Comparing Intubation Rates in Patients Receiving Parenteral Olanzapine With and Without a Parenteral Benzodiazepine in the Emergency Department.

STUDY OBJECTIVE: United States prescribing information recommends against coadministration of injectable olanzapine with injectable benzodiazepines due to a risk of cardiorespiratory depression, whereas European prescribing information recommends the 2 drugs not be administered within 60 minutes of each other. In contrast, a recently published American College of Emergency Physicians clinical policy recommends injectable olanzapine and benzodiazepines be coadministered for treating severe agitation. We sought to compare injectable olanzapine with and without injectable benzodiazepines for evidence of cardiorespiratory depression. METHODS: We performed a retrospective study of patients in an urban emergency department from January 2017 through November 2019 who received parenteral olanzapine with or without parenteral benzodiazepines. We included patients receiving 2 total medication doses, either olanzapine+benzodiazepine or 2 doses of olanzapine, coadministered within 60 minutes. The primary outcome was tracheal intubation in the emergency department. Secondary outcomes included hypotension (systolic blood pressure less than 90 mmHg) and hypoxemia (SpO2 less than 90%). RESULTS: We identified 693 patients (median [alcohol]=210 mg/dL, median age=37 years [IQR 29 to 49]). In total, 549 received 2 doses of olanzapine, and 144 patients received olanzapine and a benzodiazepine. We found no difference in intubation rates between the olanzapine-only group (21/549, 3.8%) and the olanzapine+benzodiazepine group (5/144, 3.5%; difference=0.3%, 95% confidence interval -3.0% to 3.7%). Rates of hypoxemia (2% olanzapine-only and 3% olanzapine+benzodiazepine) and hypotension (9% both groups) also were not different between groups. CONCLUSION: We found no difference in cardiorespiratory depression between patients receiving only olanzapine versus olanzapine plus a benzodiazepine.

Comparison of efficacy and frequency of akathisia and dystonia between olanzapine, metoclopramide and prochlorperazine in ED headache patients.

STUDY OBJECTIVE: To compare the efficacy and frequency of akathisia and dystonia between the dopamine antagonist headache medications olanzapine, metoclopramide and prochlorperazine. METHODS: This was a retrospective observational cohort study of patients presenting to a large urban level one trauma center between 2010 and 2018. Inclusion criteria was age ≥ 18 who presented to the emergency department with a chief complaint of headache who received either olanzapine, metoclopramide or prochlorperazine. The primary outcome was need for rescue medication. Secondary outcomes were receiving medication for either akathisia or dystonia. Logistic regression was used to identify differences between the three cohorts up to 72 h from initial presentation. RESULTS: There were 5643 patients who met inclusion criteria. Olanzapine was the most commonly used drug (n = 2994, 53%) followed by prochlorperazine (n = 2100, 37%) and metoclopramide (n = 549, 10%). After adjusting for age and gender, there were no differences in risk for receiving rescue therapy or developing akathisia or dystonia. CONCLUSION: During initial ED visit and up to 72 h after receiving olanzapine, metoclopramide or prochlorperazine, we found no difference in risk for requiring rescue medication or developing akathisia or dystonia.

Bronchoscopy in the emergency department.

BACKGROUND: Flexible bronchoscopy has been safely used for decades in ambulatory and critical care settings to aid in the diagnosis and treatment of tracheobronchial tree disorders. Although emergency physicians have the requisite skills to operate and interpret flexible bronchoscopy, no reports exist on the use of bronchoscopy by emergency physicians apart from endotracheal tube placement and confirmation. OBJECTIVE: The primary goal of this study was to describe the indications, outcomes and complications of flexible bronchoscopy performed by emergency physicians in an urban academic emergency department. METHODS: This was a single-center retrospective cohort study involving chart and video review of 146 patients over a 10.5-year study period. Patients of any age were included if they had been tracheally intubated or mechanically ventilated and underwent flexible bronchoscopy in the emergency department. After patients were identified, manual chart and video review was used to collect data on patient demographics, indications for intubation, indications for bronchoscopy, details of the bronchoscopy procedure, procedural findings, outcomes of the procedure, complications, provider training levels, and additional bronchoscopies performed after admission. The data was analyzed using descriptive statistics. RESULTS: 146 patients were included in the study and all bronchoscopies were performed or supervised by attending emergency physicians. After bronchoscopy, 24% of patients displayed improvement in oxygenation or lobar collapse while most patients had no change in clinical status. One patient had temporary hypoxemia after bronchoscopy. When another physician performed a subsequent bronchoscopy during admission, the findings were in agreement with the ED bronchoscopy 86% of the time. CONCLUSION: At our institution, emergency physicians can safely and effectively use flexible bronchoscopy to diagnose and treat critically ill patients.

