The efficacy of intravenous droperidol in the prehospital setting

Effectiveness and Safety of Intravenous Medications for the Management of Acute Disturbance (Agitation and Other Escalating Behaviors): A Systematic Review of Prospective Interventional Studies

Acute disturbance is a broad term referring to escalating behaviors secondary to a change in mental state, such as agitation, aggression, and violence. Available management options include de-escalation techniques and rapid tranquilization, mostly via parenteral formulations of medication. While the intramuscular route has been extensively studied in a range of clinical settings, the same cannot be said for intravenous (IV); this is despite potential benefits, including rapid absorption and complete bioavailability. This systematic review analyzed existing evidence for effectiveness and safety of IV medication for management of acute disturbances. It followed a preregistered protocol (PROSPERO identification CRD42020216456) and is reported following the guidelines set by Preferred Reporting Items for Systematic Review and Meta-Analysis. APA PsycINFO, MEDLINE, and EMBASE databases were searched for eligible interventional studies up until May 30th, 2023. Data analysis was limited to narrative synthesis since primary outcome measures varied significantly. Results showed mixed but positive results for the effectiveness of IV dexmedetomidine, lorazepam, droperidol, and olanzapine. Evidence was more limited for IV haloperidol, ketamine, midazolam, chlorpromazine, and valproate. There was no eligible data on the use of IV clonazepam, clonidine, diazepam, diphenhydramine, propranolol, ziprasidone, fluphenazine, carbamazepine, or promethazine. Most studies reported favorable adverse event profiles, though they are unlikely to have been sufficiently powered to pick up rare serious events. In most cases, evidence was of low or mixed quality, accentuating the need for further standardized, large-scale, multi-arm randomized controlled trials with homogeneous outcome measures. Overall, this review suggests that IV medications may offer an effective alternative parenteral route of administration in acute disturbance, particularly in general hospital settings.

A retrospective study on the safety and effectiveness of olanzapine versus midazolam for pre-hospital management of excited delirium syndrome

Objective:

To evaluate the safety and effectiveness of olanzapine compared to midazolam for the pre-hospital management of excited delirium syndrome.

Methods:

A retrospective review of patients who were treated by ambulance crew for excited delirium syndrome from 2016 to 2019 was performed. The drug of choice was given per Fire Service Department’s paramedic protocol (intramuscular midazolam January 2016 to October 2018 and intramuscular olanzapine October 2018 to December 2019). The primary outcome was the proportion of patients experienced at least one adverse event. The secondary outcome was the successful sedation rate.

Results:

A total of 201 patients were included in the study. Ninety-nine patients had pre-hospital midazolam and 102 received olanzapine. Thirty-one patients experienced adverse event after arrival to A&E, including a drop of Glasgow Coma Scale score to below 8 (90%), hypotension (6%), and airway obstruction (3%): 17 (17% patients; 1 airway obstruction and 16 Glasgow Coma Scale score below 8) in midazolam group and 14 (14% patients; 2 hypotension and 12 Glasgow Coma Scale score below 8) in olanzapine group (p = 0.41). Sixty-eight patients (69%) in midazolam group achieved successful sedation, compared with 79 (77%) in olanzapine group (p = 0.20). More adverse events were seen with midazolam than olanzapine in alcohol intoxication subgroup with statistical significance (12 vs 2, p = 0.03).

Conclusion:

Both midazolam and olanzapine can achieve a satisfactory success rate of sedation. More adverse events are associated with midazolam use in patients with acute alcohol intoxication, especially over-sedation and airway compromise. Olanzapine would be a safer choice in the pre-hospital setting where the resource is limited, and differentiation of underlying causes is not always possible.

Randomized Double-blind Trial of Intramuscular Droperidol, Ziprasidone, and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department

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.

Safety and effectiveness of olanzapine and droperidol for chemical restraint for non-consenting adults: a systematic review and meta-analysis

BACKGROUND

Chemical restraint (CR) is emergency drug management for acute behavioural disturbances in people with mental illness, provided with the aim of rapid calming and de-escalating potentially dangerous situations.

AIMS

To describe a systematic review of Randomised Controlled Trials (RCTs) reporting on short-term safety and effectiveness of drugs used for CR, administered to non-consenting adults with mental health conditions, who require emergency management of acute behavioural disturbances. A meta-analysis was conducted of those RCTs with comparable interventions, outcome measures and measurement timeframes.

METHOD

Academic databases were searched for RCTs published between 1 January 1996 and 20th April 2020. Relevant RCTs were critically appraised using the 13-item JBI checklist. All RCTs were described, and step-wise filters were applied to identify studies suitable for meta-analysis. For these, forest and funnel plots were constructed, and Q and I² statistics guided interpretation of pooled findings, tested using MedCalc Version 19.1.

RESULTS

Of 23 relevant RCTs, 18 (78.2% total) had excellent methodological quality scores (at least 90%). Eight RCTs were potentially relevant for meta-analysis (six of excellent quality), reporting 20 drug arms in total. Adverse events for 6-36% patients were reported in all 20 drug arms. Four drug arms from two homogenous studies of N = 697 people were meta-analysed. These RCTs tested two antipsychotic drugs (droperidol, olanzapine) delivered intravenously in either 5 mgs or 10 mg doses, with outcomes of time to calm, percentage calm within five or 10 min, and adverse events. There were no significant differences between drug arms for either measure of calm. However, 5 mg olanzapine incurred significantly lower risk of adverse events than 10 mg olanzapine (OR 0.4 (95%CI 0.2-0.8)), although no dose differences were found for droperidol.

CONCLUSION

5 mg intravenous olanzapine is recommended for quick, safe emergency management of people with acute behavioural disturbances associated with mental illness.

International research into 22 years of use of chemical restraint: An evidence overview

BACKGROUND

Chemical restraint (CR) (also known as rapid tranquilisation) is the forced (non-consenting) administration of medications to manage uncontrolled aggression, anxiety, or violence in people who are likely to cause harm to themselves or others. Our population of interest was adults with mental health disorders (with/without substance abuse). There has been a growing international movement over the past 22 years towards reducing/eliminating restrictive practices such as CR. It is appropriate to summarise the research that has been published over this time, identify trends and gaps in knowledge, and highlight areas for new research to inform practice.

AIMS

To undertake a comprehensive systematic search to identify, and describe, the volume and nature of primary international research into CR published since 1995.

METHODS

This paper reports the processes and overall findings of a systematic search for all available primary research on CR published between 1 January 1996 and 31 July 2018. It describes the current evidence base by hierarchy of evidence, country (ies) producing the research, CR definitions, study purpose, and outcome measures.

