- Email: [email protected]
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Research Forum Abstracts Methods: Patients with a history of psychosis complaining of psychotic symptoms without agitation were invited to participate in the study. A total of 15 patients were successfully recruited, 5 in each arm. After signing informed consent they were randomized to 1 of 3 arms: 1) lorazepam 2 mg IM. 2) lorazepam 2mg IM plus risperidone 2mg PO or 3) lorazepam 2 mg IM plus haloperidol 5mg PO. Baseline scores were obtained on the brief psychotic rating scale (BPRS) as well as the positive and negative symptoms score (PANSS). These scales were repeated at 30 and 90 minutes after treatment. Results: All groups showed significant reduction in symptoms at both time intervals (p ⬍ .05). At 30 minutes lorazapam alone showed a 16% reduction in the BPRS and 18% reduction in the PANSS. The lorazepam ⫹ risperidone group showed a 24% reduction in the BPRS and a 28% decrease in the PANSS score. The lorazepam ⫹ haloperidol group experienced a 24% reduction in the BPRS and 32 % decrease in the PANSS. At 90 minutes even greater improvement was noted in all groups. Lorazepam alone showed a 30% reduction in the BPRS and 38% reduction in the PANSS. The lorazepam ⫹ risperidone group showed a 30% reduction in the BPRS and a 40% decrease in the PANSS score. The lorazepam ⫹ haloperidol group elicited a 30% reduction in the BPRS and 40% decrease in the PANSS. ANOVA was unable to find any statistically significant difference among the study arms at any time frame. Conclusion: Both lorazepam alone and lorazepam with an antipsychotic proved useful in acutely reducing psychotic symptoms in a timely manner. There was more improvement in the group receiving either antipsychotic; however, perhaps in part due to the small number of patients studied, statistical significance was not obtained. Many clinicians believe that antipsychotics may take weeks or even months to work, but this data seems to support a more immediate response. There are several questions related to treatment that are worthy of discussion. What degree of improvement could be attributed to sedation alone? Could the retrograde amnesia associated with the lorazepam help patients “forget” their psychosis? Would antipsychotics alone prove beneficial? What happens beyond 90 minutes? More research on this subgroup of patients is warranted.
423
Droperidol for the Treatment of Conversion Disorder in the Emergency Department
Bock PJ, Smith SW/Hennepin County Medical Center, Minneapolis, MN
Study Objectives: There is little data on the emergency department therapy (medication) of conversion disorder; we investigated the efficacy of droperidol. Methods: Retrospective chart review: conversion disorder is a listed diagnosis in Emstat®, our electronic record; all such patients from March 1994 through March 2005 were queried. Charts with evidence contradicting the diagnosis, as defined by DSM IV, were excluded. Demographics, symptoms, other diagnosis, medications/ treatments used, resolution and time to resolution, and medical/psychiatric history were recorded. Statistics were by Chi square and Fisher exact test. Results: There were 112 patients: 22 had no records available and 14 were excluded because an alternate diagnosis was more likely than conversion disorder, either by follow-up exam or by diagnostic criteria. 76 patients with conversion disorder remained, 51 females and 25 males. Cases were evenly distributed over the 11 year period. Mean age (⫾ SD) was 30 ⫾ 10 years. Presenting symptoms were: catatonia (unresponsiveness with open eyes) 10 (13%), pseudoseizure 17 (22%), paralysis 14 (18%), unresponsiveness with closed eyes 9 (12%), anesthesia 15 (20%), tic 1 (1%), aphasia 2 (3%), blindness 1 (1%), paresthesias 12 (16%) stuttering 1 (1%), other neurologic deficit such as weakness or dysarthria 14 (18%), or other 5 (7%) for a total of 101 (133%). Symptoms had resolved at presentation in 4, leaving 72 with the following treatments: Droperidol in 30 (42%) cases [1.25mg (7 cases), 2.5mg (21), or 5mg (2)], a benzodiazepine in 9 (13%), and reassurance or no treatment documented or other in 33 cases (46%). Symptoms resolved in 58 of 72 (81%): 28 of 30 (93%) who received droperidol vs. 30 of 42 (71%) who did not (p ⫽ 0.02). See table. Limitations: Response to treatment may have influenced final diagnosis; conversion disorder not so coded would have been missed. Conclusion: Conversion disorder resolution is enhanced by droperidol and benzodiazepines and expedited by droperidol; further prospective study is needed.
