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Greene SL, Syrjanen R, Hodgson SE, Abouchedid R, Schumann J. Co-exposure to gamma-hydroxybutyrate is associated with attenuated neuropsychiatric and stimulant effects of metamfetamine. Clin Toxicol (Phila) 2024; 62:303-313. [PMID: 38884342 DOI: 10.1080/15563650.2024.2353265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 05/03/2024] [Indexed: 06/18/2024]
Abstract
INTRODUCTION Acute metamfetamine toxicity is characterized by stimulant effects and neuropsychiatric disturbance, which is attenuated by gamma-aminobutyric acid type A receptor agonists including benzodiazepines. We utilized clinical registry data to examine the effect of co-exposure to a gamma-aminobutyric acid type B receptor agonist (gamma-hydroxybutyrate) in illicit drug cases with analytically confirmed exposure to metamfetamine. METHODS The Emerging Drugs Network of Australia Victoria is an ethics board-approved prospective registry collecting clinical and analytical data (utilising blood samples) on emergency department illicit drug presentations. Comparison groups were defined by analytically confirmed exposure: lone metamfetamine, metamfetamine plus gamma-hydroxybutyrate, metamfetamine plus benzodiazepine, metamfetamine plus gamma-hydroxybutyrate plus benzodiazepine. Cases with co-exposure to other stimulants or sedatives were excluded. RESULTS Median metamfetamine blood concentrations were significantly greater in metamfetamine plus gamma-hydroxybutyrate (n = 153, median = 0.20 mg/L, interquartile range: 0.10-0.32 mg/L, 95 per cent confidence interval: 0.20-0.23 mg/L) and metamfetamine plus gamma-hydroxybutyrate plus benzodiazepine (n = 160, median = 0.20 mg/L, interquartile range: 0.10-0.30 mg/L, 95 per cent confidence interval: 0.20-0.30 mg/L) positive groups compared to gamma-hydroxybutyrate negative groups including metamfetamine (n = 81, median = 0.10 mg/L, interquartile range: 0.05-0.21 mg/L, 95 per cent confidence interval: 0.09-0.18 mg/L) and metamfetamine plus benzodiazepine (n = 73, median = 0.10 mg/L, interquartile range: 0.06-0.20 mg/L, 95 per cent confidence interval: 0.09-0.20 mg/L) groups (P < 0.0004). Presenting heart rate in metamfetamine plus gamma-hydroxybutyrate cases (n = 153, median = 72 beats per minute, interquartile range: 63-86 beats per minute, 95 per cent confidence interval: 70-78 beats per minute) was significantly lower than metamfetamine plus benzodiazepine cases (n = 73, median = 84 beats per minute, interquartile range: 73-98 beats per minute, 95 per cent confidence interval: 80-90 beats per minute, P < 0.0001), and lone metamfetamine cases (n = 81, median = 110 beats per minute, interquartile range: 87-131 beats per minute, 95 per cent confidence interval: 93-120 beats per minute, P < 0.0001). Presenting temperature in metamfetamine plus gamma-hydroxybutyrate cases (median = 35.8 °C, interquartile range: 35.0-36.2 °C, 95 per cent confidence interval 35.6-35.9 °C) was significantly lower than metamfetamine plus benzodiazepine cases (median 36.2 °C, interquartile range 35.7-36.6 °C, 95 per cent confidence interval, 36.0-36.4 °C, P = 0.017), and lone metamfetamine cases (median = 36.5 °C, interquartile range: 35.8-37.1 °C, 95 per cent confidence interval: 36.2-36.7 °C, P < 0.0001). Median presenting systolic blood pressure was significantly (P ≤ 0.001) lower in benzodiazepine positive groups (metamfetamine plus benzodiazepine median = 120 mmHg, interquartile range: 109-132 mmHg, 95 per cent confidence interval: 116-124 mmHg and metamfetamine plus benzodiazepine plus gamma-hydroxybutyrate median = 124 mmHg, interquartile range: 110-137 mmHg, 95 per cent confidence interval: 120-129 mmHg). Incidence of sedation (Glasgow Coma Scale less than 9) was significantly greater in metamfetamine plus gamma-hydroxybutyrate cases (63 per cent) compared to metamfetamine plus benzodiazepine cases (27 per cent, P < 0.0001) and lone metamfetamine cases (15 per cent, P < 0.0001). Incidence of agitation was significantly lower in metamfetamine plus gamma-hydroxybutyrate plus benzodiazepine cases (17 per cent, P < 0.0001) and metamfetamine plus gamma-hydroxybutyrate cases (34 per cent, P = 0.0004) compared to lone metamfetamine cases (58 per cent). DISCUSSION Differences in gamma-aminobutyric acid type A and B receptor physiology may offer a gamma-aminobutyric acid type B agonist-facilitated alternative pharmacodynamic mechanism able to attenuate metamfetamine stimulant and neuropsychiatric toxicity. CONCLUSION Metamfetamine intoxicated patients with analytically confirmed co-exposure to gamma-hydroxybutyrate had significantly reduced heart rate, body temperature and incidence of agitation compared to patients with lone metamfetamine exposure. Metamfetamine intoxicated patients with analytically confirmed co-exposure to a benzodiazepine had significantly reduced systolic blood pressure compared to patients with lone metamfetamine exposure. We hypothesize that gamma-aminobutyric acid type B receptor agonists may be beneficial in the management of acute metamfetamine toxicity.
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Affiliation(s)
- Shaun Lawrence Greene
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia
- Austin Health, Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia
- Melbourne Medical School, Department of Critical Care, The University of Melbourne, Parkville, Victoria, Australia
| | - Rebekka Syrjanen
- Austin Health, Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Forensic Medicine, Monash University, Southbank, Victoria, Australia
| | - Sarah Ellen Hodgson
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia
- Austin Health, Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia
| | - Rachelle Abouchedid
- Austin Health, Victorian Poisons Information Centre, Austin Hospital, Heidelberg, Victoria, Australia
- Bendigo Health, Emergency Department, Bendigo Hospital, Bendigo, Victoria, Australia
| | - Jennifer Schumann
- Department of Forensic Medicine, Monash University, Southbank, Victoria, Australia
- Toxicology Department, Victorian Institute of Forensic Medicine, Southbank, Victoria, Australia
- Monash Addiction Research Centre, Monash University, Frankston, Victoria, Australia
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Castro M, Butler M, Thompson AN, Gee S, Posporelis S. Effectiveness and Safety of Intravenous Medications for the Management of Acute Disturbance (Agitation and Other Escalating Behaviors): A Systematic Review of Prospective Interventional Studies. J Acad Consult Liaison Psychiatry 2024; 65:271-286. [PMID: 38309683 DOI: 10.1016/j.jaclp.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/15/2024] [Accepted: 01/28/2024] [Indexed: 02/05/2024]
Abstract
Acute disturbance is a broad term referring to escalating behaviors secondary to a change in mental state, such as agitation, aggression, and violence. Available management options include de-escalation techniques and rapid tranquilization, mostly via parenteral formulations of medication. While the intramuscular route has been extensively studied in a range of clinical settings, the same cannot be said for intravenous (IV); this is despite potential benefits, including rapid absorption and complete bioavailability. This systematic review analyzed existing evidence for effectiveness and safety of IV medication for management of acute disturbances. It followed a preregistered protocol (PROSPERO identification CRD42020216456) and is reported following the guidelines set by Preferred Reporting Items for Systematic Review and Meta-Analysis. APA PsycINFO, MEDLINE, and EMBASE databases were searched for eligible interventional studies up until May 30th, 2023. Data analysis was limited to narrative synthesis since primary outcome measures varied significantly. Results showed mixed but positive results for the effectiveness of IV dexmedetomidine, lorazepam, droperidol, and olanzapine. Evidence was more limited for IV haloperidol, ketamine, midazolam, chlorpromazine, and valproate. There was no eligible data on the use of IV clonazepam, clonidine, diazepam, diphenhydramine, propranolol, ziprasidone, fluphenazine, carbamazepine, or promethazine. Most studies reported favorable adverse event profiles, though they are unlikely to have been sufficiently powered to pick up rare serious events. In most cases, evidence was of low or mixed quality, accentuating the need for further standardized, large-scale, multi-arm randomized controlled trials with homogeneous outcome measures. Overall, this review suggests that IV medications may offer an effective alternative parenteral route of administration in acute disturbance, particularly in general hospital settings.
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Affiliation(s)
- Megan Castro
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology, and Neuroscience, London, United Kingdom
| | - Matt Butler
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology, and Neuroscience, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom.
| | | | - Siobhan Gee
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, United Kingdom; Institute of Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, KCL, London, United Kingdom
| | - Sotiris Posporelis
- Neuropsychiatry Research and Education Group, Institute of Psychiatry, Psychology, and Neuroscience, London, United Kingdom; South London and Maudsley NHS Foundation Trust, London, United Kingdom
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Li J, Zhu H, Wang Y, Chen J, He K, Wang S. Remifentanil is Superior to Propofol for Treating Emergence Agitation in Adults After General Anesthesia. Drug Des Devel Ther 2024; 18:341-350. [PMID: 38344258 PMCID: PMC10859049 DOI: 10.2147/dddt.s433155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 01/25/2024] [Indexed: 02/15/2024] Open
Abstract
Background Emergence agitation (EA) is one of the most common complications in clinical general anesthesia during recovery in adults. Remifentanil and propofol can reduce the incidence of EA, but with no randomized controlled trial to evaluate their effectiveness for treating EA. This study aims to compare the effectiveness of remifentanil and propofol for treating EA following general anesthesia. Patients and methods Among 152 randomized patients with a mean of 49.5 years, and 99 (65.1%) of them being male, 149 were divided into two groups for subsequent analysis. The remifentanil group (Group R, n = 74) received a 0.5μg kg-1 remifentanil infusion followed by a 0.05μg kg-1 min-1 infusion until 15 minutes, after the onset of agitation. The propofol group (Group P, n = 75) received a 1mg kg-1 propofol infusion once agitation occurred. Emergence agitation was assessed using the Riker Sedation Agitation Score, with a score of ≥5 defining emergence agitation. During the post-anesthesia care unit (PACU), the recurrence of emergence agitation, time to extubation, and discharge from PACU were evaluated. Results The incidence of reoccurring emergence agitation was lower in Group R (29.7%) compared with Group P (49.3%), with an odds ratio of 0.44 (95% CI 0.22-0.85; P=0.014). The time to extubation was shorter in Group R (mean 12min, range 8-15 min) compared with Group P (mean 17min, range 13-21 min) (P<0.001), as was the time discharge from the PACU (mean 30.5 min, range 25-40 min) vs Group P (mean 37.5 min, range 31-50 min) (P=0.001). Conclusion Treatment of emergence agitation in adults with remifentanil infusion is more effective than propofol, with a shorter time to extubation and discharge from PACU.
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Affiliation(s)
- Jun Li
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong, People’s Republic of China
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
| | - Hongrui Zhu
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
| | - Yu Wang
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Soochow, People’s Republic of China
| | - Jiaqi Chen
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
| | - Keqiang He
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
| | - Sheng Wang
- Department of Anesthesiology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People’s Republic of China
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Wolfe C, McCoin N. Management of the Agitated Patient. Emerg Med Clin North Am 2024; 42:13-29. [PMID: 37977745 DOI: 10.1016/j.emc.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
The acutely agitated patient should be managed in a step-wise fashion, beginning with non-coercive de-escalation strategies and moving on to pharmacologic interventions and physical restraints as necessary. Face-to-face examination, monitoring, and documentation by the physician are essential. The emergency physician should be familiar with multiple pharmaceutical options, tailored to the individual patient. Use of ketamine, benzodiazepines and antipsychotics should be considered. Patient autonomy, safety, and medical well-being are paramount.