RESULTS

This review identified 311 relevant primary studies (21 RCTs; 46 non-controlled experimental or prospective observational studies; 77 cross-sectional studies; 69 retrospective studies; 67 opinion pieces, position or policy statements; and 31 qualitative studies). The USA, UK, and Australia contributed over half the research, whilst cross-country collaborations comprised 6% of it. The most common research settings comprised acute psychiatric wards (23.3%), general psychiatric wards (21.6%), and general hospital emergency departments (19.0%).

DISCUSSION

A key lesson learnt whilst compiling this database of research into CR was to ensure that all papers described non-consenting administration of medications to manage adults with uncontrolled aggression, anxiety, or violence. There were tensions in the literature between using effective CR without producing adverse events, and how to decide when CR was needed (compared with choosing non-chemical intervention for behavioural emergencies), respecting patients' dignity whilst safeguarding their safety, and preserving safe workplaces for staff, and care environments for other patients. The range of outcome measures suggests opportunities to standardise future research.

Organisational interventions for preventing and minimising aggression directed towards healthcare workers by patients and patient advocates

BACKGROUND

Workplace aggression is becoming increasingly prevalent in health care, with serious consequences for both individuals and organisations. Research and development of organisational interventions to prevent and minimise workplace aggression has also increased. However, it is not known if interventions prevent or reduce occupational violence directed towards healthcare workers.

OBJECTIVES

To assess the effectiveness of organisational interventions that aim to prevent and minimise workplace aggression directed towards healthcare workers by patients and patient advocates.

SEARCH METHODS

We searched the following electronic databases from inception to 25 May 2019: Cochrane Central Register of Controlled Trials (CENTRAL) (Wiley Online Library); MEDLINE (PubMed); CINAHL (EBSCO); Embase (embase.com); PsycINFO (ProQuest); NIOSHTIC (OSH-UPDATE); NIOSHTIC-2 (OSH-UPDATE); HSELINE (OSH-UPDATE); and CISDOC (OSH-UPDATE). We also searched the ClinicalTrials.gov (www.ClinicalTrials.gov) and the World Health Organization (WHO) trials portals (www.who.int/ictrp/en).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or controlled before-and-after studies (CBAs) of any organisational intervention to prevent and minimise verbal or physical aggression directed towards healthcare workers and their peers in their workplace by patients or their advocates. The primary outcome measure was episodes of aggression resulting in no harm, psychological, or physical harm.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for data collection and analysis. This included independent data extraction and 'Risk of bias' assessment by at least two review authors per included study. We used the Haddon Matrix to categorise interventions aimed at the victim, the vector or the environment of the aggression and whether the intervention was applied before, during or after the event of aggression. We used the random-effects model for the meta-analysis and GRADE to assess the quality of the evidence.

MAIN RESULTS

We included seven studies. Four studies were conducted in nursing home settings, two studies were conducted in psychiatric wards and one study was conducted in an emergency department. Interventions in two studies focused on prevention of aggression by the vector in the pre-event phase, being 398 nursing home residents and 597 psychiatric patients. The humour therapy in one study in a nursing home setting did not have clear evidence of a reduction of overall aggression (mean difference (MD) 0.17, 95% confidence interval (CI) 0.00 to 0.34; very low-quality evidence). A short-term risk assessment in the other study showed a decreased incidence of aggression (risk ratio (RR) 0.36, 95% CI 0.16 to 0.78; very low-quality evidence) compared to practice as usual. Two studies compared interventions to minimise aggression by the vector in the event phase to practice as usual. In both studies the event was aggression during bathing of nursing home patients. In one study, involving 18 residents, music was played during the bathing period and in the other study, involving 69 residents, either a personalised shower or a towel bath was used. The studies provided low-quality evidence that the interventions may result in a medium-sized reduction of overall aggression (standardised mean difference (SMD -0.49, 95% CI -0.93 to -0.05; 2 studies), and physical aggression (SMD -0.85, 95% CI -1.46 to -0.24; 1 study; very low-quality evidence), but not in verbal aggression (SMD -0.31, 95% CI; -0.89 to 0.27; 1 study; very low-quality evidence). One intervention focused on the vector, the pre-event phase and the event phase. The study compared a two-year culture change programme in a nursing home to practice as usual and involved 101 residents. This study provided very low-quality evidence that the intervention may result in a medium-sized reduction of physical aggression (MD 0.51, 95% CI 0.11 to 0.91), but there was no clear evidence that it reduced verbal aggression (MD 0.76, 95% CI -0.02 to 1.54). Two studies evaluated a multicomponent intervention that focused on the vector (psychiatry patients and emergency department patients), the victim (nursing staff), and the environment during the pre-event and the event phase. The studies included 564 psychiatric staff and 209 emergency department staff. Both studies involved a comprehensive package of actions aimed at preventing violence, managing violence and environmental changes. There was no clear evidence that the psychiatry intervention may result in a reduction of overall aggression (odds ratio (OR) 0.85, 95% CI 0.63 to 1.15; low-quality evidence), compared to the control condition. The emergency department study did not result in a reduction of aggression (MD = 0) but provided insufficient data to test this.

AUTHORS' CONCLUSIONS

We found very low to low-quality evidence that interventions focused on the vector during the pre-event phase, the event phase or both, may result in a reduction of overall aggression, compared to practice as usual, and we found inconsistent low-quality evidence for multi-component interventions. None of the interventions included the post-event stage. To improve the evidence base, we need more RCT studies, that include the workers as participants and that collect information on the impact of violence on the worker in a range of healthcare settings, but especially in emergency care settings. Consensus on standardised outcomes is urgently needed.

The effectiveness of chemical restraint in managing acute agitation and aggression: A systematic review of randomized controlled trials

One approach to manage people with behaviours of concern including agitated or aggressive behaviours in health care settings is through the use of fast-acting medication, called chemical restraint. Such management often needs to be delivered in crisis situations to patients who are at risk of harm to themselves or others. This paper summarizes the available evidence on the effectiveness and safety of chemical restraint from 21 randomized controlled trials (RCTs) involving 3788 patients. The RCTs were of moderate to high quality and were conducted in pre-hospital, hospital emergency department, or ward settings. Drugs used in chemical restraint included olanzapine, haloperidol, droperidol, risperidol, flunitrazepam, midazolam, promethazine, ziprasidone, sodium valproate, or lorazepam. There was limited comparability between studies in drug choice, combination, dose, method of administration (oral, intramuscular, or intravenous drip), or timing of repeat administrations. There were 31 outcome measures, which were inconsistently reported. They included subjective measures of behaviours, direct measures of treatment effect (time to calm; time to sleep), indirect measures of agitation (staff or patient injuries, duration of agitative or aggressive episodes, subsequent violent episodes), and adverse events. The most common were time to calm and adverse events. There was little clarity about the superiority of any chemical method of managing behaviours of concern exhibited by patients in Emergency Departments or acute mental health settings. Not only is more targeted research essential, but best practice recommendations for such situations requires integrating expert input into the current evidence base.

