ED Push - March 2016 First Issue
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Ketamine Safe, Effective for Difficult-to-Sedate ED Patients
NEWSCASTLE, AUSTRALIA – Sedating patients with severe acute behavioral disturbance sometimes can be extremely challenging in the emergency department setting.
That’s why a new Australian study is so significant. The report, published recently in Annals of Emergency Medicine, finds that using ketamine appears to be safe and effective in those situations.
"Difficult to sedate patients with behavioral disturbances are highly problematic for emergency department staff," said Geoff Isbister, MD, of the Clinical Toxicology Research Group at the University of Newcastle in Newcastle, Australia. "Although such patients are uncommon, they cause significant disruption and danger to emergency department staff and consume time and resources required for other patients. Ketamine is a reasonable third-line agent to use on these patients once other sedation options have been exhausted."
During the study, only 10% of 49 ED patients with acute behavioral disturbances who were treated with ketamine failed to achieve sedation within two hours or required additional sedation within one hour. In most cases, patients were treated with ketamine only after sedation was attempted with droperidol. Average time to sedation after ketamine administration was 20 minutes.
The patients – median age 37, 57% male, and more than a third involved with police – received rescue ketamine at two hospitals over 27 months.
Among those patients, previous sedation included droperidol, 10 mg; droperidol,10+10 mg; droperidol, 10+10+5 mg; droperidol, 10+10+10 mg; combinations of droperidol and benzodiazepines; or midazolam alone, according to the study.
In terms of ketamine, the median dosage was 300 mg, with a range of 50 to 500 mg. Of the five patients who were not sedated within 120 minutes or required additional sedation within an hour, four of them had received 200 mg or less.
Side effects were minimal, according to the report, with two patients vomiting after ketamine administration and one having transient oxygen desaturation to 90% that responded to oxygen.
“Ketamine appeared effective and did not cause obvious harm in this small sample and is a potential option for patients who have failed previous attempts at sedation,” study authors conclude. “A dose of 4 to 5 mg/kg is suggested, and doses less than 200 mg are associated with treatment failure.”
"Most agitated and aggressive patients in the emergency department will either respond to verbal de-escalation or oral sedation, or be rapidly sedated with droperidol," Isbister added in an Annals of Emergency Medicine press release. "For the small number who don't, we have ketamine."
Why Some Asthma Patients Should Be Evaluated for Aneurysm Risk
BOSTON – Recent asthma activity significantly raises the risk of abdominal aortic aneurysm rupture and sudden death in patients 50 and older, according to recent research.
Authors of the study, published recently in Arteriosclerosis, Thrombosis and Vascular Biology, urged evaluation of asthma patients, especially if they are male, for signs of the dangerous condition.
"Older patients, especially men, with a recent asthma diagnosis should be checked for signs of aortic aneurysm," urged lead author Guo-Ping Shi, DSc, biochemist at Brigham and Women's Hospital and Harvard Medical School. "In addition, patients with a diagnosed aneurysm who later develop asthma should also be monitored for changes in the size and strength of the aorta."
The research team earlier conducted an animal study, finding that mice with allergic asthma developed twice as large aortic aneurysms as the controls. Then, the study group examined thousands of medical records from two studies in Denmark – one with 15,942 abdominal aortic aneurysm patients age 50 and older and the other from a study of 18,749 men age 65 to 74 with and without abdominal aortic aneurysms – to evaluate trends in humans.
Results revealed that patients with abdominal aortic aneurysm who had diagnosed asthma within the past year had more than a 50% greater risk of ruptured aneurysms than those without asthma. Those diagnosed with asthma within the past six months, meanwhile, were twice as likely as non-asthmatics to experience aortic aneurysm rupture.
In addition, patients with recorded uses of anti-asthmatic medication within the last six months showed nearly 40% greater risk for ruptured aortic aneurysms than those not reporting such treatments. Specifically, those with recent inhaler medication use had about a 45% greater risk of having abdominal aortic aneurysm than others.
Study authors posited that inflammation could play a role in the connection, noting, “These findings document and furnish novel links between airway disease and AAA, two common diseases that share inflammatory aspects.”
"IgE is one of the main players," Shi added in an American Heart Association press release. "Our study suggests that asthmatic patients have higher levels of IgE, which can activate many cells, including inflammatory cells and vascular cells that promote aneurysm and cause aortic rupture."
Marijuana-Induced Colorado Mountain High Sends Visitors to ED
CHICAGO – Colorado has legally allowed sales of marijuana in retail dispensaries since 2014, and trying out the local product apparently is one of the tourist attractions.
The problem is that visitors who use the drug are ending up in the emergency department at an increasing rate, according to a research letter recently published in the New England Journal of Medicine.
“Emergency room visits related to cannabis use have increased more dramatically among out-of-state visitors than among Colorado residents,” said lead investigator Howard Kim, MD, a postdoctoral fellow in emergency medicine at Northwestern University Feinberg School of Medicine who began the study as a resident at the University of Colorado School of Medicine.