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Affiliation(s)
- Carmen Wolfe
- Department of Emergency Medicine, Tristar Skyline Medical Center, 3443 Dickerson Pike, Suite 230, Nashville, TN 37207, USA.
| | - Nicole McCoin
- Department of Emergency Medicine, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA
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Thiessen MEW, Godwin SA, Hatten BW, Whittle JA, Haukoos JS, Diercks DB, Diercks DB, Wolf SJ, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Valente JH, Wall SP, Westafer LM, Yu Y, Cantrill SV, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Out-of-Hospital or Emergency Department Patients Presenting With Severe Agitation: Approved by the ACEP Board of Directors, October 6, 2023. Ann Emerg Med 2024; 83:e1-e30. [PMID: 38105109 DOI: 10.1016/j.annemergmed.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
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Sadlonova M, Beach SR, Funk MC, Rosen JH, Ramirez Gamero AF, Karlson RA, Huffman JC, Celano CM. Risk Stratification of QTc Prolongation in Critically Ill Patients Receiving Antipsychotics for the Management of Delirium Symptoms. J Intensive Care Med 2023:8850666231222470. [PMID: 38130132 DOI: 10.1177/08850666231222470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND Patients experiencing significant agitation or perceptual disturbances related to delirium in an intensive care setting may benefit from short-term treatment with an antipsychotic medication. Some antipsychotic medications may prolong the QTc interval, which increases the risk of potentially fatal ventricular arrhythmias. In this targeted review, we describe the evidence regarding the relationships between antipsychotic medications and QTc prolongation and practical methods for monitoring the QTc interval and mitigating arrhythmia risk. METHODS Searches of PubMed and Cochrane Library were performed to identify studies, published before February 2023, investigating the relationships between antipsychotic medications and QTc prolongation or arrhythmias. RESULTS Most antipsychotic medications commonly used for the management of delirium symptoms (eg, intravenous haloperidol, olanzapine, quetiapine) cause a moderate degree of QTc prolongation. Among other antipsychotics, those most likely to cause QTc prolongation are iloperidone and ziprasidone, while aripiprazole and lurasidone appear to have minimal risk for QTc prolongation. Genetic vulnerabilities, female sex, older age, pre-existing cardiovascular disease, electrolyte abnormalities, and non-psychiatric medications also increase the risk of QTc prolongation. For individuals at risk of QTc prolongation, it is essential to measure the QTc interval accurately and consistently and consider medication adjustments if needed. CONCLUSIONS Antipsychotic medications are one of many risk factors for QTc prolongation. When managing agitation related to delirium, it is imperative to assess an individual patient's risk for QTc prolongation and to choose a medication and monitoring strategy commensurate to the risks. In intensive care settings, we recommend regular ECG monitoring, using a linear regression formula to correct for heart rate. If substantial QTc prolongation (eg, QTc > 500 msec) is present, a change in pharmacologic treatment can be considered, though a particular medication may still be warranted if the risks of discontinuation (eg, extreme agitation, removal of invasive monitoring devices) outweigh the risks of arrhythmias. AIMS This review aims to summarize the current literature on relationships between antipsychotic medications and QTc prolongation and to make practical clinical recommendations towards the approach of antipsychotic medication use for the management of delirium-related agitation and perceptual disturbances in intensive care settings.
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Affiliation(s)
- Monika Sadlonova
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Göttingen, Germany
- Department of Cardiovascular and Thoracic Surgery, University of Göttingen Medical Center, Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Margo C Funk
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Jordan H Rosen
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Andres F Ramirez Gamero
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Rebecca A Karlson
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jeff C Huffman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Christopher M Celano
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Allen PJ, Johanson KE, Reveles KR, Neff LA, Lock AE. Comparison of Droperidol and Midazolam Versus Haloperidol and Lorazepam for Acute Agitation Management in the Emergency Department. Ann Pharmacother 2023; 57:1367-1374. [PMID: 36999520 DOI: 10.1177/10600280231163192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Acute agitation accounts for up to 2.6% of visits to the emergency department (ED). To date, a standard of care for the management of acute agitation has not been established. Few studies have evaluated antipsychotic and benzodiazepine combinations. OBJECTIVE The purpose of this study was to evaluate effectiveness and safety of combination therapy for acute agitation with intramuscular (IM) droperidol and midazolam (D+M) compared with IM haloperidol and lorazepam (H+L) in patients in the ED. METHODS This was a single-center, retrospective medical record review of patients presenting to a large, academic ED with acute agitation from July 2020 through October 2021. The primary outcome was percentage of patients requiring additional agitation medication within 60 minutes of combination administration. Secondary outcomes included average time to repeat dose administration and average number of repeat doses required before ED discharge. RESULTS A total of 306 patients were included for analysis: 102 in the D+M group and 204 in the H+L group. Repeat dose within 60 minutes occurred in 7 (6.9%) and 28 (13.8%) patients in the D+M and H+L groups, respectively (P = 0.065). A total of 28.4% of D+M patients and 30.9% of H+L patients required any repeat dose during their ED visit. Time to repeat dose was 12 and 24 minutes in the D+M and H+L, respectively (P = 0.22). The adverse event rate was 2.9% in each group. CONCLUSION AND RELEVANCE IM D+M resulted in a lower rate of repeat doses of acute agitation medication compared with IM H+L, though this was not statistically significant. Both therapies were safe, and the adverse event rate was low.
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Affiliation(s)
- Patrick J Allen
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Kendra E Johanson
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Kelly R Reveles
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Luke A Neff
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Ashley E Lock
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Department of Emergency Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Bourke EM, Knott JC, Craig S, Babl FE. Management of paediatric acute severe behavioural disturbance in emergency departments across Australia: A PREDICT survey of senior medical staff. Emerg Med Australas 2023; 35:254-260. [PMID: 36328402 PMCID: PMC10946763 DOI: 10.1111/1742-6723.14105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/20/2022] [Accepted: 10/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Acute severe behavioural disturbance (ASBD) is a condition seen with increasing frequency in EDs. It poses a significant risk to the patient and those around them. Little is known about the epidemiology or most effective management in the paediatric population. The aim of the present study is to clarify the practice of senior emergency doctors in Australia when managing paediatric ASBD. METHODS The present study was a voluntary electronic questionnaire distributed to and undertaken by senior medical staff in EDs affiliated with the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network. Respondents reported on exposure to and confidence in managing paediatric ASBD and their current practices. RESULTS A total of 227 (33%) clinicians completed the survey between February and May 2020. Most clinicians were caring for at least two young people with ASBD each week (72%), felt confident regarding the majority of components of management and referred to local clinical practice guidelines (69%). Agitation/sedation rating scales were seldom used (19%). There was a significant variation in self-reported management practices. The choice of whether to use medication at all, the medication chosen and route of administration all varied greatly. Respondents were more willing to provide parenteral medication to young people reported as having recreational drug intoxication (84%) than those with neurodevelopment disorders (65%) when the same degree of agitation was reported. CONCLUSIONS Within Australia, there is considerable variation in paediatric ASBD practice, in particular regarding medication provision. Further prospective research is required to inform best clinical practice.
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Affiliation(s)
- Elyssia M Bourke
- Emergency Research GroupMurdoch Children's Research InstituteMelbourneVictoriaAustralia
- Department of Critical CareThe University of MelbourneMelbourneVictoriaAustralia
- Emergency DepartmentGrampians HealthBallaratVictoriaAustralia
| | - Jonathan C Knott
- Department of Critical CareThe University of MelbourneMelbourneVictoriaAustralia
- Emergency DepartmentThe Royal Melbourne HospitalMelbourneVictoriaAustralia
| | - Simon Craig
- Emergency Research GroupMurdoch Children's Research InstituteMelbourneVictoriaAustralia
- Department of PaediatricsMonash UniversityMelbourneVictoriaAustralia
- Emergency DepartmentMonash Medical CentreMelbourneVictoriaAustralia
| | - Franz E Babl
- Emergency Research GroupMurdoch Children's Research InstituteMelbourneVictoriaAustralia
- Department of Critical CareThe University of MelbourneMelbourneVictoriaAustralia
- Emergency DepartmentThe Royal Children's HospitalMelbourneVictoriaAustralia
- Department of PaediatricsThe University of MelbourneMelbourneVictoriaAustralia
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9
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Bourke EM, Borland ML, Kochar A, George S, Shellshear D, Jani S, Perkins K, Tham D, Gordon MS, Klein K, Prakash C, Lee K, Davidson A, Knott JC, Craig S, Babl FE. Pharmacological Emergency management of Agitation in Children and Young people: protocol for a randomised controlled trial of intraMuscular medication (PEAChY-M). BMJ Open 2023; 13:e067436. [PMID: 36997241 PMCID: PMC10069493 DOI: 10.1136/bmjopen-2022-067436] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Abstract
INTRODUCTION Acute severe behavioural disturbance (ASBD) is a condition seen with increasing frequency in emergency departments (EDs) in adults and young people. Despite the increasing number of presentations and significant associated risks to patients, families and caregivers, there is limited evidence to guide the most effective pharmacological management in children and adolescents. The aim of this study is to determine whether a single dose of intramuscular olanzapine is more effective than intramuscular droperidol at successfully sedating young people with ASBD requiring intramuscular sedation. METHODS AND ANALYSIS This study is a multicentre, open-label, superiority randomised controlled trial. Young people aged between 9 and 17 years and 364 days presenting to an ED with ASBD who are deemed to require medication for behavioural containment will be recruited to the study. Participants will be randomised in a 1:1 allocation between a single weight-based dose of intramuscular olanzapine and intramuscular droperidol. The primary outcome is the proportion of participants who achieve successful sedation at 1-hour post randomisation without the need for additional sedation. Secondary outcomes will include assessing for adverse events, additional medications provided in the ED, further episodes of ASBD, length of stay in the ED and hospital and satisfaction with management.Effectiveness will be determined using an intention-to-treat analysis, with medication efficacy determined as part of the secondary outcomes using a per-protocol analysis. The primary outcome of successful sedation at 1 hour will be presented as a percentage within each treatment group, with comparisons presented as a risk difference with its 95% CIs. ETHICS AND DISSEMINATION Ethics approval was received from the Royal Children's Hospital Human Research Ethics Committee (HREC/69948/RCHM-2021). This incorporated a waiver of informed consent for the study. The findings will be disseminated in a peer-reviewed journal and at academic conferences. TRIAL REGISTRATION NUMBER ACTRN12621001238864.
