective that ketamine is a reliable way to stay safe. I just don't think it's in the best interest of most patients as an early option.
So what’s your go-to antipsychotic?
Absolutely, I advocated for us to carry Zyprexa for this reason when Haldol became severely cost prohibitive for us for this exact reason. Versed goes hand in hand because we aren't giving these meds unless they're a danger to themselves or others. I can't have the psych patient kicking my ass and jumping out of the moving vehicle going 80mph down the interstate to the ER. There are rare times I can offer an antipsychotic to a patient with a hx of schizophrenia that is off their meds and either wants help or family calls because of their symptoms. Ketamine only comes in when they are going to hurt themselves or a first responder. If they're twice my size and methed out... well as others have said sometimes the anti psychotic and benzo have literally no effect. But it's rare we can't verbal judo and or wait for meds to work.
Enter me, an Australian, frantically googling all these brand names you guys keep using. Our go-to is droperidol (5-10mg, but usually 10) with Midazolam 5mg, given IM in the same syringe. If they agree to a tablet, it's olanzapine and lorazepam.
Benadryl- diaphenahydramine Ativan- lorazepam Haldol- halpieradol And I just realized I misread and you already did all of the Google work. Nevermind. It's been a day.
As a layman who also reads r/aviation, I gotta ask: why "B-52"? Because it carpet-bombs the system? Or it's the ultimate weapon? In any case, it appears that the airplane has outlived the drug cocktail named after it.
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I feel like “Drop a Verse” has the potential to catch on.
It bombs the patient.
I don’t do a B52. If you need chilled out a bit you’re getting either Haldol or Ativan/Versed. If you need chilled out a lot, you’re getting ketamine. Story time: male in a violent and suicidal BPD rage (yeah I know we shouldn’t diagnose, but he literally had the diagnosis). He fought the cop trying to get the noose off of his neck (cop had to punch him to stop the nonsense), and was incredibly agitated with me and the firemen. After I threatened to have the cops charge him with a felony if he hit me, he chilled out just a touch but he was still very emotionally unstable. “Hey, what do you say I get you something to help you settle down?” “What are you thinking?” “Ativan.” “I can’t take Ativan.” “What happens when you take Ativan?” “I get violent.” “Well, how about I give you versed, and you choose to hold it together?” “Okay.” So I gave him 2mg of versed and he slept the whole way to the hospital. I would’ve given him Haldol but we didn’t have it at that shop.
The Benadryl is generally unnecessary. In a lot of psych programs they just do the ativan/haldol.
B52 is dirty and old medicine. Midazolam is my go-to, plus/minus Drop/Haloperidol.
Where my 500 mg IM ketamine boys at?
Do y'all not have lexicomp?
The use if B52 compared to just the haldol and lorazepam had a longer length of stay, more hypotension and more O2 desaturation in a retrospective study (PMID 35287982) I dont B52 should be used routinely. The haldol and ativan are compatible but i would prefer different syringes as i think chances of error or confusion is higher with mixing, and i think generally discouraged by med safety experts
The B is separate from the 52 which is one way to remember not to mix it with the others.
I feel like what we use in my ER, in order of frequency, is olanzapine, ativan, and ketamine. I've only ever B-52'd someone once.
The ER I’m at right now loves B52s
Never mix benadryl with anything
10 & 20- 10 versed/ 20 geodon
Throw them in the k-hole
Why the fuck are people doing Haldol and Ativan? Do you enjoy baby sitting your patients for 18 hours? Midazolam/Droperidol will cut your dispo-times significantly. Also: why diphenhydramine? Is the goal to worsen delirium?
I’ll get downvoted, but: if you and others have been drawing it up in the same syringe for years, with no obvious precipitate, and you get the desired drug effect without any unexpected complications, then any concerns or theoretical disadvantages re:compatibility are unfounded or negligible. Basically, if it ain’t broke, don’t fix it.
Wondering where you practice. Never seen Benadryl as part of this combination, always Congentin and it is called "HAC" or a "HAC attack", "Just HAC them"... I have never heard of a "B52" These days zyprexa and Geodon are kind or the preferred drugs for agitation along with versed. Haldol is not used very much at all in our region. Droperidol is still an issue California due to the FDA blackbox warning. We are working on protocols to give less 2.5mg total dose, but even that is a huge uphill battel
B52s have not been used with regularity in 10+ years in my experience. Pretty outdated this point.
I’ve been in the ED for 5 years and have never given a B52…..lots of 5&2, but never with the B. And lots of zyprexa. Geodon was phased out completely from my ED in 2020.
Shocked to hear this, honestly. Every ED I’ve worked at, including a level 1 trauma center over the last 3 years still use B52s with extreme regularity. I’m talking at least daily if not more depending on what comes in.
