Marc L. Martel

Discontinuation of droperidol for the control of acutely agitated out-of-hospital patients.

Objective. To identify the effects of the removal of droperidol as a treatment option for sedation of agitated out-of-hospital patients. Methods. This was a retrospective review conducted January 1, 2001, through December 5, 2002, of patients with an out-of-hospital diagnosis of agitation who received either droperidol or midazolam prior to arrival in the emergency department (ED). The need for continuous cardiac or pulse oximetry monitoring, intubation, critical care ED management, intensive care unit admission, andmortality was reviewed. Results. Seventy-one patients received droperidol or midazolam for acute agitation in the out-of-hospital setting. Forty-one patients received droperidol in 2001 (D2001); three patients received midazolam in 2001 (M2001). No patients received droperidol in 2002, and27 patients received midazolam (M2002). Comparing the D2001 andM2002 groups, the need for continuous pulse oximetry monitoring in the ED [14/41 (34.1%) versus 18/27 (66.7%)], intubations [4/41 (9.8%) versus 10/27 (37.0%)], critical emergency medical services transports [5/41 (12.2%) versus 11/27 (40.7%)], critical ED care cases [6/41 (14.6%) versus 11/27 (40.7%)], andintensive care unit admissions [6/13 (46.2%) versus 14/15 (93.3%)] were increased in the M2002 group. No difference was found in the frequencies of ED cardiac monitoring, hospital admission, complications, or death. Conclusions. Since the removal of droperidol as a treatment option for out-of-hospital agitated patients, the authors have observed an increased frequency of continuous pulse oximetry monitoring, intubation, ED critical care management, andintensive care unit admission in patients requiring chemical sedation for control of agitation in the out-of-hospital setting.

A Prospective Observational Study of Patients Receiving Intravenous and Intramuscular Olanzapine in the Emergency Department

Study objective: Parenteral olanzapine is an emerging therapy for a variety of conditions in the emergency department (ED). Intramuscular administration is standard; however, intravenous administration has been proposed as a safe alternative route. We investigate the safety and efficacy of both intramuscular and intravenous olanzapine in the ED when used for a variety of indications. Methods: This was a prospective observational study of patients presenting to an urban Level I trauma center ED. Trained research associates screened the ED for patients receiving parenteral olanzapine. The primary outcome of the study was incidence of respiratory depression measured with standard markers. Secondary outcomes included use of additional doses or sedatives, corrected QT interval (QTc) data, time to nadir sedation, adverse events, and physician assessment of efficacy. Results: There were 784 patients included in the final analysis. Intravenous olanzapine was administered to 295 patients; 489 received intramuscular olanzapine. Respiratory depression occurred in 11 of 295 patients (3.7%; 95% confidence interval [CI] 1.6% to 5.9%) receiving intravenous olanzapine and 10 of 489 (2.0%; 95% CI 0.8% to 3.3%) receiving intramuscular olanzapine. Seven patients required intubation, 2 in the intravenous group and 5 in the intramuscular group. Nonrespiratory complications occurred in 8 patients, 6 of 295 (2.0%; 95% CI 0.4% to 3.6%) in the intravenous group and 2 of 489 (0.4%; 95% CI 0% to 0.96%) in the intramuscular group. Dysrhythmias were isolated to 2 episodes of bradycardia requiring only supportive care. Conclusion: These data suggest that, with proper monitoring, administration of olanzapine, both intramuscular and intravenous, is safe for several indications in the ED.

Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication

Study objective: Emergency department (ED) visits for acute alcohol intoxication are common, but this population is at risk for decompensation and occult critical illness. The purpose of this study is to describe the incidence and predictors of unsuspected critical illness among patients with acute alcohol intoxication. Methods: This was a retrospective observational study of ED patients from 2011 to 2016 with acute alcohol intoxication. The study cohort included patients presenting for alcohol intoxication, whose initial assessment was uncomplicated alcohol intoxication without any other active acute medical or traumatic complaints. The primary outcome was defined as the unanticipated subsequent use of critical care resources during the encounter or admission to an ICU. We investigated potential predictors for this outcome with generalized estimating equations. Results: We identified 31,364 eligible patient encounters (median age 38 years; 71% men; median breath alcohol concentration 234 mg/dL); 325 encounters (1%) used critical care resources. The most common diagnoses per 1,000 ED encounters were acute hypoxic respiratory failure (3.1), alcohol withdrawal (1.7), sepsis or infection (1.1), and intracranial hemorrhage (1.0). Three patients sustained a cardiac arrest. Presence of the following had an increased adjusted odds ratio (aOR) of developing critical illness: hypoglycemia (aOR 9.2), hypotension (aOR 3.8), tachycardia (aOR 1.8), fever (aOR 7.6), hypoxia (aOR 3.8), hypothermia (aOR 4.2), and parenteral sedation (aOR 2.4). The initial blood alcohol concentration aOR was 1.0. Conclusion: Critical care resources were used for 1% of ED patients with alcohol intoxication who were initially assessed by physicians to have low risk. Abnormal vital signs, hypoglycemia, and chemical sedation were associated with increased odds of critical illness.

Retrograde Intubation for Ace Inhibitor–Induced Angioedema

R.C. is a 49-year-old man who presented to triage with complaints of lip and tongue swelling. He noted symptoms upon awakening with progression over the next 2 hours. Medical history is significant for hypertension. His medications are lisinopril and hydrochlorothiazide. On examination, the patient was afebrile, mildly tachypneic, and sitting upright on the cart. He was speaking in short sentences with a hoarse voice and complaining of dysphagia. The head, eyes, and ear ⁄ nose ⁄ throat exam revealed significant edema of his lips and his posterior oropharynx. His lungs were clear and there was no stridor. An IV was established and he was given 0.3 mg of epinephrine subcutaneously and 125 mg of Solu-Medrol intravenously. Fiber-optic–assisted nasotracheal intubation and subsequent RSI and direct laryngoscopy were unsuccessful. Because the patient maintained oxygen saturations greater than 99% with bag-valve mask ventilation, the decision was made to perform a retrograde intubation (Figure 1). The retrograde intubation was successfully completed with one attempt (available as supporting information in the online version of this paper). Oxygen saturations remained above 90% for the entire case.

The Use, Safety, and Efficacy of Olanzapine in a Level I Pediatric Trauma Center Emergency Department Over a 10-year Period

Objectives Olanzapine is a second-generation antipsychotic increasingly used in emergency medicine for many indications. Literature on its use in children is sparse. Our objectives were to describe the use, safety, and efficacy of olanzapine in pediatric emergency patients. Methods A structured chart review was performed of patients 18 years old or younger receiving olanzapine from 2007 to 2016 in the emergency department of a pediatric level I trauma center. Results A total of 285 children received olanzapine. Mean age was 16.4 years (range, 9–18 years); 121 were male (42.8%). Primary indications for olanzapine included agitation (n = 166, 58.3%), headache (n = 58, 20.4%), nausea/vomiting/abdominal pain (n = 37, 12.5%), unspecified pain (n = 20, 7%), and other (n = 4, 1.4%). Route of olanzapine administration was intramuscular (n = 160, 56%; median dose, 10 mg; range, 2.5–20), intravenous (n = 101, 36%; median dose, 5 mg; range, 1.25–5), and oral (n = 24, 8%; median dose, 10 mg; range, 5–10). For agitated patients, 28 (17%) received another sedative within 1 hour. For headache patients, 5 (8.6%) received another analgesic. For gastrointestinal complaints, 5 patients (13.5%) received another analgesic/antiemetic. Adverse respiratory events were hypoxia (pulse oximetry reading, in percentage, <92%; n = 7, 2.4%), supplemental oxygen placement (n = 9, 3.2%), and intubation (n = 2, 0.7%). No patient died or had a dysrhythmia. One patient experienced dystonia. Conclusions Olanzapine seems safe when used for a variety of conditions in pediatric emergency patients. It may be effective for acute agitation, primary headache, and gastrointestinal complaints.