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Affiliation(s)
- Elyssia M Bourke
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
- Emergency Deparment, Grampians Health, Ballarat, Victoria, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Amit Kochar
- Emergency Department, Women and Children's Hospital Adelaide, Adelaide, South Australia, Australia
| | - Shane George
- Children's Critical Care Service, Gold Coast University Hospital, Southport, Queensland, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Nathan, Queensland, Australia
| | - Deborah Shellshear
- Emergency Department, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Shefali Jani
- Emergency Department, Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kent Perkins
- Emergency Department, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Doris Tham
- Paediatric Emergency Department, Western Health, Footscray, Victoria, Australia
| | - Michael Solomon Gordon
- Psychological Medicine, Monash Health, Clayton, Victoria, Australia
- Monash University, Monash University, Clayton, Victoria, Australia
| | - Kate Klein
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Emergency Department, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Chidambaram Prakash
- Department of Psychiatry, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Katherine Lee
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Clinical Epidemiology and Biostatistics (CEBU), Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Melbourne Children's Trials Centre, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Andrew Davidson
- Melbourne Children's Trials Centre, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Anaesthesia, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Jonathan C Knott
- Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
- Emergency Department, The Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
| | - Simon Craig
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
- Emergency Department, Monash Medical Centre Clayton, Clayton, Victoria, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
- Emergency Department, Royal Childrens Hospital, Parkville, Victoria, Australia
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10
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Strayer RJ, Friedman BW, Haroz R, Ketcham E, Klein L, LaPietra AM, Motov S, Repanshek Z, Taylor S, Weiner SG, Nelson LS. Emergency Department Management of Patients With Alcohol Intoxication, Alcohol Withdrawal, and Alcohol Use Disorder: A White Paper Prepared for the American Academy of Emergency Medicine. J Emerg Med 2023; 64:517-540. [PMID: 36997435 DOI: 10.1016/j.jemermed.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/06/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Reuben J Strayer
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York.
| | - Benjamin W Friedman
- Department of Emergency Medicine, Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Rachel Haroz
- Cooper Medical School of Rowan University, Cooper University Healthcare, Camden, New Jersey
| | - Eric Ketcham
- Department of Emergency Medicine, Department of Behavioral Health, Addiction Medicine, Presbyterian Healthcare System, Santa Fe & Española, New Mexico
| | - Lauren Klein
- Department of Emergency Medicine, Good Samaritan Hospital, West Islip, New York
| | - Alexis M LaPietra
- Department of Emergency Medicine, Saint Joseph's Regional Medical Center, Paterson, New Jersey
| | - Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Zachary Repanshek
- Department of Emergency Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Scott Taylor
- Department of Emergency Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
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11
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Ramsden SC, Pergjika A, Janssen AC, Mudahar S, Fawcett A, Walkup JT, Hoffmann JA. A systematic review of the effectiveness and safety of droperidol for pediatric agitation in acute care settings. Acad Emerg Med 2022; 29:1466-1474. [PMID: 35490341 PMCID: PMC9622426 DOI: 10.1111/acem.14515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/14/2022] [Accepted: 04/27/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Agitation in children in acute care settings poses significant patient and staff safety concerns. While behavioral approaches are central to reducing agitation and oral medications are preferred, parenteral medications are used when necessary to promote safety. The goal of this systematic review was to evaluate the effectiveness and safety of an ultra-short-acting parenteral medication, droperidol, for the management of acute, severe agitation in children in acute care settings. METHODS A systematic review of randomized controlled trials, observational studies, and case series/reports examined the effectiveness and safety of parenteral droperidol for management of acute agitation in patients ≤21 years old in acute care settings. Effectiveness outcomes included time to sedation and need for a subsequent dose of medication. Safety outcomes were adverse effects such as QTc prolongation, hypotension, respiratory depression, and dystonic reactions. RESULTS A total of 431 unique articles were identified. Six articles met inclusion criteria: two in the prehospital setting, one in the emergency department, and three in the inpatient hospital setting. The articles included a prospective observational study, three retrospective observational studies, and two case reports. The largest study reported a median time to sedation of 14 min (interquartile range 10-20 min); other studies reported a time to sedation of 15 min or less. Across studies, 8%-22% of patients required a second dose of medication for ongoing agitation. The most frequent adverse effects were dystonic reactions and transient hypotension. One patient had QTc prolongation and another developed respiratory depression, but both had significant comorbidities that may have contributed. The risk of bias in included studies ranged from moderate to critical. CONCLUSIONS Existing data on droperidol for management of acute agitation in children suggest that droperidol is both effective and safe for acute, severe agitation in children. Data are limited by study designs that may introduce bias.
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Affiliation(s)
| | - Alba Pergjika
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Aron C. Janssen
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sukhraj Mudahar
- Department of Pharmacy, Children’s Hospital of Orange County, Orange, CA
| | - Andrea Fawcett
- Department of Clinical and Organizational Development, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL,Lurie Children’s Pediatric Research & Evidence Synthesis Center of Innovative Implementation Science & Engagement (PRECIISE): A JBI Affiliated Group, Chicago, IL
| | - John T. Walkup
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jennifer A. Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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12
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Abstract
PURPOSE OF REVIEW To provide updated guidance for the medication treatment of acute agitation in the setting of psychosis or mania on inpatient psychiatric units. RECENT FINDINGS This topic presented challenges: studies are sparse, tend to be under-powered, and are difficult to compare. Though there have been few recent studies, there have been several recent meta-analyses, Cochrane reviews, and published guidelines that sift through the primarily older evidence as well as more recent trials. The reviewers often do not agree on what seems to have the best evidence for efficacy and safety. SUMMARY We conclude that the best approach is to summarize in some detail the evidence for each possible treatment and the interpretations published recently on each of those treatments, and then present recommendations for medication management in tiered rankings, based on the authors' qualitative review of the data and opinions. For oral treatment, the first-tier options are (alphabetically) haloperidol with lorazepam, lorazepam alone, and olanzapine. The second tier includes haloperidol with promethazine, loxapine inhaler, and risperidone alone. Tier 3 includes asenapine and quetiapine. For intramuscular treatment, the first-tier includes haloperidol plus promethazine, and olanzapine alone, and the second-tier includes haloperidol with lorazepam, and lorazepam alone.
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13
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Emergency medicine updates: Droperidol. Am J Emerg Med 2022; 53:180-184. [DOI: 10.1016/j.ajem.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/31/2021] [Accepted: 01/09/2022] [Indexed: 11/19/2022] Open
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14
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Conrardy MJ, Tyler DJ, Cruz DS, Fant AL, Malik S, Lank PM, Kim HS. Midazolam with haloperidol versus lorazepam with haloperidol for agitation: Effect on emergency department lengths of stay. Acad Emerg Med 2022; 29:372-375. [PMID: 34786792 DOI: 10.1111/acem.14418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/30/2021] [Accepted: 11/13/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Michael J. Conrardy
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Dion J. Tyler
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Daniel S. Cruz
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Abra L. Fant
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Sanjeev Malik
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Patrick M. Lank
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Howard S. Kim
- Department of Emergency Medicine Northwestern University Feinberg School of Medicine Chicago Illinois USA
- Center for Health Services and Outcomes Research Northwestern University Feinberg School of Medicine Chicago Illinois USA
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15
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Thiemann P, Roy D, Huecker M, Senn J, Javed J, Thomas A, Shreffler J, Shaw I. Prospective study of haloperidol plus lorazepam versus droperidol plus midazolam for the treatment of acute agitation in the emergency department. Am J Emerg Med 2022; 55:76-81. [DOI: 10.1016/j.ajem.2022.02.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/07/2022] [Accepted: 02/21/2022] [Indexed: 11/28/2022] Open
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16
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Prospective real-time evaluation of the QTc interval variation after low-dose droperidol among emergency department patients. Am J Emerg Med 2022; 52:212-219. [PMID: 34959024 PMCID: PMC8761164 DOI: 10.1016/j.ajem.2021.12.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/16/2021] [Accepted: 12/16/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To assess the QTc interval variation after low-dose droperidol in a population of undifferentiated, stable, and non-agitated patients receiving droperidol in the emergency department. METHODS Prospective cohort study of patients aged ≥12 years of age who received low-dose droperidol (≤ 2.5 mg) for indications other than acute behavioral disturbances. QTc intervals were monitored in real-time during pre-specified observation periods in the ED. Primary outcome was variation of QTc interval after droperidol administration, defined as the maximum delta (change) of QTc interval. Other outcomes included proportion of patients with a QTc ≥ 500 ms after droperidol, delta ≥ +60 ms, and incidence of clinical adverse events. Patients were monitored up to 30 min after IV bolus and up to 46 min after infusion. RESULTS A total of 68 patients were included (mean age 42.1 years, 66.2% females). The median dose of droperidol was 1.875 mg (range 0.625 mg, 2.5 mg) and 94.1% received droperidol for headache management. Most patients received droperidol as a 2-min bolus (n = 41, 60.3%). The mean maximum delta of QTc interval after droperidol across all 68 patients was +29.9 ms (SD 15). A total of 12 patients (17.6%) experienced a QTc interval ≥ 500 ms during the observation period after droperidol, and 3 patients (4.4%) had a delta QTc ≥ +60 ms. There were no serious arrhythmias, such as TdP, or deaths among the 68 participants in this study (0/68). However, 13.2% (n = 9) had at least one non-serious adverse event including restlessness and/or anxiety. CONCLUSION The QTc interval slightly increased after droperidol administration, but these prolongations were brief, mostly below 500 msec and did not lead to serious arrhythmias. The yield of continuous cardiac monitoring in patients receiving low doses of droperidol is likely low.
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17
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Khatri UG, Delgado MK, South E, Friedman A. Racial Disparities in the Management of Emergency Department Patients Presenting with Psychiatric Disorders. Ann Epidemiol 2022; 69:9-16. [DOI: 10.1016/j.annepidem.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/23/2021] [Accepted: 02/13/2022] [Indexed: 11/27/2022]
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18
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Leucht S, Davis JM. Which first-generation antipsychotics should be "repurposed" for the treatment of schizophrenia. Eur Arch Psychiatry Clin Neurosci 2022; 272:1-3. [PMID: 35038002 PMCID: PMC8803798 DOI: 10.1007/s00406-021-01378-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany.
| | - John M. Davis
- Psychiatric Institute, University of Illinois at Chicago (mc 912), 1601 W. Taylor St, Chicago, IL 60612 USA ,Maryland Psychiatric Research Center, Baltimore, MD USA
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19
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Tsai YV, Fawzy JH, Durkin JB, Then JE, McGinnis CB. Off-Label Use of Intravenous Olanzapine for Agitation After Neurologic Injury. Hosp Pharm 2021; 56:697-701. [PMID: 34732924 PMCID: PMC8559032 DOI: 10.1177/0018578720946767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Background: Small studies have described the off-label use of intravenous (IV) olanzapine for the management of acute agitation. Objective: The purpose of this study was to evaluate the efficacy and safety of IV olanzapine to manage acutely agitated patients with neurological injuries. Methods: This was a retrospective analysis of IV olanzapine use in patients admitted to the neurotrauma and neurovascular intensive care units at a single academic center. The primary endpoint was the requirement of additional IV olanzapine, IV benzodiazepine, or IV haloperidol within 60 minutes from the time of first IV olanzapine dose. Secondary safety endpoints included QTc prolongation and respiratory depression. Results: Forty-six patients received IV olanzapine during the study period. One patient required an additional dose of IV olanzapine and two patients received benzodiazepine or antipsychotic agents within 60 minutes of IV olanzapine administration. One patient had a post-administration QTc level >500 ms. Two patients had an increased oxygen requirement, but none required intubation. Conclusion: IV olanzapine appears to be efficacious in reducing the need for sedatives and antipsychotics with low risk for QTc prolongation and respiratory depression in acutely agitated patients with neurological injuries.
