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Journal of Education & Teaching in... Oct 2020This scenario was developed to educate emergency medicine residents about the diagnosis and management of the agitated psychiatric patient.
AUDIENCE
This scenario was developed to educate emergency medicine residents about the diagnosis and management of the agitated psychiatric patient.
INTRODUCTION
The prevalence of agitation among patients in the emergency department is increasing, with an estimated 1.7 million events occurring annually in the United States.1 There are various methodologies for de-escalation, including verbal and chemical de-escalation and physical restraints. Chemical and/or physical restraints are sometimes necessary to ensure patient and staff safety when verbal de-escalation is ineffective, particularly since agitation is the leading cause of hospital staff injuries.2 Chemical restraints have been shown to be less physically traumatizing to patients.3 4 Adverse events associated with physical restraints include persistent psychological distress, blunt chest trauma, aspiration, respiratory depression, and asphyxiation leading to cardiac arrest.5 In regards to chemical restraints, adverse event reporting has been heterogeneous among studies, but the most consistent reported events involve respiratory compromise such as desaturation, airway obstruction, and respiratory depression.3 A study measuring QTc (corrected QT interval) after high-dose intramuscular ziprasidone or haloperidol did not demonstrate any QTc longer than 480 msec.6 Other events linked to chemical restraints include uncommon cardiovascular events and extrapyramidal side effects from medications.3 The main classes of medications utilized for chemical restraint include first-generation antipsychotics (eg, haloperidol and droperidol), second-generation antipsychotics (olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone), benzodiazipenes (eg, lorazepam and midazolam), and N-methyl-D-aspartic acid (NMDA) receptor antagonists (eg, ketamine).7,8 It is important to exclude other medical causes of agitation, consider the differential diagnoses, and then select a medication that is tailored to address underlying etiologies while remaining cognizant of the side effect profiles of these chemical agents.: At the conclusion of the simulation session, learners will be able to: 1) Obtain a relevant focused history and physical examination on the agitated psychiatric patient. 2) Develop a differential for the agitated psychiatric patient, including primary psychiatric conditions and other organic pathologies. 3) Discuss the management of the agitated psychiatric patient, including the different options available for chemical sedation. 4) Prioritize safety of self and staff when caring for an agitated psychiatric patient.
EDUCATIONAL METHODS
This session was conducted using simulation with a standardized patient, followed by a debriefing session and lecture on the presentation, differential diagnosis, and management of the agitated psychiatric patient. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board examination case.
RESEARCH METHODS
The residents are provided a survey at the completion of the debriefing session to rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. This survey is specific to the local institution's simulation center.
RESULTS
Feedback from the residents was overwhelmingly positive, although many stated that they felt some degree of intimidation or stress from the standardized patient who did not break from their role throughout the scenario.The local institution's simulation center feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form9 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. This session received mostly 7 scores (extremely effective/outstanding).
DISCUSSION
This is a physically safe method for reviewing management of the agitated psychiatric patient. There are multiple potential presentations of the agitated psychiatric patient, as well as varying underlying etiologies. These scenarios may be tailored to the needs of the learner, including identifying agitation, pharmacologic review, and de-escalation techniques.
TOPICS
Medical simulation, agitated psychiatric patient, chemical sedation, verbal de-escalation, emergency medicine, psychiatry.
PubMed: 37465334
DOI: 10.21980/J85352 -
The American Journal of Emergency... Mar 2022Droperidol is a butyrophenone that has recently been reintroduced after a United States Food and Drug Administration (US FDA) black box warning in 2001. Evidence...
INTRODUCTION
Droperidol is a butyrophenone that has recently been reintroduced after a United States Food and Drug Administration (US FDA) black box warning in 2001. Evidence demonstrates utility in a variety of clinical conditions.
OBJECTIVE
This paper provides evidence-based updates concerning the use of droperidol for the emergency clinician.
DISCUSSION
Droperidol received a black box warning by the US FDA in 2001 due to concerns for QT prolongation and torsades de pointes; however, reevaluation of the available data suggests droperidol is a safe and efficacious medication. It can be used in the emergency department (ED) setting for many conditions, including acute agitation, headaches, vertigo, nausea, and vomiting. Extensive literature supports that the QT-prolonging effects are transient and that the risk of torsades de pointes is rare with doses utilized in the ED. An electrocardiogram does not need to be routinely obtained before droperidol use but should be considered in patients at high risk for QT prolongation.
CONCLUSIONS
Current evidence suggests that droperidol is a safe and effective medication for treating nausea and vomiting, headache, vertigo, and agitation in the ED setting.
