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Poon IO, Ajewole V, Braun UK. A Review of Olanzapine in the Treatment of Cancer Anorexia-Cachexia Syndrome. PHARMACY 2024; 12:34. [PMID: 38392941 PMCID: PMC10893239 DOI: 10.3390/pharmacy12010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/25/2024] [Accepted: 02/04/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Cancer anorexia-cachexia syndrome (CAS) is a multifactorial condition that is highly prevalent in advanced cancer patients and associated with significant reduction in functional performance, reduction in quality of life, and increased mortality. Currently, no medications are approved for this indication. Recently, the American Society of Clinical Oncology (ASCO) released a rapid recommendation suggesting that low-dose olanzapine once daily may be used to treat cancer cachexia. Many questions still exist on how to use olanzapine for this indication in clinical practice. The objective of this review is to identify existing knowledge on the use of olanzapine for CAS. METHODS A comprehensive search was conducted to identify the primary literature that involved olanzapine for anorexia and cachexia in cancer patients between 2000 and 2023. RESULTS Seven articles were identified and are discussed here, including two randomized double-blinded placebo-controlled studies, one randomized comparative study, two prospective open-label studies, one retrospective chart review, and one case report. CONCLUSIONS Low dose olanzapine (2.5-5 mg once daily) may be useful in the treatment of CAS for increasing appetite, reducing nausea and vomiting, and promoting weight gain. Further large-scale multi-center randomized placebo-controlled studies will be needed to investigate the impact of olanzapine on weight change in CAS patients.
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Affiliation(s)
- Ivy O. Poon
- Department of Pharmacy Practice, Texas Southern University, Houston, TX 77004, USA; (I.O.P.); (V.A.)
| | - Veronica Ajewole
- Department of Pharmacy Practice, Texas Southern University, Houston, TX 77004, USA; (I.O.P.); (V.A.)
- Pharmacy Department, Houston Methodist Hospital, Houston, TX 77004, USA
| | - Ursula K. Braun
- Rehabilitation & Extended Care Line, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
- Section of Geriatrics & Palliative Medicine, Baylor College of Medicine, Houston, TX 77030, USA
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2
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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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4
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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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Bonfichi A, Ceresa IF, Piccioni A, Zanza C, Longhitano Y, Boudi Z, Esposito C, Savioli G. A Lethal Combination of Delirium and Overcrowding in the Emergency Department. J Clin Med 2023; 12:6587. [PMID: 37892725 PMCID: PMC10607343 DOI: 10.3390/jcm12206587] [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: 08/28/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Delirium is a common public health concern that significantly impacts older patients admitted to the Emergency Department (ED). This condition is linked to adverse outcomes such as reduced long-term functionality, higher mortality rates, extended hospital stays, and increased medical costs. The identification of risk factors is crucial for the early recognition and management of delirium in ED patients. Aging, cognitive decline, polypharmacy, and sensory impairment are some of the most common general risk factors described in the literature. Although validated delirium assessment tools already exist, they are not practical for the fast-paced ED environment because of their extended evaluation period or specialized training request. Moreover, clear guidance is needed to select the most suitable tool for detecting delirium, balancing between the accuracy and the swiftness required in an overcrowded, high-stress, and understaffed healthcare setting. This narrative review aims to analyze the updated literature on delirium risk factors in older ED patients and focuses on the methods for better screening, managing, and treating this condition in the ED.
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Affiliation(s)
- Alessandra Bonfichi
- Department of Internal Medicine, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| | - Iride Francesca Ceresa
- Department of Emergency Medicine, Humanitas University-Research Hospital, 20089 Rozzano, Italy; (I.F.C.); (Y.L.)
| | - Andrea Piccioni
- Department of Emergency, Fondazione Policlinico Universitario A. Gemelli, IRCCS Fondazione Policlinico San Matteo, 00168 Roma, Italy;
| | - Christian Zanza
- Italian Society of Pre-Hospital Emergency Medicine (SIS-118), 74121 Taranto, Italy;
| | - Yaroslava Longhitano
- Department of Emergency Medicine, Humanitas University-Research Hospital, 20089 Rozzano, Italy; (I.F.C.); (Y.L.)
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15260, USA
| | - Zoubir Boudi
- Department of Emergency Medicine, Dr Sulaiman Alhabib Hospital, Dubai 2542, United Arab Emirates;
| | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy;
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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Singh AP, Murali Mohan NT. Second-Generation Parenteral Antipsychotic (Olanzapine) as a First-Line Treatment for Acute Undifferentiated Agitation in the Emergency Department in Comparison With Haloperidol. Cureus 2023; 15:e40226. [PMID: 37435257 PMCID: PMC10332641 DOI: 10.7759/cureus.40226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2023] [Indexed: 07/13/2023] Open
Abstract
Background Acutely agitated patients are common in the emergency department (ED). Given the myriad aetiologies of the clinical conditions that can produce agitation, such a high prevalence is unsurprising. Agitation is a symptomatic presentation, not a diagnosis, secondary to a psychiatric, medical, traumatic, or toxicological condition. Most literature on the emergency management of agitated patients is from psychiatric populations, not generalised to EDs. Benzodiazepines, antipsychotics, and ketamine have been used to treat acute agitation. However, a clear consensus is lacking. Objectives The objectives are to study the effectiveness of intramuscular (IM) olanzapine as a first-line treatment for rapid tranquillisation in undifferentiated acute agitation in the ED and compare the effectiveness of sedatives to control agitation in etiologically divided groups per the following preassigned protocols: Group A: Alcohol/drug intoxication (olanzapine vs haloperidol), Group B: Traumatic brain injury (TBI) with or without alcohol intoxication (olanzapine vs haloperidol), Group C: Psychiatric conditions (olanzapine vs haloperidol and lorazepam), and Group D: Agitated delirium, organic causes (olanzapine vs haloperidol). Methods This 18-month prospective study included acutely agitated ED patients between 18 and 65. Results A total of 87 patients between 19 and 65 were included, all with a Richmond Agitation Sedation Scale (RASS) score between +2 and +4 at presentation. Nineteen of the 87 patients were managed as acute undifferentiated agitation, and 68 were assigned to one of the four groups. In acute undifferentiated agitation, IM olanzapine 10 mg effectively sedated 15 (78.9%) patients within 20 minutes, whereas the remaining four (21.1%) were sedated with a repeat IM olanzapine 10 mg over the next 25 minutes. In 13 patients with agitation due to alcohol intoxication, zero out of three with olanzapine and four out of 10 (40%) with IM haloperidol 5 mg were sedated within 20 minutes. In patients with TBI, two out of eight (25%) receiving olanzapine and four out of nine (44.4%) receiving haloperidol were sedated within 20 minutes. In acute agitation secondary to psychiatric disease, olanzapine sedated nine out of 10 (90%), and haloperidol with lorazepam sedated 16 out of 17 (94.1%) within 20 minutes. In patients with agitation secondary to organic medical conditions, olanzapine rapidly sedated 19 out of 24 (79.1%), whereas haloperidol sedated one out of four (25%). Interpretation and conclusion IM olanzapine 10 mg is effective for rapid sedation in acute undifferentiated agitation. Olanzapine is superior to haloperidol in agitation secondary to organic medical conditions and is as efficacious as haloperidol with lorazepam in agitation due to psychiatric diseases. However, in agitation due to alcohol intoxication and TBI, haloperidol 5 mg is slightly better, although not statistically significant. Olanzapine and haloperidol were well tolerated by Indian patients in the current study, with minimal side effects.