Prospective study of the safety and effectiveness of droperidol in elderly patients for pre-hospital acute behavioural disturbance

OBJECTIVE

Acute behavioural disturbance in the elderly (≥65 years) is a significant issue for emergency medical services with increasing prevalence of dementia and aging populations. We investigated the pre-hospital safety and effectiveness of droperidol in the elderly with acute behavioural disturbance.

METHODS

This was a pre-hospital prospective observational 1-year study of elderly patients with acute behavioural disturbance. The primary outcome was proportion of adverse events (AEs) (airway intervention, oxygen saturation <90% and/or respiratory rate <12/min, systolic blood pressure <90 mmHg, sedation assessment tool score of -3 and dystonic reactions). Secondary outcomes included time to sedation, additional sedation, proportion with successful sedation.

RESULTS

There were 149 patients (males 78 [52%], median age 78 years; 65-101 years) presenting on 162 occasions. Dementia was the commonest cause (107/164 [65%]) of acute behavioural disturbance. There were six AEs in five patients (5/162 [3%]; 95% confidence interval 1-7). Three had hypotension, one with associated hypoxia (80%); and two had respiratory AEs (respiratory rate, 10/min [no hypoxia] and hypoxia [88%] which required oxygen). Median time to sedation was 19 min (interquartile range 12-29 min). Additional sedation was given in 2/162 patients during ambulance transfer and 16/162 within an hour of hospital arrival; 24/162 (15%) failed to sedate in the ambulance; 16 subsequently settled in ED and 8/24 received additional sedation. Of 162, 123 (76%) patients successfully sedated, without AEs or additional sedation. Of 162, 114 (70%) patients received 5 mg, 46 (29%) received two doses of 5 mg and two patients (1%) received three doses.

CONCLUSIONS

Droperidol appeared to be safe and effective for pre-hospital sedation of acute behavioural disturbance in elderly patients.

Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach

Objective:

To present the essential guidelines for pharmacological management of patients with psychomotor agitation in Brazil.

Methods:

This is a systematic review of articles retrieved from the MEDLINE (PubMed), Cochrane Database of Systematic Reviews, and SciELO databases published from 1997 to 2017. Other relevant articles in the literature were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools.

Results:

Of 5,362 articles retrieved, 1,731 abstracts were selected for further reading. The final sample included 74 articles that met all inclusion criteria. The evidence shows that pharmacologic treatment is indicated only after non-pharmacologic approaches have failed. The cause of the agitation, side effects of the medications, and contraindications must guide the medication choice. The oral route should be preferred for drug administration; IV administration must be avoided. All subjects must be monitored before and after medication administration.

Conclusion:

If non-pharmacological strategies fail, medications are needed to control agitation and violent behavior. Once medicated, the patient should be monitored until a tranquil state is possible without excessive sedation.

Systematic review registry number:

CRD42017054440.

A Prospective Study of the Safety and Effectiveness of Droperidol in Children for Prehospital Acute Behavioral Disturbance

Study objective: Although uncommon, children (<16 years) with acute behavioral disturbance are a significant issue for emergency medical service providers. In this study, we aimed to investigate the safety and effectiveness of droperidol in children with prehospital acute behavioral disturbance. Methods: This was a prospective observational study over 1 year investigating the use of droperidol (0.1-0.2 mg/kg) for children (< 16 years) with acute behavioral disturbance. Inclusion criteria for acute behavioral disturbance were defined by a sedation assessment tool score of ≥2 determined by the attending paramedic. The primary outcome was the proportion of adverse effects (need for airway intervention, oxygen saturation <90% and/or respiratory rate <12, systolic blood pressure <90 mmHg, sedation assessment tool score of -3 and dystonic reactions). Secondary outcomes included time to sedation (sedation assessment tool score decreased by 2 or more, or a score of zero), requirement for additional sedation, failure to sedate and proportion of sedation success defined as the number of patients successfully sedated who did not suffer any adverse events or receive additional sedation. Results: There were 96 patients (males 51 [53%], median age 14 years [range 7-15 years]) who presented on 102 occasions over the one year study period. Self-harm and/or harm to others was the commonest (74/105 [70%]) cause of acute behavioral disturbance followed by alcohol (16/105 [15%]). There were 9 adverse events in 8 patients (8/102 [8%]; 95% confidence intervals [CI]: 3-13%) Five patients had hypotension, all asymptomatic and only one required treatment; 2 dystonic reactions managed with benztropine and one patient with respiratory depression. Median time to sedation was 14 min (interquartile range (IQR): 10-20 min; range: 3-85 min). There was no requirement for prehospital additional sedation (0/102 [0%]; 95% CI: 0-4%) and additional sedation in the first hour of arrival to hospital was required by 4 patients (4/102 [4%]; 95% CI: 1-10%). Overall successful sedation was achieved in 89 (87%) patients. Conclusions: The use of droperidol in children for acute behavioral disturbance in the prehospital setting is both safe and effective.

Droperidol for psychosis-induced aggression or agitation

BACKGROUND

People experiencing acute psychotic illnesses, especially those associated with agitated or violent behaviour, may require urgent pharmacological tranquillisation or sedation. Droperidol, a butyrophenone antipsychotic, has been used for this purpose in several countries.

OBJECTIVES

To estimate the effects of droperidol, including its cost-effectiveness, when compared to placebo, other 'standard' or 'non-standard' treatments, or other forms of management of psychotic illness, in controlling acutely disturbed behaviour and reducing psychotic symptoms in people with schizophrenia-like illnesses.

SEARCH METHODS

We updated previous searches by searching the Cochrane Schizophrenia Group Register (18 December 2015). We searched references of all identified studies for further trial citations and contacted authors of trials. We supplemented these electronic searches by handsearching reference lists and contacting both the pharmaceutical industry and relevant authors.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) with useable data that compared droperidol to any other treatment for people acutely ill with suspected acute psychotic illnesses, including schizophrenia, schizoaffective disorder, mixed affective disorders, the manic phase of bipolar disorder or a brief psychotic episode.

DATA COLLECTION AND ANALYSIS

For included studies, we assessed quality, risk of bias and extracted data. We excluded data when more than 50% of participants were lost to follow-up. For binary outcomes, we calculated standard estimates of risk ratio (RR) and the corresponding 95% confidence intervals (CI). We created a 'Summary of findings' table using GRADE.