Topics: Droperidol; Emergency Medicine; Headache; Humans; Long QT Syndrome; Nausea; Torsades de Pointes; United States; Vertigo; Vomiting
PubMed: 35063889
DOI: 10.1016/j.ajem.2022.01.011 -
Best Practice & Research. Clinical... Dec 2020Postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) are frequent unpleasant complaints that patients and clinicians report after... (Review)
Review
Postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) are frequent unpleasant complaints that patients and clinicians report after surgery. PONV and PDNV have been associated with postoperative complications and hospital discharge delays. Despite the extensive evidence describing the use of several regimens in different surgical populations, the ideal regimen has not been established. Several antiemetic drugs have been evaluated in more than 1000 clinical controlled trials for management of this complex emetogenic pathway, including the 5-hydroxytryptamine (5-HT) receptor antagonists, dopamine receptor antagonists, neurokinin-type receptor antagonists, antihistaminics, anticholinergics, and corticosteroids, with the 5-HT receptor antagonists being the most commonly used for PONV prophylaxis. Because of the complex emetogenic pathway and multifactorial etiology of PONV, a multimodal approach using two or more drugs that act at different neuro-receptor sites is suggested in patients with one or more risk factors to successfully address PONV and reduce its incidence. Nevertheless, the most studied regimens in randomized clinical trials (RCTs) are the combination of serotonin 5-HT3 receptor antagonists with dexamethasone or dopamine receptor antagonists (droperidol). Therefore, the safest and more effective combination regimen appears to be the use of serotonin 5-HT3 receptor antagonist antiemetic drugs with dexamethasone.
Topics: Aftercare; Antiemetics; Dopamine Antagonists; Drug Therapy, Combination; Histamine Antagonists; Humans; Meta-Analysis as Topic; Patient Discharge; Postoperative Nausea and Vomiting; Risk Factors; Serotonin 5-HT3 Receptor Antagonists; Sex Factors; Systematic Reviews as Topic
PubMed: 33288120
DOI: 10.1016/j.bpa.2020.10.009 -
The Journal of Emergency Medicine Mar 2023Droperidol is a butyrophenone, with antiemetic, sedative, anxiolytic, and analgesic properties. Although droperidol was once widely used in both emergency and... (Review)
Review
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.
Topics: Humans; Analgesics; Analgesics, Opioid; Anti-Anxiety Agents; Antiemetics; Droperidol; Emergency Service, Hospital; Hypnotics and Sedatives; Ondansetron; Pain
PubMed: 36925442
DOI: 10.1016/j.jemermed.2022.12.012 -
The Medical Letter on Drugs and... Oct 2020
Topics: Acupuncture Therapy; Adult; Analgesics; Anti-Inflammatory Agents, Non-Steroidal; Antiemetics; Calcitonin Gene-Related Peptide Receptor Antagonists; Drug Interactions; Ergot Alkaloids; Female; Humans; Migraine Disorders; Pregnancy; Serotonin 5-HT1 Receptor Antagonists; Tryptamines
PubMed: 33434187
DOI: No ID Found -
Journal of Anesthesia Dec 2023Perioperative shivering is common and can occur as a result of hypothermia or changes in the threshold of thermoregulation. Droperidol usage for anesthesia is currently...
PURPOSE
Perioperative shivering is common and can occur as a result of hypothermia or changes in the threshold of thermoregulation. Droperidol usage for anesthesia is currently limited to its sedative and antiemetic effects. We investigated the effects of high and low doses of droperidol on the shivering threshold in rabbits.
METHODS
Forty-two male Japanese white rabbits were anesthetized with isoflurane and randomly assigned to the control, high-dose, or low-dose group. Rabbits in the high-dose group received a 5 mg/kg droperidol bolus followed by continuous infusion at 5 mg/kg/h, those in the low-dose group received a 0.5 mg/kg droperidol bolus, and those in the control group received the same volume of saline as the high-dose group. Body temperature was reduced at a rate of 2-3 °C/h, and the shivering threshold was defined as the subject's core temperature (°C) at the onset of shivering.
RESULTS
The shivering thresholds in the control, high-dose, and low-dose groups were 38.1 °C ± 1.1 °C, 36.7 °C ± 1.2 °C, and 36.9 °C ± 1.0 °C, respectively. The shivering thresholds were significantly lower in the high-dose and low-dose groups than in the control group (P < 0.01). The thresholds were comparable between the high-dose and low-dose groups.
CONCLUSIONS
Droperidol in high and low doses effectively reduced the shivering threshold in rabbits. Droperidol has been used in low doses as an antiemetic. Low doses of droperidol can reduce the incidence of shivering perioperatively and during the induction of therapeutic hypothermia.
Topics: Animals; Rabbits; Male; Shivering; Droperidol; Body Temperature; Isoflurane; Hypothermia
PubMed: 37566231
DOI: 10.1007/s00540-023-03240-1 -
Pediatrics Jul 2023Pediatric mental health emergency department (ED) visits are rising in the United States, with more visits involving medication for acute agitation. Timely, standardized...
BACKGROUND AND OBJECTIVES
Pediatric mental health emergency department (ED) visits are rising in the United States, with more visits involving medication for acute agitation. Timely, standardized implementation of behavioral strategies and medications may reduce the need for physical restraint. Our objective was to standardize agitation management in a pediatric ED and reduce time in physical restraints.