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Affiliation(s)
- Adheera P Singh
- Emergency Medicine, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, IND
| | - N T Murali Mohan
- Emergency Medicine, Vydehi Institute of Medical Sciences and Research Centre, Bangalore, IND
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Wu Y, Li Y, Liang W, Bai L, Yu J, Li K, Zhang Y, Guo Y, Liu Z, Wang J, Zhang C, Wang X, Xu J, Liu L, Li J, Yang F. The safety and efficacy of sequential intramuscular/oral ziprasidone treatment of acute episode in patients with schizophrenia: a multicenter, open-labeled study. BMC Psychiatry 2023; 23:166. [PMID: 36922763 PMCID: PMC10015911 DOI: 10.1186/s12888-023-04588-0] [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: 03/12/2022] [Accepted: 02/03/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Ziprasidone mesylate injection is an atypical antipsychotic drug which is recently approved in China. In combination with its oral formulation, sequential therapy with ziprasidone brings new interventions to patients with agitation in the acute phase of schizophrenia. The purpose of this 7-day multicenter study conducted in China was to evaluate the efficacy and safety of ziprasidone sequential treatment through intramuscular/oral routes in agitated patients with schizophrenia. METHODS A total of 95 patients were enrolled from three centers in this study. The study duration was 7 days. In the first 3 days, subjects were administered an intramuscular injection of ziprasidone 10-40 mg daily and started sequentially with oral ziprasidone 40-80 mg at dinner (or lunch) from the day of the last intramuscular injection. In the following 4 days, according to the severity of the symptoms and the drug response, 120-160 mg of ziprasidone was orally administered daily. In total, six visits were scheduled to assess the Positive and Negative Syndrome Scale (PANSS), the Behavioral Activity Rating Scale (BARS), the Clinical Global Impression of Severity (CGI-S), and Improvement (CGI-I) scores throughout the procedure. Lastly, adverse events were recorded during treatment. RESULTS Out of the 95 patients that were enrolled, 83 cases were effectively completed. Visits 3, 4, 6, PANSS, and PANSS-excited component (PANSS-EC) subscale points, and Visit 2-Visit 6 viewpoints, BARS scale points, and baseline scores denote a progressive downward trend (P < 0.001). In this study, 62 adverse events were reported. The most common adverse events were extrapyramidal symptoms (EPS) (23 cases) and excessive sedation(10 cases), and 13 cases of prolonged QTc interval were reported. CONCLUSIONS Ziprasidone IM demonstrated significant and rapid reduction in agitation, and sequential oral formulation keep stability and continuation of the treatment can further ensure efficacy. Ziprasidone sequential therapy may provide a new approach to acute agitation in schizophrenic patients. TRIAL REGISTRATION The Chinese Clinical Trials Registry; URL: https://www.chictr.org.cn : ChiCTR-OIC-16007970.
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Affiliation(s)
- Yaxue Wu
- Peking University HuiLongGuan Clinical Medical School, Beijing Huilongguan Hospital, Beijing, People's Republic of China
| | - Yanli Li
- Peking University HuiLongGuan Clinical Medical School, Beijing Huilongguan Hospital, Beijing, People's Republic of China
| | - Weiye Liang
- Peking University HuiLongGuan Clinical Medical School, Beijing Huilongguan Hospital, Beijing, People's Republic of China
| | - Luyuan Bai
- Peking University HuiLongGuan Clinical Medical School, Beijing Huilongguan Hospital, Beijing, People's Republic of China
| | - Jianjin Yu
- Peking University HuiLongGuan Clinical Medical School, Beijing Huilongguan Hospital, Beijing, People's Republic of China
| | - Keqing Li
- The Mental Health Center of Hebei Province, Baoding, People's Republic of China
| | - Yunshu Zhang
- The Sixth People's Hospital of Hebei Province, Baoding, People's Republic of China
| | - Yanmei Guo
- The Sixth People's Hospital of Hebei Province, Baoding, People's Republic of China
| | - Zenglong Liu
- The Sixth People's Hospital of Hebei Province, Baoding, People's Republic of China
| | - Jian Wang
- The Sixth People's Hospital of Hebei Province, Baoding, People's Republic of China
| | - Congpei Zhang
- Harbin First Specialized Hospital, Harbin, People's Republic of China
| | - Xijin Wang
- Harbin First Specialized Hospital, Harbin, People's Republic of China
| | - Jia Xu
- Harbin First Specialized Hospital, Harbin, People's Republic of China
| | - Liping Liu
- Harbin First Specialized Hospital, Harbin, People's Republic of China
| | - Juan Li
- Beijing Geriatric Hospital, Beijing, People's Republic of China
| | - Fude Yang
- Peking University HuiLongGuan Clinical Medical School, Beijing Huilongguan Hospital, Beijing, People's Republic of China.
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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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Safety and effectiveness of benzodiazepines and antipsychotics for agitation in older adults in the emergency department. Am J Emerg Med 2023; 67:156-162. [PMID: 36893629 DOI: 10.1016/j.ajem.2023.02.032] [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: 09/16/2022] [Revised: 02/15/2023] [Accepted: 02/23/2023] [Indexed: 03/05/2023] Open
Abstract
PURPOSE To examine the safety and effectiveness of benzodiazepines (BZD) as compared to antipsychotics for the management of acute agitation in older adults in the emergency department (ED). BASIC PROCEDURES Retrospective observational cohort study of 21 EDs across four states in the US, including adults ≥60 years old who received either BZD or antipsychotics for acute agitation in the ED and subsequently were admitted to the hospital. Safety was measured as presence of adverse events: respiratory depression, cardiovascular effects, extrapyramidal side effects, or a fall during hospitalization. Effectiveness was measured as indicators of treatment failure: need for additional medication, one-to-one observation, or physical restraints following initial medication administration. Proportions and odds ratios with 95% confidence intervals (CI) were calculated. Univariable and multivariable logistic regression were used to assess the association between potential risk factors and for efficacy and safety endpoints. MAIN FINDINGS A total of 684 patients were included (63.9% received a BZD and 36.1% an antipsychotic). There was no difference in the incidence of adverse events between groups (20.6% vs 14.6%, difference 6.0%, 95% CI -0.2% to 11.8%), but there was a higher intubation rate in the BZD group (2.7% vs 0.4%, difference 2.3%). There were more treatment failures in the antipsychotic group for the composite primary efficacy endpoint (94.3% vs 87.6%, difference 6.7%, 95% CI 2.5% to 10.9%). This appears to have been driven by the need for 1:1 observation; sensitivity analysis excluding 1:1 observation in the composite outcome demonstrated no significant difference with a failure rate of 38.5% in the antipsychotic group and 35.2% in the benzodiazepine group. PRINCIPAL CONCLUSIONS Overall there are high rates of treatment failure among agitated older adults receiving pharmacological treatment for agitation in the emergency department. The optimal selection of pharmacological treatment for agitation in older adults should be made considering patient-specific factors that could increase the risk of adverse effects or treatment failure.
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Behavioral Health Emergencies. PHYSICIAN ASSISTANT CLINICS 2023. [DOI: 10.1016/j.cpha.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Curry A, Malas N, Mroczkowski M, Hong V, Nordstrom K, Terrell C. Updates in the Assessment and Management of Agitation. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2023; 21:35-45. [PMID: 37205032 PMCID: PMC10172538 DOI: 10.1176/appi.focus.20220064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Agitated patients can be dangerous to themselves and others. In fact, severe medical complications and death can occur with severe agitation. Because of this, agitation is considered a medical and psychiatric emergency. Regardless of the treatment setting, identifying the agitated patient early is a necessary skill. The authors review relevant literature regarding the identification and management of agitation and summarize current recommendations for adults, as well as children and adolescents.
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Affiliation(s)
- Ashley Curry
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Nasuh Malas
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Megan Mroczkowski
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Victor Hong
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Kimberly Nordstrom
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
| | - Christina Terrell
- Department of Psychiatry, University of Colorado School of Medicine, Aurora (Curry, Nordstrom); Department of Psychiatry (Malas, Hong) and Department of Pediatrics (Malas), University of Michigan, Ann Arbor; Department of Psychiatry, Columbia University Irving Medical Center, New York City (Mroczkowski); Department of Psychiatry, University of Louisville, Louisville, Kentucky (Terrell)
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12
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Rutherford-Hemming T, Taber E, Linder G. Pharmacologic Therapy to Mitigate Acute Agitation in the Emergency Department: Case Reports of Diverse Patient Presentations. J Emerg Nurs 2022; 49:336-340. [PMID: 36593151 DOI: 10.1016/j.jen.2022.12.005] [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: 11/10/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 01/02/2023]
Abstract
Nurses in the emergency department often encounter patients exhibiting signs of aggressive behavior. Nurses need to know the pharmacologic treatment appropriate for the patient scenario to ensure safety for the patient and the emergency department team. This case review examines 4 common scenarios where a patient exhibits aggressive behavior. After each case review is a discussion about the appropriate pharmacologic therapy for that patient. The cases portrayed are fictional but based on experience and previous observations.