A Prospective Study of Intramuscular Droperidol or Olanzapine for Acute Agitation in the Emergency Department: A Natural Experiment Owing to Drug Shortages.

STUDY OBJECTIVE: Intramuscular medications are commonly used to treat agitation in the emergency department (ED). The purpose of this study is to compare intramuscular droperidol and olanzapine for treating agitation. METHODS: This was a prospective observational study of ED patients receiving intramuscular droperidol or olanzapine for acute agitation. The treating physician determined the medication and dose; however, over time drug shortages made either olanzapine (July to September 2019) or droperidol (November 2019 to March 2020) unavailable, creating a natural experiment. The primary outcome was time to adequate sedation, assessed by the Altered Mental Status Scale (AMSS), defined as time to AMSS score less than or equal to 0. RESULTS: We analyzed 1,257 patients (median age 42 years; 73% men); 538 received droperidol (median dose 5 mg) and 719 received olanzapine (median dose 10 mg). The majority of patients (1,086; 86%) had agitation owing to alcohol intoxication. Time to adequate sedation was 16 minutes (interquartile range 10 to 30 minutes) for droperidol and 17.5 minutes (interquartile range 10 to 30 minutes) for olanzapine (absolute difference -0.7 minutes; 95% confidence interval -2.1 to 0.5 minutes). Adjusted Cox proportional hazard model analysis revealed no difference between groups in time to sedation (hazard ratio for adequate sedation for droperidol compared with olanzapine 1.12; 95% confidence interval 1.00 to 1.25). Patients receiving olanzapine were more likely to receive additional medications for sedation (droperidol 17%; olanzapine 24%; absolute difference -8% [95% confidence interval -12% to -3%]). We observed no difference between drugs regarding adverse effects except for extrapyramidal adverse effects, which were more common with droperidol (n=6; 1%) than olanzapine (n=1; 0.1%). CONCLUSION: We found no difference in time to adequate sedation between intramuscular droperidol and olanzapine.

Medical needs of emergency department patients presenting with acute alcohol and drug intoxication.

STUDY OBJECTIVE: Some contend that patients with acute alcohol or illicit substance intoxication should be treated in outpatient detoxification centers rather than in the ED. However, these patients often have underlying acute medical needs. We sought to determine the frequency of medical interventions required by ED patients with alcohol or illicit substance intoxication. METHODS: This was a prospective observational study of consecutive ED patients presenting to an urban tertiary care ED with altered mental status due to alcohol or illicit substance use. We performed data collection for patients deemed to be low-risk for complications, as defined by receiving care in an intoxication observation unit. Trained staff observed and recorded all medical interventions, including medications administered, diagnostic testing, procedures performed, and airway interventions. The incidence of agitation was recorded using the Altered Mental Status Scale (AMSS, ordinal scale from -4 to +4, where +4 is most agitated). The data analysis is descriptive. RESULTS: This analysis included 2685 encounters (1645 unique patients; median age 39; 73% male) from January to May 2019. Average breath alcohol concentration was 0.20 g/dL (range 0.00-0.47). There were 89% encounters with alcohol intoxication, and in 17% encounters the patient was suspected or known to have drug intoxication (either alone or in conjunction with alcohol use). On arrival to the ED, 372 (14%) had agitation (AMSS +1 or higher) and 32 (1%) were profoundly agitated (AMSS +4). In total, 1526 (56%) received at least one intervention that could not be provided by a local detoxification or sobering facility. Of the study population, 955 (36%) received a sedating medication, 903 (34%) required physical restraints for patients or staff safety, 575 (21%) underwent imaging studies, 318 (12%) underwent laboratory testing, 367 (13%) received another intervention (IV access, EKG, splinting, wound care, etc). Additionally, 111 (4%) patients received an airway intervention (19 intubation, 23 nasal airway, 85 supplemental oxygen) and 275 (10%) required repositioning to protect the airway. There were 168 (6%) patients admitted to the hospital. CONCLUSION: In this population of relatively low-risk ED patients with drug and alcohol intoxication, a substantial proportion of patients received medical interventions.

Time to Loss of Preoxygenation in Emergency Department Patients.