METHODS
A multidisciplinary team conducted a quality improvement initiative from September 2020 to August 2021, followed by a 6-month maintenance period. A barrier assessment revealed that agitation triggers were inadequately recognized, few activities were offered during long ED visits, staff lacked confidence in verbal deescalation techniques, medication choices were inconsistent, and medications were slow to take effect. Sequential interventions included development of an agitation care pathway and order set, optimization of child life and psychiatry workflows, implementation of personalized deescalation plans, and adding droperidol to the formulary. Measures include standardization of medication choice for severe agitation and time in physical restraints.
RESULTS
During the intervention and maintenance periods, there were 129 ED visits with medication given for severe agitation and 10 ED visits with physical restraint use. Among ED visits with medication given for severe agitation, standardized medication choice (olanzapine or droperidol) increased from 8% to 88%. Mean minutes in physical restraints decreased from 173 to 71.
CONCLUSIONS
Implementing an agitation care pathway standardized and improved care for a vulnerable and high-priority population. Future studies are needed to translate interventions to community ED settings and to evaluate optimal management strategies for pediatric acute agitation.
Topics: Humans; Child; United States; Droperidol; Quality Improvement; Psychomotor Agitation; Emergency Service, Hospital; Restraint, Physical
PubMed: 37317809
DOI: 10.1542/peds.2022-059586 -
The Annals of Pharmacotherapy Dec 2023Acute 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...
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 ( = 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 ( = 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.
Topics: Humans; Haloperidol; Midazolam; Lorazepam; Droperidol; Retrospective Studies; Psychomotor Agitation; Injections, Intramuscular; Antipsychotic Agents; Emergency Service, Hospital
PubMed: 36999520
DOI: 10.1177/10600280231163192 -
The Annals of Pharmacotherapy Aug 2019The purpose of this review is to summarize the current evidence of the off-label use of intravenous (IV) olanzapine and discuss its risks versus benefits for the... (Review)
Review
The purpose of this review is to summarize the current evidence of the off-label use of intravenous (IV) olanzapine and discuss its risks versus benefits for the management of agitation. : A literature search was conducted to gather relevant data regarding IV use of olanzapine for the management of acute agitation. PubMed, EMBASE, MEDLINE, and IPA were searched using the keywords and MESH terms: , and . : All case reports, and retrospective and prospective studies evaluating the efficacy and safety of IV olanzapine administration for agitation from January 2004 to December 2018 were analyzed. : Doses from 2.5 to 10 mg given as an IV bolus (maximum dose of 30 mg/d) have been administered. Rescue medications such as droperidol or parenteral benzodiazepines are sometimes coadministered to assist with achieving adequate sedation. Prospective studies demonstrate efficacy similar to droperidol in achieving adequate sedation within 10 minutes and similar time to onset of sedation. Rates of respiratory depression and airway obstruction are low and similar to that of comparative agents, including intramuscular olanzapine. This review evaluated the off-label use of IV olanzapine to manage agitation based on case reports, and retrospective and prospective data. : The use of IV olanzapine remains controversial in the absence of clear evidence evaluating safety and efficacy. Future studies are warranted comparing IV olanzapine with more commonly utilized and Food and Drug Administration-approved treatment modalities for acute agitation in the emergency department and other settings.
Topics: Antipsychotic Agents; Humans; Injections, Intravenous; Male; Off-Label Use; Olanzapine; Psychomotor Agitation; Treatment Outcome; United States
PubMed: 30758221
DOI: 10.1177/1060028019831634 -
Emergency Medicine Australasia : EMA Aug 2023A randomised single-blind trial was undertaken in an adult ED population, comparing the effectiveness of droperidol 2.5 mg IV with ondansetron 8 mg IV for the... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
A randomised single-blind trial was undertaken in an adult ED population, comparing the effectiveness of droperidol 2.5 mg IV with ondansetron 8 mg IV for the treatment of nausea and vomiting.
METHODS
Patients were randomly allocated to receive droperidol (n = 60) or ondansetron (n = 60). Patients rated their nausea severity on a Visual Analogue Scale (VAS) immediately before and 30 min after drug administration. The primary outcome was of symptom improvement, defined by a VAS change ≥-8 mm 30 min post-treatment. Mean VAS change and percentage experiencing desired effect were secondary outcomes compared.
RESULTS
Of 120 study patients, 60 (50%) received droperidol or ondansetron. Symptom improvement occurred in 93% (56 of 60) and 87% (52 of 60), respectively (P = 0.362). Mean VAS change was -38 mm and -29 mm, respectively (P = 0.031). Percentage of patients indicating desired effect was 85% and 63%, respectively (P = 0.006). Additional antiemetics were required for 16% and 37% of subjects, respectively (P = 0.006).
CONCLUSION
There was no statistically significant difference in the primary outcome of symptom improvement between droperidol and ondansetron. Secondary outcomes which favour droperidol warrant further exploration.
Topics: Adult; Humans; Droperidol; Ondansetron; Single-Blind Method; Postoperative Complications; Double-Blind Method; Nausea; Antiemetics; Emergency Service, Hospital
PubMed: 36755492
DOI: 10.1111/1742-6723.14174