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Zaki HA, Shaban E, Bashir K, Iftikhar H, Zahran A, Salem EEDM, Elmoheen A. A Comparative Analysis Between Ketamine Versus Combination of Midazolam and Haloperidol for Rapid Safe Control of Agitated Patients in Emergency Department: A Systematic Review. Cureus 2022; 14:e26162. [PMID: 35891834 PMCID: PMC9302860 DOI: 10.7759/cureus.26162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 01/08/2023] Open
Abstract
We aim to discuss the efficacy and adverse effects of using ketamine in agitated patients in the emergency department (ED) compared with the combination therapy of haloperidol with benzodiazepine. This systematic review followed Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. An electronic search from PubMed/Medline, Cochrane library, and Google Scholar was conducted from their inception to 30th April 2022. We included agitated patients in ED who were given infusion with ketamine only. Our comparative group was patients infused with combined therapy of haloperidol and benzodiazepine. We did not include letters, case reports, abstracts, conference papers, appraisals, reviews, and studies where full text was unavailable. We did not put any language restrictions. Three studies were selected in our manuscript (one cohort and two randomized controlled trials). All three studies showed that ketamine was used to achieve sedation in less time than the other group. However, two studies reported significantly more adverse effects in ketamine-infused groups. We concluded that ketamine use is superior when its primary focus is to sedate the patient as quickly as possible, but it carries some side effects that should be considered. However, we still need more studies assessing the efficacy of ketamine in agitated patients presenting in the ED.
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Coralic Z, Rader ES, Vinson DR, Wilson MP. Haloperidol Versus Ziprasidone With Concomitant Medications and Other Predictors of Physical Restraint Duration in the Emergency Department. J Emerg Med 2022; 62:636-647. [PMID: 35361510 DOI: 10.1016/j.jemermed.2021.12.018] [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: 05/27/2021] [Revised: 11/09/2021] [Accepted: 12/28/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with severe agitation are frequently encountered in the emergency department (ED). At times, these patients are physically restrained and given calming medications; however, little is known about the effects of medications and other predictors on restraint duration. OBJECTIVE Our aim was to compare restraint duration when haloperidol or ziprasidone was used as the primary antipsychotic with or without concomitant medications, and to identify predictors of restraint duration. METHODS We performed a review of a retrospective cohort of physically restrained ED patients between January 1, 2013 and November 30, 2017. An unadjusted analysis and adjusted linear regression model were used to evaluate the effect of antipsychotic choice on restraint duration, controlling for sex, age, race, homelessness, arrival in restraints, re-restraint during visit, concomitant medications (i.e., benzodiazepines or anticholinergics), additional medications given during restraint, time of day, and patient disposition. RESULTS In 386 patients (319 haloperidol, 67 ziprasidone), the average restraint duration was 2.4 h (95% confidence interval [CI] 2.2 to 2.6 h). There were no differences in physical restraint times between ziprasidone and haloperidol groups in the unadjusted (mean difference 0.12 h; 95% CI -0.42 to 0.66 h) or adjusted analyses (-12.7%; 95% CI -33.9% to 8.6%). Haloperidol given with diphenhydramine alone was associated with decreased restraint duration (-30.8%; 95% CI -50.6% to -11.1%) The largest association with restraint duration was administration of additional sedating medications during restraint, prolonging restraint by 62% (95% CI 27.1% to 96.9%). In addition, compared with White patients, Black patients spent significantly more time restrained (mean difference 33.9%; 95% CI 9.0% to 58.9%). CONCLUSIONS Restraint duration of agitated ED patients was similar when haloperidol or ziprasidone was used as the primary antipsychotic. However, race and additional medications given during restraint were significantly associated with restraint duration.
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Affiliation(s)
- Zlatan Coralic
- Department of Pharmacy, University of California San Francisco, San Francisco, California; Department of Emergency Medicine, University of California San Francisco, San Francisco, California
| | | | - David R Vinson
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California; Division of Research, Kaiser Permanente, Oakland, California
| | - Michael P Wilson
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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15
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Jeffers T, Darling B, Edwards C, Vadiei N. Efficacy of Combination Haloperidol, Lorazepam, and Diphenhydramine vs. Combination Haloperidol and Lorazepam in the Treatment of Acute Agitation: A Multicenter Retrospective Cohort Study. J Emerg Med 2022; 62:516-523. [PMID: 35287982 DOI: 10.1016/j.jemermed.2022.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/20/2021] [Accepted: 01/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antipsychotic and sedative combinations are commonly used for treating agitation in the emergency department despite limited evidence regarding their comparative safety and efficacy. OBJECTIVES To compare the efficacy and safety of combination haloperidol, lorazepam, and diphenhydramine (B52) to combination haloperidol and lorazepam (52) in treating acute agitation. METHODS This multicenter, retrospective cohort study included adult patients ≥ 18 years of age who received either B52 or 52 at a Banner Health facility between August 2017 and September 2020. Patients were excluded if they had a pre-existing movement disorder or were withdrawing from alcohol. The primary outcome was administration of additional agitation medication(s) within 2 h of B52 or 52. Secondary outcomes included incidence of extrapyramidal symptoms, length of stay, and additional safety measures. RESULTS There was no difference in administration frequency of additional agitation medication(s) (B52: n = 28 [14%] vs. 52: n = 40 [20%]; p = 0.11). Patients who received 52 were more likely to require an antimuscarinic medication within 2 days (15 vs. 6 patients, p = 0.04). Of the patients who received an antimuscarinic medication, none had documented extrapyramidal symptoms. The 52 group had shorter length of stay (13.8 vs. 17 h; p = 0.03), lower incidence of hypotension (7 vs. 32 patients; p < 0.001), and oxygen desaturation (0 vs. 6 patients; p = 0.01), and fewer physical restraints (53 vs. 86 patients; p = 0.001) compared with the B52 group. CONCLUSIONS Both the B52 and 52 combinations infrequently required repeat agitation medication; however, the B52 combination resulted in more oxygen desaturation, hypotension, physical restraint use, and longer length of stay.
