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Conference 5/21/2020

Week nine of Virtual Conference is here. Thanks to last weeks’ lecturers for a great job, including our guest lecturers! This week we feature a guest lecture from Dr Christopher Trigger MD, (https://greatlakessmcc.com/about-us/provider-bios/christopher-trigger-md-caqsm/) an EM and Sports Medicine Physician who specializes in non-surgical orthopedics and concussions.

Head injuries and concussions are something we see on a frequent basis in the ED. Typically head injuries in peds (0-17) and >65 are secondary to falls (accounting for 49% and 81% of TBI related ED visits respectively)(1), and MVC injuries, and subsequently after that self inflicted and sports-related injuries.

But enough about the epidemiology – what you need to know is that the followup rate after being seen for a head injury in the ED is Dismal, even those with a positive finding on CT or who continue to experience postconcussive symptoms.

A study called the TRACK-TBI study (here) evaluated patients following up after TBI. They found of 831 patients in their sample population (289 [35%] female; 483 [58%] non-Hispanic white; mean [SD] age, 40.3 [16.9] years), that less than half self-reported receiving TBI educational material at discharge (353 patients [42%]) or seeing a physician or other health care practitioner within 3 months after injury (367 patients [44%]) (2).

Conclusions and Relevance:  There are gaps in follow-up care for patients with mTBI after hospital discharge.(2) Patients need to be emphasized the need for proper followup, post concussive care, and from a legal standpoint – need for graded evaluation and clearance for return to play guidelines, especially in the current climate of sports related TBI. You can read how Northwestern University implemented a protocol (here) that improved their followup from 8.6% to 22%.

In Other News

Congratulations to Dr Katie Holmes and Dr Chad Holmes for 5 years of service, and Dr Charles Huggins for 10 years of service!

Onto Psychiatry

Pharmacologic treatment options for the agitated patient in the ED

Most guidelines for treatment for acute agitation generally recommend verbal and distraction de-escalation techniques for acutely agitated patients and when these techniques fail then proceed to utilization of medications. (5,8,9,10),

Benzodiazepines
Multiple class II studies done –> Benzos are equal to haldol for acute agitation (9,10). All used 2 mg or 4 mg lorazepam compared with 5-mg doses of haloperidol. The class III study by Garza-Trevino et al reached similar conclusions. (4).

Nobay et al compared IM midazolam (5 mg) to IM lorazepam (2 mg) or IM haloperidol (5 mg). Midazolam had a significantly shorter time to sedation than did lorazepam or haloperidol as expected due to its onset and half life. Midazolam was significantly better than haloperidol in controlling motor agitation in a small study of schizophrenic patients. (11)

Conventional antipsychotics
Haldol has the most evidence and literature with support in this regard. Clinton et al. study treated 136 agitated patients with haloperidol (average dose 8.4 mg) –> behavior alleviated in 113 patients with only 3 patients showing no response. Four complications were noted, including 2 cases of dystonia. (4).

Haloperidol vs benzodiazepines ? –> Several studies found little to no additional benefit in sedation after 10 mg of IM haloperidol had been
administered to psychotic patients.(4,8,10)

Haldol vs Droperidol? –> Droperidol was found to be superior to haloperidol in acutely reducing the level of agitation in patients for violent behavior in a class II study comparing IM haloperidol 5 mg to IM droperidol 5 mg. (12)

Atypical antipsychotics
class II report –> Found that ziprasidone IM 20 mg was the most effective dose for acute agitation and was well tolerated. The efficacy of the 10-mg dose is not as great as the 20-mg dose, although it is significantly better than a 2-mg dose. (13) It also has much less extrapyramidal symptoms than Haldol/Droperidol. It was also better at reducing acute psychosis than haldol and Droperidol when redosed at 4-6 hr intervals. (13)

Olanzapine vs Haldol –> Studied in schizophrenic patients in 2 class
II studies and found to be equivalent in reducing agitation. (14). More dystonia in the Haldol group. Quicker onset to symptom reduction in the Onlazapine group at 15 and 45 mins (15).