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Affiliation(s)
- Yuwei V. Tsai
- University of Pittsburgh School of
Pharmacy, PA, USA
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20
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Childers R, Cronin AO, Castillo EM, Neuman T, Chan TC, Coyne CJ, Sloane C, Vilke GM. Evaluation of the ventilatory effects on human subjects in prolonged hip-flexed/head-down restraint position. Am J Emerg Med 2021; 50:1-4. [PMID: 34265730 DOI: 10.1016/j.ajem.2021.06.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND The restraint chair is a tool used by law enforcement and correction personnel to control aggressive, agitated individuals. When initiating its use, subjects are often placed in a hip-flexed/head-down (HFHD) position to remove handcuffs. Usually, this period of time is less than two minutes but can become more prolonged in particularly agitated patients. Some have proposed this positioning limits ventilation and can result in asphyxia. The aim of this study is to evaluate if a prolonged HFHD restraint position causes significant ventilatory compromise. METHODS Subjects exercised on a stationary bicycle until they reached 85% of their predicted maximal heart rate. They were then handcuffed with their hands behind their back and placed into a HFHD seated position for five minutes. The primary outcome measurement was maximal voluntary ventilation (MVV). This was measured at baseline, after initial placement into the HFHD position, and after five minutes of being in the position while still maintaining the HFHD position. Baseline measurements were compared with final measurements for statistically significant differences. RESULTS We analyzed data for 15 subjects. Subjects had a mean MVV of 165.3 L/min at baseline, 157.8 L/min after initially being placed into the HFHD position, and a mean of 138.7 L/min after 5 min in the position. The mean baseline % predicted MVV was 115%; after 5 min in the HFHD position the mean was 96%. This 19% absolute difference was statistically significant (p = 0.001). CONCLUSIONS In healthy seated male subjects with recent exertion, up to five minutes in a HFHD position results in a small decrease in MVV compared with baseline MVV levels. Even with this decrease, mean MVV levels were still 96% of predicted after five minutes. Though a measurable decrease was found, there was no clinically significant change that would support that this positioning would lead to asphyxia over a five-minute time period.
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Affiliation(s)
- Richard Childers
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America.
| | - Alexandrea O Cronin
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America
| | - Edward M Castillo
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America
| | - Tom Neuman
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America
| | - Theodore C Chan
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America
| | - Christopher J Coyne
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America
| | - Christian Sloane
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America
| | - Gary M Vilke
- Department of Emergency Medicine, University of California, San Diego, San Diego, CA, United States of America
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21
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Cole JB, Stang JL, DeVries PA, Martel ML, Miner JR, Driver BE. A Prospective Study of Intramuscular Droperidol or Olanzapine for Acute Agitation in the Emergency Department: A Natural Experiment Owing to Drug Shortages. Ann Emerg Med 2021; 78:274-286. [PMID: 33846015 DOI: 10.1016/j.annemergmed.2021.01.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/23/2020] [Accepted: 01/04/2021] [Indexed: 12/22/2022]
Abstract
STUDY OBJECTIVE Intramuscular medications are commonly used to treat agitation in the emergency department (ED). The purpose of this study is to compare intramuscular droperidol and olanzapine for treating agitation. METHODS This was a prospective observational study of ED patients receiving intramuscular droperidol or olanzapine for acute agitation. The treating physician determined the medication and dose; however, over time drug shortages made either olanzapine (July to September 2019) or droperidol (November 2019 to March 2020) unavailable, creating a natural experiment. The primary outcome was time to adequate sedation, assessed by the Altered Mental Status Scale (AMSS), defined as time to AMSS score less than or equal to 0. RESULTS We analyzed 1,257 patients (median age 42 years; 73% men); 538 received droperidol (median dose 5 mg) and 719 received olanzapine (median dose 10 mg). The majority of patients (1,086; 86%) had agitation owing to alcohol intoxication. Time to adequate sedation was 16 minutes (interquartile range 10 to 30 minutes) for droperidol and 17.5 minutes (interquartile range 10 to 30 minutes) for olanzapine (absolute difference -0.7 minutes; 95% confidence interval -2.1 to 0.5 minutes). Adjusted Cox proportional hazard model analysis revealed no difference between groups in time to sedation (hazard ratio for adequate sedation for droperidol compared with olanzapine 1.12; 95% confidence interval 1.00 to 1.25). Patients receiving olanzapine were more likely to receive additional medications for sedation (droperidol 17%; olanzapine 24%; absolute difference -8% [95% confidence interval -12% to -3%]). We observed no difference between drugs regarding adverse effects except for extrapyramidal adverse effects, which were more common with droperidol (n=6; 1%) than olanzapine (n=1; 0.1%). CONCLUSION We found no difference in time to adequate sedation between intramuscular droperidol and olanzapine.
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Affiliation(s)
- Jon B Cole
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN.
| | - Jamie L Stang
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Paige A DeVries
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
| | - Marc L Martel
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
| | - James R Miner
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
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22
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Martel ML, Driver BE, Miner JR, Biros MH, Cole JB. Randomized Double-blind Trial of Intramuscular Droperidol, Ziprasidone, and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department. Acad Emerg Med 2021; 28:421-434. [PMID: 32888340 DOI: 10.1111/acem.14124] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The optimal agent to treat acute agitation in the emergency department (ED) has not been determined. The objective of this study was to compare the effectiveness and safety of intramuscular droperidol, ziprasidone, and lorazepam for acute agitation in the ED. METHODS This was a randomized, double-blind trial of ED patients with acute agitation requiring parenteral sedation. The study was conducted under exception from informed consent (21 CFR 50.24) from July 2004 to March 2005. Patients were randomized to receive 5 mg of droperidol, 10 mg of ziprasidone, 20 mg of ziprasidone, or 2 mg of lorazepam intramuscularly. We recorded Altered Mental Status Scale (AMSS) scores, nasal end-tidal carbon dioxide (ETCO2 ), and pulse oximetry (SpO2 ) at 0, 15, 30, 45, 60, 90, and 120 minutes as well as QTc durations and dysrhythmias. Respiratory depression was defined as a change in ETCO2 consistent with respiratory depression or SpO2 < 90%. The primary outcome was the proportion of patients adequately sedated (AMSS ≤ 0) at 15 minutes. RESULTS We enrolled 115 patients. Baseline AMSS scores were similar between groups. For the primary outcome, adequate sedation at 15 minutes, droperidol administration was effective in 16 of 25 (64%) patients, compared to seven of 28 (25%) for 10 mg of ziprasidone, 11 of 31 (35%) for 20 mg of ziprasidone, and nine of 31 (29%) for lorazepam. Pairwise comparisons revealed that droperidol was more effective that the other medications, with 39% (95% confidence interval [CI] = 3% to 54%) more compared to 20 mg of ziprasidone and 33% (95% CI = 8% to 58%) more compared to lorazepam. There was no significant difference between groups in need of additional rescue sedation. Numerically, respiratory depression was lower with droperidol (3/25 [12%]) compared to 10 mg of ziprasidone (10/28 [36%]), 20 mg of ziprasidone (12/31 [39%]), or lorazepam (15/31 [48%]). One patient receiving 20 mg of ziprasidone required intubation to manage an acute subdural hematoma. No patients had ventricular dysrhythmias. QTc durations were similar in all groups. CONCLUSIONS Droperidol was more effective than lorazepam or either dose of ziprasidone for the treatment of acute agitation in the ED and caused fewer episodes of respiratory depression.
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Affiliation(s)
- Marc L. Martel
- From the Department of Emergency Medicine Hennepin County Medical Center Minneapolis MNUSA
| | - Brian E. Driver
- From the Department of Emergency Medicine Hennepin County Medical Center Minneapolis MNUSA
| | - James R. Miner
- From the Department of Emergency Medicine Hennepin County Medical Center Minneapolis MNUSA
- and the Department of Emergency Medicine University of Minnesota Minneapolis MNUSA
| | - Michelle H. Biros
- and the Department of Emergency Medicine University of Minnesota Minneapolis MNUSA
| | - Jon B. Cole
- From the Department of Emergency Medicine Hennepin County Medical Center Minneapolis MNUSA
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23
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Muir-Cochrane E, Oster C. Chemical restraint: A qualitative synthesis review of adult service user and staff experiences in mental health settings. Nurs Health Sci 2021; 23:325-336. [PMID: 33605053 DOI: 10.1111/nhs.12822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/12/2021] [Accepted: 02/12/2021] [Indexed: 01/21/2023]
Abstract
With an imperative to reduce or eliminate the use of coercive practices in mental health care it is important to understand the experience of service users and staff. This review aimed to synthesize qualitative studies, published between 1996 and 2020, reporting on mental health service users' and staff's experiences of chemical restraint. The databases PsycINFO, CINAHL, MEDLINE, Embase, Emcare, Web of Science, and Scopus were searched. Three analytic themes were identified from 17 included articles, synthesizing the experiences of service users and staff. These were "Unjustified versusjustified," "Violence versus necessity," and "Reflecting back: Positives and negatives." Service users viewed chemical restraint as an unjustified response to "behaviors of concern" and experienced it as a violent act with negative outcomes, although some saw it as necessary in retrospect and preferred it to other forms of coercion. Staff generally viewed it as a justified response to "behaviors of concern" and experienced it as appropriate within the constraints of staff numbers and limited alternatives. These findings identify nuances not apparent in the literature, which has generally conflated all forms of coercive practices.
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Affiliation(s)
| | - Candice Oster
- College of Nursing & Health Sciences, Flinders University, Adelaide, Australia
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24
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Chan EW, Lao KS, Lam L, Tsui SH, Lui CT, Wong CP, Graham CA, Cheng CH, Chung TS, Lam HF, Ting SM, Knott JC, Taylor DM, Kong DC, Leung LP, Wong IC. Intramuscular midazolam, olanzapine, or haloperidol for the management of acute agitation: A multi-centre, double-blind, randomised clinical trial. EClinicalMedicine 2021; 32:100751. [PMID: 33681744 PMCID: PMC7910711 DOI: 10.1016/j.eclinm.2021.100751] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/20/2021] [Accepted: 01/25/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The safety and effectiveness of intramuscular olanzapine or haloperidol compared to midazolam as the initial pharmacological treatment for acute agitation in emergency departments (EDs) has not been evaluated. METHODS A pragmatic, randomised, double-blind, active-controlled trial was conducted from December 2014 to September 2019, in six Hong Kong EDs. Patients (aged 18-75 years) with undifferentiated acute agitation requiring parenteral sedation were randomised to 5 mg intramuscular midazolam (n = 56), olanzapine (n = 54), or haloperidol (n = 57). Primary outcomes were time to adequate sedation and proportion of patients who achieved adequate sedation at each follow-up interval. Sedation levels were measured on a 6-level validated scale (ClinicalTrials.gov Identifier: NCT02380118). FINDINGS Of 206 patients randomised, 167 (mean age, 42 years; 98 [58·7%] male) were analysed. Median time to sedation for IM midazolam, olanzapine, and haloperidol was 8·5 (IQR 8·0), 11·5 (IQR 30·0), and 23·0 (IQR 21·0) min, respectively. At 60 min, similar proportions of patients were adequately sedated (98%, 87%, and 97%). There were statistically significant differences for time to sedation with midazolam compared to olanzapine (p = 0·03) and haloperidol (p = 0·002). Adverse event rates were similar across the three arms. Dystonia (n = 1) and cardiac arrest (n = 1) were reported in the haloperidol group. INTERPRETATION Midazolam resulted in faster sedation in patients with undifferentiated agitation in the emergency setting compared to olanzapine and haloperidol. Midazolam and olanzapine are preferred over haloperidol's slower time to sedation and potential for cardiovascular and extrapyramidal side effects. FUNDING Research Grants Council, Hong Kong.