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Affiliation(s)
- Trevor Jeffers
- Department of Pharmacy, Banner - University Medical Center South, Tucson, Arizona
| | - Brenna Darling
- Department of Pharmacy, Banner - University Medical Center Tucson, Tucson, Arizona
| | - Christopher Edwards
- Department of Pharmacy, Banner - University Medical Center Tucson, Tucson, Arizona; Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona; Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Nina Vadiei
- Department of Pharmacy, Banner - University Medical Center South, Tucson, Arizona; Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona; Department of Psychiatry, University of Arizona College of Medicine, Tucson, AZ
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16
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The Management of Agitated Toxidromes. Emerg Med Clin North Am 2022; 40:223-235. [DOI: 10.1016/j.emc.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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17
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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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18
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Affiliation(s)
- John K Hsiao
- National Institutes of Health, Bethesda, Maryland
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19
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Erstad BL, Barletta JF. Implications of obesity for drug administration and absorption from subcutaneous and intramuscular injections: A primer. Am J Health Syst Pharm 2022; 79:1236-1244. [PMID: 35176754 DOI: 10.1093/ajhp/zxac058] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To discuss the potential implications of obesity for drug administration and absorption from subcutaneous (SC) and intramuscular (IM) injection sites. SUMMARY The SC and IM routes are useful for the parenteral administration of medications to optimize pharmacokinetic properties such as time to onset and duration of effect, for cost considerations, or for ease of administration, such as when intravenous access is unavailable. The choice of SC or IM injection depends on the specific medication, with SC administration preferred for products such as insulin where a slower and more sustained response is desirable, while IM administration is usually preferred for products such as vaccines where more rapid absorption leads to a more rapid antibody response. Obesity has the potential to influence the rate and extent of absorption, as well as adverse effects, of medications administered by the SC or IM route through changes in SC tissue composition and depth or by inadvertent administration of IM medications into SC tissue because of improper needle length. Potential adverse effects associated with IM or SC injections in addition to pain, bruising, and hematoma formation include sciatic nerve injury, particularly with IM injection in the upper outer quadrant of the buttock; bone contusion or rarely osteonecrosis if the IM injection is excessively deep; and granulomas, fat necrosis, and calcification with SC injection. CONCLUSION Issues related to medication absorption in obese patients are likely to become more prominent in the future with increasing approvals of a wide range of biotherapeutic agents administered by SC injection. Studies should be directed toward these and other agents to assist with dosing decisions in this challenging population.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy, Midwestern University, Glendale, AZ, USA
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20
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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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21
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deSouza IS, Thode HC, Shrestha P, Allen R, Koos J, Singer AJ. Rapid tranquilization of the agitated patient in the emergency department: A systematic review and network meta-analysis. Am J Emerg Med 2021; 51:363-373. [PMID: 34823192 DOI: 10.1016/j.ajem.2021.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/29/2021] [Accepted: 11/04/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Safe and effective tranquilization of the acutely agitated patient is challenging, and head-to-head comparisons of medications are limited. We aimed to identify the most optimal agent(s) for rapid tranquilization of the severely agitated patient in the emergency department (ED). METHODS The protocol for systematic review was registered (PROSPERO; CRD42020212534). We searched MEDLINE, Embase, PsycINFO, and Cochrane Database/CENTRAL from inception to June 2, 2021. We limited studies to randomized controlled trials that enrolled adult ED patients with severe agitation and compared drugs for rapid tranquilization. Predetermined outcomes were: 1) Adequate sedation within 30 min (effectiveness), 2) Immediate, serious adverse event - cardiac arrest, ventricular tachydysrhythmia, endotracheal intubation, laryngospasm, hypoxemia, hypotension (safety), and 3) Time to adequate sedation (effect onset). We extracted data according to PRISMA-NMA and appraised trials using Cochrane RoB 2 tool. We performed Bayesian network meta-analysis (NMA) using a Markov Chain Monte Carlo method with random-effects model and vague prior distribution to calculate odds ratios with 95% credible intervals for dichotomous outcomes and frequentist NMA to calculate mean differences with 95% confidence intervals for continuous outcomes. We assessed confidence in results using CINeMA. We used surface under the cumulative ranking (SUCRA) curves to rank agent(s) for each outcome. RESULTS Eleven studies provided data for effectiveness (1142 patients) and safety (1147 patients). Data was insufficient for effect onset. The NMA found that ketamine (SUCRA = 93.0%) is most likely to have superior effectiveness; droperidol-midazolam (SUCRA = 78.8%) is most likely to be safest. There are concerns with study quality and imprecision. Quality of the point estimates varied for effectiveness but mostly rated "very low" for safety. CONCLUSIONS Available evidence suggests that ketamine and droperidol have intermediate effectiveness for rapid tranquilization of the severely agitated patient in the ED. There is insufficient evidence to definitively determine which agent(s) may be safest or fastest-acting. Further, direct-comparison study of ketamine and droperidol is recommended.
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Affiliation(s)
- Ian S deSouza
- Department of Emergency Medicine, SUNY Downstate Health Sciences University and Kings County Hospital Center, Brooklyn, NY, USA.
| | - Henry C Thode
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Pragati Shrestha
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Robert Allen
- Department of Emergency Medicine, SUNY Downstate Health Sciences University and Kings County Hospital Center, Brooklyn, NY, USA.
| | - Jessica Koos
- Department of Emergency Medicine, Stony Brook University, NY, USA.
| | - Adam J Singer
- Department of Emergency Medicine, Stony Brook University, NY, USA.
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22
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Gil-Jardiné C, Gil C, Saint Jammes JT, Villoing B, Lefort H. [Pre-hospital management of a psychiatric emergency]. Soins Psychiatr 2021; 42:10-12. [PMID: 34763757 DOI: 10.1016/j.spsy.2021.06.005] [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] [Indexed: 01/22/2023]
Abstract
The pre-hospital care process of a patient presenting a psychiatric emergency involves many pre-hospital and hospital personnel. Identifying such high-risk situations, allowing an initial approach that is adjusted and authorises care are often very delicate moments. An adapted management, concerted within a network, allows the safety of the patient, his entourage and the interveners. These situations are characterised by their polymorphism with major constants: training, anticipation and knowledge of organisations.
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Affiliation(s)
- Cédric Gil-Jardiné
- Service des urgences adultes, hôpital Pellegrin, centre hospitalo-universitaire de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France; Bordeaux Population Health, Inserm U1219, université de Bordeaux, Case 11, 146 rue Léo-Saignat, 33076 Bordeaux cedex, France.
| | - Coralie Gil
- Bordeaux Population Health, Inserm U1219, université de Bordeaux, Case 11, 146 rue Léo-Saignat, 33076 Bordeaux cedex, France
| | - Juliane Tortes Saint Jammes
- Bordeaux Population Health, Inserm U1219, université de Bordeaux, Case 11, 146 rue Léo-Saignat, 33076 Bordeaux cedex, France; Cellule d'urgence médico-psychologique zone de défense Sud-Ouest, centre hospitalier Charles-Perrens, 121 rue de la Béchade, 33076 Bordeaux, France
| | - Barbara Villoing
- Service d'accueil des urgences, Smur, centre-Université de Paris, hôpital Cochin Hôtel-Dieu, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Hugues Lefort
- Structure des urgences, hôpital d'instruction des armées Laveran, 4 boulevard Laveran, 13384 Marseille, France
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23
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Mouaffak F, Ferreri F, Bourgin-Duchesnay J, Baloche E, Blin O, Vandel P, Garay RP, Vidailhet P, Corruble E, Llorca PM. Dosing antipsychotics in special populations of patients with schizophrenia: severe psychotic agitation, first psychotic episode and elderly patients. Expert Opin Pharmacother 2021; 22:2507-2519. [PMID: 34338130 DOI: 10.1080/14656566.2021.1958781] [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: 10/20/2022]
Abstract
Antipsychotic (AP) dosing is well established in nonelderly patients with acute exacerbations of schizophrenia, but not in special populations.This review describes the AP dosing procedures that have been used in clinical studies for acute psychotic agitation, a first episode of psychosis (FEP), and elderly patients. AP dosing data was extracted from the databases of drug regulatory authorities, and from clinical studies available in the medical literature. In acute psychotic agitation, intramuscular and oral APs are frequently prescribed in higher doses than those that saturate D2 receptors. Supersaturating doses of APs should be avoided due to an increased risk of adverse effects. In FEP, many studies showed efficacy of low doses of APs. Studies with risperidone and haloperidol suggested a dose reduction of approximately one third. Titration with a lower starting dose is recommended in elderly patients, due to possible decreases in pharmacokinetic clearance, and due to the risk of concomitant diseases and drug interactions. Exposure to some APs has been associated with QTc prolongation and arrhythmias, and a small but significant increase in the risk of stroke and mortality with APs has been seen, particularly in older people with dementia-related psychosis.
