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Mazer-Amirshahi M, Cole JB, Stolbach AI, Perrone J, Nelson LS. Ensuring the Efficacy and Safety of Approved Medications. J Med Toxicol 2024; 20:81-83. [PMID: 38393519 PMCID: PMC10959846 DOI: 10.1007/s13181-024-00998-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 02/10/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Affiliation(s)
- Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, National Capital Poison Center, 110 Irving St NW, 20010, Washington, DC, USA.
| | - Jon B Cole
- Department of Emergency Medicine, Minnesota Poison Control System, Hennepin Healthcare, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Andrew I Stolbach
- Department of Emergency Medicine, John Hopkins School of Medicine, Baltimore, MD, USA
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, 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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Sadlonova M, Beach SR, Funk MC, Rosen JH, Ramirez Gamero AF, Karlson RA, Huffman JC, Celano CM. Risk Stratification of QTc Prolongation in Critically Ill Patients Receiving Antipsychotics for the Management of Delirium Symptoms. J Intensive Care Med 2023:8850666231222470. [PMID: 38130132 DOI: 10.1177/08850666231222470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND Patients experiencing significant agitation or perceptual disturbances related to delirium in an intensive care setting may benefit from short-term treatment with an antipsychotic medication. Some antipsychotic medications may prolong the QTc interval, which increases the risk of potentially fatal ventricular arrhythmias. In this targeted review, we describe the evidence regarding the relationships between antipsychotic medications and QTc prolongation and practical methods for monitoring the QTc interval and mitigating arrhythmia risk. METHODS Searches of PubMed and Cochrane Library were performed to identify studies, published before February 2023, investigating the relationships between antipsychotic medications and QTc prolongation or arrhythmias. RESULTS Most antipsychotic medications commonly used for the management of delirium symptoms (eg, intravenous haloperidol, olanzapine, quetiapine) cause a moderate degree of QTc prolongation. Among other antipsychotics, those most likely to cause QTc prolongation are iloperidone and ziprasidone, while aripiprazole and lurasidone appear to have minimal risk for QTc prolongation. Genetic vulnerabilities, female sex, older age, pre-existing cardiovascular disease, electrolyte abnormalities, and non-psychiatric medications also increase the risk of QTc prolongation. For individuals at risk of QTc prolongation, it is essential to measure the QTc interval accurately and consistently and consider medication adjustments if needed. CONCLUSIONS Antipsychotic medications are one of many risk factors for QTc prolongation. When managing agitation related to delirium, it is imperative to assess an individual patient's risk for QTc prolongation and to choose a medication and monitoring strategy commensurate to the risks. In intensive care settings, we recommend regular ECG monitoring, using a linear regression formula to correct for heart rate. If substantial QTc prolongation (eg, QTc > 500 msec) is present, a change in pharmacologic treatment can be considered, though a particular medication may still be warranted if the risks of discontinuation (eg, extreme agitation, removal of invasive monitoring devices) outweigh the risks of arrhythmias. AIMS This review aims to summarize the current literature on relationships between antipsychotic medications and QTc prolongation and to make practical clinical recommendations towards the approach of antipsychotic medication use for the management of delirium-related agitation and perceptual disturbances in intensive care settings.
