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Zanza C, Romenskaya T, Zuliani M, Piccolella F, Bottinelli M, Caputo G, Rocca E, Maconi A, Savioli G, Longhitano Y. Acute Traumatic Pain in the Emergency Department. Diseases 2023; 11:diseases11010045. [PMID: 36975594 PMCID: PMC10046963 DOI: 10.3390/diseases11010045] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/01/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Trauma is a major cause of mortality throughout the world. Traumatic pain—acute, sudden, or chronic—is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”. Patients’ perceptions of pain assessment and management have become an important criterion and relevant outcome measure for healthcare institutions. Several studies show that 60–70% of ER patients experience pain, and more than half of them express a feeling of sorrow, which can be moderate or severe, at triage. The few studies that have analyzed how pain is assessed and managed in these departments agree that approximately 70% of patients receive no analgesia or receive it with remarkable delay. Specifically, less than half of the patients receive treatment for pain during admission and 60% of discharged patients have higher intensity pain than at admission. Trauma patients are also the ones who most commonly report low satisfaction with pain management. Associated with this lack of satisfaction, we can describe the poor use of tools for measuring and recording pain, poor communication among caregivers, inadequate training in pain assessment and management, and widespread misconceptions among nurses about the reliability of patients’ estimation of pain. The aim of this article is to review the scientific literature to explore the methodologies of pain management in trauma patients attending the emergency room and analyzing their weaknesses as a starting point to improve the approach to this, unfortunately too often, underestimated issue. A literature search was performed using the major databases to identify relevant studies in indexed scientific journals. The literature showed that the multimodal approach in trauma patients is the best approach to pain management. It is becoming increasingly crucial to manage the patient on multiple fronts. Drugs acting on different pathways can be administered together at lower doses, minimizing risks. Every emergency department must have staff trained in the assessment and immediate management of pain symptoms as this allows the reduction of mortality and morbidity and shortens hospital stays, contributing to early mobilization, reduced hospital costs, and enhanced patient satisfaction and quality of life.
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Affiliation(s)
- Christian Zanza
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
- Correspondence:
| | - Tatsiana Romenskaya
- Department of Physiology and Pharmacology, Sapienza University of Rome, 00185 Rome, Italy
| | - Marta Zuliani
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Fabio Piccolella
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Maria Bottinelli
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Giorgia Caputo
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Eduardo Rocca
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Antonio Maconi
- Department of Integrated Research and Innovation Activities, Unit of Translational Medicine AON SS, Antonio e Biagio e Cesare Arrigo H, 15121 Alessandria, Italy
| | - Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
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Corwell BN, Motov SM, Davis N, Kim HK. Novel uses of ketamine in the emergency department. Expert Opin Drug Saf 2022; 21:1009-1025. [PMID: 35822534 DOI: 10.1080/14740338.2022.2100883] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : Ketamine is gaining renewed interest among healthcare providers due to its novel clinical applications in the emergency department (ED) setting. AREAS COVERED : This article provides a comprehensive discussion of ketamine's pharmacological properties, including safety profile and adverse effects, in addition to an overview of current evidence for ketamine (racemic formulation) in the management of ED patients with acute agitation, pain, and depression/suicide ideation. EXPERT OPINION : Ketamine is an effective adjunct to opioids, providing greater pain relief than morphine alone. As an analgesic agent, administration of ketamine (0.1-0.3 mg/kg IV) alone can provide analgesia similar to that of morphine in patients with acute visceral and musculoskeletal pain. Moreover, ketamine provides equal analgesic efficacy to morphine in a variety of chronic painful conditions including pain associated with cancer, vaso-occlusive pain crisis associated with sickle cell disease, and in patients with high opioid tolerance and/or opioid dependency. Available literature shows that ketamine (1-2mg/kg IV or 4-5 mg/kg IM) is a safe, rapid (<5 minutes) and effective tranquilization agent for ED patients with acute agitation. Finally, there is growing evidence that suggests ketamine may have a potential utility in the management of patients with self-harm ideation or acute depressive episodes. Intravenous infusion of ketamine (0.5 mg/kg over 40 mins) has been shown to produce an antidepressant effect and decrease in suicidal ideation within 4 hours with effects lasting up to one week.
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Affiliation(s)
- Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Sergey M Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY
| | - Natalie Davis
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
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Kroll MW, Hall CA, Bozeman WP, Luceri RM. The prone position paradox. MEDICINE, SCIENCE, AND THE LAW 2022; 62:233-235. [PMID: 34730057 DOI: 10.1177/00258024211051436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Mark W Kroll
- Department of Biomedical Engineering, California Polytechnical University, USA
| | - Christine A Hall
- Faculty of Medicine, 12358University of British Columbia, Canada
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Goyal A, Frawley J, Gappy R, Sandoval S, Chen NW, Crowe R, Swor R. Prehospital Ketamine Use in Pediatrics. PREHOSP EMERG CARE 2022; 27:360-365. [PMID: 35771721 DOI: 10.1080/10903127.2022.2096161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Introduction: Information regarding prehospital ketamine use in the pediatric population is limited as existing literature focuses primarily on critical care and air transport. Our objective was to describe patient characteristics among pediatric EMS patients who received ketamine. Secondarily, we assessed effectiveness, deviation from recommended dosing, and adverse outcomes of pediatric EMS patients who received ketamine.Methods: We conducted a retrospective data review of records from the ESO Data Collaborative for all 9-1-1 transports of pediatric patients (≤ 18 years of age) who received ketamine from 2019-2020. We categorized EMS primary impressions as a proxy for medication indication. We defined effectiveness as paramedic-identified clinical improvement, and pain relief as decrease in pain score ≥2 points between initial and final recording. Descriptive statistics were used to summarize clinical characteristics. Non-parametric Wilcoxon signed-rank test was used to assess change in pain score.Results: Out of 422,968 ground-ambulance pediatric patients, 1,291 received ketamine. They were predominately male (842, 65.2%), teenagers (median age 16, IQR: 13-17), Caucasian (810, 62.7%), and from urban areas (1,041, 80.6%). The most common EMS impressions were related to injuries (810, 62.7%) and behavior disorders (281, 21.8%). Only 980/1,291 (75.9%) had weights and identifiable routes recorded. Most patients (960, 74.4%) received single doses of ketamine, with EMS clinicians reporting improvement in 855 (89.1%) of 960 patients. Among non-behavioral emergency patients, 727/1,010 (72.0%) had pain scores recorded. Pain scores decreased significantly from a median of 8 (IQR: 4-10) to 2 (IQR: 0-6) (p < 0.001) with 59% (429) of 727 patients reporting pain score reductions of 2 or more points. Desaturation (<90% SpO2) events were noted to be minimal (1.8%). A small number (28, 2.2%) received positive pressure ventilation without advanced airway placement. No prehospital deaths were documented.Conclusion: In this large review of pediatric prehospital ketamine use, ketamine was primarily used for analgesia, but was frequently used for other indications. Most patients were observed to improve after ketamine use, with most injured patients reporting decreases in pain scores. We observed few significant adverse events related to ketamine use in this population.
