@emresidents family! Let’s have a little #journalclub 🧵from the EMRA Research Comm. Agitation is super common problem(~2mil presentations per year) so what’s in your 🧰 to care for these patients? Let’s talk about it!📢
📄: IM Droperidol vs IM Olanzapine for Agitation in the ED
📄: IM Droperidol vs IM Olanzapine for Agitation in the ED
Before we dive in 🤿 what do you reach for when you need an IM medication for acute agitation? 🚑💉
Let’s introduce the main characters of this study 🎭
5mg IM Droperidol: a butyrophenone works by dopamine blockade (1️⃣ gen anti-psychotic)
10mg IM Olanzapine: a thienobenzodiazepine, works mostly through antagonism of serotonin, dopamine, histamine (2️⃣ gen anti-psychotic)
5mg IM Droperidol: a butyrophenone works by dopamine blockade (1️⃣ gen anti-psychotic)
10mg IM Olanzapine: a thienobenzodiazepine, works mostly through antagonism of serotonin, dopamine, histamine (2️⃣ gen anti-psychotic)
The Study 🔬🧪
A natural experiment due to drug shortages. Imperfectly mimicked a prospective crossover study 🔀Olanzapine -> Droperidol -> Olanzipine
1️⃣ Outcome: ⏱Time to sedation
W/ sedation quantified with AMSS Scale
2️⃣ Outcome:safety, rescue meds, side effects and LOS
A natural experiment due to drug shortages. Imperfectly mimicked a prospective crossover study 🔀Olanzapine -> Droperidol -> Olanzipine
1️⃣ Outcome: ⏱Time to sedation
W/ sedation quantified with AMSS Scale
2️⃣ Outcome:safety, rescue meds, side effects and LOS
Setting 🏥: ED observation unit for intoxicated 🍻 and agitated 🤬 patients.
Population: those treated for acute agitation in the ED Obs Unit who were given 💉IM Droperidol or Olanzapine.
Population: those treated for acute agitation in the ED Obs Unit who were given 💉IM Droperidol or Olanzapine.
Not included 🙅: those treated outside of the Obs unit (Unknown # said to be small), Patients receiving any other meds except diphenhydramine. Data collection from research staff 24/7. Physicians👩⚕️asked about the general cause of agitation and side affects. 7 day f/u for dystonia
Results 🎉🥳
1257 in final analysis
Excluded 🚫~500 patients due to data collection limitations,112 received other meds, 32 received orals
1️⃣ Outcome: ⏱Time to Sedation 16mins for Droperidol and 17.5mins for Olanzapine (no difference). No difference in sedation in Cox Model
1257 in final analysis
Excluded 🚫~500 patients due to data collection limitations,112 received other meds, 32 received orals
1️⃣ Outcome: ⏱Time to Sedation 16mins for Droperidol and 17.5mins for Olanzapine (no difference). No difference in sedation in Cox Model
2️⃣ Outcomes
🌬Respiratory adverse events 4% for Droperidol and 7% for olanzapine
⛑Rescue medications 17% for Droperidol and 24% for Olanzapine
⌚️ED length of stay 444 for Droperidol and 500 mins for Olanzapine
🔺Extrapyramidal effects Droperidol 1% and Olanzipine 0.1%
🌬Respiratory adverse events 4% for Droperidol and 7% for olanzapine
⛑Rescue medications 17% for Droperidol and 24% for Olanzapine
⌚️ED length of stay 444 for Droperidol and 500 mins for Olanzapine
🔺Extrapyramidal effects Droperidol 1% and Olanzipine 0.1%
Important details 🕵️🔍
diphenhydramine used more ⬆️with Droperidol and it still had a signal of more 🔺dystonic reactions
Similar rates of psych history, substance use, agitation cause, vitals, prehospital meds 🚑
Olanzapine had slightly longer and deeper sedation 😴💤
diphenhydramine used more ⬆️with Droperidol and it still had a signal of more 🔺dystonic reactions
Similar rates of psych history, substance use, agitation cause, vitals, prehospital meds 🚑
Olanzapine had slightly longer and deeper sedation 😴💤
⭐️Summary⭐️In this natural experiment,IM Olanzapine and Droperidol showed similar⏱ to sedation in patients w/ agitation mostly due to ETOH.Olanzapine caused a deeper sedation with a small increase in respiratory events. Droperidol had less rescue meds but more dystonic reactions
EBM Quick Hit 🧑🏫🧮
Cox Proportional Hazard Model 📉
Think of this as a time to event analysis. In this study it was used to model the time to adequate sedation. It uses a hazard function to show the “hazard” of adequate sedation in each group at each time point
Cox Proportional Hazard Model 📉
Think of this as a time to event analysis. In this study it was used to model the time to adequate sedation. It uses a hazard function to show the “hazard” of adequate sedation in each group at each time point
Cox Models allow for multiple variables to be controlled for while comparing the hazard of the outcome in each group. This study adjusted for sex, dx of bipolar, dx of schizophrenia, ETOH/drug as the cause for agitation, Pre-hospital meds, initial ETOH concentration
Cox Models are used to calculate a Hazard Ratio which compares the rate of the outcome in each group across the time points. Greater than 1 means the variable is positively associated with the outcome. HR = 1: No effect
HR < 1: Reduction in the Hazard
HR > 1: Increase in Hazard
HR < 1: Reduction in the Hazard
HR > 1: Increase in Hazard
In this study Droperidol had a Hazard Ratio of 1.12(95% CI 1.00-1.25)for adequate sedation but the confidence interval included 1 raising some concern that the results may point more toward no effect. The confidence interval did cross 1 in the sensitivity analyses.
Check out this paper for more learning on survival and hazard analysis journal.chestnet.org/article/S0012-…
Thanks for reading this journal club 🧵 and EBM quick hit 💥. Does this paper paper change your approach to the treatment of agitation with IM Meds??
If these are your only IM options what would you reach for?
Did this paper effect your practice at all?? @srrezaie @EMHighAK @ResusOne @EMinMiami @LWestafer @NotSoLilMD @debdiercks @AliRaja_MD @laertezz @EMBoardBombs @MedFactChecks @nerdymedic @JasonVadhan @shawkdoc @TamingtheSRU #EBM #medtwitter #emra
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