Volume , . : October
424
Parenteral Antiemetic Trends in an Emergency Department and Inpatient Population From 19962005
Baker MB, Hafner JW, Lin GC, Peterson SC/University of Illinois College of Medicine at Peoria, Peoria, IL; Bradley University; Department of Industrial & Manufacturing Engineering & Technology, Peoria, IL; OSF Saint Francis Medical Center, Peoria, IL
Study Objectives: Nausea and vomiting are frequent presenting complaints in the emergency department (ED) and parenteral antiemetic agents are the 6th most common class of drugs used in EDs. Recently, potent but more costly drugs have been introduced while inexpensive older medications are less available. This study seeks to describe ED parenteral antiemetic trends and compare them to a hospital inpatient population. Methods: A retrospective time series analysis of parenteral antiemetic medication utilization was conducted at a large urban academic medical center. Antiemetics from several pharmacologic classes (prochlorperazine, metoclopramide, droperidol, promethazine, ondansetron, hydroxazine, granisetron) used from 1996-2005 were identified from a hospital pharmacy database. Drugs with primary indications other than antiemesis (i.e. diphenhydramine, corticosteroids), were excluded. Aggregate adult and pediatric usage data was described by medication units (frequency) and individual cases, comparing between inpatient and ED locations. Charges were converted to costs by multiplying by hospital-specific, cost center ratios of costs to charges. Linear regression models (Minitab 14.0) were used to identify significant (p ⬍ 0.05) changes in annual drug patterns, and changes between populations were described using nonparametric tests (t test and Mann-Whitney test). Trend analysis plots for future antiemetic use patterns were conducted using linear, quadratic, and growth curve models, and the mean absolute deviation used for ideal model identification. Results: During the study period, a total of 589,838 drug units were dispensed (93.4% inpatients vs. 6.6% ED). The most common inpatient drug used was metoclopramide (240,885 units or 43.7%) and the most common ED drug was promethazine (10,534 units or 27.2%). The total hospital costs from 1996-2005 were $3,810,654.54, with 96.5% of costs resulting from inpatients; ondansetron represented the largest percentage of costs in both the ED (38.5%) and inpatient populations (58.6%). Time series analysis indicated individual drug use and cost patterns (as a percentage of total costs and use) were not different between two populations (inpatient vs. emergency). From 1996 to 2005 prochlorperazine and droperidol had use reductions in both the inpatient and the ED setting, while ondansetron had increased use patterns in the ED (2886.8%) and inpatient populations (620.3%). Trend analysis demonstrated increases in the projected growth rate for ondansetron in both the ED and inpatient settings. Conclusion: Parenteral antiemetic use patterns have changed significantly between 1996 and 2004 for inpatients and ED patients. Serotonin inhibitor agent use has increased rapidly in both populations.
425
Medication Duplication in Patients Presenting to the Emergency Department
Richman R, Triner W/Albany Medical College, Albany, NY
Study Objectives: To determine the prevalence of patients taking duplicative medications (DMd) seen in the emergency department (ED). We define DMd as two or more medications from the same class or subclass taken by a patient for which there would be no rationale for the redundancy (e.g. propranolol and atenolol). Methods: Design: This was a cross-sectional observational study. Setting: An academic tertiary care ED. Type of Participants: The study population consisted of a convenience sample, proportionally representing days of the week and hours of the day, of patients in an academic tertiary care ED. Intervention: During a six week period, individual charts were reviewed while the patient was in the ED. The following information was collected on all patients; age, gender, insurance status and medication lists. From the medication list, a determination was made regarding the
Annals of Emergency Medicine S127
423
Droperidol for the Treatment of Conversion Disorder in the Emergency Department
Bock PJ, Smith SW/Hennepin County Medical Center, Minneapolis, MN
Study Objectives: There is little data on the emergency department therapy (medication) of conversion disorder; we investigated the efficacy of droperidol. Methods: Retrospective chart review: conversion disorder is a listed diagnosis in Emstat®, our electronic record; all such patients from March 1994 through March 2005 were queried. Charts with evidence contradicting the diagnosis, as defined by DSM IV, were excluded. Demographics, symptoms, other diagnosis, medications/ treatments used, resolution and time to resolution, and medical/psychiatric history were recorded. Statistics were by Chi square and Fisher exact test. Results: There were 112 patients: 22 had no records available and 14 were excluded because an alternate diagnosis was more likely than conversion disorder, either by follow-up exam or by diagnostic criteria. 76 patients with conversion disorder remained, 51 females and 25 males. Cases were evenly distributed over the 11 year period. Mean age (⫾ SD) was 30 ⫾ 10 years. Presenting symptoms were: catatonia (unresponsiveness with open eyes) 10 (13%), pseudoseizure 17 (22%), paralysis 14 (18%), unresponsiveness with closed eyes 9 (12%), anesthesia 15 (20%), tic 1 (1%), aphasia 2 (3%), blindness 1 (1%), paresthesias 12 (16%) stuttering 1 (1%), other neurologic deficit such as weakness or dysarthria 14 (18%), or other 5 (7%) for a total of 101 (133%). Symptoms had resolved at presentation in 4, leaving 72 with the following treatments: Droperidol in 30 (42%) cases [1.25mg (7 cases), 2.5mg (21), or 5mg (2)], a benzodiazepine in 9 (13%), and reassurance or no treatment documented or other in 33 cases (46%). Symptoms resolved in 58 of 72 (81%): 28 of 30 (93%) who received droperidol vs. 30 of 42 (71%) who did not (p ⫽ 0.02). See table. Limitations: Response to treatment may have influenced final diagnosis; conversion disorder not so coded would have been missed. Conclusion: Conversion disorder resolution is enhanced by droperidol and benzodiazepines and expedited by droperidol; further prospective study is needed.