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Affiliation(s)
- Ashima Goyal
- Division of Pediatric Emergency Medicine, Beaumont Hospital
| | - John Frawley
- Department of Emergency Medicine, Beaumont Hospital
| | - Revelle Gappy
- Oakland University William Beaumont School of Medicine
| | | | - Nai-Wei Chen
- Division of Informatics and Biostatistics, Beaumont Research Institute
| | | | - Robert Swor
- Department of Emergency Medicine, Beaumont Hospital
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Abebe Y, Hetmann F, Sumera K, Holland M, Staff T. The effectiveness and safety of paediatric prehospital pain management: a systematic review. Scand J Trauma Resusc Emerg Med 2021; 29:170. [PMID: 34895311 PMCID: PMC8665507 DOI: 10.1186/s13049-021-00974-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinically meaningful pain reduction with respect to severity and the adverse events of drugs used in prehospital pain management for children are areas that have not received sufficient attention. The present systematic review therefore aims to perform a comprehensive search of databases to examine the preferable drugs for prehospital pain relief in paediatric patients with acute pain, irrespective of aetiology. METHODS The systematic review includes studies from 2000 and up to 2020 that focus on children's prehospital pain management. The study protocol is registered in PROSPERO with registration no. CRD42019126699. Pharmacological pain management using any type of analgesic drug and in all routes of administration was included. The main outcomes were (1) measurable pain reduction (effectiveness) and (2) no occurrence of any serious adverse events. Searches were conducted in PubMed, Medline, Embase, CINAHL, Epistemonikos and Cochrane library. Finally, the risk of bias was assessed using the Joanna Briggs Institute (JBI) checklist and a textual narrative analysis was performed due to the heterogeneity of the results. RESULTS The present systematic review on the effectiveness and safety of analgesic drugs in prehospital pain relief in children identified a total of eight articles. Most of the articles reviewed identified analgesic drugs such as fentanyl (intranasal/IV), morphine (IV), methoxyflurane (inhalational) and ketamine (IV/IM). The effects of fentanyl, morphine and methoxyflurane were examined and all of the included analgesic drugs were evaluated as effective. Adverse events of fentanyl, methoxyflurane and ketamine were also reported, although none of these were considered serious. CONCLUSION The systematic review revealed that fentanyl, morphine, methoxyflurane and combination drugs are effective analgesic drugs for children in prehospital settings. No serious adverse events were reported following the administration of fentanyl, methoxyflurane and ketamine. Intranasal fentanyl and inhalational methoxyflurane seem to be the preferred drugs for children in pre-hospital settings due to their ease of administration, similar effect and safety profile when compared to other analgesic drugs. However, the level of evidence (LOE) in the included studies was only three or four, and further studies are therefore necessary.
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Affiliation(s)
- Yonas Abebe
- Department of Emergency and Critical Care Nursing, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
- Bachelor Programme in Paramedics, Institute of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway.
| | - Fredrik Hetmann
- Bachelor Programme in Paramedics, Institute of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway
| | | | - Matt Holland
- Library and Knowledge Services for NHS Ambulance Services in England, Bolton, UK
| | - Trine Staff
- Bachelor Programme in Paramedics, Institute of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway
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Coffey SK, Vakkalanka JP, Egan H, Wallace K, Harland KK, Mohr NM, Ahmed A. Outcomes Associated with Lower Doses of Ketamine by Emergency Medical Services for Profound Agitation. West J Emerg Med 2021; 22:1183-1189. [PMID: 34546896 PMCID: PMC8463066 DOI: 10.5811/westjem.2021.5.50845] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 05/25/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction Ketamine is commonly used to treat profound agitation in the prehospital setting. Early in ketamine’s prehospital use, intubation after arrival in the emergency department (ED) was frequent. We sought to measure the frequency of ED intubation at a Midwest academic medical center after prehospital ketamine use for profound agitation, hypothesizing that intubation has become less frequent as prehospital ketamine has become more common and prehospital dosing has improved. Methods We conducted a retrospective cohort study of adult patients receiving ketamine in the prehospital setting for profound agitation and transported to a midwestern, 60,000-visit, Level 1 trauma center between January 1, 2017–March 1, 2021. We report descriptive analyses of patient-level prehospital clinical data and ED outcomes. The primary outcome was proportion of patients intubated in the ED. Results A total of 78 patients received ketamine in the prehospital setting (69% male, mean age 36 years). Of the 42 (54%) admitted patients, 15 (36% of admissions) were admissions to the intensive care unit. Overall, 12% (95% confidence interval [CI]), 4.5–18.6%)] of patients were intubated, and indications included agitation (n = 4), airway protection not otherwise specified (n = 4), and respiratory failure (n = 1). Conclusion Endotracheal intubation in the ED after prehospital ketamine use for profound agitation in our study sample was found to be less than previously reported.
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Affiliation(s)
- Shaila K Coffey
- University of Iowa Carver College of Medicine, Department of Emergency Medicine, Iowa City, Iowa
| | - J Priyanka Vakkalanka
- University of Iowa Carver College of Medicine, Department of Emergency Medicine, Iowa City, Iowa.,University of Iowa Carver College of Public Health, Department of Epidemiology, Iowa City, Iowa
| | - Haley Egan
- University of Iowa Carver College of Medicine, Department of Emergency Medicine, Iowa City, Iowa
| | - Kelli Wallace
- University of Iowa Carver College of Medicine, Department of Emergency Medicine, Iowa City, Iowa
| | - Karisa K Harland
- University of Iowa Carver College of Medicine, Department of Emergency Medicine, Iowa City, Iowa.,University of Iowa Carver College of Public Health, Department of Epidemiology, Iowa City, Iowa
| | - Nicholas M Mohr
- University of Iowa Carver College of Medicine, Department of Emergency Medicine, Iowa City, Iowa.,University of Iowa Carver College of Public Health, Department of Epidemiology, Iowa City, Iowa.,University of Iowa Carver College of Medicine, Department of Anesthesia, Iowa City, Iowa
| | - Azeemuddin Ahmed
- University of Iowa Carver College of Medicine, Department of Emergency Medicine, Iowa City, Iowa.,University of Iowa Tippie College of Business, Iowa City, Iowa
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Barbic D, Andolfatto G, Grunau B, Scheuermeyer FX, Macewan B, Qian H, Wong H, Barbic SP, Honer WG. Rapid Agitation Control With Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial. Ann Emerg Med 2021; 78:788-795. [PMID: 34353650 DOI: 10.1016/j.annemergmed.2021.05.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/12/2021] [Accepted: 05/24/2021] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE We hypothesized that the use of intramuscular ketamine would result in a clinically relevant shorter time to target sedation. METHODS We conducted a randomized clinical trial comparing the rapidity of onset, level of sedation, and adverse effect profile of ketamine compared to a combination of midazolam and haloperidol for behavioral control of emergency department patients with severe psychomotor agitation. We included patients with severe psychomotor agitation measured by a Richmond Agitation Score (RASS) ≥+3. Patients in the ketamine group were treated with a 5 mg/kg intramuscular injection. Patients in the midazolam and haloperidol group were treated with a single intramuscular injection of 5 mg midazolam and 5 mg haloperidol. The primary outcome was the time, in minutes, from study medication administration to adequate sedation, defined as RASS ≤-1. Secondary outcomes included the need for rescue medications and serious adverse events. RESULTS Between June 30, 2018, and March 13, 2020, we screened 308 patients and enrolled 80. The median time to sedation was 14.7 minutes for midazolam and haloperidol versus 5.8 minutes for ketamine (difference 8.8 minutes [95% confidence interval (CI) 3.0 to 14.5]). Adjusted Cox proportional model analysis favored the ketamine arm (hazard ratio 2.43, 95% CI 1.43 to 4.12). Five (12.5%) patients in the ketamine arm and 2 (5.0%) patients in the midazolam and haloperidol arm experienced serious adverse events (difference 7.5% [95% CI -4.8% to 19.8%]). CONCLUSION In ED patients with severe agitation, intramuscular ketamine provided significantly shorter time to adequate sedation than a combination of intramuscular midazolam and haloperidol.