Oral vs IM medications? –> Currier et al study found oral treatment with risperidone (2 mg) and lorazepam (2 mg) was comparable to IM haloperidol (5 mg) However – they claimed it was possible that the group receiving intramuscular haloperidol and lorazepam had more severe psychotic agitation.

In Conclusion – here are the ACEP Clinical Policy recommendations (4)

What is the most effective pharmacologic treatment for the acutely agitated patient in the ED?

– Use a benzodiazepine (lorazepam or midazolam) or a conventional antipsychotic (droperidol* or haloperidol) as effective monotherapy for the initial drug treatment of the acutely agitated undifferentiated patient in the ED. Level A recommendations.

If rapid sedation is required, consider droperidol instead of haloperidol.

Use a combination of an oral benzodiazepine (lorazepam) and an oral antipsychotic (risperidone) for agitated but cooperative patients. Level C recommendations. The combination of a parenteral benzodiazepine and haloperidol may produce more rapid sedation than monotherapy in the acutely agitated psychiatric patient in the ED.

References

  1. Centers for Disease Control and Prevention (2019). Surveillance Report of Traumatic Brain Injury-related Emergency Department Visits, Hospitalizations, and Deaths—United States, 2014. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.
  2. Assessment of Follow-up Care After Emergency Department Presentation for Mild Traumatic Brain Injury and Concussion: Results From the TRACK-TBI Study. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2681571
  3. https://www.acep.org/how-we-serve/sections/sports-medicine/news/august-2018/emergency-medicine-wants-you…to-optimize-ed-concussion-management/
  4. From the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department: https://www.macep.org/Files/Department.pdf
  5. Breslow RE, Klinger BI, Erickson BJ. Acute intoxication and substance abuse among patients presenting to a psychiatric emergency service. Gen Hosp Psychiatry. 1996;18:183-191.
  6. Dhossche D, Rubinstein J. Drug detection in a suburban psychiatric
    emergency room. Ann Clin Psychiatry. 1996;8:59-69.
  7. Lavoie FW. Consent, involuntary treatment, and the use of force in
    an urban emergency department. Ann Emerg Med. 1992;21:25-32.
  8. Allen M. Managing the agitated psychotic patient: a reappraisal of
    the evidence. J Clin Psychiatry. 2000;61:11-20.
  9. McAllister-Williams RH, Ferrier IN. Rapid tranquillisation: time for a
    reappraisal of options for parenteral therapy. Br J Psychiatry. 2002;
    180:485-489.
  10. Yildiz A, Sachs GS, Turgay A. Pharmacological management of
    agitation in emergency settings. Emerg Med J. 2003;20:339-346.
  11. Wyant M, Diamond BI, O’Neal E, et al. The use of midazolam in acutely agitated psychiatric patients. Psychopharmacol Bull. 1990; 26:126-129
  12. Thomas H Jr, Schwartz E, Petrilli R. Droperidol versus haloperidol for chemical restraint of agitated and combative patients. Ann Emerg Med. 1992;21:407-413
  13. Lesem MD, Zajecka JM, Swift RH, et al. Intramuscular ziprasidone, 2 mg versus 10 mg, in the short-term management of agitated psychotic patients. J Clin Psychiatry. 2001;62:12-18
  14. Breier A, Meehan K, Birkett M, et al. A double-blind, placebo-controlled dose-response comparison of intramuscular olanzapine and haloperidol in the treatment of acute agitation in schizophrenia. Arch Gen Psychiatry. 2002;59:441-448.
  15. Wright P, Birkett M, David SR, et al. Double-blind, placebo-controlled comparison of intramuscular olanzapine and intramuscular haloperidol in the treatment of acute agitation. Am J. Psychiatry. 2001;158:1149-1151.


Image Credits
https://unsplash.com/@frankiefoto

Stefan Meyering DO, FAAEM

Dad, Academic EM Attending Physician, Fish Nerd & Backyard Mechanic | APD @ Ft Worth EM | Interests: Graduate Medical Education, Risk Management and Legal Medicine, POCUS, Free Open Access Medical Education (FOAMed), Physician Wellness

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