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Affiliation(s)
- Monika Sadlonova
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Göttingen, Germany
- Department of Cardiovascular and Thoracic Surgery, University of Göttingen Medical Center, Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Margo C Funk
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Jordan H Rosen
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Andres F Ramirez Gamero
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Rebecca A Karlson
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jeff C Huffman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Christopher M Celano
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Allen PJ, Johanson KE, Reveles KR, Neff LA, Lock AE. Comparison of Droperidol and Midazolam Versus Haloperidol and Lorazepam for Acute Agitation Management in the Emergency Department. Ann Pharmacother 2023; 57:1367-1374. [PMID: 36999520 DOI: 10.1177/10600280231163192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Acute agitation accounts for up to 2.6% of visits to the emergency department (ED). To date, a standard of care for the management of acute agitation has not been established. Few studies have evaluated antipsychotic and benzodiazepine combinations. OBJECTIVE The purpose of this study was to evaluate effectiveness and safety of combination therapy for acute agitation with intramuscular (IM) droperidol and midazolam (D+M) compared with IM haloperidol and lorazepam (H+L) in patients in the ED. METHODS This was a single-center, retrospective medical record review of patients presenting to a large, academic ED with acute agitation from July 2020 through October 2021. The primary outcome was percentage of patients requiring additional agitation medication within 60 minutes of combination administration. Secondary outcomes included average time to repeat dose administration and average number of repeat doses required before ED discharge. RESULTS A total of 306 patients were included for analysis: 102 in the D+M group and 204 in the H+L group. Repeat dose within 60 minutes occurred in 7 (6.9%) and 28 (13.8%) patients in the D+M and H+L groups, respectively (P = 0.065). A total of 28.4% of D+M patients and 30.9% of H+L patients required any repeat dose during their ED visit. Time to repeat dose was 12 and 24 minutes in the D+M and H+L, respectively (P = 0.22). The adverse event rate was 2.9% in each group. CONCLUSION AND RELEVANCE IM D+M resulted in a lower rate of repeat doses of acute agitation medication compared with IM H+L, though this was not statistically significant. Both therapies were safe, and the adverse event rate was low.
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Affiliation(s)
- Patrick J Allen
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Kendra E Johanson
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Kelly R Reveles
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Luke A Neff
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Ashley E Lock
- Department of Pharmacotherapy and Pharmacy Services, University Health, Antonio, TX, USA
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
- Pharmacotherapy Education & Research Center, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
- Department of Emergency Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Krenz JR, Medeiros K, Lupez K. Retrospective evaluation of ketamine versus droperidol on time to restraint removal in agitated emergency department patients. Am J Emerg Med 2023; 69:23-27. [PMID: 37031618 DOI: 10.1016/j.ajem.2023.03.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
PURPOSE Acute agitation and violent behavior in the emergency department (ED) can lead to significant patient morbidity and contribute to the growing problem of workplace violence against health care providers. To our knowledge, there is no available literature directly comparing intramuscular ketamine to intramuscular droperidol in ED patients presenting with undifferentiated agitation. The purpose of this investigation was to compare the effectiveness and safety of these agents for acute agitation in the ED. METHODS This was a retrospective observational study conducted at an urban, academic ED. The primary endpoint was time from the first dose of study medication to restraint removal. Safety endpoints included incidence of bradycardia (heart rate < 60 bpm), hypotension (systolic blood pressure < 90 mmHg), hypoxia (oxygen saturation < 90% or need for respiratory support), and incidence of intubation for ongoing agitation or respiratory failure. RESULTS An initial 189 patients were screened, of which, 92 met inclusion criteria. The median time from initial drug administration to restraint removal was 49 min (IQR 30, 168) in the ketamine group and 43 min (IQR 30, 80) in the droperidol group (Median difference 6 min; 95% CI [-7, 26]). There was no significant difference in rates of bradycardia (3% vs 3%, 95% CI [-7%, 8%]), hypotension (0% vs 2%, 95% CI [-5%, 2%]), or hypoxia (7% vs 10%, 95% CI [-15%, 9%]) in the ketamine versus droperidol groups respectively. One patient in the ketamine group was intubated for ongoing agitation, and one patient in the droperidol group was intubated for respiratory failure. CONCLUSIONS Intramuscular droperidol and intramuscular ketamine were associated with similar times from drug administration to restraint removal in patients presenting to the ED with undifferentiated agitation. Prospective studies are warranted to evaluate IM droperidol and IM ketamine head-to-head as first line agents for acute agitation in the ED.