BACKGROUND: In patients requiring emergency rapid sequence intubation (RSI), 100% oxygen is often delivered for preoxygenation to replace alveolar nitrogen with oxygen. Sometimes, however, preoxygenation devices are prematurely removed from the patient prior to the onset of apnea, which can lead to rapid loss of preoxygenation. OBJECTIVE: We sought to determine the elapsed time, on average, between removing the oxygen source and the loss of preoxygenation among non-critically ill patients in the emergency department (ED). METHODS: We conducted a prospective, crossover study of non-critically ill patients in the ED. Each patient received two identical preoxygenation trials for 4 min using a non-rebreather mask with oxygen flow at flush rate and a nasal cannula with oxygen flow at 10 L/min. After each preoxygenation trial, patients underwent two trials in random order while continuing spontaneous breathing: 1) removal of both oxygen sources and 2) removal of non-rebreather mask with nasal cannula left in place. We defined loss of preoxygenation as an end-tidal oxygen (exhaled oxygen percentage; EtO2) value < 70%. We measured EtO2 breath by breath until loss of preoxygenation occurred. RESULTS: We enrolled 42 patients, median age was 43 years (interquartile range [IQR] 30 to 54 years) and 72% were male. Median time to loss of preoxygenation was 20 s (IQR 17-25 s, 4.5 breaths) when all oxygen devices were removed, and 39 s (IQR 21-56 s, 8 breaths) when the nasal cannula was left in place. CONCLUSIONS: In this population of non-critically ill ED patients, most had loss of preoxygenation after 5 breaths if all oxygen devices were removed, and after 8 breaths if a nasal cannula was left in place. These data suggest that during ED RSI, preoxygenation devices should be left in place until the patient is completely apneic.

A comparative study of conducted electrical weapon incapacitation during a goal-directed task.

Conducted electrical weapons (CEW) are ubiquitous in law enforcement given their unique ability to physically incapacitate violently resisting subjects. Early use of animal models to study CEW incapacitation effectiveness (e.g. porcine model with 4-limb strain gauges) proved to be poorly predictive of human incapacitation effectiveness. In a previously published human study, we developed a methodology for the prospective assessment of the incapacitation effectiveness of CEWs in highly motivated human subjects. Here we use this methodology in Part 1 to compare the incapacitation effectiveness of the newly released Axon® (formerly TASER® International) T(ASER) 7 to the TASER X26E, the "gold standard", and the TASER X2, a current model. The T7 has a new "adaptive cross-connect" technology that may improve incapacitation effectiveness in the scenario of small spreads between probe pairs, a common cause of weapon "failure" in the field. In Part 2, we use our methodology to test the functionality of the T7 cross-connect technology by comparing different bay and probe configurations. This is the first published study in the literature comparing different CEW models using this human model. For Part 1, 29 subjects completed the study and had data available for analysis. For Part 2, 21 subjects completed the study and had data available for analysis. The subjects were motivated to complete the task of reaching a suspended martial arts dummy 3.4 m (11 ft) away while being exposed "under power" to the CEW. In Part 1, subjects were assigned to 1 of 6 groups with probe spreads of 10, 20, and 30 cm (4, 8, 12 in). Subjects were exposed to a "control" CEW (either the X2 or X26E) and the T7 on alternating sides. Exposures with the X2 and T7 included 2 bay-exposures. In Part 2, 21 subjects were assigned to 1 of 5 groups of different T7 bay and probe configurations all with a theoretical effective spread of 30 cm (12 in). Subjects were rated on their progress towards successfully reaching the dummy and on the extent of limb incapacitation using a quasi-blinded expert-observer scoring panel based on high-speed video review. In Part 1, all CEW models achieved maximal or near-maximal subject control with the 30 cm probe spread. With probe spreads of 10 and 20 cm the pooled data showed the T7 to be superior to the X2 for goal achievement (p < 0.001) and limb incapacitation (p = 0.002) mostly driven by differences seen with the 10 cm spread (2-bay exposures). The T7 was non-inferior to the X26E. In Part 2, there was no statistical significance between the limb capture scores, but there was a statistically significant difference in goal scores. The results overall validate that the T7 CEW cross-connect feature performed as expected. The T7 adaptive cross-connect feature with two simultaneous deployed probe pairs demonstrated a significant improvement in incapacitation effectiveness compared to the current X2 CEW with two simultaneously deployed probe pairs. Small probe spreads are a common reason for limited incapacitation effectiveness in the field and this study suggests the T7 may offer an improvement in this scenario. The T7, with single-bay exposures, was non-inferior to the single-bay X26E.