Developing a Medical Scribe Program at an Academic Hospital: The Hennepin County Medical Center Experience

BACKGROUND Medical scribes are frequently incorporated into the patient care model to improve provider efficiency and enable providers to refocus their attention to the patient rather than the electronic health record (EHR). The medical scribe program was based on four pillars (objectives): (1) provider satisfaction, (2) standardized documentation, (3) documentation components for risk adjustment, and (4) revenue enhancement. METHODS The medical scribe program was deployed in nine non-resident-supported clinics (internal medicine, ophthalmology, orthopedics, hematology/oncology, urology), with the medical scribes (who have no clinical duties) supporting both physicians and advanced practice providers (nurse practitioners and physician assistants). This paper describes a prospective quasi-experimental study conducted at an academic, inner-city, hospital-based clinic system, RESULTS: A pre-post analysis showed positive results; of the 51 providers, 44 responded to the survey pre and 41 responded post. Respondents in the post-scribe group felt that a scribe was valuable (90.2%), that documentation time at the office improved (75.0% poor or marginal pre-scribe, vs. 24% post; p <0.0001), and that time spent on the EHR at home declined (63.6% with excessive or moderately high home EHR time pre vs. 31.7% post; p = 0.003). More providers felt satisfied with their role in clinic with the use of scribes, and more providers felt that with scribes they could listen sufficiently to patients (p <0.05). CONCLUSION Scribe support was well received across the institution in multiple clinical settings. Benefits for providers were seen in documentation time and ability to listen to patients. Scribes appear to be an effective intervention for improving clinician work life.

Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department

Study objective Agitation in the emergency department (ED) can pose a threat to patient and provider safety; therefore, treatment is indicated. The purpose of this study is to compare haloperidol, olanzapine, midazolam, and ziprasidone to treat agitation. Methods This was a prospective observational study of consecutive patients receiving intramuscular medication to treat agitation in the ED. Medications were administered according to an a priori protocol in which the initial medication given was predetermined in the following 3‐week blocks: haloperidol 5 mg, ziprasidone 20 mg, olanzapine 10 mg, midazolam 5 mg, and haloperidol 10 mg. The primary outcome was the proportion of patients adequately sedated at 15 minutes, assessed with the Altered Mental Status Scale. Results Seven hundred thirty‐seven patients were enrolled (median age 40 years; 72% men). At 15 minutes, midazolam resulted in a greater proportion of patients adequately sedated (Altered Mental Status Scale <1) compared with ziprasidone (difference 18%; 95% confidence interval [CI] 6% to 29%), haloperidol 5 mg (difference 30%; 95% CI 19% to 41%), haloperidol 10 mg (difference 28%; 95% CI 17% to 39%), and olanzapine (difference 9%; 95% CI –1% to 20%). Olanzapine resulted in a greater proportion of patients adequately sedated at 15 minutes compared with haloperidol 5 mg (difference 20%; 95% CI 10% to 31%), haloperidol 10 mg (difference 18%; 95% CI 7% to 29%), and ziprasidone (difference 8%; 95% CI –3% to 19%). Adverse events were uncommon: cardiac arrest (0), extrapyramidal adverse effects (2; 0.3%), hypotension (5; 0.5%), hypoxemia (10; 1%), and intubation (4; 0.5%), and occurred at similar rates in each group. Conclusion Intramuscular midazolam achieved more effective sedation in agitated ED patients at 15 minutes than haloperidol, ziprasidone, and perhaps olanzapine. Olanzapine provided more effective sedation than haloperidol. No differences in adverse events were identified.