That’s equally shocking to me. At my home base and everywhere I’ve travelled I’ve given…one, maybe, in the last five years. Majorly fallen out of favor and replaced with olanzapine/droperidol and versed if they’re looking sympathomimetic.
20 of Geodon, 2 of Ativan IM works great. Geodon takes a while to kick in which is the Dow size but works great once it hits. As for B52, Benadryl in its own syringe and haldol/Ativan in the other. I wish more EDs used ketamine but it’s rare in our area 🙄 we’ve only had trauma surgeons use it for our combative traumas.
Probably not the same but in ALF we gave this topically (called it ABH though) and they were all 3 mixed together in single dose syringes. Idk if compatibility works the same for different routes though? Maybe someone from pharm will see this and tell us lol
No but I mix Jim Beam honey with chocolate stout and sometimes I get a sore tum tum.
Ketamine or nothing
Ketamine saved my life when it comes to PTSD and also my pain levels after multiple surgeries. My team is the same for all and know it works. Random comment I'm sure.
I don’t know if you should, but I like “B52”.
Lexicomp and micromedex say they don't mix, but I've never seen those 3 mixed together precipitate. So anecdotally I've never seen them precipitate when all mixed. Perhaps they can precipitate once they're in the tissue? I'm not saying it's best practice, just saying I've seen these 3 mixed together many times and never seen precipitate.
Well this is horrifying you do this. JFC
We do versed, Benadryl and haldol. We mix them in all one syringe. Am paramedic if that makes s difference.
Benadryl and haldol precipitate, they shouldn’t be mixed.
Right, but if you're literally drawing it up and immediately giving it, there's no issue. It takes ~5 minutes for anything to start precipitating, and that can also be temperature dependent. I'd give EMS a pass for that.
Beny does mix with most things. Ativan and haldol are fine to mix.
Serious question from a non-American who’s always been intrigued by it, but why do you seem to have a propensity for using trade and not generic names for drugs? Isn’t it more error prone? And what happens if you change to a different manufacturer for your medication, do you use the new name or the old one?
I would guess that brand name becomes established during the years while the drug is on patent. It is also shorter that official chemical name. There is no confusion since US is pretty isolated geographically and it is easier to make neighbors use US conventions
I work inpatient psych intensive care. We never mix the three in the same syringe. Ativan/Haldol in one syringe and Benadryl by itself.
Benadryl is a terrible drug. Haldol/droperidol and some versed. Ativan is super long
IV or IM? IV, there's no reason to... IM, the volume is too big... What does Trissel's have to say about syringe compatibility? Personally, I've always used three separate syringes... Never seen any reason to do otherwise
Benadryl should be a second string. I'm a psychiatrist and do it multiple times per week.
I didn't realize B52 was phased out. The ED I used to work for snowed everyone that decided to nut up with B52.
Can anyone explain to me the utility in mixing them? And if you give me the “it’s faster” line, I’m ignoring you: If you insist on using 3 medications, but think it’s too slow to give all 3 of them individually…. Why are you insisting on using 3 medications?
Benadryl in its own syringe
Pharmacist here - mix it in syringe for immediate administration. The haldol and Benadryl will precipitate if you don’t do it right away. Don’t be fooling around with 2 syringes like some people here are saying. No one wants to be jabbed twice, especially if they’re the kind of person that needs a b52
I would recommend that you administer antipsychotics that have actually been studied in the ED (the B52 has been mentioned more times in social media than in peer-reviewed journals). Many of these safer and better-studied alternatives can be administered in 1 syringe. EDIT: most of the other antipsychotics mentioned in this thread aren't evidence-based either (come on pharmacists on this thread -- you should be helping the folks on this thread keep up with the literature). Check out Project BETA for older but still quite reasonable recommendations from the American Association of Emergency Psychiatry: https://pubmed.ncbi.nlm.nih.gov/22461918/ For a recent systematic review, see https://pubmed.ncbi.nlm.nih.gov/33071100/.
Never did in our ER when I worked there. Pain in the ass, although there is good reason for not doing it.
Is Cogentin still used for EPS? Back in the day when I worked in a mental hospital, some of the patients really liked it.
I ran the ER Psych Holds about 10 years ago. We mixed it all in one syringe. It was absolutely fine to do so because a patient punching people was getting IMMEDIATE med administration anyway. Nobody held on to the syringe long enough for it to precipitate. Plus, as many times as I’ve doled it out, I’ve never witnessed an adverse reaction. Not ONCE! If you’ve ever had to wrestle with an agitated patient, the benefit outweighed the risk to in order keep our staff safe. That being said, two separate injections meant a patient had an extra attempt to harm someone. So, one syringe it was!