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Affiliation(s)
- Fayçal Mouaffak
- Emergency Psychiatry Unit, Ville Evrard Psychiatric Hospital, Seine-Saint-Denis, France
| | - Florian Ferreri
- Sorbonne University. APHP. Department of Adult Psychiatry and Medical Psychology, ICRIN, Saint-Antoine Hospital, Paris, France
| | - Julie Bourgin-Duchesnay
- Department Head of the Department of Child and Adolescent Psychiatry, Orsay Hospital, University Paris Saclay, France
| | - Emmanuelle Baloche
- Department of Neurosciences, Medical Advisor Neurosciences, Eisai SAS, La Défense, France
| | - Olivier Blin
- Institute of Neurosciences, Aix-Marseille University, Marseille, France
| | - Pierre Vandel
- Department of Adult Psychiatry, University Hospital of Besançon, EA-481, Laboratory of Neurosciences, UBFC, Besançon, France
| | - Ricardo P Garay
- Department of Pharmacology and Therapeutics, Craven, France; CNRS, National Centre of Scientific Research, Paris, France
| | - Pierre Vidailhet
- Department of Psychiatry, Strasbourg University Hospital, Strasbourg, France
| | - Emmanuelle Corruble
- Head of the Department of Psychiatry, Bicetre Hospital, APHP, INSERM UMR-1018, MOODS Team, Saclay School of Medicine, University Paris Saclay, Paris, France
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24
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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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25
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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: 19] [Impact Index Per Article: 6.3] [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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26
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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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Stang JL, DeVries PA, Klein LR, Cole JB, Martel M, Reing ML, Raiter AM, Driver BE. Medical needs of emergency department patients presenting with acute alcohol and drug intoxication. Am J Emerg Med 2021; 42:38-42. [PMID: 33440329 DOI: 10.1016/j.ajem.2020.12.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/23/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022] Open
Abstract
STUDY OBJECTIVE Some contend that patients with acute alcohol or illicit substance intoxication should be treated in outpatient detoxification centers rather than in the ED. However, these patients often have underlying acute medical needs. We sought to determine the frequency of medical interventions required by ED patients with alcohol or illicit substance intoxication. METHODS This was a prospective observational study of consecutive ED patients presenting to an urban tertiary care ED with altered mental status due to alcohol or illicit substance use. We performed data collection for patients deemed to be low-risk for complications, as defined by receiving care in an intoxication observation unit. Trained staff observed and recorded all medical interventions, including medications administered, diagnostic testing, procedures performed, and airway interventions. The incidence of agitation was recorded using the Altered Mental Status Scale (AMSS, ordinal scale from -4 to +4, where +4 is most agitated). The data analysis is descriptive. RESULTS This analysis included 2685 encounters (1645 unique patients; median age 39; 73% male) from January to May 2019. Average breath alcohol concentration was 0.20 g/dL (range 0.00-0.47). There were 89% encounters with alcohol intoxication, and in 17% encounters the patient was suspected or known to have drug intoxication (either alone or in conjunction with alcohol use). On arrival to the ED, 372 (14%) had agitation (AMSS +1 or higher) and 32 (1%) were profoundly agitated (AMSS +4). In total, 1526 (56%) received at least one intervention that could not be provided by a local detoxification or sobering facility. Of the study population, 955 (36%) received a sedating medication, 903 (34%) required physical restraints for patients or staff safety, 575 (21%) underwent imaging studies, 318 (12%) underwent laboratory testing, 367 (13%) received another intervention (IV access, EKG, splinting, wound care, etc). Additionally, 111 (4%) patients received an airway intervention (19 intubation, 23 nasal airway, 85 supplemental oxygen) and 275 (10%) required repositioning to protect the airway. There were 168 (6%) patients admitted to the hospital. CONCLUSION In this population of relatively low-risk ED patients with drug and alcohol intoxication, a substantial proportion of patients received medical interventions.
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Affiliation(s)
- Jamie L Stang
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA.
| | - Paige A DeVries
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Lauren R Klein
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jon B Cole
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Marc Martel
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Mackenzie L Reing
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Abagail M Raiter
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
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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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The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An update on management of behavioral and psychological symptoms in dementia. Psychiatry Res 2021; 295:113641. [PMID: 33340800 DOI: 10.1016/j.psychres.2020.113641] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/09/2020] [Indexed: 12/27/2022]
Abstract
Geriatric patients with dementia frequently present with agitation, aggression, psychosis, and other behavioral and psychological symptoms of dementia (BPSD). We present an update of our previously published algorithms for the use of psychopharmacologic agents in these patients taking into account more recent studies and findings in meta-analyses, reviews, and other published algorithms. We propose three algorithms: BPSD in an emergent, urgent, and non-urgent setting. In the emergent setting when intramuscular (IM) administration is necessary, the first-line recommendation is for olanzapine (since IM aripiprazole, previously favored, is no longer available) and haloperidol injection is the second choice, followed by possible consideration of an IM benzodiazepine. In the urgent setting, the first line would be oral second-generation antipsychotics (SGAs) aripiprazole and risperidone. Perhaps next could be then prazosin, and lastly electroconvulsive therapy is a consideration. There are risks associated with these agents, and adverse effects can be severe. Dosing strategies, discontinuation considerations, and side effects are discussed. In the non-emergent setting, medications are proposed for use in the following order: trazodone, donepezil and memantine, antidepressants such as escitalopram and sertraline, SGAs, prazosin, and carbamazepine. Other options with less support but potential future promise are discussed.
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Searles Quick VB, Herbst ED, Kalapatapu RK. Which Emergent Medication Should I Give Next? Repeated Use of Emergent Medications to Treat Acute Agitation. Front Psychiatry 2021; 12:750686. [PMID: 34950067 PMCID: PMC8688542 DOI: 10.3389/fpsyt.2021.750686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 11/10/2021] [Indexed: 11/28/2022] Open
Abstract
Agitation is a common symptom encountered among patients treated in psychiatric emergency settings. While there are many guidelines available for initial management of the acutely agitated patient, there is a notable dearth of guidelines that delineate recommended approaches to the acutely agitated patient in whom an initial medication intervention has failed. This manuscript aims to fill this gap by examining evidence available in the literature and providing clinical algorithms suggested by the authors for sequential medication administration in patients with persistent acute agitation in psychiatric emergency settings. We discuss risk factors for medication-related adverse events and provide options for patients who are able to take oral medications and for patients who require parenteral intervention. We conclude with a discussion of the current need for well-designed studies that examine sequential medication options in patients with persistent acute agitation.
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Affiliation(s)
- Veronica B Searles Quick
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Ellen D Herbst
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
| | - Raj K Kalapatapu
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
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Piechowski W, Clapper TC, Park JC, Ching K, St. George J. A prospective randomised simulation trial comparing our novel AIR-BOX to standard airway equipment storage modalities. BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2020; 7:311-318. [DOI: 10.1136/bmjstel-2020-000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/18/2020] [Accepted: 10/12/2020] [Indexed: 11/04/2022]
Abstract
BackgroundThere is little evidence guiding equipment handling during emergency endotracheal intubations (EEI). Available evidence and current practice are either outdated, anecdotal or focused on difficult—not emergency—intubation. In this study, we describe and evaluate our equipment handling unit: the AIR-BOX.MethodsThis is a proof-of-concept, prospective, randomised simulation trial. A convenience sample of 50 airway course participants voluntarily underwent randomisation: 21 to the AIR-BOX group, 14 to the intubation box group, and 15 to the crash cart group. The volunteers were asked to intubate a manikin using the equipment from the storage unit of their randomisation. Outcome measures included time-to-readiness, time-to-intubation, first-pass success, and subjective operator experience.ResultsThe mean time-to-readiness was 67.2 s with the AIR-BOX, 84.6 s with the intubation box, and 115 s with the crash cart. The mean time-to-intubation was 105 s with the AIR-BOX, 127 s with the intubation box and 167 s with the crash cart. A statistically significant difference was achieved between the AIR-BOX and the crash cart. No statistically significant difference was found between the three groups with regard to first-pass success or the time between intubation readiness and intubation.ConclusionsThis study supports the AIR-BOX as a viable tool that can improve and simplify access to emergency intubating equipment. It also opens doors for multiple future innovations that can positively impact equipment handling practices. Future studies can focus on assessing whether applying the AIR-BOX will yield a clinically significant impact on patient outcomes.