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Affiliation(s)
- Esther W. Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Shenzhen Institute of Research and Innovation, The University of Hong Kong, Shenzhen, China
- Corresponding author at: Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR
| | - Kim S.J. Lao
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR
- Global Medical Affairs, Merck Sharp & Dohme, Xuhui, Shanghai, China
| | - Lam Lam
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR
| | - Sik-Hon Tsui
- Accident and Emergency Department, Queen Mary Hospital, Pok Fu Lam, Hong Kong SAR
| | - Chun-Tat Lui
- Accident and Emergency Department, Tuen Mun Hospital, Tuen Mun, Hong Kong SAR
| | - Chi-Pang Wong
- Accident and Emergency Department, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong SAR
| | - Colin A. Graham
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR
- Department of Emergency Medicine, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR
| | - Chi-Hung Cheng
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong SAR
- Department of Emergency Medicine, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR
| | - Tong-Shun Chung
- Accident and Emergency Department, Ruttonjee Hospital, Wan Chai, Hong Kong SAR
| | - Hiu-Fung Lam
- Accident and Emergency Department, United Christian Hospital, Kwun Tong, Hong Kong SAR
| | - Soo-Moi Ting
- Accident and Emergency Department, United Christian Hospital, Kwun Tong, Hong Kong SAR
| | - Jonathan C. Knott
- Department of Critical Care, University of Melbourne, Parkville, Australia
| | - David M. Taylor
- Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - David C.M. Kong
- Pharmacy Department, Ballarat Health Services, Ballarat, Victoria, Australia
- Centre for Medicine Use and Safety, Monash University, Victoria, Australia
| | - Ling-Pong Leung
- Emergency Medicine Unit, The University of Hong Kong, Pok Fu Lam, Hong Kong SAR
| | - Ian C.K. Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom
- Corresponding author at: Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR
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Hunt NF, McLaughlin KC, Kovacevic MP, Lupi KE, Dube KM. Safety of Intravenous Olanzapine Administration at a Tertiary Academic Medical Center. Ann Pharmacother 2021; 55:1127-1133. [PMID: 33455436 DOI: 10.1177/1060028020988734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Although approved by the Food and Drug Administration for intramuscular administration only, analyses have described the administration of intravenous push (IVP) olanzapine, particularly for acute agitation. The safety and efficacy of IVP olanzapine has mostly been limited to emergency department patients. OBJECTIVE To evaluate the safety of IVP olanzapine administration in the inpatient setting. METHODS This single-center, retrospective analysis was conducted between July 1, 2018, and December 31, 2019, at Brigham and Women's Hospital in Boston, Massachusetts. Adult patients who received at least 1 dose of IVP olanzapine were included in the analysis. Safety endpoints analyzed included the following adverse drug events (ADEs): hypotension, bradycardia, cardiac arrhythmias, extrapyramidal adverse effects, and respiratory depressive events. Data on IV site reactions, including phlebitis and infiltration, were also collected. RESULTS A total of 1,247 IVP administrations of olanzapine were identified across 252 patients. Two or more doses were received by 159 patients (63.1%). Most administrations (66%) took place in intensive care units, with 33% administered on general medicine wards. Overall, 104 administrations (8.3%) were associated with at least 1 ADE. Hypotension and bradycardia occurred in 62 (5.2%) and 16 (1.3%) administrations, respectively. Phlebitis occurred with 8 administrations (1.4%). All other adverse events were rare (<1%). CONCLUSION AND RELEVANCE Hypotension, the most commonly noted ADE, occurred more frequently than in previous studies. IVP olanzapine appears to be a safe route of administration in hospitalized patients, including those receiving multiple doses. Further studies are required to evaluate the effect of IV olanzapine on hemodynamics.
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Kim HK, Leonard JB, Corwell BN, Connors NJ. Safety and efficacy of pharmacologic agents used for rapid tranquilization of emergency department patients with acute agitation or excited delirium. Expert Opin Drug Saf 2021; 20:123-138. [PMID: 33327811 DOI: 10.1080/14740338.2021.1865911] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Management of patients with acute agitation or aggressive behavior can pose a significant challenge to health-care providers in emergency departments. Areas covered: This article provides a comprehensive review of the pharmacologic properties, efficacy, and safety profiles of select intramuscular (IM) sedative agents (i.e., antipsychotics, benzodiazepines, and ketamine) for rapid tranquilization. Expert opinion: Using antipsychotics and benzodiazepines - whether a single agent or combined - will have similar efficacy in producing sedation. But there are differences in the time to sedation depending on which agent is used. Based upon the available studies, droperidol (5-10 mg IM) and midazolam (5-10 mg IM) have the fastest onset of sedation when either is used as a single agent. When combination therapy is used, using midazolam with an antipsychotic agent, instead of lorazepam, may result in faster sedative effect. QT prolongation and torsades de pointes are uncommon adverse drug effects of antipsychotic administration. Ketamine is often reserved as a second-line agent when antipsychotics and benzodiazepines fail to produce the desired tranquilization. However, ketamine (5 mg/kg IM) is more frequently associated with airway compromise requiring endotracheal intubation. A low-dose of ketamine (2 mg/kg IM) may reduce the risk of airway compromise while providing adequate sedation.
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Affiliation(s)
- Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - James B Leonard
- Maryland Poison Center, University of Maryland School of Pharmacy , Baltimore, MD, USA
| | - Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - Nicholas J Connors
- Department of Emergency Medicine, HCA Healthcare Trident Medical Center , Charleston, SC, USA
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Wang M, Yankama TT, Abdallah GT, Eche IJ, Knoph KN, Wong A, Patel P, Hsu D, Eche IM. A Retrospective Comparison of the Effectiveness and Safety of Intravenous Olanzapine Versus Intravenous Haloperidol for Agitation in Adult Intensive Care Unit Patients. J Intensive Care Med 2021; 37:222-230. [PMID: 33426981 DOI: 10.1177/0885066620984450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Intravenous (IV) olanzapine could be an alternative to first-generation antipsychotics for the management of agitation in intensive care unit (ICU) patients. We compared the effectiveness and safety of IV olanzapine to IV haloperidol for agitation management in adult patients in the ICU at a tertiary academic medical center. METHODS A retrospective cohort study was conducted. The primary outcome was the proportion of patients who achieved a Richmond Agitation Sedation Scale (RASS) score of < +1 within 4 hours of IV olanzapine or IV haloperidol administration. Secondary outcomes included the proportion of patients who required rescue medications for agitation within 4 hours of initial IV olanzapine or IV haloperidol administration, incidence of adverse events and ICU length of stay. RESULTS In the 192 patient analytic cohort, there was no difference in the proportion of patients who achieved a RASS score of < +1 within 4 hours of receiving IV olanzapine or IV haloperidol (49% vs. 42%, p = 0.31). Patients in the IV haloperidol group were more likely to receive rescue medications (28% vs 55%, p < 0.01). There was no difference in the incidence of respiratory events or hypotension between IV olanzapine and IV haloperidol. Patients in the IV olanzapine group experienced more bradycardia (11% vs. 3%, p = 0.04) and somnolence (9% vs. 1%, p = 0.02) compared to the IV haloperidol group. Patients in the IV olanzapine group had a longer median ICU length of stay (7.5 days vs. 5 days, p = 0.04). CONCLUSION In this retrospective cohort study, there was no difference in the effectiveness of IV olanzapine compared to IV haloperidol for the management of agitation. IV olanzapine was associated with an increased incidence of bradycardia and somnolence.
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Affiliation(s)
- Michelle Wang
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Tuyen T Yankama
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - George T Abdallah
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ijeoma Julie Eche
- Bone Marrow Transplantation and Hematologic Malignancies Program, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kristen N Knoph
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Adrian Wong
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Pharmacy Practice, MCPHS University, Boston, MA, USA
| | - Parth Patel
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Douglas Hsu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ifeoma Mary Eche
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Muir-Cochrane E, Grimmer K, Gerace A, Bastiampillai T, Oster C. Safety and effectiveness of olanzapine and droperidol for chemical restraint for non-consenting adults: a systematic review and meta-analysis. Australas Emerg Care 2020; 24:96-111. [PMID: 33046432 DOI: 10.1016/j.auec.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/24/2020] [Accepted: 08/27/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chemical restraint (CR) is emergency drug management for acute behavioural disturbances in people with mental illness, provided with the aim of rapid calming and de-escalating potentially dangerous situations. AIMS To describe a systematic review of Randomised Controlled Trials (RCTs) reporting on short-term safety and effectiveness of drugs used for CR, administered to non-consenting adults with mental health conditions, who require emergency management of acute behavioural disturbances. A meta-analysis was conducted of those RCTs with comparable interventions, outcome measures and measurement timeframes. METHOD Academic databases were searched for RCTs published between 1 January 1996 and 20th April 2020. Relevant RCTs were critically appraised using the 13-item JBI checklist. All RCTs were described, and step-wise filters were applied to identify studies suitable for meta-analysis. For these, forest and funnel plots were constructed, and Q and I2 statistics guided interpretation of pooled findings, tested using MedCalc Version 19.1. RESULTS Of 23 relevant RCTs, 18 (78.2% total) had excellent methodological quality scores (at least 90%). Eight RCTs were potentially relevant for meta-analysis (six of excellent quality), reporting 20 drug arms in total. Adverse events for 6-36% patients were reported in all 20 drug arms. Four drug arms from two homogenous studies of N = 697 people were meta-analysed. These RCTs tested two antipsychotic drugs (droperidol, olanzapine) delivered intravenously in either 5 mgs or 10 mg doses, with outcomes of time to calm, percentage calm within five or 10 min, and adverse events. There were no significant differences between drug arms for either measure of calm. However, 5 mg olanzapine incurred significantly lower risk of adverse events than 10 mg olanzapine (OR 0.4 (95%CI 0.2-0.8)), although no dose differences were found for droperidol. CONCLUSION 5 mg intravenous olanzapine is recommended for quick, safe emergency management of people with acute behavioural disturbances associated with mental illness.
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Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia.
| | - Karen Grimmer
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
| | - Adam Gerace
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia; School of Health, Medical and Applied Sciences, Central Queensland University, 44 Greenhill Rd, Wayville, South Australia, Australia
| | - Tarun Bastiampillai
- College of Medicine & Public Health, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
| | - Candice Oster
- College of Nursing & Health Sciences, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia; College of Medicine & Public Health, Flinders University, GPO Box 2100, Adelaide, South Australia, Australia
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O'Donnell SM, Carison A, Hill A, Say D, Hiscock H, Babl FE. Psychotropic medication use for paediatric mental health patients in an emergency department. Emerg Med Australas 2020; 33:292-301. [PMID: 33000554 DOI: 10.1111/1742-6723.13617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE There is paucity of evidence for psychotropic medication use in children and adolescents presenting with mental health (MH) problems to the ED. We set out to describe paediatric psychotropic medication use in the ED. METHODS We conducted a retrospective electronic medical record review of ED patients with MH discharge codes at a tertiary paediatric ED in 2018. We assessed the epidemiology and management of patients who received a psychotropic medication. We calculated the odds ratios (ORs with 95% confidence intervals [CIs]) of key demographic factors of medicated versus non-medicated MH patients. RESULTS During 2018 there were 1695 MH-related presentations to the ED. Of these, 280 presentations resulted in the patient receiving a psychotropic medication (16.5%). Medicated children with MH illness were more likely to be male (OR 1.50, 95% CI 1.16-1.96), have a more acute triage category (OR 3.37, 95% CI 2.28-4.98), have an ED length of stay greater than 12 h (OR 3.96, 95% CI 2.56-6.13) and present after hours (OR 1.51, 95% CI 1.16-1.96). Most had a diagnosis of acute behavioural disturbance or suicidal ideation. A variety of treatment regimens were used but children primarily received a single oral agent (diazepam or olanzapine). Parenteral medications were given in 8.6%. No adverse events were recorded. CONCLUSION A minority of children with MH presentations to the ED were medicated. It will require multicentre research to determine the most effective and safe acute psychotropic agents for oral and parenteral use in children in the ED.