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Affiliation(s)
- David Barbic
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada.
| | - Gary Andolfatto
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Brian Grunau
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Bill Macewan
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Hong Qian
- Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Hubert Wong
- Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Skye P Barbic
- Centre for Health Evaluation & Outcomes Sciences, St. Paul's Hospital, Vancouver, BC, Canada; Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, BC, Canada
| | - William G Honer
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
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Fernandez AR, Bourn SS, Crowe RP, Bronsky ES, Scheppke KA, Antevy P, Myers JB. Out-of-Hospital Ketamine: Indications for Use, Patient Outcomes, and Associated Mortality. Ann Emerg Med 2021; 78:123-131. [PMID: 34112540 DOI: 10.1016/j.annemergmed.2021.02.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/16/2021] [Accepted: 02/19/2021] [Indexed: 01/08/2023]
Abstract
STUDY OBJECTIVE To describe out-of-hospital ketamine use, patient outcomes, and the potential contribution of ketamine to patient death. METHODS We retrospectively evaluated consecutive occurrences of out-of-hospital ketamine administration from January 1, 2019 to December 31, 2019 reported to the national ESO Data Collaborative (Austin, TX), a consortium of 1,322 emergency medical service agencies distributed throughout the United States. We descriptively assessed indications for ketamine administration, dosing, route, transport disposition, hypoxia, hypercapnia, and mortality. We reviewed cases involving patient death to determine whether ketamine could be excluded as a potential contributing factor. RESULTS Indications for out-of-hospital ketamine administrations in our 11,291 patients were trauma/pain (49%; n=5,575), altered mental status/behavioral indications (34%; n=3,795), cardiovascular/pulmonary indications (13%; n=1,454), seizure (2%; n=248), and other (2%; n=219). The highest median dose was for altered mental status/behavioral indications at 3.7 mg/kg (interquartile range, 2.2 to 4.4 mg/kg). Over 99% of patients (n=11,274) were transported to a hospital. Following ketamine administration, hypoxia and hypercapnia were documented in 8.4% (n=897) and 17.2% (n=1,311) of patients, respectively. Eight on-scene and 120 in-hospital deaths were reviewed. Ketamine could not be excluded as a contributing factor in 2 on-scene deaths, representing 0.02% (95% confidence interval 0.00% to 0.07%) of those who received out-of-hospital ketamine. Among those with in-hospital data, ketamine could not be excluded as a contributing factor in 6 deaths (0.3%; 95% confidence interval 0.1% to 0.7%). CONCLUSION In this large sample, out-of-hospital ketamine was administered for a variety of indications. Patient mortality was rare. Ketamine could not be ruled out as a contributing factor in 8 deaths, representing 0.07% of those who received ketamine.
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Affiliation(s)
- Antonio R Fernandez
- ESO, Inc, Austin, TX; Department of Emergency Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | | | | | - E Stein Bronsky
- Colorado Springs Fire Department, Colorado Springs, CO; El Paso County American Medical Response, Colorado Springs, CO; Plains to Peaks Regional Emergency Trauma Advisory Council, Colorado Springs, CO; El Paso-Teller County 911 Authority, Colorado Springs, CO
| | - Kenneth A Scheppke
- Florida Department of Health, Tallahassee, FL; Palm Beach County Fire Rescue, West Palm Beach, FL
| | - Peter Antevy
- Davie Fire and Rescue, Davie, FL; Coral Springs Fire Department, Coral Springs, FL; Southwest Ranches Fire Rescue, Southwest Ranches, FL
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Kim HK, Leonard JB, Corwell BN, Connors NJ. Safety and efficacy of pharmacologic agents used for rapid tranquilization of emergency department patients with acute agitation or excited delirium. Expert Opin Drug Saf 2021; 20:123-138. [PMID: 33327811 DOI: 10.1080/14740338.2021.1865911] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Management of patients with acute agitation or aggressive behavior can pose a significant challenge to health-care providers in emergency departments. Areas covered: This article provides a comprehensive review of the pharmacologic properties, efficacy, and safety profiles of select intramuscular (IM) sedative agents (i.e., antipsychotics, benzodiazepines, and ketamine) for rapid tranquilization. Expert opinion: Using antipsychotics and benzodiazepines - whether a single agent or combined - will have similar efficacy in producing sedation. But there are differences in the time to sedation depending on which agent is used. Based upon the available studies, droperidol (5-10 mg IM) and midazolam (5-10 mg IM) have the fastest onset of sedation when either is used as a single agent. When combination therapy is used, using midazolam with an antipsychotic agent, instead of lorazepam, may result in faster sedative effect. QT prolongation and torsades de pointes are uncommon adverse drug effects of antipsychotic administration. Ketamine is often reserved as a second-line agent when antipsychotics and benzodiazepines fail to produce the desired tranquilization. However, ketamine (5 mg/kg IM) is more frequently associated with airway compromise requiring endotracheal intubation. A low-dose of ketamine (2 mg/kg IM) may reduce the risk of airway compromise while providing adequate sedation.
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Affiliation(s)
- Hong K Kim
- Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - James B Leonard
- Maryland Poison Center, University of Maryland School of Pharmacy , Baltimore, MD, USA
| | - Brian N Corwell
- Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, MD, USA
| | - Nicholas J Connors
- Department of Emergency Medicine, HCA Healthcare Trident Medical Center , Charleston, SC, USA
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10
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Burket GA, Horowitz BZ, Hendrickson RG, Beauchamp GA. Endotracheal Intubation in the Pharmaceutical-Poisoned Patient: a Narrative Review of the Literature. J Med Toxicol 2021; 17:61-69. [PMID: 32394224 PMCID: PMC7785763 DOI: 10.1007/s13181-020-00779-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/08/2020] [Accepted: 04/16/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Endotracheal intubation (ETI) is an essential component of the supportive care provided to the critically ill patient with pharmaceutical poisoning; however, specific nuances surrounding intubation including techniques and complications in the context of pharmaceutical poisoning have not been well elucidated. DISCUSSION A search of the available literature on ETI in pharmaceutical-poisoned patients was undertaken using Medline, ERIC, Cochrane database, and PsycINFO using the following MeSH and keyword terms: ("toxicology" OR "poisons" OR "drug overdose" OR "poisoning") AND ("intubation, intratracheal" OR "intubation, endotracheal" OR "airway management" OR "respiration, artificial"). A hand-search was also performed when the literature in the above search required additional conceptual clarification, including using the "Similar Articles" feature of PubMed, along with reviewing articles' reference lists that discussed intubation in the context of a poisoning scenario. Articles with any discussion around the ETI process in the context of a pharmaceutical poisoning were then included. Intubation may be performed in patients poisoned with pharmaceuticals in the context of both single and multiple organ dysfunction including central and peripheral nervous system, pulmonary, or cardiovascular toxicity with hemodynamic instability, or localized effects resulting in mechanical airway obstruction. Certain classes of poisonings may require modifications to the standard rapid sequence induction airway management algorithm. CONCLUSIONS ETI is a key component of the supportive care provided to the patient poisoned by a pharmaceutical agent. Clinicians should be aware of the spectrum of toxicities that can necessitate intubation, as well as airway management nuances that are specific to various poisoning presentations.