Volume , . : October
424
Parenteral Antiemetic Trends in an Emergency Department and Inpatient Population From 19962005
Baker MB, Hafner JW, Lin GC, Peterson SC/University of Illinois College of Medicine at Peoria, Peoria, IL; Bradley University; Department of Industrial & Manufacturing Engineering & Technology, Peoria, IL; OSF Saint Francis Medical Center, Peoria, IL
Study Objectives: Nausea and vomiting are frequent presenting complaints in the emergency department (ED) and parenteral antiemetic agents are the 6th most common class of drugs used in EDs. Recently, potent but more costly drugs have been introduced while inexpensive older medications are less available. This study seeks to describe ED parenteral antiemetic trends and compare them to a hospital inpatient population. Methods: A retrospective time series analysis of parenteral antiemetic medication utilization was conducted at a large urban academic medical center. Antiemetics from several pharmacologic classes (prochlorperazine, metoclopramide, droperidol, promethazine, ondansetron, hydroxazine, granisetron) used from 1996-2005 were identified from a hospital pharmacy database. Drugs with primary indications other than antiemesis (i.e. diphenhydramine, corticosteroids), were excluded. Aggregate adult and pediatric usage data was described by medication units (frequency) and individual cases, comparing between inpatient and ED locations. Charges were converted to costs by multiplying by hospital-specific, cost center ratios of costs to charges. Linear regression models (Minitab 14.0) were used to identify significant (p ⬍ 0.05) changes in annual drug patterns, and changes between populations were described using nonparametric tests (t test and Mann-Whitney test). Trend analysis plots for future antiemetic use patterns were conducted using linear, quadratic, and growth curve models, and the mean absolute deviation used for ideal model identification. Results: During the study period, a total of 589,838 drug units were dispensed (93.4% inpatients vs. 6.6% ED). The most common inpatient drug used was metoclopramide (240,885 units or 43.7%) and the most common ED drug was promethazine (10,534 units or 27.2%). The total hospital costs from 1996-2005 were $3,810,654.54, with 96.5% of costs resulting from inpatients; ondansetron represented the largest percentage of costs in both the ED (38.5%) and inpatient populations (58.6%). Time series analysis indicated individual drug use and cost patterns (as a percentage of total costs and use) were not different between two populations (inpatient vs. emergency). From 1996 to 2005 prochlorperazine and droperidol had use reductions in both the inpatient and the ED setting, while ondansetron had increased use patterns in the ED (2886.8%) and inpatient populations (620.3%). Trend analysis demonstrated increases in the projected growth rate for ondansetron in both the ED and inpatient settings. Conclusion: Parenteral antiemetic use patterns have changed significantly between 1996 and 2004 for inpatients and ED patients. Serotonin inhibitor agent use has increased rapidly in both populations.
425
Medication Duplication in Patients Presenting to the Emergency Department
Richman R, Triner W/Albany Medical College, Albany, NY
Study Objectives: To determine the prevalence of patients taking duplicative medications (DMd) seen in the emergency department (ED). We define DMd as two or more medications from the same class or subclass taken by a patient for which there would be no rationale for the redundancy (e.g. propranolol and atenolol). Methods: Design: This was a cross-sectional observational study. Setting: An academic tertiary care ED. Type of Participants: The study population consisted of a convenience sample, proportionally representing days of the week and hours of the day, of patients in an academic tertiary care ED. Intervention: During a six week period, individual charts were reviewed while the patient was in the ED. The following information was collected on all patients; age, gender, insurance status and medication lists. From the medication list, a determination was made regarding the
Annals of Emergency Medicine S127