[Psychopharmacological treatment in the pre-clinical emergency medicine]

Use of antipsychotics and benzodiazepines in patients with psychiatric emergencies: results of an observational trial

BACKGROUND

Conventional antipsychotics augmented with benzodiazepines have been the standard acute treatment for psychiatric emergencies for more than 50 years. The inability of patients to give informed consent limits randomised, controlled studies. This observational study on immediate therapy for aggression and impulse control in acutely agitated patients (IMPULSE) evaluated the short-term effectiveness and tolerability of atypical and typical antipsychotic medications (AP) in a non-interventional setting.

METHODS

This was a comparative, non-randomised, prospective, open-label, observational study. Treatment over the first 5 days was classified according to whether any olanzapine, risperidone, or haloperidol was included or not. Documentations (PANSS-excited component, CGI-aggression, CGI-suicidality, tranquilisation score) were at baseline (day 1) and days 2-6 after start of AP.

RESULTS

During the short treatment-period, PANSS-EC and CGI-aggression scores improved in all cohorts. 68.7% of patients treated with olanzapine, 72.2% of patients treated with risperidone, and 83.3% of patients treated with haloperidol received concomitant benzodiazepines (haloperidol vs. non-haloperidol: p < 0.001). More patients treated with olanzapine (73.8%) were fully alert according to a tranquilisation score and active at day 2 than patients treated with risperidone (57.1%) or haloperidol (58.0%).

CONCLUSION

Current medication practices for immediate aggression control are effective with positive results present within a few days. In this study, concomitant benzodiazepine use was significantly more frequent in patients receiving haloperidol.

Psychiatric emergencies in prehospital emergency medical systems: a prospective comparison of two urban settings

BACKGROUND

Psychiatric emergency situations (PES) are of high importance to the German prehospital physician-based emergency medical system. So far, however, no prospective studies regarding the incidence of PES have been performed, neither have effects of training programs on diagnostic and therapeutic accuracy been studied.

METHOD

The protocols of two emergency medical services (EMS) were collected and analyzed prospectively. Emergency physicians (EPs) in Kaiserslautern (KL) attended a standardized educational program and underwent daily supervision. EPs in Homburg (HOM) had not been informed about the study. In KL, sociodemographic variables were collected. An investigator who was not involved in the individual EMS mission assessed the correct classification of PES.

RESULTS

Among all calls for an EP, 11.8% were classified as PES. There was no difference between the two centers. Correct classification of PES in KL was significantly higher than that in HOM (94.3% vs. 80.6%). Documentation of suicidal behavior was deficient in both centers. EPs in KL gave verbal crisis intervention significantly more often, administered less medication overall, and dispensed more specific drugs in psychotic disorders and significantly less drugs in substance abuse disorders. Patients were more often treated at the scene and were less often transported to a hospital. Some sociodemographic variables were associated with psychiatric morbidity of treatment.

CONCLUSION

Accounting for 12% of all missions, psychiatric emergencies are a frequent reason for calls for EPs, equaling trauma-related and neurological emergencies. The most frequent reasons for calls were alcohol intoxication, states of agitation and suicidal behavior. The diagnostic and therapeutic accuracy of EPs may be improved with a concise standardized teaching program.

[Assessment of psychiatric emergencies by physicians in the pre-hospital emergency medical system. A re-evaluation after 7 years]

OBJECTIVE

In the German emergency medical system (EMS) psychiatric emergency situations (PES) are now responsible for up to 15% of all calls for the emergency physician (EP). A survey which was first conducted in 1996 to reveal knowledge about PES, reported a significant need for training. Seven years later it is interesting to investigate whether different conditions in the EMS may have changed assessments and attitudes.

METHODS

The questionnaire of 1996 was modified to enable a comparison of PES and other frequent emergency situations with respect to the estimated number and the subjective stress. Open and multiple-choice questions or visual analogue scales were used to obtain the following data: demographic data, frequency of and stress by PES and other medical emergencies, own knowledge, and interest about training programs.

RESULTS

Of the EPs 274 responded (male/female: 74/26%, mean age: 38 years, mean experience as an EP 6 years, anaesthesiologists 69%). The frequency of PES was estimated at 5% and 44% of EPs thought that there had been an increase in recent years. Personal knowledge was judged to be good by only 24%. The interest in training programs even increased slightly compared to the first survey; of particular interest was training in drug abuse disorders. Subsequent to internal, neurological and surgical emergencies, PES are considered to rank fourth in frequency, however the strain imposed by PES is significantly higher than for these other emergency situations.

DISCUSSION

The results indicate an increase of relevance of PES in the German EMS, however, assessments made by the EP only changed marginally over the time period. The subjective awareness of the frequency of PES underestimates the reality in emergency medicine. The importance of training programs remains high to improve knowledge and to reduce feelings of incapability.