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Affiliation(s)
- Glenn A Burket
- SCL Health St Mary's Medical Center, 2635 North 7th Street, Grand Junction, CO, 81501, USA
- Mesa County EMS, 215 Rice St, Grand Junction, CO, 81501, USA
| | - B Zane Horowitz
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
- Oregon Poison Center, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Robert G Hendrickson
- Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
- Oregon Poison Center, 3181 S.W. Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Gillian A Beauchamp
- Lehigh Valley Health Network Department of Emergency and Hospital Medicine, Division of Medical Toxicology, USF Morsani College of Medicine, Lehigh Valley Campus, Cedar Crest Boulevard & I-78, Allentown, PA, 18101, USA.
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11
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Prehospital sedation with ketamine vs. midazolam: Repeat sedation, intubation, and hospital outcomes. Am J Emerg Med 2020; 38:1748-1753. [DOI: 10.1016/j.ajem.2020.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 04/20/2020] [Accepted: 05/04/2020] [Indexed: 11/18/2022] Open
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12
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Kitch BB. Out-of-hospital ketamine: review of a growing trend in patient care. J Am Coll Emerg Physicians Open 2020; 1:183-189. [PMID: 33000033 PMCID: PMC7493477 DOI: 10.1002/emp2.12023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/31/2019] [Accepted: 01/21/2020] [Indexed: 11/18/2022] Open
Abstract
Ketamine is a unique medication with a long history of use in the emergency department. Out-of-hospital indications for ketamine have been explored and are currently expanding in some systems. This article provides background on ketamine history and pharmacology, its use in the hospital environment and possible applications for emergency medical services usage of this medication. Contraindications and adverse reactions are discussed to provide education on the nuances of ketamine administration and mitigation strategies. Out-of-hospital indications for ketamine are discussed including airway management, rapid sequence induction, analgesia, sedation, and treatment of excited delirium.
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Affiliation(s)
- Bryan B. Kitch
- Department of Emergency MedicineEast Carolina UniversityGreenvilleNorth Carolina
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Triple Therapeutic Effects of Ketamine in Prehospital Settings: Systematic Review. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2020. [DOI: 10.1007/s40138-020-00215-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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14
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Huebinger RM, Zaidi HQ, Tataris KL, Weber JM, Pearlman KS, Markul E, Stein-Spencer L, Richards CT. Retrospective Study of Midazolam Protocol for Prehospital Behavioral Emergencies. West J Emerg Med 2020; 21:677-683. [PMID: 32421519 PMCID: PMC7234702 DOI: 10.5811/westjem.2020.3.45552] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/08/2020] [Indexed: 12/01/2022] Open
Abstract
Introduction Agitated patients in the prehospital setting pose challenges for both patient care and emergency medical services (EMS) provider safety. Midazolam is frequently used to control agitation in the emergency department setting; however, limited data exist in the prehospital setting. We describe our experience treating patients with midazolam for behavioral emergencies in a large urban EMS system. We hypothesized that using midazolam for acute agitation leads to improved clinical conditions without causing significant clinical deterioration. Methods We performed a retrospective review of EMS patient care reports following implementation of a behavioral emergencies protocol in a large urban EMS system from February 2014–June 2016. For acute agitation, paramedics administered midazolam 1 milligram (mg) intravenous (IV), 5 mg intramuscular (IM), or 5 mg intranasal (IN). Results were analyzed using descriptive statistics, Levene’s test for assessing variance among study groups, and t-test to evaluate effectiveness based on route. Results In total, midazolam was administered 294 times to 257 patients. Median age was 30 (interquartile range 24–42) years, and 66.5% were male. Doses administered were 1 mg (7.1%) and 5 mg (92.9%). Routes were IM (52.0%), IN (40.8%), and IV (7.1%). A second dose was administered to 37 patients. In the majority of administrations, midazolam improved the patient’s condition (73.5%) with infrequent adverse events (3.4%). There was no significant difference between the effectiveness of IM and IN midazolam (71.0% vs 75.4%; p = 0.24). Conclusion A midazolam protocol for prehospital agitation was associated with reduced agitation and a low rate of adverse events.
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Affiliation(s)
- Ryan M Huebinger
- McGovern Medical School at The University of Texas Health Science Center at Houston (UT Health), Department of Emergency Medicine, Houston, Texas
| | - Hashim Q Zaidi
- University of Chicago Pritzker School of Medicine, Section of Emergency Medicine, Chicago, Illinois.,Chicago Emergency Medical Services System, Chicago, Illinois
| | - Katie L Tataris
- University of Chicago Pritzker School of Medicine, Section of Emergency Medicine, Chicago, Illinois.,Chicago Emergency Medical Services System, Chicago, Illinois
| | - Joseph M Weber
- Chicago Emergency Medical Services System, Chicago, Illinois.,John H. Stroger, Jr., Hospital of Cook County, Department of Emergency Medicine, Chicago, Illinois
| | - Kenneth S Pearlman
- Chicago Emergency Medical Services System, Chicago, Illinois.,Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Eddie Markul
- Chicago Emergency Medical Services System, Chicago, Illinois.,Advocate Illinois Masonic Medical Center, Department of Emergency Medicine, Chicago, Illinois
| | - Leslee Stein-Spencer
- Chicago Emergency Medical Services System, Chicago, Illinois.,Illinois Department of Public Health, Springfield, Illinois
| | - Christopher T Richards
- Chicago Emergency Medical Services System, Chicago, Illinois.,Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois.,Northwestern Feinberg School of Medicine Center for Healthcare Studies, Institute for Public Health and Medicine, Chicago, Illinois.,University of Cincinnati School of Medicine, Division of EMS, Department of Emergency Medicine, Cincinnati, Ohio
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15
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Abstract
OBJECTIVE Analgesia in the prehospital setting is an extremely important, yet controversial topic. Ketamine, a N-methyl D-aspartate (NMDA) receptor antagonist, has been commonly used in the prehospital setting, including recommendations by the US Department of Defense and by the Royal Australian College of Pain Medicine, despite the paucity of high-level evidence. METHODS Accordingly, a review of the literature was conducted using several electronic medical literature databases from the earliest available records to the time at which the search was conducted (October 2018). RESULTS The search strategy yielded a total of 707 unique papers, of which 43 were short-listed for full review, and ultimately, ten papers were identified as meeting all the relevant inclusion criteria. The included studies varied significantly in the prehospital context and in the means of administering ketamine. There was only low-grade evidence that ketamine offered a safe and effective analgesia when used as the only analgesic, and only low-grade evidence that it was as effective as alternative opioid options. However, there was moderate evidence that co-administration of ketamine with morphine may improve analgesic efficacy and reduce morphine requirement. CONCLUSIONS Overall, ketamine as a prehospital analgesic may be best used in combination with opioids to reduce opioid requirement. It is suggested that future studies should use a standardized approach to measuring pain reduction. Future studies should also investigate short-term side effects and long-term complications or benefits of prehospital ketamine.