MAIN RESULTS

We identified four relevant trials from the update search (previous version of this review included only two trials). When droperidol was compared with placebo, for the outcome of tranquillisation or asleep by 30 minutes we found evidence of a clear difference (1 RCT, N = 227, RR 1.18, 95% CI 1.05 to 1.31, high-quality evidence). There was a clear demonstration of reduced risk of needing additional medication after 60 minutes for the droperidol group (1 RCT, N = 227, RR 0.55, 95% CI 0.36 to 0.85, high-quality evidence). There was no evidence that droperidol caused more cardiovascular arrhythmia (1 RCT, N = 227, RR 0.34, 95% CI 0.01 to 8.31, moderate-quality evidence) and respiratory airway obstruction (1 RCT, N = 227, RR 0.62, 95% CI 0.15 to 2.52, low-quality evidence) than placebo. For 'being ready for discharge', there was no clear difference between groups (1 RCT, N = 227, RR 1.16, 95% CI 0.90 to 1.48, high-quality evidence). There were no data for mental state and costs.Similarly, when droperidol was compared to haloperidol, for the outcome of tranquillisation or asleep by 30 minutes we found evidence of a clear difference (1 RCT, N = 228, RR 1.01, 95% CI 0.93 to 1.09, high-quality evidence). There was a clear demonstration of reduced risk of needing additional medication after 60 minutes for participants in the droperidol group (2 RCTs, N = 255, RR 0.37, 95% CI 0.16 to 0.90, high-quality evidence). There was no evidence that droperidol caused more cardiovascular hypotension (1 RCT, N = 228, RR 2.80, 95% CI 0.30 to 26.49,moderate-quality evidence) and cardiovascular hypotension/desaturation (1 RCT, N = 228, RR 2.80, 95% CI 0.12 to 67.98, low-quality evidence) than haloperidol. There was no suggestion that use of droperidol was unsafe. For mental state, there was no evidence of clear difference between the efficacy of droperidol compared to haloperidol (Scale for Quantification of Psychotic Symptom Severity, 1 RCT, N = 40, mean difference (MD) 0.11, 95% CI -0.07 to 0.29, low-quality evidence). There were no data for service use and costs.Whereas, when droperidol was compared with midazolam, for the outcome of tranquillisation or asleep by 30 minutes we found droperidol to be less acutely tranquillising than midazolam (1 RCT, N = 153, RR 0.96, 95% CI 0.72 to 1.28, high-quality evidence). As regards the 'need for additional medication by 60 minutes after initial adequate sedation, we found an effect (1 RCT, N = 153, RR 0.54, 95% CI 0.24 to 1.20, moderate-quality evidence). In terms of adverse effects, we found no statistically significant differences between the two drugs for either airway obstruction (1 RCT, N = 153, RR 0.13, 95% CI 0.01 to 2.55, low-quality evidence) or respiratory hypoxia (1 RCT, N = 153, RR 0.70, 95% CI 0.16 to 3.03, moderate-quality evidence) - but use of midazolam did result in three people (out of around 70) needing some sort of 'airway management' with no such events in the droperidol group. There were no data for mental state, service use and costs.Furthermore, when droperidol was compared to olanzapine, for the outcome of tranquillisation or asleep by any time point, we found no clear differences between the older drug (droperidol) and olanzapine (e.g. at 30 minutes: 1 RCT, N = 221, RR 1.02, 95% CI 0.94 to 1.11, high-quality evidence). There was a suggestion that participants allocated droperidol needed less additional medication after 60 minutes than people given the olanzapine (1 RCT, N = 221, RR 0.56, 95% CI 0.36 to 0.87, high-quality evidence). There was no evidence that droperidol caused more cardiovascular arrhythmia (1 RCT, N = 221, RR 0.32, 95% CI 0.01 to 7.88, moderate-quality evidence) and respiratory airway obstruction (1 RCT, N = 221, RR 0.97, 95% CI 0.20 to 4.72, low-quality evidence) than olanzapine. For 'being ready for discharge', there was no difference between groups (1 RCT, N = 221, RR 1.06, 95% CI 0.83 to 1.34, high-quality evidence). There were no data for mental state and costs.

AUTHORS' CONCLUSIONS

Previously, the use of droperidol was justified based on experience rather than evidence from well-conducted and reported randomised trials. However, this update found high-quality evidence with minimal risk of bias to support the use of droperidol for acute psychosis. Also, we found no evidence to suggest that droperidol should not be a treatment option for people acutely ill and disturbed because of serious mental illnesses.

Assessment and management of agitation in psychiatry: Expert consensus

BACKGROUND

Psychomotor agitation is associated with different psychiatric conditions and represents an important issue in psychiatry. Current recommendations on agitation in psychiatry are not univocal. Actually, an improper assessment and management may result in unnecessary coercive or sedative treatments. A thorough and balanced review plus an expert consensus can guide assessment and treatment decisions.

METHODS

An expert task force iteratively developed consensus using the Delphi method. Initial survey items were based on systematic review of the literature. Subsequent surveys included new, re-worded or re-rated items.

RESULTS

Out of 2175 papers assessing psychomotor agitation, 124 were included in the review. Each component was assigned a level of evidence. Integrating the evidence and the experience of the task force members, a consensus was reached on 22 statements on this topic.

CONCLUSIONS

Recommendations on the assessment of agitation emphasise the importance of identifying any possible medical cause. For its management, experts agreed in considering verbal de-escalation and environmental modification techniques as first choice, considering physical restraint as a last resort strategy. Regarding pharmacological treatment, the "ideal" medication should calm without over-sedate. Generally, oral or inhaled formulations should be preferred over i.m. routes in mildly agitated patients. Intravenous treatments should be avoided.

Prehospital Agitation and Sedation Trial (PhAST): A Randomized Control Trial of Intramuscular Haloperidol versus Intramuscular Midazolam for the Sedation of the Agitated or Violent Patient in the Prehospital Environment

INTRODUCTION

Violent patients in the prehospital environment pose a threat to health care workers tasked with managing their medical conditions. While research has focused on methods to control the agitated patient in the emergency department (ED), there is a paucity of data looking at the optimal approach to subdue these patients safely in the prehospital setting. Hypothesis This study evaluated the efficacy of two different intramuscular medications, midazolam and haloperidol, to determine their efficacy in sedating agitated patients in the prehospital setting.

METHODS

This was a prospective, randomized, observational trial wherein agitated patients were administered intramuscular haloperidol or intramuscular midazolam to control agitation. Agitation was quantified by the Richmond Agitation and Sedation Scale (RASS). Paramedics recorded the RASS and vital signs every five minutes during transport and again upon arrival to the ED. The primary outcome was mean time to achieve a RASS less than +1. Secondary outcomes included mean time for patients to return to baseline mental status and adverse events.