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Schneider A, Mullinax S, Hall N, Acheson A, Oliveto AH, Wilson MP. Intramuscular medication for treatment of agitation in the emergency department: A systematic review of controlled trials. Am J Emerg Med 2020; 46:193-199. [PMID: 33071100 DOI: 10.1016/j.ajem.2020.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Severely agitated patients in the emergency department (ED) are often sedated with intramuscularly-administered medications. The evidence base underlying particular medication choices is surprisingly sparse, as existing reviews either have methodological limitations or have included data collected outside of emergent settings. OBJECTIVES The objective of this review was to examine all controlled trials in emergent settings that have used standardized scales to measure the effectiveness of intramuscular medication for the treatment of acute agitation. METHODS This review was registered in Prospero as CRD42018105745. PubMed, International Pharmaceutical Abstracts, Web of Science, PsycINFO, and clinicaltrials.gov were searched for prospective controlled trials investigating intramuscular antipsychotics for agitation. Articles were assessed for bias across five domains using the revised Cochrane Risk of Bias Tool. RESULTS Eight studies were eligible for inclusion in the systematic review, none of which had a low risk of bias. Five studies had a moderate risk of bias with heterogenous designs, populations, and treatments. These studies seemed to suggest that second generation antipsychotics (SGAs) likely reduce agitation as effectively as first generation antipsychotics (FGAs) plus an adjunctive medication with similar or lower risk of side effects. CONCLUSIONS Existing trials on the use of intramuscular antipsychotics in the ED/psychiatric ED setting were small, heterogenous, and at a moderate or high risk of bias. Given the clinical importance of this topic, further prospective investigations are desperately needed but are currently unfeasible under Food and Drug Administration Exception From Informed Consent regulations.
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Affiliation(s)
- Allison Schneider
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Samuel Mullinax
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Nathanael Hall
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Ashley Acheson
- Center for Addiction Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Alison H Oliveto
- Center for Addiction Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Michael P Wilson
- Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
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Kennedy M, Koehl J, Shenvi CL, Greenberg A, Zurek O, LaMantia M, Lo AX. The agitated older adult in the emergency department: a narrative review of common causes and management strategies. J Am Coll Emerg Physicians Open 2020; 1:812-823. [PMID: 33145525 PMCID: PMC7593470 DOI: 10.1002/emp2.12110] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 12/12/2022] Open
Abstract
Agitation and aggression are common in older emergency department (ED) patients, can impede the expedient diagnosis of potentially life-threatening conditions, and can adversely impact ED functioning and efficiency. Agitation and aggression in older adults may be due to multiple causes, but chief among them are primary psychiatric disorders, substance use, hyperactive delirium, and symptoms of dementia. Understanding the etiology of agitation in an older adult is critical to proper management. Effective non-pharmacologic modalities are available for the management of mild to moderate agitation and aggression in patients with dementia. Pharmacologic management is indicated for agitation related to a psychiatric condition, severe agitation where a patient is at risk to harm self or others, and to facilitate time-sensitive diagnostic imaging, procedures, and treatment. Emergency physicians have several pharmacologic agents at their disposal, including opioid and non-opioid analgesics, antipsychotics, benzodiazepines, ketamine, and combination agents. Emergency physicians should be familiar with geriatric-specific dosing, contraindications, and common adverse effects of these agents. This review article discusses the common causes and non-pharmacologic and pharmacologic management of agitation in older adults, with a specific focus on dementia, delirium, and pain.
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Affiliation(s)
- Maura Kennedy
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Jennifer Koehl
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
- Department of PharmacyMassachusetts General HospitalBostonMassachusettsUSA
| | - Christina L. Shenvi
- Department of Emergency MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Allyson Greenberg
- Department of PharmacyNorthwestern Memorial HospitalChicagoIllinoisUSA
- Department of Emergency MedicineNorthwestern Memorial HospitalChicagoIllinoisUSA
| | - Olivia Zurek
- Department of PsychiatryMassachusetts General HospitalBostonMassachusettsUSA
- Department of PsychiatryHarvard Medical SchoolBostonMassachusettsUSA
| | - Michael LaMantia
- Division of Geriatric MedicineUniversity of VermontBurlingtonVermontUSA
| | - Alexander X. Lo
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
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Wong AH, Roppolo LP, Chang BP, Yonkers KA, Wilson MP, Powsner S, Rozel JS. Management of Agitation During the COVID-19 Pandemic. West J Emerg Med 2020; 21:795-800. [PMID: 32726244 PMCID: PMC7390577 DOI: 10.5811/westjem.2020.5.47789] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/02/2020] [Accepted: 05/10/2020] [Indexed: 01/10/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic caused by the coronavirus SARS-CoV-2 has radically altered delivery of care in emergency settings. Unprecedented hardship due to ongoing fears of exposure and threats to personal safety, along with societal measures enacted to curb disease transmission, have had broad psychosocial impact on patients and healthcare workers alike. These changes can significantly affect diagnosing and managing behavioral emergencies such as agitation in the emergency department. On behalf of the American Association for Emergency Psychiatry, we highlight unique considerations for patients with severe behavioral symptoms and staff members managing symptoms of agitation during COVID-19. Early detection and treatment of agitation, precautions to minimize staff hazards, coordination with security personnel and psychiatric services, and avoidance of coercive strategies that cause respiratory depression will help mitigate heightened risks to safety caused by this outbreak.
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Affiliation(s)
- Ambrose H. Wong
- Yale School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
| | - Lynn P. Roppolo
- University of Texas Southwestern, Department of Emergency Medicine, Dallas, Texas
| | - Bernard P. Chang
- Columbia University, Irving Medical Center, Department of Emergency Medicine, New York, New York
| | - Kimberly A. Yonkers
- Yale School of Medicine, Department of Psychiatry, Department of Obstetrics, Gynecology, and Reproductive Sciences, New Haven, Connecticut
| | - Michael P. Wilson
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Department of Psychiatry, Little Rock, Arkansas
| | - Seth Powsner
- Yale School of Medicine, Department of Psychiatry, Department of Emergency Medicine New Haven, Connecticut
| | - John S. Rozel
- University of Pittsburgh School of Law and School of Medicine, Department of Psychiatry, Pittsburgh, Pennsylvania
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Huebinger RM, Zaidi HQ, Tataris KL, Weber JM, Pearlman KS, Markul E, Stein-Spencer L, Richards CT. Retrospective Study of Midazolam Protocol for Prehospital Behavioral Emergencies. West J Emerg Med 2020; 21:677-683. [PMID: 32421519 PMCID: PMC7234702 DOI: 10.5811/westjem.2020.3.45552] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/08/2020] [Indexed: 12/01/2022] Open
Abstract
Introduction Agitated patients in the prehospital setting pose challenges for both patient care and emergency medical services (EMS) provider safety. Midazolam is frequently used to control agitation in the emergency department setting; however, limited data exist in the prehospital setting. We describe our experience treating patients with midazolam for behavioral emergencies in a large urban EMS system. We hypothesized that using midazolam for acute agitation leads to improved clinical conditions without causing significant clinical deterioration. Methods We performed a retrospective review of EMS patient care reports following implementation of a behavioral emergencies protocol in a large urban EMS system from February 2014–June 2016. For acute agitation, paramedics administered midazolam 1 milligram (mg) intravenous (IV), 5 mg intramuscular (IM), or 5 mg intranasal (IN). Results were analyzed using descriptive statistics, Levene’s test for assessing variance among study groups, and t-test to evaluate effectiveness based on route. Results In total, midazolam was administered 294 times to 257 patients. Median age was 30 (interquartile range 24–42) years, and 66.5% were male. Doses administered were 1 mg (7.1%) and 5 mg (92.9%). Routes were IM (52.0%), IN (40.8%), and IV (7.1%). A second dose was administered to 37 patients. In the majority of administrations, midazolam improved the patient’s condition (73.5%) with infrequent adverse events (3.4%). There was no significant difference between the effectiveness of IM and IN midazolam (71.0% vs 75.4%; p = 0.24). Conclusion A midazolam protocol for prehospital agitation was associated with reduced agitation and a low rate of adverse events.