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Affiliation(s)
- Sinead M O'Donnell
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Anna Carison
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Ashley Hill
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Daniela Say
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Harriet Hiscock
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Health Services Research Unit, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Centre for Community Child Health, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Franz E Babl
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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30
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Roppolo LP, Morris DW, Khan F, Downs R, Metzger J, Carder T, Wong AH, Wilson MP. Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation). J Am Coll Emerg Physicians Open 2020; 1:898-907. [PMID: 33145538 PMCID: PMC7593430 DOI: 10.1002/emp2.12138] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/26/2022] Open
Abstract
Agitated patients presenting to the emergency department (ED) can escalate to aggressive and violent behaviors with the potential for injury to themselves, ED staff, and others. Agitation is a nonspecific symptom that may be caused by or result in a life-threatening condition. Project BETA (Best Practices in the Evaluation and Treatment of Agitation) is a compilation of the best evidence and consensus recommendations developed by emergency medicine and psychiatry experts in behavioral emergencies to improve our approach to the acutely agitated patient. These recommendations focus on verbal de-escalation as a first-line treatment for agitation; pharmacotherapy that treats the most likely etiology of the agitation; appropriate psychiatric evaluation and treatment of associated medical conditions; and minimization of physical restraint/seclusion. Implementation of Project BETA in the ED can improve our ability to manage a patient's agitation and reduce the number of physical assaults on ED staff. This article summarizes the BETA guidelines and recent supporting literature for managing the acutely agitated patient in the ED followed by a discussion of how a large county hospital integrated these recommendations into daily practice.
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Affiliation(s)
- Lynn P. Roppolo
- University of Texas Southwestern Medical CenterDepartment of Emergency MedicineDallasTexasUSA
| | - David W. Morris
- University of Texas Southwestern Medical CenterDepartment of PsychiatryDallasTexasUSA
| | - Fuad Khan
- University of Texas Southwestern Medical CenterDepartment of PsychiatryDallasTexasUSA
| | - Rohini Downs
- Parkland Memorial HospitalPharmacy ServicesDallasTexasUSA
| | - Jeffery Metzger
- University of Texas Southwestern Medical CenterDepartment of Emergency MedicineDallasTexasUSA
| | - Tiffany Carder
- Parkland Memorial HospitalEmergency Services DepartmentDallasTexasUSA
| | - Ambrose H. Wong
- Yale School of MedicineDepartment of Emergency MedicineNew HavenConnecticutUSA
| | - Michael P. Wilson
- University of Arkansas for Medical SciencesDepartment of Emergency MedicineLittle RockArkansasUSA
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Mattson A, Friend K, Brown CS, Cabrera D. Reintegrating droperidol into emergency medicine practice. Am J Health Syst Pharm 2020; 77:1838-1845. [DOI: 10.1093/ajhp/zxaa271] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Abstract
Purpose
After a long period of low utilization, droperidol has become easier to obtain in the US market. This comprehensive review discusses the safety, indications, clinical efficacy, and dosing of droperidol for use in the emergency department (ED) setting.
Summary
In 2001 the US Food and Drug Administration (FDA) mandated a boxed warning in the labeling of droperidol after reports of QT interval prolongation associated with droperidol use. Since that time, it has been difficult to access droperidol in the United States; as a result, many practicing clinicians lack experience in its clinical use. Multiple studies have been conducted to assess the clinical efficacy and safety of droperidol use in ED patients. Results consistently show the safety of droperidol and its clinical efficacy when used as an analgesic, antiemetic, and sedative. Now that droperidol is more widely available for use in the US market, pharmacists and prescribers need to reliably translate safety and efficacy data compiled since 2001 to help ensure appropriate and effective use of the medication.
Conclusion
Droperidol is an effective and safe option for the treatment of acute agitation, migraine, nausea, and pain for patients in the ED setting. Healthcare professionals can adopt droperidol for use in clinical practice, and they should become familiar with how to dose and monitor droperidol for safe and effective use.
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Affiliation(s)
| | | | | | - Daniel Cabrera
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
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Muir-Cochrane E, Grimmer K, Gerace A, Bastiampillai T, Oster C. Prevalence of the use of chemical restraint in the management of challenging behaviours associated with adult mental health conditions: A meta-synthesis. J Psychiatr Ment Health Nurs 2020; 27:425-445. [PMID: 31867795 DOI: 10.1111/jpm.12585] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 12/15/2022]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: The use of chemical restraint in emergency situations is to control aggression or violence to protect consumers and staff and is to be used as a last resort when all other behavioural control alternatives have been exhausted. Chemical restraint involves the use of medication. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first paper to systematically review the prevalence of the use of chemical restraint. The use of chemical restraint is common across emergency departments and acute psychiatric inpatient units worldwide. Consumers who are restrained are also likely to receive chemical restraint. The studies reviewed demonstrate that there is a need for more standardized data collection so that clearer comparisons can be made between healthcare settings and countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Implications of practice include the need to report adverse events post-chemical restraint as these can deleteriously affect a person's physical health. Identification of and staff education about first-line management techniques before chemical restraint is administered are significant to reduce its use. ABSTRACT: Introduction Chemical restraint is used to manage uncontrolled aggression, agitation or violent behaviours of consumers with mental health disorders admitted to acute psychiatric or emergency settings. Aim This systematic review aimed to synthesize the international prevalence of chemical restraint for non-consenting adults. Method PsycINFO, CINAHL, MEDLINE/PubMed and Google Scholar databases were searched for peer-reviewed literature published between January 1996 and July 2018. This paper reports on data extracted from retrospective audits of chemical restraint practice. Results Forty-eight papers were included. The median prevalence of use of any restraint was 21.2% (25th% 8.0 to 75th% 36.3). Median prevalence of people who were chemically restrained, of all people restrained in any manner, was 43.1% (25th% 22.9% to 75th% 70.7%). Of all people admitted to facility(ies), the median prevalence of chemical restraint was 7.4% (25th% 2.7 to 75th% 17.6). There was no statistically significant difference in any prevalence measure considering healthcare setting or country. There was a significant decrease over the review period in the use of any restraint, including chemical restraint. Discussion and implications for practice This is the first known comprehensive meta-view of chemical restraint use worldwide, highlighting the need for standardized data collection to enable comparisons between healthcare settings and countries. Relevance statement There is an international imperative to reduce or eliminate the use of coercive practices, such as physical and chemical restraint, in mental health care. This study provides important information for mental health nursing by synthesizing the international prevalence of chemical restraint for non-consenting adults. This meta-view of the worldwide use of chemical restraint can inform ongoing efforts to reduce its use.
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Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Karen Grimmer
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Adam Gerace
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia.,School of Health, Medical and Applied Sciences, Central Queensland University, Wayville, SA, Australia
| | - Tarun Bastiampillai
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Candice Oster
- College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
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33
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Gaw CM, Cabrera D, Bellolio F, Mattson AE, Lohse CM, Jeffery MM. Effectiveness and safety of droperidol in a United States emergency department. Am J Emerg Med 2020; 38:1310-1314. [DOI: 10.1016/j.ajem.2019.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/12/2019] [Accepted: 09/19/2019] [Indexed: 01/21/2023] Open
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Muir-Cochrane E, Oster C, Grimmer K. International research into 22 years of use of chemical restraint: An evidence overview. J Eval Clin Pract 2020; 26:927-956. [PMID: 31318109 DOI: 10.1111/jep.13232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice. AIMS To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995. METHODS This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures. RESULTS This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%). DISCUSSION A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.
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Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia, 5042
| | - Candice Oster
- On-Line Education and Development, Flinders Human Behaviour and Health Research Unit (FHBHRU), College of Medicine and Public Health, Flinders University, South Australia, Australia, 5042
| | - Karen Grimmer
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia, 5042.,Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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35
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Carison A, Babl FE, Hill A, O'Donnell SM. Children and adolescents with severe acute behavioural disturbance in the emergency department. Emerg Med Australas 2020; 32:747-755. [DOI: 10.1111/1742-6723.13515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/20/2020] [Accepted: 02/24/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Anna Carison
- Emergency Department The Royal Children's Hospital Melbourne Victoria Australia
| | - Franz E Babl
- Emergency Department The Royal Children's Hospital Melbourne Victoria Australia
- Department of Paediatrics, The University of Melbourne Melbourne Victoria Australia
- Department of Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Ashley Hill
- Department of Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Sinead M O'Donnell
- Emergency Department The Royal Children's Hospital Melbourne Victoria Australia
- Department of Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
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36
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Muir-Cochrane E, Oster C, Gerace A, Dawson S, Damarell R, Grimmer K. The effectiveness of chemical restraint in managing acute agitation and aggression: A systematic review of randomized controlled trials. Int J Ment Health Nurs 2020; 29:110-126. [PMID: 31498960 DOI: 10.1111/inm.12654] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2019] [Indexed: 12/26/2022]
Abstract
One approach to manage people with behaviours of concern including agitated or aggressive behaviours in health care settings is through the use of fast-acting medication, called chemical restraint. Such management often needs to be delivered in crisis situations to patients who are at risk of harm to themselves or others. This paper summarizes the available evidence on the effectiveness and safety of chemical restraint from 21 randomized controlled trials (RCTs) involving 3788 patients. The RCTs were of moderate to high quality and were conducted in pre-hospital, hospital emergency department, or ward settings. Drugs used in chemical restraint included olanzapine, haloperidol, droperidol, risperidol, flunitrazepam, midazolam, promethazine, ziprasidone, sodium valproate, or lorazepam. There was limited comparability between studies in drug choice, combination, dose, method of administration (oral, intramuscular, or intravenous drip), or timing of repeat administrations. There were 31 outcome measures, which were inconsistently reported. They included subjective measures of behaviours, direct measures of treatment effect (time to calm; time to sleep), indirect measures of agitation (staff or patient injuries, duration of agitative or aggressive episodes, subsequent violent episodes), and adverse events. The most common were time to calm and adverse events. There was little clarity about the superiority of any chemical method of managing behaviours of concern exhibited by patients in Emergency Departments or acute mental health settings. Not only is more targeted research essential, but best practice recommendations for such situations requires integrating expert input into the current evidence base.