RESULTS

Five patients were enrolled in each study group. In the haloperidol group, the mean time to achieve a RASS score of less than +1 was 24.8 minutes (95% CI, 8-49 minutes), and the mean time for the return of a normal mental status was 84 minutes (95% CI, 0-202 minutes). Two patients required additional prehospital doses for adequate sedation. There were no adverse events recorded in the patients administered haloperidol. In the midazolam group, the mean time to achieve a RASS score of less than +1 was 13.5 minutes (95% CI, 8-19 minutes) and the mean time for the return of normal mental status was 105 minutes (95% CI, 0-178 minutes). One patient required additional sedation in the ED. There were no adverse events recorded among the patients administered midazolam.

CONCLUSIONS

Midazolam and haloperidol administered intramuscularly appear equally effective for sedating an agitated patient in the prehospital setting. Midazolam appears to have a faster onset of action, as evidenced by the shorter time required to achieve a RASS score of less than +1 in the patients who received midazolam. Haloperidol offers an alternative option for the sedation of an agitated patient. Further studies should focus on continued investigation into appropriate sedation of agitated patients in the prehospital setting.

Comparison of droperidol and haloperidol for use by paramedics: assessment of safety and effectiveness

BACKGROUND

Since the 2001 "black box" warning on droperidol, its use in the prehospital setting has decreased substantially in favor of haloperidol. There are no studies comparing the prehospital use of either drug. The goal of this study was to compare QTc prolongation, adverse events, and effectiveness of droperidol and haloperidol among a cohort of agitated patients in the prehospital setting.

METHODS

In this institutional review board-approved before and after study, we collected data on 532 patients receiving haloperidol (n = 314) or droperidol (n = 218) between 2007 and 2010. We reviewed emergency department (ED) electrocardiograms when available (haloperidol, n = 78, 25%; droperidol, n = 178, 76%) for QTc length (in milliseconds), medical records for clinically relevant adverse events (defined a priori as systolic blood pressure (SBP) <90 mmHg, seizure, administration of anti-dysrhythmic medications, cardioversion or defibrillation, bag-valve-mask ventilation, intubation, cardiopulmonary arrest, and prehospital or in-hospital death). We also compared effectiveness of the medications, using administration of additional sedating medications within 30 minutes of ED arrival as a proxy for effectiveness.

RESULTS

The mean haloperidol dose was 7.9 mg (median 10 mg, range 4-20 mg). The mean droperidol dose was 2.9 mg (median 2.5 mg, range 1.25-10 mg.) Haloperidol was given i.m. in 289 cases (92%), and droperidol was given i.m. in 132 cases (61%); in all other cases, the medication was given i.v.. There was no statistically significant difference in median QTc after medication administration (haloperidol 447 ms, 95% CI: 440-454 ms; droperidol 454 ms, 95% CI: 450-457). There were no statistically significant differences in adverse events in the droperidol group as compared to the haloperidol group. One patient in the droperidol group with a history of congenital heart disease suffered a cardiopulmonary arrest and was resuscitated with neurologically intact survival. There was no significant difference in the use of additional sedating medications within 30 minutes of ED arrival after receiving droperidol (2.9%, 95% CI: -2.5-8.4%).

CONCLUSIONS

In this cohort of agitated patients treated with haloperidol or droperidol in the prehospital setting, there was no significant difference found in QTc prolongation, adverse events, or need for repeat sedation between haloperidol and droperidol.

T HE I NCIDENCE AND T REATMENT OF P REHOSPITAL M OTION S ICKNESS

OBJECTIVES

The authors' objectives were: 1) to determine the incidence of motion sickness during ambulance transport on a mountainous route in healthy volunteers, and 2) to determine if droperidol alleviated the signs and symptoms of motion sickness in those volunteers who developed it.

METHODS

This was a prospective, randomized, double-blind, placebo-controlled trial. Subjects were healthy volunteers over age 18 and not currently taking an antiemetic. Participants were transported in the back of an ambulance over a mountainous road. Those who developed motion sickness rated their nausea on a 100-mm visual analog scale (VAS) and were randomized to receive placebo (saline) or 2.5 mg droperidol intravenously. Symptoms were recorded on a VAS every 5 minutes until the end of the transport. Incidence of motion sickness was calculated as a percentage with 95% confidence intervals (CIs). Pretreatment characteristics were compared with chi-square tests, and mean VAS scores were compared using t-tests.

RESULTS

Thirty-seven subjects completed the study. Sixteen (43%, 95% CI=27%-59%) developed motion sickness. Fifteen were randomized and completed data collection. Eight received droperidol (mean baseline VAS, 45) and seven received placebo (mean baseline VAS, 40). Droperidol trended toward a greater mean reduction of nausea than placebo at 5 minutes (20 versus 4, p=0.077).

CONCLUSIONS

The incidence of motion sickness during ambulance transport in a mountainous setting is substantial. There was a strong trend toward a positive treatment effect with droperidol. Further prospective study in an actual patient setting is warranted.

DISCONTINUATION OF DROPERIDOL FOR THE CONTROL OF ACUTELY AGITATED OUT-OF-HOSPITAL PATIENTS

OBJECTIVE

To identify the effects of the removal of droperidol as a treatment option for sedation of agitated out-of-hospital patients.

METHODS

This was a retrospective review conducted January 1, 2001, through December 5, 2002, of patients with an out-of-hospital diagnosis of agitation who received either droperidol or midazolam prior to arrival in the emergency department (ED). The need for continuous cardiac or pulse oximetry monitoring, intubation, critical care ED management, intensive care unit admission, and mortality was reviewed.

RESULTS

Seventy-one patients received droperidol or midazolam for acute agitation in the out-of-hospital setting. Forty-one patients received droperidol in 2001 (D2001); three patients received midazolam in 2001 (M2001). No patients received droperidol in 2002, and 27 patients received midazolam (M2002). Comparing the D2001 and M2002 groups, the need for continuous pulse oximetry monitoring in the ED [14/41 (34.1%) versus 18/27 (66.7%)], intubations [4/41 (9.8%) versus 10/27 (37.0%)], critical emergency medical services transports [5/41 (12.2%) versus 11/27 (40.7%)], critical ED care cases [6/41 (14.6%) versus 11/27 (40.7%)], and intensive care unit admissions [6/13 (46.2%) versus 14/15 (93.3%)] were increased in the M2002 group. No difference was found in the frequencies of ED cardiac monitoring, hospital admission, complications, or death.

CONCLUSIONS

Since the removal of droperidol as a treatment option for out-of-hospital agitated patients, the authors have observed an increased frequency of continuous pulse oximetry monitoring, intubation, ED critical care management, and intensive care unit admission in patients requiring chemical sedation for control of agitation in the out-of-hospital setting.