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Brendt P, Mathews A, Greenberg R, Arnold M. Autistic Man Falling Through the Cracks: Advanced Patient Transport and the "Pop-up" Recovery Ward. PREHOSP EMERG CARE 2018; 23:578-579. [PMID: 30501448 DOI: 10.1080/10903127.2018.1555296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The Royal Flying Doctor Service was tasked to relocate a 19 year-old autistic patient with severe social anxiety, agoraphobia, and morbid obesity from one residential location to another. The retrieval team was confronted with two main challenges: 1) Continuous risk elevation in an elective patient transportation as distinct from other urgent prehospital transfers of mental health patients; and 2) prehospital ketamine/propofol sedation of an aggressive/combative patient with recovery from sedation in a private property. The transfer accomplished the successful relocation of the patient.
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17
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Barbic D, Andolfatto G, Grunau B, Scheuermeyer FX, MacEwan W, Honer WG, Wong H, Barbic SP. Rapid agitation control with ketamine in the emergency department (RACKED): a randomized controlled trial protocol. Trials 2018; 19:651. [PMID: 30477544 PMCID: PMC6258312 DOI: 10.1186/s13063-018-2992-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 10/16/2018] [Indexed: 01/26/2023] Open
Abstract
Background The rapid control of patients presenting to the emergency department (ED) with psychomotor agitation and violent behavior is paramount for the safety of patients and ED staff. The use of intramuscular (IM) ketamine in the pre-hospital and ED settings has demonstrated promising preliminary results to provide rapid and safe behavioral control. A prospective, randomized controlled trial is required to measure the potential superiority of IM ketamine compared to current standard care (IM benzodiazepines plus antipsychotics). Methods This will be a parallel, prospective, randomized, controlled trial of 5 mg/kg IM ketamine compared to a combination of 5 mg IM midazolam and 5 mg IM haloperidol. The study will enroll approximately 184 patients, randomized equally to two study arms. There will be one study visit during which study medication will be administered and assessments will be completed. A follow-up safety visit will occur on day 3. The primary objective of this study is to compare IM ketamine to a combination of IM midazolam and haloperidol with regards to the time required for adequate behavioral control, in minutes, in patients presenting to the ED with psychomotor agitation and violent behavior, as measured by the Richmond Agitation-Sedation Scale (RASS). Discussion We present a novel study to determine whether ketamine is a rapid and safe option, compared to a combination of midazolam and haloperidol for the sedation of patients presenting to the ED with psychomotor agitation and violent behavior. To our knowledge, this study is the first randomized controlled trial to compare ketamine to current standard care for this indication. We have attempted to address numerous logistical issues with the design of this study including a waiver of consent, ensuring adequate blinding of outcome assessors, patient enrolment, and data monitoring. Trial registration Clinicaltrials.gov, NCT03375671. Registered on 18 December 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2992-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Barbic
- Department of Emergency Medicine, St Paul's Hospital, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada. .,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada.
| | - Gary Andolfatto
- Department of Emergency Medicine, Lion's Gate Hospital, 231 15th St E, North Vancouver, BC, Canada
| | - Brian Grunau
- Department of Emergency Medicine, St Paul's Hospital, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada.,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada
| | - Frank X Scheuermeyer
- Department of Emergency Medicine, St Paul's Hospital, 1081 Burrard St, Vancouver, BC, V6Z 1Y6, Canada.,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada
| | - William MacEwan
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - William G Honer
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Hubert Wong
- School of Public Health and Epidemiology, University of British Columbia, Vancouver, BC, Canada.,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada
| | - Skye P Barbic
- Department of Occupational Science and Occupational Therapy, Vancouver, BC, Canada.,Centre for Health Evaluation Outcome Sciences, Vancouver, BC, Canada
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18
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Heydari F, Gholamian A, Zamani M, Majidinejad S. Effect of Intramuscular Ketamine versus Haloperidol on Short-Term Control of Severe Agitated Patients in Emergency Department; A Randomized Clinical Trial. Bull Emerg Trauma 2018; 6:292-299. [PMID: 30402516 PMCID: PMC6215072 DOI: 10.29252/beat-060404] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective To evaluate the efficacy and safety of intramuscular ketamine and haloperidol in sedation of severely agitated patients in emergency department (ED). Methods This randomized, double-blind clinical trial study was performed on agitated patients referring to two university educational hospitals. Patients were randomly assigned to receive intramuscular (IM) haloperidol (5 mg) or IM ketamine (4 mg/kg). The primary outcome was time to adequate sedation (AMSS ≤ +1). Secondary outcomes included the need for additional sedatives, required intubation, duration of hospitalization, and side effects. Results The 90 agitated patients were enrolled. The mean age was 30.37±7.36 years (range 18-56); 74% (67/90) were men. The mean time to adequate sedation in ketamine group (7.73 ± 4.71 minutes) was significantly lower than haloperidol group (11.42 ± 7.20 minutes) (p= 0.005). 15 minutes after intervention, the sedation score did not differ significantly in both groups (Ketamine:0.14 ± 0.59 vs. Haloperidol: 0.30 ± 0.60; p=0.167). The incidence of complications was not significantly different between groups. The physician's satisfaction from the patients' aggression control was significantly higher in ketamine group. Conclusion These data suggest ketamine may be used for short-term control of agitated patients, additional studies are needed to confirm if ketamine is safe in this patient population. Given rapid effective sedation and the higher physician satisfaction of ketamine in comparison to haloperidol, it may be considered as a safe and appropriate alternative to haloperidol.IRCT Code: IRCT20180129038549N5.
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Affiliation(s)
- Farhad Heydari
- Emergency Medicine Research Center, Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Gholamian
- Department of Emergency Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Majid Zamani
- Emergency Medicine Research Center, Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeed Majidinejad
- Emergency Medicine Research Center, Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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19
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Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis. J Emerg Med 2018; 55:670-681. [PMID: 30197153 DOI: 10.1016/j.jemermed.2018.07.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 07/06/2018] [Accepted: 07/11/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Rapid tranquilization of agitated patients can prevent injuries and expedite care. Whereas antipsychotics and benzodiazepines are commonly used for this purpose, ketamine has been suggested as an alternative. OBJECTIVE The aim of this systematic review is to determine the safety and effectiveness of ketamine to sedate prehospital and emergency department (ED) patients with undifferentiated agitation. METHODS Studies and case series of patients receiving ketamine for agitation were included. Studies were excluded if ketamine was used for analgesia, procedural sedation, asthma, or induction. Information sources included traditional and gray literature. RESULTS The initial search yielded 1176 results from 14 databases. After review of titles and abstracts, 32 studies were reviewed and 18 were included in the analysis, representing 650 patient encounters. The mean dose of ketamine was 315 mg (SD 52) given intramuscularly, with adequate sedation achieved in 7.2 min (SD 6.2, range 2-500). Intubation occurred in 30.5% of patients (95% confidence interval [CI] 27.0-34.1%). In the majority of those patients, ketamine was administered by paramedics during ground transport and the patient was intubated on ED arrival. When ketamine was administered in the ED, the intubation rate was 1.8% (95% CI 0.0-4.4%); in air medical transport, the rate was 4.9% (95% CI 0.0-10.3%). Other reported side effects included: vomiting, 5.2% (2.3-8.1%); hypertension, 12.1% (5.7-18.6%); emergence reactions, 3.5% (1.4-5.6%); transient hypoxia, 1.8% (0.1-3.6%) and laryngospasm, 1.3% (0.3-2.3%). CONCLUSIONS Ketamine provides rapid sedation for undifferentiated agitated patients and is associated with higher intubation rates when used by ground Emergency Medical Services paramedics, compared with ED or air medical transport patients. Other side effects are common but usually self-limiting.