The physiologic effects of a new generation conducted electrical weapon on human volunteers at rest.

Axon Enterprise, Inc. (Axon) released its newest generation conducted electrical weapon (CEW), the T7, in October 2018. In order to compare the effects of this new CEW to prior generations, we used our previously described methodology to study the physiologic effects of CEWs on human volunteers at rest. This was a prospective, observational study of human subjects consisting of two parts. Part 1 was testing a single cartridge (2-probe) exposure. Subjects received a 10-s exposure from the T7 to the back with a 30 cm (12 in.) spread between the two probes. Part 2 was testing a simultaneous two-cartridge (4-probe) exposure. Subjects received a 10-s exposure from the T7 to the back with two cartridges with a 10 cm (4 in.) spread between each probe pair. The probe pairs were arranged cephalad to caudal such that the distance between the top probe of the first cartridge and the bottom probe of the second cartridge was 30 cm (12 in.). Vital signs were measured immediately before and after the exposure. Continuous spirometry was performed. ECG monitoring was performed immediately before and after the exposure. Venous pH, lactate, potassium, CK, catecholamines, and troponin were measured before and immediately after the exposure, at 1-h post-exposure, and again at 24 h. 11 subjects completed part 1 of the study. 9 subjects completed part 2 of the study. No subjects had a dysrhythmia or morphology change in the surface ECG. There were no statistical changes in vital signs pre- and post-exposure. While subjects did not have a statistical change in spirometry parameters pre-exposure to exposure except for a small drop in PETCO2, there was an increase in minute ventilation after the exposure that could have several explanations. A similar pattern was seen with prior generation weapons. No subject had elevated troponin levels. Other blood parameters including venous pH, lactate, potassium, CK, and catecholamines had changes similar to prior generation weapons. Comparison of the data for the single-cartridge exposures against the simultaneous two-cartridge exposures yielded no difference in vital signs, but the minute ventilation was higher for the two-cartridge exposures. The blood data, where there was a difference, was mixed. In our study, the physiologic effects of the Axon T7 are modest, consistent with the electrically-induced motor nerve-driven muscle contraction, and were similar to prior generation weapons.

First attempt success with continued versus paused chest compressions during cardiac arrest in the emergency department.

AIM: Tracheal intubation is associated with interruption in cardiopulmonary resuscitation (CPR). Current knowledge of tracheal intubation during active CPR focuses on the out-of-hospital environment. We aim to describe characteristics of tracheal intubation during active CPR in the emergency department (ED) and determine whether first attempt success was associated with CPR being continued vs paused. MEASUREMENTS: We reviewed overhead video from adult ED patients receiving chest compressions at the start of the orotracheal intubation attempt. We recorded procedural detail including method of CPR, whether CPR was continued vs paused, and first attempt intubation success (primary outcome). We performed logistic regression to determine whether continuing CPR was associated with first attempt success. RESULTS: We reviewed 169 instances of tracheal intubation, including 143 patients with continued CPR and 26 patients with paused CPR. Those with paused CPR were more likely to be receiving manual rather than mechanical chest compressions. Video laryngoscopy and bougie use were common. First attempt success was higher in the continued CPR group (87%, 95% CI 81% to 92%) than the interrupted CPR group (65%, 95% CI 44% to 83%, difference 22% [95% CI 3% to 41%]). The multivariable model demonstrated an adjusted odds ratio of 0.67 (95% CI 0.17 to 2.60) for first attempt intubation success when CPR was interrupted vs continued. CONCLUSIONS: It was common to continue CPR during tracheal intubation, with success comparable to that achieved in patients without cardiac arrest. It is reasonable to attempt tracheal intubation without interrupting CPR, pausing only if necessary.

Evaluation of the Nutritional Quality of Commissary Foods Offered in American Women's Prisons.

Weight gain and obesity among female prisoners is of public health concern. This study analyzed the nutritional quality of commissary food and recipes cooked within eight women's prisons in the United States. Food items from commissary lists were categorized into the MyPlate food groups. Nutrition Data System for Research was used to analyze the nutritional content of recipes ( N = 175). Mean nutrient content, percent Daily Values, and food group servings were calculated. Recipes were generally high in sodium, saturated fat, added sugars, and calories but low in vitamin D. Commissary items and recipes were both low in fruits, vegetables, and whole grains and excessive in refined grains. Additional research is needed to inform policies that ensure commissary offerings better reflect dietary recommendations.