Pharmacological control of acute agitation: focus on intramuscular preparations

Acute agitation in the psychiatric emergency setting is a common presentation, which can endanger the patient, caregivers and professional staff. Rapid and effective treatment, followed by ongoing evaluation and maintenance treatment where appropriate, is key to circumvent negative outcomes. Nonpharmacological measures are the first step in treating the acutely agitated patient, and include verbal intervention and physical restraint. Pharmacological treatment is often required to ensure the safety of the patient, caregivers and the treatment team. The need for drug delivery in uncooperative patients favours the use of intramuscular preparations for the acutely agitated patient. Intramuscular treatment options include benzodiazepines, conventional antipsychotics and atypical antipsychotics. Each of these medications offers a unique pharmacological profile that must be considered when treating acutely agitated patients, who may be unwilling or unable to accurately communicate their co-morbid conditions and concomitant medications.

The combative multitrauma patient: a protocol for prehospital management

OBJECTIVE

To describe the management of the combative trauma patient in the prehospital setting, and to suggest a protocol for management.

METHODS

A retrospective, prehospital case series conducted in Israel among military medical teams over the course of nearly 2 years, between January 2000 and October 2002. We collected a case series of patients who became combative following traumatic injury. Following data collection, we summoned an expert panel and developed a protocol for physicians and paramedics upon encountering a combative trauma patient.

RESULTS

Available data were found for 11 patients and these were included in the analysis. Most victims included in this study were injured under military or geographical circumstances mandating a long time interval from injury to definitive care, namely 114 min (range 38-225 min). Five patients received intravenous ketamine, in three of which it was coadministered with midazolam. Sedation with ketamine given alone, or combined with other drugs, was effective in all five cases. In no case did a patient become more agitated after administration. No adverse effects were recorded by the prehospital caregivers.

CONCLUSIONS

In this article, an algorithmic approach to the treatment of the patient's agitation is outlined, using ketamine as the principal sedating agent, either alone or combined with midazolam. The combination of both drugs is suggested for the effective sedation of adult prehospital combative patient population.

Agitation is common in γ-hydroxybutyrate toxicity

Gamma-Hydroxybutyrate (GHB)-related compounds are most commonly described as depressants, with emphasis on somnolence, obtundation, stupor, and coma (SOSC). We sought to demonstrate the full spectrum of clinical presentations of GHB intoxication, including agitation and other nonsedative effects. Our observational study identified 66 patients with GHB toxicity, 40 of whom manifested agitation; 25 had agitation before or after SOSC, 10 had agitation alternating abruptly with SOSC, and 5 had agitation only. Fourteen presentations also included "bizarre" or self-injurious behaviors. Of 40 presentations with agitation, 19 had stimulant co-intoxicants confirmed by screen (14) or history (5). The remaining 21 patients with agitation were negative for stimulants by screen (12) or history (9). Gas chromatography/mass spectrometry detected GHB in 25 cases; 12 manifested agitation, 4 of which also screened negative for stimulants. Clinicians should broaden their definitions of GHB toxicity to include nonsedative effects such as agitation, combativeness, and bizarre or self-injurious behavior.

Droperidol for acute psychosis

BACKGROUND

People suffering from acute psychotic illnesses, especially those associated with agitated or violent behaviour, may require urgent pharmacological tranquillisation or sedation. Droperidol, a butyrophenone neuroleptic, has been used for this purpose in several countries.

OBJECTIVES

To estimate the effects of droperidol compared to other treatments for controlling disturbed behaviour and reducing psychotic symptoms for people with suspected acute psychotic illnesses.

SEARCH STRATEGY

We updated previous searches by searching the Cochrane Schizophrenia Group Register (September 2003). References of all identified studies were searched for further trial citations and authors of trials were contacted. Twenty-one other databases were also searched as part of a broader project and this composite database was searched for this review. This was supplemented by hand searching reference lists and contacting both the pharmacological industry and relevant authors.

SELECTION CRITERIA

The review included randomised controlled trials comparing droperidol to any other treatment for people with suspected acute psychotic illnesses, including schizophrenia, schizoaffective disorder, mixed affective disorders, the manic phase of bipolar disorder or a brief psychotic episode.

DATA COLLECTION AND ANALYSIS

Relevant studies were selected for inclusion, their quality was assessed and data extracted. Data were excluded when more than 50% of participants were lost to follow up. For binary outcomes, standard estimates of risk ratio (RR) and the corresponding 95% confidence intervals (CI) were calculated. Where possible, weighted number needed to treat or harm statistics (NNT, NNH), and the corresponding 95% confidence intervals (CI), were calculated.

MAIN RESULTS

We identified only two relevant trials. One additional study focused on outcomes at 30 days rather than at a few hours. One small (n = 41) randomised trial compared intravenous (iv) droperidol (10 mg) with iv placebo and found that people allocated to droperidol were significantly less likely to need additional injections of another drug, haloperidol, in the first few minutes (n = 41, RR 0.37 CI 0.2 to 0.7, NNT 2 CI 1 to 10) compared to those given placebo. By 90 minutes this difference was still evident but not statistically significant (RR 0.46 CI 0.2 to 1.2). When 5 mg intramuscular (im) droperidol was compared with 5 mg im haloperidol, those given droperidol were also less likely to need additional injections by 30 minutes, than those given haloperidol, but this result was not statistically significant (n = 27, RR 0.45 CI 0.2 to 1.01). One person out of the 16 given haloperidol experienced a mild dystonic reaction (muscle spasms or abnormal contractions), while none of the 11 people allocated to droperidol were reported to have experienced adverse effects.

REVIEWERS' CONCLUSIONS

This is an important, and surprisingly under-researched, area. To date, use of droperidol for emergency situations has been justified by experience rather than evidence from well conducted and reported randomised trials, but, as world reserves diminish, droperidol will no longer be a treatment option.

Droperidol, QT prolongation, and sudden death: what is the evidence?

STUDY OBJECTIVE

Droperidol is a butyrophenone commonly used as an antiemetic and antipsychotic in the United States since US Food and Drug Administration (FDA) approval in 1970. Its labeling has recently been revised, with a black box warning for cases of QT prolongation leading to torsades de pointes and death. A black box warning is applied when serious adverse drug reactions are uncovered for medications. We sought to examine the evidence of a causal association suggested by the black box warning to aid clinicians in their risk-benefit analyses regarding further use of droperidol.

METHODS

A literature search was undertaken to determine the evidence regarding the association between droperidol and QT prolongation or torsades de pointes. The evidence was then evaluated by using evidence-based medicine principles. In addition, a review of the FDA regulatory process is presented.