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Affiliation(s)
- Ryan M Huebinger
- McGovern Medical School at The University of Texas Health Science Center at Houston (UT Health), Department of Emergency Medicine, Houston, Texas
| | - Hashim Q Zaidi
- University of Chicago Pritzker School of Medicine, Section of Emergency Medicine, Chicago, Illinois.,Chicago Emergency Medical Services System, Chicago, Illinois
| | - Katie L Tataris
- University of Chicago Pritzker School of Medicine, Section of Emergency Medicine, Chicago, Illinois.,Chicago Emergency Medical Services System, Chicago, Illinois
| | - Joseph M Weber
- Chicago Emergency Medical Services System, Chicago, Illinois.,John H. Stroger, Jr., Hospital of Cook County, Department of Emergency Medicine, Chicago, Illinois
| | - Kenneth S Pearlman
- Chicago Emergency Medical Services System, Chicago, Illinois.,Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Eddie Markul
- Chicago Emergency Medical Services System, Chicago, Illinois.,Advocate Illinois Masonic Medical Center, Department of Emergency Medicine, Chicago, Illinois
| | - Leslee Stein-Spencer
- Chicago Emergency Medical Services System, Chicago, Illinois.,Illinois Department of Public Health, Springfield, Illinois
| | - Christopher T Richards
- Chicago Emergency Medical Services System, Chicago, Illinois.,Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois.,Northwestern Feinberg School of Medicine Center for Healthcare Studies, Institute for Public Health and Medicine, Chicago, Illinois.,University of Cincinnati School of Medicine, Division of EMS, Department of Emergency Medicine, Cincinnati, Ohio
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Yokoyama S, Wakamoto S, Tanaka Y, Nakagawa C, Hosomi K, Takada M. Association Between Antipsychotics and Osteoporosis Based on Real-World Data. Ann Pharmacother 2020; 54:988-995. [DOI: 10.1177/1060028020913974] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Osteoporosis, which is a major public health concern, has been known to reduce health-related quality of life. Some studies have suggested that antipsychotics could perhaps cause osteoporosis by increasing serum prolactin levels. However, the association between antipsychotics and the risk for developing osteoporosis has been controversial. Objective: The present study aimed to assess the association between antipsychotic use and onset of osteoporosis in real-world settings. Methods: A multimethod data-mining approach using different algorithms and databases was used. First, disproportionality analysis was conducted using the US Food and Drug Administration Adverse Event Reporting System (FAERS) database (2004-2017) with reporting odds ratio (ROR) and information component (IC) being used to indicate a signal. Furthermore, a sequence symmetry analysis using data from a large Japanese administrative claims database (2005-2017; JMDC Inc, Japan) was conducted. Short-term intervals (ie, 12, 24, and 36 months) were set to investigate the association between antipsychotic use and onset of osteoporosis using the adjusted sequence ratio (SR) to indicate a signal. Results: No potential association between osteoporosis and all antipsychotics was observed in the FAERS database, except for perphenazine, which exhibited significant signals using both ROR and IC. Moreover, no potential association between osteoporosis and antipsychotics was observed in the JMDC claims database, except for sulpiride and aripiprazole. None of the antipsychotics indicated significant signals using all analyzed items (ROR, IC, and adjusted SR). Conclusion and Relevance: Real-world data show no association between antipsychotic use and the onset of osteoporosis. Further pharmacoepidemiological studies are needed for causality assessment.
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Abstract
We read with interest the recent editorial, "The Hennepin Ketamine Study," by Dr. Samuel Stratton commenting on the research ethics, methodology, and the current public controversy surrounding this study.1 As researchers and investigators of this study, we strongly agree that prospective clinical research in the prehospital environment is necessary to advance the science of Emergency Medical Services (EMS) and emergency medicine. We also agree that accomplishing this is challenging as the prehospital environment often encounters patient populations who cannot provide meaningful informed consent due to their emergent conditions. To ensure that fellow emergency medicine researchers understand the facts of our work so they may plan future studies, and to address some of the questions and concerns in Dr. Stratton's editorial, the lay press, and in social media,2 we would like to call attention to some inaccuracies in Dr. Stratton's editorial, and to the lay media stories on which it appears to be based.Ho JD, Cole JB, Klein LR, Olives TD, Driver BE, Moore JC, Nystrom PC, Arens AM, Simpson NS, Hick JL, Chavez RA, Lynch WL, Miner JR. The Hennepin Ketamine Study investigators' reply. Prehosp Disaster Med. 2019;34(2):111-113.
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Monte AA, Hopkinson A, Saben J, Shelton S, Thornton S, Schneir A, Pomerleau A, Hendrickson R, Arens AM, Cole JB, Chenoweth J, Martin S, Adams A, Banister SD, Gerona RR. The Psychoactive Surveillance Consortium and Analysis Network (PSCAN): the first year. Addiction 2020; 115:270-278. [PMID: 31769125 PMCID: PMC6982594 DOI: 10.1111/add.14808] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/21/2019] [Accepted: 08/30/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND AIMS The Psychoactive Surveillance Consortium and Analysis Network (PSCAN) is a national network of academic emergency departments (ED), analytical toxicologists and pharmacologists that collects clinical data paired with biological samples to identify and improve treatments of medical conditions arising from use of new psychoactive substances (NPS). The aim of this study was to gather clinical data with paired drug identification from NPS users who presented to EDs within PSCAN during its first year (2016-17). DESIGN Observational study involving patient records and biological samples. SETTING Seven academic emergency medical centers across the United States. PARTICIPANTS ED patients (n = 127) > 8 years of age with possible NPS use who were identified and enrolled in PSCAN by clinical providers or research personnel. MEASUREMENTS Clinical signs, symptoms and treatments were abstracted from the patients' health records. Biological samples were collected from leftover urine, serum and whole blood. Biological and drug samples, when available, were tested for drugs and drug metabolites via liquid chromatography-quadrupole time-of-flight mass spectrometry (LC-QTOF/MS). FINDINGS Patients in whom synthetic opioids were detected (n = 9) showed higher rates of intubation (four of nine), impaired mental status (four of nine) and respiratory acidosis (five of nine) compared with the rest of the cohort (nine of 118, P-value < 0.05). Patients in whom synthetic cannabinoid (SC) were found (n = 27) had lower median diastolic blood pressures (70.5 versus 77 mmHg, P = 0.046) compared with the rest of the cohort. In 64 cases of single drug ingestion, benzodiazepines were administered in 25 cases and considered effective by the treating physician in 21 (84%) cases. CONCLUSIONS During its first year of operation, the Psychoactive Surveillance Consortium and Analysis Network captured clinical data on new classes of drugs paired with biological samples over a large geographical area in the United States. Synthetic cannabinoids were the most common new psychoactive drug identified. Synthetic opioids were associated with a high rate of intubation and respiratory acidosis.
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Affiliation(s)
- Andrew A. Monte
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, CO,Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, Denver, CO
| | - Andrew Hopkinson
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, CO
| | - Jessica Saben
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, CO
| | - Shelby Shelton
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, CO
| | - Stephen Thornton
- University of Kansas, Department of Emergency Medicine, Kansas City, KS
| | - Aaron Schneir
- University of California San Diego Health System, Division of Medical Toxicology, Department of Emergency Medicine, San Diego, CA, USA
| | - Adam Pomerleau
- Department of Emergency Medicine, Emory University, Atlanta, GA
| | - Robert Hendrickson
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
| | - Ann M. Arens
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
| | - Jon B. Cole
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN
| | | | - Spencer Martin
- Clinical Toxicology and Environmental Biomonitoring Lab, University of California San Francisco, San Francisco, CA
| | - Axel Adams
- Clinical Toxicology and Environmental Biomonitoring Lab, University of California San Francisco, San Francisco, CA
| | - Samuel D. Banister
- The School of Chemistry, The University of Sydney, Sydney, NSW, Australia,The Lambert Initiative for Cannabinoid Therapeutics, The Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
| | - Roy R. Gerona
- Clinical Toxicology and Environmental Biomonitoring Lab, University of California San Francisco, San Francisco, CA
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Cowan E, Sahan K, Sheehan M. Misuse of "Usual Care" in Emergency Care Research: A Call for Adapting Rules Governing Exception from Informed Consent (EFIC) Studies. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:59-61. [PMID: 31910139 DOI: 10.1080/15265161.2019.1687782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Bregstein JS, Wagh AM, Tsze DS. Intranasal Lorazepam for Treatment of Severe Agitation in a Pediatric Behavioral Health Patient in the Emergency Department. Ann Emerg Med 2019; 75:86-89. [PMID: 31280921 DOI: 10.1016/j.annemergmed.2019.05.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Indexed: 11/25/2022]
Abstract
The treatment of severe agitation, aggression, and violent behavior in behavioral health patients who present to the emergency department (ED) often requires the intramuscular administration of a sedative. However, administering an intramuscular sedative to an uncooperative patient is associated with the risk of needlestick injuries to both patients and health care providers, and times to onset of sedation range from 15 to 45 minutes. Intranasal absorption is more rapid than intramuscular, with sedatives such as lorazepam reaching peak serum concentrations up to 6 times faster when administered intranasally. We present the first report of using intranasal lorazepam as a needle-free method of providing rapid and effective sedation to treat severe agitation in a pediatric behavioral health patient presenting to the ED.