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20
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Gonin P, Beysard N, Yersin B, Carron P. Excited Delirium: A Systematic Review. Acad Emerg Med 2018; 25:552-565. [PMID: 28990246 DOI: 10.1111/acem.13330] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/18/2017] [Accepted: 10/02/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVE We aimed to clarify the definition, epidemiology, and pathophysiology of excited delirium syndrome (ExDS) and to summarize evidence-based treatment recommendations. METHODS We conducted a systematic literature search of MEDLINE, Ovid, Web of Knowledge, and Cochrane Library for articles published to March 18, 2017. We also searched the gray literature (Google Scholar) and official police or medical expert reports to complete specific epidemiologic data. Search results and full-text articles were independently assessed by two investigators and agreements between reviewers assessed with K statistics. We classified articles by study type, setting, and evidence level. RESULTS After reviewing the title and abstract of 3,604 references, we fully reviewed 284 potentially relevant references, from which 66 were selected for final review. Six contributed to the definition of ExDS, 24 to its epidemiology, 38 to its pathophysiology, and 27 to its management. The incidence of ExDS varies widely with medical or medicolegal context. Mortality is estimated to be as much as 8.3% to 16.5%. Patients are predominantly male. Male sex, young age, African-American race, and being overweight are independent risk factors. Pathophysiology hypotheses mostly implicate dopaminergic pathways. Most cases occur with psychostimulant use or among psychiatric patients or both. Proposed treatments are symptomatic, often with rapid sedation with benzodiazepines or antipsychotic agents. Ketamine is suggested as an alternative. CONCLUSION The overall quality of studies was poor. A universally recognized definition is lacking, remaining mostly syndromic and based on clinical subjective criteria. High mortality rate may be due to definition inconsistency and reporting bias. Our results suggest that ExDS is a real clinical entity that still kills people and that has probably specific mechanisms and risk factors. No comparative study has been performed to conclude whether one treatment approach is preferable to another in the case of ExDS.
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Affiliation(s)
- Philippe Gonin
- Emergency Department Lausanne University Hospital CHUV Lausanne Switzerland
| | - Nicolas Beysard
- Emergency Department Lausanne University Hospital CHUV Lausanne Switzerland
| | - Bertrand Yersin
- Emergency Department Lausanne University Hospital CHUV Lausanne Switzerland
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21
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Linder LM, Ross CA, Weant KA. Ketamine for the Acute Management of Excited Delirium and Agitation in the Prehospital Setting. Pharmacotherapy 2017; 38:139-151. [DOI: 10.1002/phar.2060] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Lauren M. Linder
- Pharmacy Services; Medical University of South Carolina; Charleston South Carolina
| | - Clint A. Ross
- Pharmacy Services; Medical University of South Carolina; Charleston South Carolina
- South Carolina College of Pharmacy; Columbia South Carolina
| | - Kyle A. Weant
- Pharmacy Services; Medical University of South Carolina; Charleston South Carolina
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22
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23
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Nazarian DJ, Broder JS, Thiessen ME, Wilson MP, Zun LS, Brown MD, Brown MD, Byyny R, Diercks DB, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Ingalsbe GS, Kaji A, Kwok H, Lo BM, Mace SE, Nazarian DJ, Proehl JA, Promes SB, Shah KH, Shih RD, Silvers SM, Smith MD, Thiessen ME, Tomaszewski CA, Valente JH, Wall SP, Wolf SJ, Cantrill SV, O'Connor RE, Hirshon JM, Whitson RR. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Ann Emerg Med 2017; 69:480-498. [DOI: 10.1016/j.annemergmed.2017.01.036] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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24
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Hollis GJ, Keene TM, Ardlie RM, Caldicott DGE, Stapleton SG. Prehospital ketamine use by paramedics in the Australian Capital Territory: A 12 month retrospective analysis. Emerg Med Australas 2016; 29:89-95. [DOI: 10.1111/1742-6723.12685] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 07/24/2016] [Accepted: 08/21/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Gregory J Hollis
- Emergency Department and Capital Region Retrieval Service; Canberra Hospital; Canberra Australian Capital Territory Australia
| | - Toby M Keene
- Quality, Safety and Risk Management; ACT Ambulance Service; Canberra Australian Capital Territory Australia
| | - Rory M Ardlie
- Emergency Department and Capital Region Retrieval Service; Canberra Hospital; Canberra Australian Capital Territory Australia
| | - David GE Caldicott
- Emergency Department; Calvary Health Care; Canberra Australian Capital Territory Australia
| | - Stuart G Stapleton
- Emergency Department; Calvary Health Care; Canberra Australian Capital Territory Australia
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25
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Abstract
AbstractBackgroundProfound agitation in the prehospital setting confers substantial risk to patients and providers. Optimal chemical sedation in this setting remains unclear.ObjectiveThe goal of this study was to describe intubation rates among profoundly agitated patients treated with prehospital ketamine and to characterize clinically significant outcomes of a prehospital ketamine protocol.MethodsThis was a retrospective cohort study of all patients who received prehospital ketamine, per a predefined protocol, for control of profound agitation and who subsequently were transported to an urban Level 1 trauma center from May 1, 2010 through August 31, 2013. Identified records were reviewed for basic ambulance run information, subject characteristics, ketamine dosing, and rate of intubation. Emergency Medical Services (EMS) ambulance run data were matched to hospital-based electronic medical records. Clinically significant outcomes are characterized, including unadjusted and adjusted rates of intubation.ResultsOverall, ketamine was administered 227 times in the prehospital setting with 135 cases meeting study criteria of use of ketamine for treatment of agitation. Endotracheal intubation was undertaken for 63% (85/135) of patients, including attempted prehospital intubation in four cases. Male gender and late night arrival were associated with intubation in univariate analyses (χ2=12.02; P=.001 and χ2=5.34; P=.021, respectively). Neither ketamine dose, co-administration of additional sedating medications, nor evidence of ethanol (ETOH) or sympathomimetic ingestion was associated with intubation. The association between intubation and both male gender and late night emergency department (ED) arrival persisted in multivariate analysis. Neither higher dose (>5mg/kg) ketamine nor co-administration of midazolam or haloperidol was associated with intubation in logistic regression modeling of the 120 subjects with weights recorded. Two deaths were observed. Post-hoc analysis of intubation rates suggested a high degree of provider-dependent variability.ConclusionsPrehospital ketamine is associated with a high rate of endotracheal intubation in profoundly agitated patients; however, ketamine dosing is not associated with intubation rate when adjusted for potential confounders. It is likely that factors not included in this analysis, including both provider comfort with post-ketamine patients and anticipated clinical course, play a role in the decision to intubate patients who receive prehospital ketamine.OlivesTD, NystromPC, ColeJB, DoddKW, HoJD. Intubation of profoundly agitated patients treated with prehospital ketamine. Prehosp Disaster Med. 2016;31(6):593–602.