RESULTS

Three clinical studies, 1 published abstract, and 7 case reports were reviewed. Available postmarketing surveillance data (MedWatch reports) were also reviewed. Applying the criteria of evidence-based medicine and Hill's criteria, the evidence is not convincing for a causal relationship between therapeutic droperidol administration and life-threatening cardiac events.

CONCLUSION

The recent black box warning appears to have originated from postmarketing surveillance data rather than data reported in the peer-reviewed medical literature. Ongoing monitoring of drug safety and more definitive study appear appropriate.

Management of the violent patient

Emergency medical services (EMS) providers must often manage violent or combative patients. The data regarding violence against EMS personnel are poor, but according to studies conducted thus far, between 0.8% and 5.0% of incidents to which EMS personnel respond involve violence or the threat of violence. Physical or chemical restraint is usually the only option available to emergency care providers to control violent patients. Physical restraint, however, can lead to sudden death in otherwise healthy patients, possibly as a result of positional asphyxia, severe acidosis, or a patient's excited delirium. Chemical restraint has traditionally consisted of either neuroleptics or benzodiazepines, but those drugs also have drawbacks. Haloperidol and droperidol, the neuroleptics most frequently used for restraint, can cause serious side effects such as extrapyramidal symptoms or QTc (QT interval corrected for heart rate) prolongation. The Food and Drug Administration recently issued a black box warning regarding the use of droperidol, because the QTc prolongation associated with the drug has led to fatal torsades de pointes in some patients. Benzodiazepines are also associated with adverse effects, such as sedation and respiratory depression, especially when the drugs are mixed with alcohol. The atypical antipsychotics, a new option that may be available soon, are less likely to cause such effects and therefore may be preferred over the neuroleptics. Liquid and injectable formulations of various atypical antipsychotics are currently in clinical trials. Because few options are currently available to EMS personnel for managing violent patients outside of the hospital, more research regarding violence against emergency care providers is necessary.

The development of a register of randomized controlled trials in prehospital trauma care

OBJECTIVES

To establish a register of randomized controlled trials of interventions in the prehospital care of trauma patients.

METHODS

A systematic search was conducted for all randomized controlled trials of interventions in the prehospital care of trauma patients. The search included the Cochrane Controlled Trial Register, the Cochrane Injuries Group Specialised Register, Medline, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), Science Citation Index, National Research Register, Dissertation Abstracts, and PubMed for the time period 1966-2000. There were no language restrictions. In addition, full-text hand searching of a range of relevant journals was done, and the authors of included trials were contacted.

RESULTS

The combined search strategy identified 16,037 potentially eligible records, of which 28 were reports of randomized controlled trials evaluating prehospital trauma care interventions. After excluding duplicate reports, there were 24 separate randomized controlled trials including 6,806 patients. The largest and smallest trials involved 1,309 and 30 trauma patients, respectively.

CONCLUSIONS

This register will facilitate the conduct of systematic reviews of the effectiveness of interventions in prehospital trauma care. However, despite the extensive searching, very few randomized trials in this area were found. In view of the absence of evidence for the effectiveness of many of the interventions that are used in the prehospital care of trauma patients, further randomized controlled trials are required.

Prehospital sedation with intramuscular droperidol: a one-year pilot

OBJECTIVE

Combative patients pose a threat to themselves and prehospital personnel, and are at risk for sudden death. Droperidol is an antipsychotic and sedative agent that might be effectively utilized by paramedics to assist in the management of uncontrollably violent patients.

METHODS

A prospective observational study of patients requiring sedation was conducted in an urban third-service emergency medical services system (55,000 calls per year). Patients were scored by paramedics on a five-point agitation scale with 5 being extremely combative (continuous, vigorous fighting against restraints) and 1 being somnolent (sleeping or sleepy). Eligible (score 4-5) patients received 5 mg of intramuscular droperidol on direct physician order. Data including vital signs and agitation scores were recorded at 5-minute intervals until hospital arrival. Adverse effects were also recorded.

RESULTS

Fifty-three patients received droperidol (51 patients received 5 mg; two received 2.5 mg) during the study period. The average predrug agitation score was 4.7 (+/- 0.1 SD). The average 5-minute postdrug score was 3.9 (+/- 0.1 SD, 95% CI 3.7-4.1. The average 10-minute postdrug score was 3.3 (+/- 0.1 SD, 95% CI 3.1-3.6). The average hospital arrival score was 2.8 (+/- 0.1 SD, 95% CI 2.5-3.1). One patient became obtunded and required supplemental oxygen; no other patient experienced an adverse event after receiving droperidol. Sedation was ineffective in seven patients, three of whom had head injuries, and one of whom received 2.5 mg of droperidol per physician order. Paramedics sustained no needlestick exposures.

CONCLUSION

Intramuscular droperidol contributed to effective and rapid prehospital sedation in this observational series of 53 combative patients.

Droperidol for acute psychosis

BACKGROUND

People with acute psychotic illnesses, especially when associated with agitated or violent behaviour, may require urgent pharmacological tranquillisation or sedation. Droperidol, a butyrophenone neuroleptic, is used for this purpose in several countries.

OBJECTIVES

To estimate the effects of droperidol when compared to other treatments for controlling disturbed behaviour and reducing psychotic symptoms for people with suspected acute psychotic illnesses.

SEARCH STRATEGY

The Cochrane Controlled Trials Register (Issue 2, 2000), The Cochrane Schizophrenia Group's Register (May 2000), EMBASE (1980-2000), MEDLINE (1966-2000), PASCAL (1973-2000) and PsycLIT (1970-2000) were methodically searched. Twenty-one other databases were also searched as part of a broader project and this composite database was searched for this review. This was supplemented by hand searching reference lists, contacting industry and relevant authors.

SELECTION CRITERIA

Randomised clinical trials comparing droperidol to any treatment, for people with suspected acute psychotic illnesses, such as schizophrenia, schizoaffective disorder, mixed affective disorders, manic phase of bipolar disorder or brief psychotic episode.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality assessed and data extracted. Data were excluded where more than 50% of participants were lost to follow up. For binary outcomes, standard estimations of risk ratio (RR) and their 95% confidence intervals (CI) were calculated. Where possible, weighted number needed to treat or harm statistics (NNT, NNH), and their 95% confidence intervals (CI), were also calculated.