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7
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Siegel RB, Motov SM, Marcolini EG. Droperidol Use in the Emergency Department: A Clinical Review. J Emerg Med 2023; 64:289-294. [PMID: 36925442 DOI: 10.1016/j.jemermed.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 11/21/2022] [Accepted: 12/13/2022] [Indexed: 03/17/2023]
Abstract
BACKGROUND Droperidol is a butyrophenone, with antiemetic, sedative, anxiolytic, and analgesic properties. Although droperidol was once widely used in both emergency and perioperative settings, use of the medication declined rapidly after a 2001 U.S. Food and Drug Administration (FDA) boxed warning called the medication's safety into question. OBJECTIVE The purpose of this clinical review was to provide evidence-based answers to questions about droperidol's safety and to examine its efficacy in its various clinical indications. DISCUSSION Droperidol is an effective sedative, anxiolytic, analgesic, and antiemetic medication. As a sedative, when compared with haloperidol, droperidol has faster onset, as well as greater efficacy, in patients experiencing acute psychosis, with no increase in adverse events. As an antiemetic, droperidol has been found to have equal or greater efficacy in reducing nausea and vomiting than ondansetron and metoclopramide, with similar adverse effects and the added effect of reducing the need for rescue analgesia in these patients. As an analgesic, droperidol is effective for migraines and has opioid-sparing effects when used to treat abdominal pain. Droperidol is a particularly useful adjunct in patients who are opioid-tolerant, whose pain is often difficulty to manage adequately. CONCLUSIONS Droperidol seems to be effective and safe, despite the boxed warning issued by the FDA. Droperidol is a powerful antiemetic, sedative, anxiolytic, antimigraine, and adjuvant to opioid analgesia and does not require routine screening with electrocardiography when used in low doses in otherwise healthy patients before administration in the emergency department.
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Affiliation(s)
- Rebecca B Siegel
- Department of Emergency Medicine, Brookdale University Hospital Medical Center, Brooklyn, New York
| | - Sergey M Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Evie G Marcolini
- Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Department of Emergency Medicine, Brookdale University Hospital Medical Center, Brooklyn, New York.
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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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Ramsden SC, Pergjika A, Janssen AC, Mudahar S, Fawcett A, Walkup JT, Hoffmann JA. A systematic review of the effectiveness and safety of droperidol for pediatric agitation in acute care settings. Acad Emerg Med 2022; 29:1466-1474. [PMID: 35490341 PMCID: PMC9622426 DOI: 10.1111/acem.14515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/14/2022] [Accepted: 04/27/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Agitation in children in acute care settings poses significant patient and staff safety concerns. While behavioral approaches are central to reducing agitation and oral medications are preferred, parenteral medications are used when necessary to promote safety. The goal of this systematic review was to evaluate the effectiveness and safety of an ultra-short-acting parenteral medication, droperidol, for the management of acute, severe agitation in children in acute care settings. METHODS A systematic review of randomized controlled trials, observational studies, and case series/reports examined the effectiveness and safety of parenteral droperidol for management of acute agitation in patients ≤21 years old in acute care settings. Effectiveness outcomes included time to sedation and need for a subsequent dose of medication. Safety outcomes were adverse effects such as QTc prolongation, hypotension, respiratory depression, and dystonic reactions. RESULTS A total of 431 unique articles were identified. Six articles met inclusion criteria: two in the prehospital setting, one in the emergency department, and three in the inpatient hospital setting. The articles included a prospective observational study, three retrospective observational studies, and two case reports. The largest study reported a median time to sedation of 14 min (interquartile range 10-20 min); other studies reported a time to sedation of 15 min or less. Across studies, 8%-22% of patients required a second dose of medication for ongoing agitation. The most frequent adverse effects were dystonic reactions and transient hypotension. One patient had QTc prolongation and another developed respiratory depression, but both had significant comorbidities that may have contributed. The risk of bias in included studies ranged from moderate to critical. CONCLUSIONS Existing data on droperidol for management of acute agitation in children suggest that droperidol is both effective and safe for acute, severe agitation in children. Data are limited by study designs that may introduce bias.