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Prehospital Ketamine is a Safe and Effective Treatment for Excited Delirium in a Community Hospital Based EMS System. Prehosp Disaster Med 2016; 31:563-9. [PMID: 27517801 DOI: 10.1017/s1049023x16000662] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Excited delirium syndrome (ExDS) is defined by marked agitation and confusion with sympathomimetic surge and incessant physical struggle, despite futility, which may lead to profound pathophysiologic changes and sudden death. Severe metabolic derangements, including lactic acidosis, rhabdomyolysis, and hyperthermia, occur. The pathophysiology of excited delirium is a subject of ongoing basic science and clinical research. Positive associations with ExDS include male gender, mental health disorders, and substance abuse (especially sympathomimetics). Excited delirium syndrome patients often exhibit violent, psychotic behavior and have "superhuman" strength which can result in the patient fighting with police and first responders. Continued struggle can cause a patient with ExDS to experience elevated temperature (T) and acidosis which causes enzymes to fail, leading to sudden death from cardiovascular collapse and multi-system organ failure. Therefore, effective early sedation is optimal to stop this fulminant process. Treatment of ExDS must be focused on rapidly, safely, and effectively sedating the patient and providing intensive, supportive care. Benzodiazepines, like midazolam, may not be ideal to sedate ExDS patients since their onset takes several minutes, and their side effects include loss of airway control and respiratory depression. Injectable antipsychotic medications have a relatively slow onset and may cause prolongation of the QTc interval. Ketamine is the ideal medication to sedate patients with ExDS. Ketamine has a rapid, predictable onset within three to four minutes when given by intramuscular (IM) injection. It does not adversely affect airway control, breathing, heart rate, or blood pressure (BP). In this retrospective case series, prehospital scenarios in which ExDS patients received ketamine by paramedics for sedation, and their subsequent treatment in the emergency department (ED) and hospital, are described. It is demonstrated that ketamine administered by paramedics in the prehospital setting of a community hospital based Emergency Medical Services (EMS) system is a safe and effective treatment for ExDS. Scaggs TR , Glass DM , Hutchcraft MG , Weir WB . Prehospital ketamine is a safe and effective treatment for excited delirium in a community hospital based EMS system. Prehosp Disaster Med. 2016;31(5):563-569.
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27
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Hayes BD. Ketamine for agitation: a key cog in the prehospital treatment armamentarium wheelhouse. Clin Toxicol (Phila) 2016; 54:545-6. [DOI: 10.1080/15563650.2016.1180391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Bryan D. Hayes
- Department of Pharmacy, University of Maryland Medical Center and Department of Emergency Medicine University of Maryland School of Medicine, Baltimore, MD, USA
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29
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Cole JB, Moore JC, Nystrom PC, Orozco BS, Stellpflug SJ, Kornas RL, Fryza BJ, Steinberg LW, O’Brien-Lambert A, Bache-Wiig P, Engebretsen KM, Ho JD. A prospective study of ketamine versus haloperidol for severe prehospital agitation. Clin Toxicol (Phila) 2016; 54:556-62. [DOI: 10.1080/15563650.2016.1177652] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Jon B. Cole
- Minnesota Poison Control System, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Johanna C. Moore
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Paul C. Nystrom
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Benjamin S. Orozco
- Minnesota Poison Control System, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | | | - Rebecca L. Kornas
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Brandon J. Fryza
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Lila W. Steinberg
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Alex O’Brien-Lambert
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Peter Bache-Wiig
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | | | - Jeffrey D. Ho
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
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30
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Normandin PA, Khorey SJ, Donahue MA, Benotti SA, Manning BA. Use of Intranasal Ketamine for the Severely Agitated or Violent ED Patient. J Emerg Nurs 2016; 42:61-3. [DOI: 10.1016/j.jen.2015.09.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Deal N, Hong M, Matorin A, Shah AA. Stabilization and Management of the Acutely Agitated or Psychotic Patient. Emerg Med Clin North Am 2015; 33:739-52. [DOI: 10.1016/j.emc.2015.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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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. Prehosp Disaster Med 2015; 30:491-5. [PMID: 26323511 DOI: 10.1017/s1049023x15004999] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Ketamine Use for Acute Agitation in the Emergency Department. J Emerg Med 2015; 48:712-9. [DOI: 10.1016/j.jemermed.2015.02.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 01/15/2015] [Accepted: 02/21/2015] [Indexed: 11/19/2022]
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Richards JR, Albertson TE, Derlet RW, Lange RA, Olson KR, Horowitz BZ. Treatment of toxicity from amphetamines, related derivatives, and analogues: a systematic clinical review. Drug Alcohol Depend 2015; 150:1-13. [PMID: 25724076 DOI: 10.1016/j.drugalcdep.2015.01.040] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 12/24/2014] [Accepted: 01/28/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Overdose of amphetamine, related derivatives, and analogues (ARDA) continues to be a serious worldwide health problem. Patients frequently present to the hospital and require treatment for agitation, psychosis, and hyperadrenegic symptoms leading to pathologic sequelae and mortality. OBJECTIVE To review the pharmacologic treatment of agitation, psychosis, and the hyperadrenergic state resulting from ARDA toxicity. METHODS MEDLINE, PsycINFO, and the Cochrane Library were searched from inception to September 2014. Articles on pharmacologic treatment of ARDA-induced agitation, psychosis, and hyperadrenergic symptoms were selected. Evidence was graded using Oxford CEBM. Treatment recommendations were compared to current ACCF/AHA guidelines. RESULTS The search resulted in 6082 articles with 81 eligible treatment involving 835 human subjects. There were 6 high-quality studies supporting the use of antipsychotics and benzodiazepines for control of agitation and psychosis. There were several case reports detailing the successful use of dexmedetomidine for this indication. There were 9 high-quality studies reporting the overall safety and efficacy of β-blockers for control of hypertension and tachycardia associated with ARDA. There were 3 high-quality studies of calcium channel blockers. There were 2 level I studies of α-blockers and a small number of case reports for nitric oxide-mediated vasodilators. CONCLUSIONS High-quality evidence for pharmacologic treatment of overdose from ARDA is limited but can help guide management of acute agitation, psychosis, tachycardia, and hypertension. The use of butyrophenone and later-generation antipsychotics, benzodiazepines, and β-blockers is recommended based on existing evidence. Future randomized prospective trials are needed to evaluate new agents and further define treatment of these patients.