MAIN RESULTS

Only two clearly relevant randomised trials with usable data were identified. One additional study was included but focused on outcomes at 30 days rather than a few hours. One small (n=41) randomised trial compared droperidol (10mg IV) with placebo IV and found that people allocated to droperidol were significantly less likely to need additional haloperidol injections in the first few minutes (n=41, RR 0.37 CI 0.2 to 0.7, NNT 2 CI 1 to 10) than those given placebo. By 90 minutes this difference was still evident but not statistically significant (RR 0.46 CI 0.2 to 1.2). When 5mg IM droperidol was compared to 5mg IM haloperidol people given droperidol were again less likely to need additional injections by 30 minutes, than those given haloperidol, but this result did not quite reach conventional levels of statistical significance (n=27, RR 0.45 CI 0.2 to 1.01). One person out of 16 given haloperidol experienced a mild dystonic reaction, and none of the 11 people allocated to droperidol were reported to have experienced adverse effects.

REVIEWER'S CONCLUSIONS

This is an important and surprisingly under-researched area. Use of droperidol for the emergency situation is currently justified on experience rather than evidence from well conducted and reported randomised trials.

Psychosis

Psychosis is the term used to describe a mental state of dysfunction in behavior and thought processes. In patients with psychoses, mental capacity is grossly distorted and thought is disorganized. These factors cause an inability to recognize reality or relate to others in a meaningful way. A medical cause is found in approximately 20% of patients with acute psychosis. Emergency medicine physicians must differentiate psychotic symptoms caused by general medical conditions from psychosis caused by a primary psychiatric disorder. A careful evaluation must be performed to identify the cause of the psychosis. Correction of reversible causes, sedation, and appropriate disposition are the keys to the successful management of these patients.

The violent patient

Encounters with violent behavior are an inevitable part of working in emergency departments. By adoption of a cohesive, multidisciplinary approach to behavioral decompensation, as is done in preparation for airway compromise, the risk for injury to patients and staff is minimized. As with airway compromise, anticipation of and preparation for deterioration can avoid the necessity of the most invasive measures and can ensure a calm, positive outcome. With the appropriate knowledge, teamwork, and skills, even patients requiring the most intensive intervention can be treated safely and professionally.

Evaluating the usage of droperidol in acutely agitated persons with brain injury

The objective of this study was to compare the effectiveness and safety of intramuscular droperidol to other intramuscularly administered agents used in the management of acutely agitated patients. Twenty-seven inpatients with a history of brain injury were prospectively monitored over a period of 2 months. Data collected for each episode of agitation include: dose, number of doses, time to achieve an adequate response or calming effect, post-episodic functioning, treatment-emergent side effects, and other patient demographics. A retrospective medical records review was also performed on the same cohort, to compare clinical outcomes associated with other intramuscular agents previously used for acute agitation. Time to achieve calming was significantly shorter with intramuscular droperidol (mean = 27.0 minutes) compared to intramuscular haloperidol, lorazepam, or diphenhydramine (group mean = 36.2 minutes, p = 0.02). Of the three comparative agents, the time to achieve calming was the fastest with lorazepam (mean = 35.0 minutes), and slower with diphenhydramine (mean = 42.6 minutes) and haloperidol (mean = 43.0 minutes). Single doses of droperidol controlled agitation more frequently than did single doses of comparative agents, and there was less post-episodic sedation with droperidol following release from seclusion or restraints. Both groups were similar in regard to the incidence of treatment-emergent events. This data represents the first published experience supporting the effectiveness of droperidol in reducing acute agitation in persons with brain injury. Follow-up studies with prospective, double-blind, parallel treatment groups should be performed to validate these preliminary findings.

Phenomenology and treatment of psychotic disorders in the psychiatric emergency service

The emergency evaluation of a psychotic patient calls on all of the skills of the psychiatrist. The immediate control of dangerous behavior takes place at the same time that clinicians evaluate patients for delirium. A screening physical examination, a brief mental status examination, and a high index of suspicion for medical diseases are essential tools in the first few minutes of a patient's stay in the psychiatric emergency service. Drugs of abuse are often part of a patient's presentation. Here, too, the first task is to rule out delirium, particularly from sedative or alcohol withdrawal. As soon as a patient's condition is stabilized, the psychiatrist should review all of the available information, develop a working diagnosis, and initiate definitive treatment of the presumed disorder. With fewer emergency patients being hospitalized and with shorter lengths of hospital stay, these initial decisions acquire increasing significance for patient outcome.

Searching for the evidence in pre-hospital care: a review of randomised controlled trials. On behalf of the Ambulance Response Time Sub-Group of the National Ambulance Advisory Committee

OBJECTIVES

To identify randomised controlled trials (RCTs) which evaluate aspects of pre-hospital care; to perform categorisation by theme; to compare the sensitivity and precision of the search databases.

DATA SOURCES

August 1997 updates of MEDLINE and EMBASE databases, using the Datastar online system. Papers published in 1987 or later were included, with no language restrictions.

STUDY SELECTION

A trial was eligible for inclusion if it was judged, by two independent and blinded assessors, that participants followed up in the trial were definitely or possibly assigned prospectively to one of two or more alternative forms of healthcare with random allocation or a quasi-random method of allocation.

RESULTS

The literature search retrieved 849 papers, of which 569 (67%) were in MEDLINE and 486 (57%) in EMBASE. Forty one (5%) were confirmed as reports of RCTs or quasi-RCTs, and the total number of individual trials was 38. Ten of these trials dealt with thrombolytic drugs; 14 were concerned with other drugs, 12 with equipment, and two with other interventions. Four trials were based on a sample size of more than 1000, and seven reported a statistically significant effect on mortality. All 41 papers were in EMBASE, and all but one were also in MEDLINE.

CONCLUSIONS

Evidence based policy making with respect to the organisation of pre-hospital services cannot depend on RCTs. In the current relative absence of such evidence, practitioners and decision makers must use alternative information sources. A future review could examine a broader range of literature and be based on a wider search of published and unpublished material.

Quantifying the scanty science of prehospital emergency care

Research can produce false-positive results just as can diagnostic tests. Uncontrolled studies have a specificity of only 11%, versus 88% for randomized controlled trials (RCTs), which have been designed to minimize the bias of investigators toward a positive outcome. A search of all the scientific studies in Medicine since 1985 revealed 5,842 publications on prehospital EMS, but only 54 were RCTs (and therefore unlikely to produce false-positive results). By way of comparison, during the same time hundreds of RCTs have been conducted on major medical emergency conditions, and RCTs on even minor topics such as urticaria and constipation exceed the scientific database on all of EMS. Of the 54 EMS RCTs, 4 (7%) reported harm from the new therapy, and 74% reported no effect of the new therapy at all. Only 7 (13%) RCTs showing a positive outcome of the intervention were uncontradicted; of these only 1 examined a major outcome such as survival, and only 1 compared the intervention with a placebo and could therefore evaluate the efficacy of EMS itself. Because there is such a paucity of scientific support for EMS interventions and because monitoring of outcomes and adverse effects is so poor, a serious reexamination of EMS practice is indicated.