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Affiliation(s)
| | - Alba Pergjika
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Aron C. Janssen
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sukhraj Mudahar
- Department of Pharmacy, Children’s Hospital of Orange County, Orange, CA
| | - Andrea Fawcett
- Department of Clinical and Organizational Development, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL,Lurie Children’s Pediatric Research & Evidence Synthesis Center of Innovative Implementation Science & Engagement (PRECIISE): A JBI Affiliated Group, Chicago, IL
| | - John T. Walkup
- Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jennifer A. Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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Brown CS, Sarangarm P, Faine B, Rech MA, Flack T, Gilbert B, Howington GT, Laub J, Porter B, Slocum GW, Zepeski A, Zimmerman DE. A year ReviewED: Top emergency medicine pharmacotherapy articles of 2021. Am J Emerg Med 2022; 60:88-95. [DOI: 10.1016/j.ajem.2022.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/09/2022] [Accepted: 07/17/2022] [Indexed: 11/24/2022] Open
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Gettel CJ, Yiadom MYA, Bernstein SL, Grudzen CR, Nath B, Li F, Hwang U, Hess EP, Melnick ER. Pragmatic clinical trial design in emergency medicine: Study considerations and design types. Acad Emerg Med 2022; 29:1247-1257. [PMID: 35475533 PMCID: PMC9790188 DOI: 10.1111/acem.14513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/04/2022] [Accepted: 04/25/2022] [Indexed: 01/25/2023]
Abstract
Pragmatic clinical trials (PCTs) focus on correlation between treatment and outcomes in real-world clinical practice, yet a guide highlighting key study considerations and design types for emergency medicine investigators pursuing this important study type is not available. Investigators conducting emergency department (ED)-based PCTs face multiple decisions within the planning phase to ensure robust and meaningful study findings. The PRagmatic Explanatory Continuum Indicator Summary 2 (PRECIS-2) tool allows trialists to consider both pragmatic and explanatory components across nine domains, shaping the trial design to the purpose intended by the investigators. Aside from the PRECIS-2 tool domains, ED-based investigators conducting PCTs should also consider randomization techniques, human subjects concerns, and integration of trial components within the electronic health record. The authors additionally highlight the advantages, disadvantages, and rationale for the use of four common randomized study design types to be considered in PCTs: parallel, crossover, factorial, and stepped-wedge. With increasing emphasis on the conduct of PCTs, emergency medicine investigators will benefit from a rigorous approach to clinical trial design.
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Affiliation(s)
- Cameron J. Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, USA
| | - Maame Yaa A.B. Yiadom
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Erik P. Hess
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
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14
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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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15
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Peel M. Acute behavioural disturbance: recognition, assessment and management. Emerg Nurse 2022; 30:e2126. [PMID: 35357781 DOI: 10.7748/en.2022.e2126] [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: 02/08/2022] [Indexed: 11/09/2022]
Abstract
Acute behavioural disturbance (ABD) is a clinical emergency which typically affects overweight men in their mid-thirties who chronically misuse illicit stimulants. People with ABD are most likely to be seen in police custody or emergency departments, therefore nurses working in these areas must be able to recognise the signs and symptoms and know how to respond appropriately. Presentation varies, but the signs and symptoms commonly include extreme agitation, hyperthermia, hostility and exceptional strength without fatigue. Further, it is important to recognise that people with ABD are at risk of developing metabolic acidosis, hyperkalaemia, rhabdomyolysis or disseminated intravascular coagulation. This article gives an overview of ABD and describes the main elements of management and treatment.
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Affiliation(s)
- Matthew Peel
- Leeds Community Healthcare NHS Trust, Leeds, England
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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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Goldberg EM, Zullo AR, Beaudoin FL. When one size doesn't fit all: Agitation in older adults requires a tailored approach. Acad Emerg Med 2021; 28:1200-1201. [PMID: 33899982 DOI: 10.1111/acem.14267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Elizabeth M. Goldberg
- Department of Health Services, Policy, and Practice Brown University School of Public Health Providence Rhode Island USA
- Department of Emergency Medicine The Alpert Medical School of Brown University Providence Rhode Island USA
| | - Andrew R. Zullo
- Department of Health Services, Policy, and Practice Brown University School of Public Health Providence Rhode Island USA
| | - Francesca L. Beaudoin
- Department of Health Services, Policy, and Practice Brown University School of Public Health Providence Rhode Island USA
- Department of Emergency Medicine The Alpert Medical School of Brown University Providence Rhode Island USA
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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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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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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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