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Affiliation(s)
- Joan S Bregstein
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY.
| | - Anju M Wagh
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Daniel S Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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In reply:. Ann Emerg Med 2019; 73:692-693. [DOI: 10.1016/j.annemergmed.2019.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Indexed: 11/17/2022]
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Klein LR, Driver BE, Martel ML, Miner JR, Cole JB. In reply:. Ann Emerg Med 2019; 73:693-694. [DOI: 10.1016/j.annemergmed.2019.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Indexed: 11/26/2022]
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Wheeler AR, Schauer SG, April MD, De Lorenzo RA. Acute Agitation and the Exception From Informed Consent Requirements. Ann Emerg Med 2019; 73:691-692. [PMID: 31133185 DOI: 10.1016/j.annemergmed.2019.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Indexed: 11/17/2022]
Affiliation(s)
| | - Steven G Schauer
- US Army Institute of Surgical Research, Brooke Army Medical Center, JBSA Fort Sam Houston, TX
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Cole JB, Klein LR, Mullinax SZ, Nordstrom KD, Driver BE, Wilson MP. Study Enrollment When "Preconsent" Is Utilized for a Randomized Clinical Trial of Two Treatments for Acute Agitation in the Emergency Department. Acad Emerg Med 2019; 26:559-566. [PMID: 30548977 DOI: 10.1111/acem.13673] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 11/27/2018] [Accepted: 12/05/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute agitation in the emergency department (ED) represents a danger to both patients and their caregivers. Medication is often needed, and few high-quality randomized trials have evaluated the optimal drugs for this vulnerable population. In the United States, as of 2017, randomized trials of drugs typically cannot be conducted under Waiver of Consent (46 CFR 45.116), and Exception From Informed Consent trials (21 CFR 50.24) are limited to life-threatening conditions, are onerous, and require filing an investigational new drug application with the FDA. We sought to conduct a randomized double-dummy trial of inhaled loxapine versus intramuscular haloperidol + lorazepam for acute agitation in the ED by obtaining consent in advance ("preconsent") in patients at risk of future agitation, allowing study drug administration up to 3 years later if the patient presented with acute agitation. OBJECTIVE We sought to report the successful enrollment rate of patients preconsented at an earlier ED visit for this trial. METHODS This was an analysis of patients age 18 to 64 with bipolar I disorder or schizophrenia preconsented for enrollment in the trial (clinicaltrials.gov, NCT02877108) conducted at a single urban academic center seeing approximately 60,000 patients per year. Eligible patients were assessed for capacity to consent by trained research associates, and informed consent was obtained at an ED visit for the possibility of administering drugs for agitation within the next 3 years. In the event the patient later presented to the ED and the attending physician deemed the patient required treatment for acute agitation, preconsent was confirmed and study drug would be administered. RESULTS Over 67 days, 1,461 patients were screened in the ED, 269 had bipolar I or schizophrenia, 194 of whom had a contraindication to inhaled loxapine leaving 75 eligible patients; preconsent was obtained in 43 patients. Four additional patients who had not preconsented were consented for the trial in real time (three by surrogate, one patient had capacity while agitated) resulting in a total of 47 consented patients. Of these 47, a total of 12 were later removed from the study: 10 patients had unrecognized exclusion criteria for inhaled loxapine, one preconsented patient contacted the investigators at a later date and asked to be removed, and one surrogate revoked consent immediately after providing it. Only two patients were successfully enrolled, neither by preconsent: one was enrolled via a surrogate the day of enrollment, and the other was mildly agitated and had capacity to consent. The remaining patient with a valid surrogate consent did not receive study medication. CONCLUSIONS Utilization of preconsent to enroll patients in a randomized trial of treatments for acute agitation in the ED requires substantial resources and may not be feasible.
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Affiliation(s)
- Jon B Cole
- Department of Emergency Medicine Hennepin Healthcare Minneapolis MN
| | - Lauren R. Klein
- Department of Emergency Medicine Hennepin Healthcare Minneapolis MN
| | - Samuel Z. Mullinax
- Department of Emergency Medicine University of Arkansas for Medical Sciences Little Rock AR
| | | | - Brian E. Driver
- Department of Emergency Medicine Hennepin Healthcare Minneapolis MN
| | - Michael P. Wilson
- Department of Emergency Medicine University of Arkansas for Medical Sciences Little Rock AR
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Zeller S, Wilson M, Nordstrom K. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation. Ann Emerg Med 2019; 73:422-423. [DOI: 10.1016/j.annemergmed.2018.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Indexed: 11/26/2022]
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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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Heydari F, Gholamian A, Zamani M, Majidinejad S. Effect of Intramuscular Ketamine versus Haloperidol on Short-Term Control of Severe Agitated Patients in Emergency Department; A Randomized Clinical Trial. Bull Emerg Trauma 2018; 6:292-299. [PMID: 30402516 PMCID: PMC6215072 DOI: 10.29252/beat-060404] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective To evaluate the efficacy and safety of intramuscular ketamine and haloperidol in sedation of severely agitated patients in emergency department (ED). Methods This randomized, double-blind clinical trial study was performed on agitated patients referring to two university educational hospitals. Patients were randomly assigned to receive intramuscular (IM) haloperidol (5 mg) or IM ketamine (4 mg/kg). The primary outcome was time to adequate sedation (AMSS ≤ +1). Secondary outcomes included the need for additional sedatives, required intubation, duration of hospitalization, and side effects. Results The 90 agitated patients were enrolled. The mean age was 30.37±7.36 years (range 18-56); 74% (67/90) were men. The mean time to adequate sedation in ketamine group (7.73 ± 4.71 minutes) was significantly lower than haloperidol group (11.42 ± 7.20 minutes) (p= 0.005). 15 minutes after intervention, the sedation score did not differ significantly in both groups (Ketamine:0.14 ± 0.59 vs. Haloperidol: 0.30 ± 0.60; p=0.167). The incidence of complications was not significantly different between groups. The physician's satisfaction from the patients' aggression control was significantly higher in ketamine group. Conclusion These data suggest ketamine may be used for short-term control of agitated patients, additional studies are needed to confirm if ketamine is safe in this patient population. Given rapid effective sedation and the higher physician satisfaction of ketamine in comparison to haloperidol, it may be considered as a safe and appropriate alternative to haloperidol.IRCT Code: IRCT20180129038549N5.
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Affiliation(s)
- Farhad Heydari
- Emergency Medicine Research Center, Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Gholamian
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Majid Zamani
- Emergency Medicine Research Center, Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeed Majidinejad
- Emergency Medicine Research Center, Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Dickert NW, Sugarman J. Ethics and Regulatory Barriers to Research in Emergency Settings. Ann Emerg Med 2018; 72:386-388. [DOI: 10.1016/j.annemergmed.2018.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Indexed: 10/28/2022]
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Affiliation(s)
- Jessica Mason
- Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, CA.
| | - Christopher B Colwell
- Zuckerberg San Francisco General Hospital and Trauma Center, and the Department of Emergency Medicine, UCSF School of Medicine, San Francisco, CA
| | - Andrew Grock
- Division of Emergency Medicine Greater Los Angeles VA Healthcare System, and the David Geffen School of Medicine at UCLA, Los Angeles, CA
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