Etiologies of altered mental status in patients with presumed ethanol intoxication

Background Altered mental status is a commonly evaluated problem in the ED. Ethanol intoxication is common, and prehospital history may bias emergency physicians to suspect this as the cause of altered mental status. Quantitative ethanol measurement can rapidly confirm the diagnosis, or if negative, prompt further evaluation. Our objective was to identify the etiologies of altered mental status in ED patients initially presumed to be intoxicated with ethanol but found to have negative quantitative ethanol levels. Methods This was a 5‐year (2012–2016) electronic medical record review of ED patients presenting with altered mental status. Patients were included if they presented with presumed ethanol intoxication and had an initial ethanol concentration of zero. Etiologies of altered mental status were categorized into medical, traumatic, psychiatric, and drug‐related causes. Results 29,322 patients presented during the study period with presumed alcohol intoxication, 1875 patients had negative ethanol levels. The etiology of altered mental status was due to illicit substances in 1337 patients (71%), psychiatric causes in 354 patients (19%), medical causes in 166 patients (9%) and trauma in 18 patients (1%). A total of 179 patients (10%) were admitted to the hospital; 19 patients (1%) to the ICU. Conclusions The presumptive diagnosis of ethanol intoxication in patients presenting to the ED with altered mental status was inaccurate in 5% of patients. The etiology of altered mental status was serious and required hospitalization in 10% of the cohort. Rapid assessment of quantitative ethanol levels should be performed, breathalyzers may be preferred over serum testing.

Emergency Department Experience with Novel Electronic Medical Record Order for Referral to Food Resources

Introduction Food insecurity is a significant issue in the United States and is prevalent in emergency department (ED) patients. The purpose of this study was to report the novel use of an integrated electronic medical record (EMR) order for food resources, and to describe our initial institutional referral patterns after focused education and implementation of the order. Methods This was a retrospective, observational study, describing food-bank referral patterns before and after the implementation of dedicated ED education on the novel EMR order for food resources. Results In 2015, prior to formal education a total of 1,003 referrals were made to the regional food bank, Second Harvest Heartland. Five referrals were made from the ED. In 2016, after the educational interventions regarding the referral, there were 1,519 referrals hospital-wide, and 55 referrals were made from the ED. Of the 1,519 referrals 1,129 (74%) were successfully contacted by Second Harvest Heartland, and 954 (63%) accepted and received assistance. Conclusion Use of the EMR as a tool to refer patients to partner organizations for food resources is plausible and may result in an increase in ED referrals for food resources. Appropriate education is crucial for application of this novel ED process.

Emergency Department Frequent Users for Acute Alcohol Intoxication

Introduction A subset of frequent users of emergency services are those who use the emergency department (ED) for acute alcohol intoxication. This population and their ED encounters have not been previously described. Methods This was a retrospective, observational, cohort study of patients presenting to the ED for acute alcohol intoxication between 2012 and 2016. We collected all data from the electronic medical record. Frequent users for alcohol intoxication were defined as those with greater than 20 visits for acute intoxication without additional medical chief complaints in the previous 12 months. We used descriptive statistics to evaluate characteristics of frequent users for alcohol intoxication, as well as their ED encounters. Results We identified 32,121 patient encounters. Of those, 325 patients were defined as frequent users for alcohol intoxication, comprising 11,370 of the encounters during the study period. The median maximum number of encounters per person for alcohol intoxication in a one-year period was 47 encounters (range 20 to 169). Frequent users were older (47 years vs. 39 years), and more commonly male (86% vs. 71%). Frequent users for alcohol intoxication had higher rates of medical and psychiatric comorbidities including liver disease, chronic kidney disease, ischemic vascular disease, dementia, chronic obstructive pulmonary disease, history of traumatic brain injury, schizophrenia, and bipolar disorder. Conclusion In this study, we identified a group of ED frequent users who use the ED for acute alcohol intoxication. This population had higher rates of medical and psychiatric comorbidities compared to non-frequent users.