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Affiliation(s)
- Eimear Muir-Cochrane
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Candice Oster
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Adam Gerace
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia.,School of Health, Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland, Australia
| | - Suzanne Dawson
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Raechel Damarell
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Karen Grimmer
- College of Nursing & Health Sciences, Flinders University, Adelaide, South Australia, Australia
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Page CB, Parker LE, Rashford SJ, Kulawickrama S, Isoardi KZ, Isbister GK. Prospective study of the safety and effectiveness of droperidol in elderly patients for pre-hospital acute behavioural disturbance. Emerg Med Australas 2020; 32:731-736. [PMID: 32216048 DOI: 10.1111/1742-6723.13496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/06/2020] [Accepted: 02/19/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Acute behavioural disturbance in the elderly (≥65 years) is a significant issue for emergency medical services with increasing prevalence of dementia and aging populations. We investigated the pre-hospital safety and effectiveness of droperidol in the elderly with acute behavioural disturbance. METHODS This was a pre-hospital prospective observational 1-year study of elderly patients with acute behavioural disturbance. The primary outcome was proportion of adverse events (AEs) (airway intervention, oxygen saturation <90% and/or respiratory rate <12/min, systolic blood pressure <90 mmHg, sedation assessment tool score of -3 and dystonic reactions). Secondary outcomes included time to sedation, additional sedation, proportion with successful sedation. RESULTS There were 149 patients (males 78 [52%], median age 78 years; 65-101 years) presenting on 162 occasions. Dementia was the commonest cause (107/164 [65%]) of acute behavioural disturbance. There were six AEs in five patients (5/162 [3%]; 95% confidence interval 1-7). Three had hypotension, one with associated hypoxia (80%); and two had respiratory AEs (respiratory rate, 10/min [no hypoxia] and hypoxia [88%] which required oxygen). Median time to sedation was 19 min (interquartile range 12-29 min). Additional sedation was given in 2/162 patients during ambulance transfer and 16/162 within an hour of hospital arrival; 24/162 (15%) failed to sedate in the ambulance; 16 subsequently settled in ED and 8/24 received additional sedation. Of 162, 123 (76%) patients successfully sedated, without AEs or additional sedation. Of 162, 114 (70%) patients received 5 mg, 46 (29%) received two doses of 5 mg and two patients (1%) received three doses. CONCLUSIONS Droperidol appeared to be safe and effective for pre-hospital sedation of acute behavioural disturbance in elderly patients.
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Affiliation(s)
- Colin B Page
- Clinical Toxicology Research Group, The University of Newcastle, Newcastle, New South Wales, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Clincial Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | | | - Sanjeewa Kulawickrama
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Faculty of Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Katherine Z Isoardi
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Clincial Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Geoffrey K Isbister
- Clinical Toxicology Research Group, The University of Newcastle, Newcastle, New South Wales, Australia.,Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
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The Use, Safety, and Efficacy of Olanzapine in a Level I Pediatric Trauma Center Emergency Department Over a 10-Year Period. Pediatr Emerg Care 2020; 36:70-76. [PMID: 28697164 DOI: 10.1097/pec.0000000000001231] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Olanzapine is a second-generation antipsychotic increasingly used in emergency medicine for many indications. Literature on its use in children is sparse. Our objectives were to describe the use, safety, and efficacy of olanzapine in pediatric emergency patients. METHODS A structured chart review was performed of patients 18 years old or younger receiving olanzapine from 2007 to 2016 in the emergency department of a pediatric level I trauma center. RESULTS A total of 285 children received olanzapine. Mean age was 16.4 years (range, 9-18 years); 121 were male (42.8%). Primary indications for olanzapine included agitation (n = 166, 58.3%), headache (n = 58, 20.4%), nausea/vomiting/abdominal pain (n = 37, 12.5%), unspecified pain (n = 20, 7%), and other (n = 4, 1.4%). Route of olanzapine administration was intramuscular (n = 160, 56%; median dose, 10 mg; range, 2.5-20), intravenous (n = 101, 36%; median dose, 5 mg; range, 1.25-5), and oral (n = 24, 8%; median dose, 10 mg; range, 5-10). For agitated patients, 28 (17%) received another sedative within 1 hour. For headache patients, 5 (8.6%) received another analgesic. For gastrointestinal complaints, 5 patients (13.5%) received another analgesic/antiemetic. Adverse respiratory events were hypoxia (pulse oximetry reading, in percentage, <92%; n = 7, 2.4%), supplemental oxygen placement (n = 9, 3.2%), and intubation (n = 2, 0.7%). No patient died or had a dysrhythmia. One patient experienced dystonia. CONCLUSIONS Olanzapine seems safe when used for a variety of conditions in pediatric emergency patients. It may be effective for acute agitation, primary headache, and gastrointestinal complaints.
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Prommer E. Midazolam: an essential palliative care drug. Palliat Care Soc Pract 2020; 14:2632352419895527. [PMID: 32215374 PMCID: PMC7065504 DOI: 10.1177/2632352419895527] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 11/13/2019] [Indexed: 12/16/2022] Open
Abstract
Midazolam is a commonly used benzodiazepine in palliative care and is considered one of the four essential drugs needed for the promotion of quality care in dying patients. Acting on the benzodiazepine receptor, it promotes the action of gamma-aminobutyric acid. Gamma-aminobutyric acid action promotes sedative, anxiolytic, and anticonvulsant properties. Midazolam has a faster onset and shorter duration of action than other benzodiazepines such as diazepam and lorazepam lending itself to greater flexibility in dosing than other benzodiazepines. The kidneys excrete midazolam and its active metabolite. Metabolism occurs in the liver by the P450 system. This article examines the pharmacology, pharmacodynamics, and clinical uses of midazolam in palliative care.
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Affiliation(s)
- Eric Prommer
- UCLA/VA Hospice and Palliative Medicine Program, UCLA School of Medicine, 11301 Wilshire Blvd., Bldg. 500, Room 2064A, Los Angeles, CA 90073, USA
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Claret PG, Gil-Jardine C, Martinez M, Simonnet B, Lefort H, Oberlin M. Actualités en médecine d’urgence. ANNALES FRANCAISES DE MEDECINE D URGENCE 2020. [DOI: 10.3166/afmu-2019-0211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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41
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Yap CYL, Taylor DM, Kong DCM, Knott JC, Taylor SE, Graudins A, Keijzers G, Kulawickrama S, Thom O, Lawton L, Furyk J, Finucci D, Holdgate A, Watkins G, Jordan P. Management of behavioural emergencies: a prospective observational study in Australian emergency departments. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Celene Y. L. Yap
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Emergency Department The Royal Melbourne Hospital Melbourne Australia
- Centre for Medicine Use and Safety Monash University Melbourne Australia
| | - David McD. Taylor
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Emergency Department Austin Health Melbourne Australia
| | - David C. M. Kong
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Centre for Medicine Use and Safety Monash University Melbourne Australia
- Pharmacy Department Ballarat Health Services Ballarat Australia
| | - Jonathan C. Knott
- Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Melbourne Australia
- Emergency Department The Royal Melbourne Hospital Melbourne Australia
| | | | - Andis Graudins
- Emergency Department Monash Health Melbourne Australia
- Department of Medicine, Clinical Sciences at Monash Health Monash University Melbourne Australia
| | - Gerben Keijzers
- Emergency Department Gold Coast University Hospital Gold Coast Australia
- School of Medicine Bond University Gold Coast Australia
- School of Medicine Griffith University Gold Coast Australia
| | | | - Ogilvie Thom
- Emergency Department Nambour General Hospital Nambour Australia
| | - Luke Lawton
- Emergency Department The Townsville Hospital Townsville Australia
| | - Jeremy Furyk
- Emergency Department The Townsville Hospital Townsville Australia
| | - Daniel Finucci
- Emergency Department Liverpool Hospital Sydney Australia
| | - Anna Holdgate
- Emergency Department Liverpool Hospital Sydney Australia
| | - Gina Watkins
- Emergency Department Sutherland Hospital Sydney Australia
| | - Peter Jordan
- Emergency Department The Northern Hospital Melbourne Australia
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Welch S. Pharmacy research in the emergency medicine environment. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Baldaçara L, Diaz AP, Leite V, Pereira LA, Dos Santos RM, Gomes Júnior VDP, Calfat ELB, Ismael F, Périco CAM, Porto DM, Zacharias CEK, Cordeiro Q, da Silva AG, Tung TC. Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach. ACTA ACUST UNITED AC 2019; 41:324-335. [PMID: 30843960 PMCID: PMC6804299 DOI: 10.1590/1516-4446-2018-0177] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/18/2018] [Indexed: 01/07/2023]
Abstract
Objective: To present the essential guidelines for pharmacological management of patients with psychomotor agitation in Brazil. Methods: This is a systematic review of articles retrieved from the MEDLINE (PubMed), Cochrane Database of Systematic Reviews, and SciELO databases published from 1997 to 2017. Other relevant articles in the literature were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools. Results: Of 5,362 articles retrieved, 1,731 abstracts were selected for further reading. The final sample included 74 articles that met all inclusion criteria. The evidence shows that pharmacologic treatment is indicated only after non-pharmacologic approaches have failed. The cause of the agitation, side effects of the medications, and contraindications must guide the medication choice. The oral route should be preferred for drug administration; IV administration must be avoided. All subjects must be monitored before and after medication administration. Conclusion: If non-pharmacological strategies fail, medications are needed to control agitation and violent behavior. Once medicated, the patient should be monitored until a tranquil state is possible without excessive sedation. Systematic review registry number: CRD42017054440.
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Affiliation(s)
- Leonardo Baldaçara
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Universidade Federal do Tocantins (UFT), Palmas, TO, Brazil.,Secretaria de Estado de Saúde do Tocantins, Palmas, TO, Brazil
| | - Alexandre P Diaz
- Programa de Pós-Graduação em Ciências da Saúde, Universidade do Sul de Santa Catarina (UNISUL), Palhoça, SC, Brazil
| | - Verônica Leite
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Secretaria de Estado de Saúde do Tocantins, Palmas, TO, Brazil.,Secretaria de Saúde do Município de Palmas, Palmas, TO, Brazil
| | - Lucas A Pereira
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Universidade Salvador (UNIFACS), Salvador, BA, Brazil.,Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, BA, Brazil.,Faculdade de Tecnologia e Ciências (FTC), Salvador, BA, Brazil
| | - Roberto M Dos Santos
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Hospital Universitário Lauro Wanderley, Universidade Federal da Paraíba (UFPB), João Pessoa, PB, Brazil.,Pronto Atendimento em Saúde Mental, João Pessoa, PB, Brazil
| | - Vicente de P Gomes Júnior
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Associação Psiquiátrica do Piauí (APPI), Teresina, PI, Brazil
| | - Elie L B Calfat
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brazil.,Centro de Atenção Integrada à Saúde Mental, Franco da Rocha, SP, Brazil
| | - Flávia Ismael
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina do ABC, Santo André, SP, Brazil.,Coordenadoria de Saúde Mental, São Caetano do Sul, SP, Brazil.,Universidade de São Caetano do Sul, São Caetano do Sul, SP, Brazil
| | - Cintia A M Périco
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina do ABC, Santo André, SP, Brazil.,Coordenadoria de Saúde Mental, São Bernardo do Campo, SP, Brazil
| | - Deisy M Porto
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Instituto de Psiquiatria de Santa Catarina, São José, SC, Brazil.,Coordenação Estadual de Saúde Mental, Florianópolis, SC, Brazil
| | - Carlos E K Zacharias
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Secretaria de Estado da Saúde de São Paulo, São Paulo, SP, Brazil.,Secretaria de Saúde do Município de Sorocaba, São Paulo, SP, Brazil
| | - Quirino Cordeiro
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brazil.,Coordenação-Geral de Saúde Mental, Álcool e Outras Drogas, Ministério da Saúde, Brazil
| | - Antônio Geraldo da Silva
- Asociación Psiquiátrica de América Latina (APAL)Asociación Psiquiátrica de América Latina (APAL).,ABP, Rio de Janeiro, RJ, Brazil.,Faculdade de Medicina, Universidade do Porto/Conselho Federal de Medicina (CFM), Porto, Portugal
| | - Teng C Tung
- Comissão de Emergências Psiquiátricas, Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brazil.,Instituto de Psiquiatria, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brazil
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Khorassani F, Saad M. Intravenous Olanzapine for the Management of Agitation: Review of the Literature. Ann Pharmacother 2019; 53:853-859. [DOI: 10.1177/1060028019831634] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objective: The purpose of this review is to summarize the current evidence of the off-label use of intravenous (IV) olanzapine and discuss its risks versus benefits for the management of agitation. Data Sources: A literature search was conducted to gather relevant data regarding IV use of olanzapine for the management of acute agitation. PubMed, EMBASE, MEDLINE, and IPA were searched using the keywords and MESH terms: olanzapine, intravenous, IV, off-label, and agitation. Study Selection and Data Extraction: All case reports, and retrospective and prospective studies evaluating the efficacy and safety of IV olanzapine administration for agitation from January 2004 to December 2018 were analyzed. Data Synthesis: Doses from 2.5 to 10 mg given as an IV bolus (maximum dose of 30 mg/d) have been administered. Rescue medications such as droperidol or parenteral benzodiazepines are sometimes coadministered to assist with achieving adequate sedation. Prospective studies demonstrate efficacy similar to droperidol in achieving adequate sedation within 10 minutes and similar time to onset of sedation. Rates of respiratory depression and airway obstruction are low and similar to that of comparative agents, including intramuscular olanzapine. Relevance to Patient Care and Clinical Practice: This review evaluated the off-label use of IV olanzapine to manage agitation based on case reports, and retrospective and prospective data. Conclusions: The use of IV olanzapine remains controversial in the absence of clear evidence evaluating safety and efficacy. Future studies are warranted comparing IV olanzapine with more commonly utilized and Food and Drug Administration–approved treatment modalities for acute agitation in the emergency department and other settings.