According to study results, out-of-state visitors to the emergency room for marijuana-related symptoms accounted for 78 per 10,000 emergency room visits in 2012 compared to 163 per 10,000 visits in 2014 – an increase of 109%. Among Colorado residents, the number of marijuana-related visits was 70 per 10,000 in 2012 compared to 101 per 10,000 in 2014, a 44% increase.
Kim suggests the research might be a cautionary tale for other states in which recreational marijuana is legal, such as Alaska, Oregon, and Washington, or those considering a change in laws.
The report notes that adverse effects of marijuana use may include psychiatric symptoms such as anxiety, hallucinations, and altered mental status; cardiovascular symptoms such as a fast heart rate, high blood pressure, or palpitations; and gastrointestinal symptoms, including abdominal pain and vomiting.
Kim pointed out that edible products, often cookies or brownies, might vary in strength and have a delayed effect, which could lead to overdosing. "People eating marijuana products often don't feel any effect immediately, leading them to eat another edible," he said. "Then they've ingested multiple products, so when the effect finally kicks in, it is much stronger."
The study didn’t distinguish whether the marijuana use leading to the ED visit was by ingested or inhaled products.
"Anecdotally, we noticed that most out-of-towners were in Colorado for other reasons, such as visiting friends or on business," Kim added in a Northwestern press release. "They ended up in the ER because they decided to try some marijuana."
For most patients, supportive care was offered and they were discharged after a few hours, but some had to be admitted for observation.
Senior author Andrew Monte, MD, assistant professor of emergency medicine at the University of Colorado School of Medicine, pointed out that the Colorado Department of Public Health and Environment's "Good to Know" campaign has improved education of users across the state and that is reflected in lower rates of ED visits by Colorado residents.
“ED visits related to cannabis use appear to be increasing more rapidly among out-of-state residents than among Colorado residents,” according to the study authors. “The initial educational efforts through mass media have focused primarily on Colorado residents. These data underscore the importance of point-of-sale education for visitors regarding the safe and appropriate use of marijuana products."
Young Adults Diverting ADHD Drug Increase ED Visits
BALTIMORE – If you’ve wondered why patients presenting to your ED with adverse effects from dextroamphetamine-amphetamine look a lot older than the typical kid with an attention deficit/hyperactivity disorder, a new study offers some explanation.
A study published recently in The Journal of Clinical Psychiatry finds that misuse of the drugs isn’t primarily among older children and adolescents, although that is the common misconception. Instead, inappropriate use by young adults, 18-25, is fueling the problem.
Johns Hopkins Bloomberg School of Public Health researchers and colleagues analyzed trends from 2006 to 2011 and found that the abusers tended to be getting the medication from friends and family and didn’t have prescriptions themselves.
The study also notes that 18- to 25-year-olds were responsible for 60% of all nonmedical use of dextroamphetamine-amphetamine, among users age 12 and older.
"The growing problem is among young adults," explained co-author Ramin Mojtabai, MD, MPH, PhD, professor of mental health at the Bloomberg School. "In college, especially, these drugs are used as study-aid medication to help students stay up all night and cram. Our sense is that a sizeable proportion of those who use them believe these medications make them smarter and more capable of studying. We need to educate this group that there could be serious adverse effects from taking these drugs and we don't know much at all about their long-term health effects."
While dextroamphetamine-amphetamine, marketed as Adderall, improves focus, it also can cause sleep disruption and serious cardiovascular side effects, such as high blood pressure and stroke, according to the study. The drug also can increase the risk for mental health problems, including depression, bipolar disorder, and unusual behaviors, including aggressive or hostile behavior.
Researchers mined three sources of data for the study: the National Survey on Drug Use and Health, a population survey of substance use; the Drug Abuse Warning Network, a survey of emergency department visits; and the National Disease and Therapeutic Index, a survey of office-based practices including prescribing.
In the six-year study period, routine treatment visits involving Adderall were unchanged for adults, but nonmedical use of dextroamphetamine-amphetamine shot up 67%, and ED visits relating to that use rose 156%. At the same time, treatment visits involving the drug went down for adolescents, who also had stable nonmedical use and a drop in ED visits of 54%.
Trends for other stimulants, such as methylphenidate, sold under the brand name Ritalin, were unchanged, according to study authors.
The researchers urge monitoring of stimulants similar to prescription painkillers so that physicians could check a database before writing a prescription.
First author Lian-Yu Chen, MD, PhD, said the results suggest that “the main driver of misuse and emergency room visits related to the drug is the result of diversion, people taking medication that is legitimately prescribed to someone else.”
Chen emphasized in a Johns Hopkins press release that emergency physicians and other healthcare professionals need to be much more aware of the trend in order to help prevent it.
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Psych Patients in the ED: Medical Clearance through Multidisciplinary Collaboration
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Restraint and Seclusion: The Most Problematic of All CMS Standards
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Violence Prevention in Healthcare: OSHA Requirements
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Managing Acute Agitation in the ED: Evaluation and Treatment
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Sepsis in the Era of 405 Regulations
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