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Affiliation(s)
- John R Richards
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, United States.
| | - Timothy E Albertson
- Department of Internal Medicine, Divisions of Toxicology, Pulmonary and Critical Care, University of California Davis Medical Center, Sacramento, CA, United States; Northern California VA Medical System, Sacramento, CA, United States
| | - Robert W Derlet
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, United States
| | - Richard A Lange
- Department of Medicine, Division of Cardiology, University of Texas Health Sciences Center, San Antonio, TX, United States
| | - Kent R Olson
- Department of Medicine, University of California, San Francisco, CA, United States; Department of Clinical Pharmacy, University of California, San Francisco, California Poison Control System, San Francisco Division, San Francisco, CA, United States
| | - B Zane Horowitz
- Department of Emergency Medicine, Oregon Health Sciences University, Oregon Poison Center, Portland, OR, United States
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XXXV International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 26–29 May 2015, St Julian's, Malta. Clin Toxicol (Phila) 2015. [DOI: 10.3109/15563650.2015.1024953] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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The association between ketamine given for prehospital chemical restraint with intubation and hospital admission. Am J Emerg Med 2015; 33:76-9. [DOI: 10.1016/j.ajem.2014.10.016] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 09/20/2014] [Accepted: 10/11/2014] [Indexed: 12/31/2022] Open
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Keseg D, Cortez E, Rund D, Caterino J. The Use of Prehospital Ketamine for Control of Agitation in a Metropolitan Firefighter-based EMS System. PREHOSP EMERG CARE 2014; 19:110-115. [PMID: 25153713 DOI: 10.3109/10903127.2014.942478] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract Introduction. Prehospital personnel frequently encounter agitated, combative, and intoxicated patients in the field. In recent years, ketamine has been described as an effective sedative agent to treat such patients; however, a paucity of research exists describing the use of prehospital ketamine. The objective of this study was to provide a descriptive analysis of the Columbus Division of Fire's experience with utilizing ketamine in the prehospital setting. We hypothesized that ketamine administration improves patient condition, is effective at sedating patients, and does not result in endotracheal intubation in the prehospital setting or in the emergency department (ED). Methods. We conducted a retrospective cohort chart review of Columbus Division of Fire patient care reports and hospital records from destination hospitals in the central Ohio region between October 2010 and October 2012. All patients receiving ketamine administered by Columbus Division of Fire personnel for sedation were included. Patients 17 years and younger were excluded. The primary outcome was the percentage of patients noted to have an "improved" condition recorded in the data field of the patient care report. The secondary outcomes were the effectiveness of sedation and the performance of endotracheal intubation. Results. A total of 36 patients met inclusion criteria over the study period. Data were available on 35 patients for analysis. The mean IV dose of ketamine was 138 mg (SD = 59.5, 100-200). The mean IM dose of ketamine was 324 mg (SD = 120, 100-500). Prehospital records noted an improvement in patient condition after ketamine administration in 32 cases (91%, 95% CI 77-98%). Six patients required sedation post-ketamine administration either by EMS (2) or in the ED (4) (17%, 95% CI 6.5-34%). Endotracheal intubation was performed in eight (23%, 95% CI 10-40%) patients post-ketamine administration. Conclusion. We found that in a cohort of patients administered ketamine, paramedics reported a subjective improvement in patient condition. Endotracheal intubation was performed in 8 patients.
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Wiel E, Zitouni D, Assez N, Sebilleau Q, Lys S, Duval A, Mauriaucourt P, Hubert H. Continuous Infusion of Ketamine for Out-of-hospital Isolated Orthopedic Injuries Secondary to Trauma: A Randomized Controlled Trial. PREHOSP EMERG CARE 2014; 19:10-16. [PMID: 24932670 DOI: 10.3109/10903127.2014.923076] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract Objective. Although ketamine has recently been demonstrated to provide a morphine-sparing effect, no previous study reports the effect of continuous infusion of ketamine for analgesia in out-of-hospital environments. The aim of this study was to compare the effect of a continuous infusion of ketamine (IK group) vs. a continuous infusion of saline (IS group) on morphine requirements in out-of-hospital trauma patients suffering from severe acute pain. Methods. In this prospective, multicenter, randomized, single-blind clinical study, patients suffering from isolated orthopedic injuries secondary to trauma with severe acute pain received a low-dose intravenous (IV) bolus of ketamine (0.2 mg·kg-1) combined with an IV bolus of morphine (0.1 mg·kg-1) and were randomized either in the IK group (IV continuous infusion of ketamine 0.2 mg·kg-1·h-1), or in the IS group (IV continuous infusion of saline at the same volume). The primary endpoint was morphine requirements in terms of total dose of morphine (excluding the baseline bolus) injected at the end of prehospital emergency care at hospital admission (final time, Tf). The secondary endpoint was evaluation of pain with visual analogic scale (VAS). Results. Sixty-six patients were enrolled. Total morphine dose was not significantly reduced with continuous infusion of ketamine (0.048 [0.000; 0.150] vs. 0.107 [0.052; 0.150] in IK and IS groups), with similar mean duration of care (median 35.0 min). Analgesia was as efficient without any significant difference in VAS at Tf between groups (3.1 ± 2.3 (IK group) vs. 3.7 ± 2.7 (IS group), p = 0.5). Conclusions. Continuous ketamine infusion did not reduce morphine requirements in severe acute pain trauma patients in the out-of-hospital emergency settings.
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Macht M, Mull AC, McVaney KE, Caruso EH, Johnston JB, Gaither JB, Shupp AM, Marquez KD, Haukoos JS, Colwell CB. Comparison of droperidol and haloperidol for use by paramedics: assessment of safety and effectiveness. PREHOSP EMERG CARE 2014; 18:375-80. [PMID: 24460451 DOI: 10.3109/10903127.2013.864353] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Abstract
New groups of synthetic "designer drugs" have increased in popularity over the past several years. These products mimic the euphoric effects of other well-known illicit drugs but are advertised as "legal" highs and are sold over the internet, at raves and night clubs, and in head shops. The 2C series drugs are ring-substituted phenethylamines that belong to a group of designer agents similar in structure to 3,4-methylenedioxy-N-methylamphetamine (MDMA, Ecstasy). Understanding the pharmacology and toxicology of these agents is essential in order to provide the best medical care for these patients. This review focuses on the pharmacology, pharmacokinetics, clinical effects, and treatment of 2C drug intoxication based on available published literature. Multiple names under which 2C drugs are sold were identified and tabulated. Common features identified in patients intoxicated with 2Cs included hallucinations, agitation, aggression, violence, dysphoria, hypertension, tachycardia, seizures, and hyperthermia. Patients may exhibit sympathomimetic symptoms or symptoms consistent with serotonin toxicity, but an excited delirium presentation seems to be consistent amongst deaths attributed to 2C drugs; at least five deaths have been reported in the literature in patients intoxicated with 2C drugs. 2C drugs are a group of designer intoxicants, many of which are marketed as legal, but may carry risks that consumers are unaware of. These drugs may be characterized by either serotonergic toxicity or a sympathomimetic toxidrome, but a presentation consistent with excited delirium is consistent amongst the reported 2C-related deaths. Treatment of 2C intoxication is primarily supportive, but immediate action is required in the context of excited delirium, hyperthermia, and seizure activity.
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Affiliation(s)
- Be Vang Dean
- />Clinical Toxicology Service and Department of Emergency Medicine, Regions Hospital, 640 Jackson St, St. Paul, MN 55101 USA
| | - Samuel J. Stellpflug
- />Clinical Toxicology Service and Department of Emergency Medicine, Regions Hospital, 640 Jackson St, St. Paul, MN 55101 USA
| | - Aaron M. Burnett
- />Regions Emergency Medical Services and Department of Emergency Medicine, Regions Hospital, St. Paul, MN USA
| | - Kristin M. Engebretsen
- />Clinical Toxicology Service and Department of Emergency Medicine, Regions Hospital, 640 Jackson St, St. Paul, MN 55101 USA
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Use and efficacy of nebulized naloxone in patients with suspected opioid intoxication. Am J Emerg Med 2013; 31:585-8. [DOI: 10.1016/j.ajem.2012.10.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 10/03/2012] [Accepted: 10/03/2012] [Indexed: 11/21/2022] Open
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