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Affiliation(s)
- Farah Khorassani
- St John’s University College of Pharmacy and Health Sciences, Queens, NY, USA
- Bellevue Hospital Center, New York, NY, USA
| | - Maha Saad
- St John’s University College of Pharmacy and Health Sciences, Queens, NY, USA
- Long Island Jewish Hospital, Northwell Health, New Hyde Park, NY, USA
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Klein LR, Driver BE, Horton G, Scharber S, Martel ML, Cole JB. Rescue Sedation When Treating Acute Agitation in the Emergency Department With Intramuscular Antipsychotics. J Emerg Med 2019; 56:484-490. [PMID: 30745194 DOI: 10.1016/j.jemermed.2018.12.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 12/21/2018] [Accepted: 12/24/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Rapid treatment of agitation in the emergency department (ED) is critical to avoid injury to patients and providers. Treatment with intramuscular antipsychotics is often utilized, but there is a paucity of comparative effectiveness evidence available. OBJECTIVE The purpose of this investigation was to compare the effectiveness of droperidol, olanzapine, and haloperidol for treating agitation in the ED. METHODS This was a retrospective observational study of adult patients who received intramuscular medication to treat agitation. Patients were classified based on the initial antipsychotic they received. The primary effectiveness outcome was the rate of additional sedation administered (rescue medication) within 1 h. Secondary outcomes included rescue sedation for the entire encounter and adverse events. RESULTS There were 15,918 patients included (median age 37 years, 75% male). Rescue rates at 1 h were: 547/4947 for droperidol (11%, 95% confidence interval [CI] 10-12%), 988/8825 olanzapine (11%, 95% CI 10-12%), and 390/2146 for haloperidol (18%, 95% CI 17-20%). Rescue rates for the entire ED encounter were: 832/4947 for droperidol (17%, 95% CI 16-18%), 1665/8825 for olanzapine (19%, 95% CI 18-20%), and 560/2146 for haloperidol (26%, 95% CI 24-28%). Adverse events were uncommon: intubation (49, 0.3%), akathisia (7, 0.04%), dystonia (5, 0.03%), respiratory arrest (1, 0.006%), and torsades de pointes (0), with no significant differences between drugs. CONCLUSIONS Olanzapine and droperidol lead to lower rates of rescue sedation at 1 h and overall, compared with haloperidol. There were no significant differences in major adverse events.
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Affiliation(s)
- Lauren R Klein
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Gabriella Horton
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Sarah Scharber
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Marc L Martel
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Jon B Cole
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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Klein LR, Cole JB, Driver BE, Miner JR, Laes JR, Fagerstrom E, L Martel M. An open-label randomized trial of intramuscular olanzapine versus oral clonidine for symptomatic treatment of opioid withdrawal in the emergency department. Clin Toxicol (Phila) 2019; 57:697-702. [PMID: 30712404 DOI: 10.1080/15563650.2018.1547828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Patients with opioid withdrawal often present to the Emergency Department (ED), but many EDs do not have the infrastructure in place to initiate treatment with opioid agonists (methadone or buprenorphine). Therefore, ED management often entails symptomatic control. The purpose of this study was to compare olanzapine to clonidine for the treatment of opioid withdrawal symptoms. Methods: This was a prospective, randomized clinical trial comparing 10 mg of IM olanzapine to 0.3 mg of oral clonidine for symptoms of opioid withdrawal. Adult (18 years and older) ED patients reporting a history of opioid use and symptoms consistent with withdrawal were eligible. Patients were excluded if they had already received treatment during the ED encounter, were pregnant, incarcerated, or unable to provide consent. Patients were randomized 1:1 to receive olanzapine or clonidine for their initial treatment. A baseline Clinical Opiate Withdrawal Scale (COWS) score was calculated. After 30 min, the patient could receive any additional treatment at the ED physician's discretion. The primary outcome was need for additional medication (rescue) within 1 h of study medication administration. Secondary outcomes included change in COWS score and adverse reactions. Results: We enrolled 63 patients (33 olanzapine, 30 clonidine). Demographic characteristics were similar for both groups (median age 45, range 21-67, 54% male) as well as baseline COWS score (median score 11). The median time since last opiate use was 48 h for both groups (range 4-116). Rescue was given within 1 h for olanzapine for 9 (27%) patients and for clonidine in 19 (63%) patients (difference 36%, 95% CI 13-59%). Decrease in COWS score at 1 h was 8.3 for olanzapine and 5.1 for clonidine (difference 3.2, 95% CI 0.3-6). Adverse events were uncommon: akathisia (1, olanzapine), hypotension (2, clonidine), respiratory depression (0). Conclusions: Treatment of opioid withdrawal symptoms with 10 mg of IM olanzapine results in a lower incidence of rescue medication administration and improved symptoms (COWS score) compared to 0.3 mg of oral clonidine.
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Affiliation(s)
- Lauren R Klein
- a Department of Emergency Medicine , Hennepin County Medical Center , Minneapolis , MN , USA
| | - Jon B Cole
- a Department of Emergency Medicine , Hennepin County Medical Center , Minneapolis , MN , USA.,b Minnesota Poison Control System , Minneapolis , MN , USA
| | - Brian E Driver
- a Department of Emergency Medicine , Hennepin County Medical Center , Minneapolis , MN , USA
| | - James R Miner
- a Department of Emergency Medicine , Hennepin County Medical Center , Minneapolis , MN , USA
| | - JoAn R Laes
- b Minnesota Poison Control System , Minneapolis , MN , USA.,c Department of Internal Medicine, Division of Addiction Medicine , Hennepin County Medical Center , Minneapolis , MN , USA
| | - Erik Fagerstrom
- a Department of Emergency Medicine , Hennepin County Medical Center , Minneapolis , MN , USA
| | - Marc L Martel
- a Department of Emergency Medicine , Hennepin County Medical Center , Minneapolis , MN , USA
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The pharmacological management of agitated and aggressive behaviour: A systematic review and meta-analysis. Eur Psychiatry 2019; 57:78-100. [DOI: 10.1016/j.eurpsy.2019.01.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/10/2019] [Indexed: 01/12/2023] Open
Abstract
AbstractIntroduction:Non-pharmacological interventions preferably precede pharmacological interventions in acute agitation. Reviews of pharmacological interventions remain descriptive or compare only one compound with several other compounds. The goal of this study is to compute a systematic review and meta-analysis of the effect on restoring calmness after a pharmacological intervention, so a more precise recommendation is possible.Method:A search in Pubmed and Embase was done to isolate RCT’s considering pharmacological interventions in acute agitation. The outcome is reaching calmness within maximum of 2 h, assessed by the psychometric scales of PANSS-EC, CGI or ACES. Also the percentages of adverse effects was assessed.Results:Fifty-three papers were included for a systematic review and meta-analysis. Most frequent studied drug is olanzapine. Changes on PANNS-EC and ACES at 2 h showed the strongest changes for haloperidol plus promethazine, risperidon, olanzapine, droperidol and aripiprazole. However, incomplete data showed that the effect of risperidon is overestimated. Adverse effects are most prominent for haloperidol and haloperidol plus lorazepam.Conclusion:Olanzapine, haloperidol plus promethazine or droperidol are most effective and safe for use as rapid tranquilisation. Midazolam sedates most quickly. But due to increased saturation problems, midazolam is restricted to use within an emergency department of a general hospital.
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Page CB, Parker LE, Rashford SJ, Isoardi KZ, Isbister GK. A Prospective Study of the Safety and Effectiveness of Droperidol in Children for Prehospital Acute Behavioral Disturbance. PREHOSP EMERG CARE 2018; 23:519-526. [PMID: 30380965 DOI: 10.1080/10903127.2018.1542473] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Study objective: Although uncommon, children (<16 years) with acute behavioral disturbance are a significant issue for emergency medical service providers. In this study, we aimed to investigate the safety and effectiveness of droperidol in children with prehospital acute behavioral disturbance. Methods: This was a prospective observational study over 1 year investigating the use of droperidol (0.1-0.2 mg/kg) for children (< 16 years) with acute behavioral disturbance. Inclusion criteria for acute behavioral disturbance were defined by a sedation assessment tool score of ≥2 determined by the attending paramedic. The primary outcome was the proportion of adverse effects (need for airway intervention, oxygen saturation <90% and/or respiratory rate <12, systolic blood pressure <90 mmHg, sedation assessment tool score of -3 and dystonic reactions). Secondary outcomes included time to sedation (sedation assessment tool score decreased by 2 or more, or a score of zero), requirement for additional sedation, failure to sedate and proportion of sedation success defined as the number of patients successfully sedated who did not suffer any adverse events or receive additional sedation. Results: There were 96 patients (males 51 [53%], median age 14 years [range 7-15 years]) who presented on 102 occasions over the one year study period. Self-harm and/or harm to others was the commonest (74/105 [70%]) cause of acute behavioral disturbance followed by alcohol (16/105 [15%]). There were 9 adverse events in 8 patients (8/102 [8%]; 95% confidence intervals [CI]: 3-13%) Five patients had hypotension, all asymptomatic and only one required treatment; 2 dystonic reactions managed with benztropine and one patient with respiratory depression. Median time to sedation was 14 min (interquartile range (IQR): 10-20 min; range: 3-85 min). There was no requirement for prehospital additional sedation (0/102 [0%]; 95% CI: 0-4%) and additional sedation in the first hour of arrival to hospital was required by 4 patients (4/102 [4%]; 95% CI: 1-10%). Overall successful sedation was achieved in 89 (87%) patients. Conclusions: The use of droperidol in children for acute behavioral disturbance in the prehospital setting is both safe and effective.
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Miner JR, Klein LR, Cole JB, Driver BE, Moore JC, Ho JD. The Characteristics and Prevalence of Agitation in an Urban County Emergency Department. Ann Emerg Med 2018; 72:361-370. [DOI: 10.1016/j.annemergmed.2018.06.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 05/09/2018] [Accepted: 05/31/2018] [Indexed: 10/28/2022]
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Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med 2018; 72:374-385. [DOI: 10.1016/j.annemergmed.2018.04.027] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/17/2018] [Accepted: 04/24/2018] [Indexed: 11/17/2022]
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