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A Retrospective Review of the Use and Safety of Droperidol in a Large, High-Risk, Inner-City Emergency Department Patient Populaton

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A Retrospective Review of the Use and Safety of Droperidol in a Large, High-Risk, Inner-City Emergency Department Patient Populaton 1402 Chase, Biros · DROPERIDOL USE IN THE ED A Retrospective Review of the Use and Safety of Droperidol in a Large, High-risk, Inner-city Emergency Department Patient Populaton Peter B. Chase, MD, PhD, Michelle H. Biros, MD, MS Abstract Droperidol (DROP) is used in the emergency department teria for high risk. There were 622 pts with head trauma (ED) for sedation, analgesia, and its antiemetic effect. Its (401 with alcohol use), including 47 with computed to- ED safety pro®le has not yet been reported in patients mography (CT) scans positive for brain injury, 64 with (pts). Objectives: To document the use of DROP in high- cocaine use, and 197 with recent or remote seizures (137 risk pts (those with head injury, alcohol or cocaine intox- with alcohol use). Minor AEs such as transient hypoten- ication, and/or remote or recent seizures), and to deter- sion occurred in 96 pts after DROP (73 with alcohol use); mine the number of serious and minor adverse events 20 received intravenous ¯uids, while an additonal 28 pts (AEs)Ðseizures, hypotension, extrapyramidal side ef- (8 with alcohol use) received rescue medications for fects (EPSEs)Ðafter DROP. Methods: The ED database EPSEs. Six possible serious AEs occurred in pts with se- (EmSTAT) was queried to determine who received intra- rious comorbidities; 2 cases of respiratory depression, 3 muscular or intravenous DROP in the ED in 1998; further post-DROP seizures, and 1 cardiac arrest (resuscitated) 11 chart review was done if the patient was considered high hours after DROP in a cocaine-intoxicated pt (normal QT risk for or had experienced an AE. Multiple regression interval). There was no signi®cant difference among analysis using a random-effects model determined the high-risk groups in the occurrence of AEs. Conclusions: signi®cance of each variable in the occurrence of AEs. The vast majority of pts who received DROP in the ED Results: 2,468 patients (aged 20 months to 98 years; 112 did not experience an AE. A few serious AEs were noted Յ17 years; 141 Ն66 years) received DROP for agitation (n following DROP in patients with serious comorbidities; it = 1,357), pain (1,135), anxiety (99), vomiting (173), or is not clear that DROP was causative. Key words: dro- other reasons (50). There were 945 pts considered high peridol; dystonic reactions; seizures; adverse events; risk; 933 charts were reviewed (DROP mean dose 4.1 Ϯ emergency department. ACADEMIC EMERGENCY 2.0 mg); of these, 50 patient visits did not meet the cri- MEDICINE 2002; 9:1402±1410. The use of droperidol (DROP) in the emergency de- Droperidol is a butyrophenone used for sedating partment (ED) as a chemical restraint for extremely agitated patients but has also been used for the agitated and out-of-control patients has been re- treatment of headaches,3,4 nausea,5 and vertigo,6 ported.1,2 Although it is presumed to offer effective and in augmenting relief of pain when used with sedation, the safety of DROP use in the acutely in- opioids.7 It is generally not recommended in those toxicated/agitated patient is not known. Its safety patients who have a history of seizures or in pa- is also not known for other select groups, such as tients with acute head injury because DROP is elders, patients with a history of seizures, those thought to lower seizure threshold.8,9 However, with cardiovascular or central nervous system upon arrival to the ED it is often not clear whether (CNS) dysfunction (i.e., hypotension or extrapy- an agitated or intoxicated patient has just had a sei- ramidal symptoms), extremely intoxicated patients, zure, has a known seizure history, or has a signi®- or those abusing cocaine. Information supporting cant brain injury to warrant seizure precautions. the effectiveness and safety of DROP in reducing Another potential adverse side effect of DROP is acute agitation in patients with acute brain injury cardiovascular instability. Recently, there have been is also lacking. reports of widened QT complex and torsades de 10 From the Department of Emergency Medicine, Hennepin pointes in patients receiving DROP, raising addi- County Medical Center, Minneapolis, MN (PBC, MHB). tional concerns about its use in patients whose pre- Received March 1, 2002; revision received July 9, 2002; accepted July 15, 2002. vious medical history is uncertain or unobtainable Presented at the SAEM annual meeting, May 2002, St. Louis, because of the patient's current medical condition MO. or agitated state. Address for correspondence amd reprints: Michelle H. Biros, The objective of this study was to document the MD, MS, Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, safety of DROP when used in a non-selected pa- MN 55415. Fax: 612-904-4241; e-mail: [email protected]. tient population for any reason. Our hypothesis ACAD EMERG MED · December 2002, Vol. 9, No. 12 · www.aemj.org 1403 was that DROP would be safe and effective in all breath alcohol analysis; on rare occasions, serum patients. alcohol levels were measured. The DROP observation period (DOP) was de®ned METHODS as the isolated observation time when DROP was the only medication the patient had received in the ED Study Design. A retrospective review of DROP use (other than antibiotic, pain, or additional antiemetic for ED patients during 1998 was performed utiliz- medications). As soon as any other drug was given ing the ED database (EmSTAT) at Hennepin (such as an antiepileptic medication) or when the County Medical Center (HCMC). This study was patient was discharged from the ED, the DOP reviewed by the institutional review board and ended. If the patient received any medication with considered exempt from informed consent because antiepileptic potential prior to or concurrent with of its retrospective nature and its use of archival DROP, no DOP time was generated (i.e., 0 minutes). data. The entire medical record was also reviewed for all admitted patients. Study Setting and Population. Hennepin County Medical Center is an urban hospital located in Data Analysis. All charts were identi®ed and data downtown Minneapolis, Minnesota, with approxi- collected in a standardized manner. Means and mately 95,000 patient ED visits per year. EmSTAT standard deviations were calculated when appro- is a computerized database for all ED patients. Data priate. A random-effects model multiple regression 11,12 are entered online and can be retrieved directly analysis was used to account for multiple visits from EmSTAT as a highly formatted patient record, by the same patient and to determine signi®cance which includes the following ®elds: patient's name of the following variables: age, level of alcohol in- and hospital record number, age, gender, date and toxication, gender, total time in ED, DOP, total time for all entries (including evaluations, contin- amount of DROP, route of delivery, degree of closed uing assessments, treatment and diagnostic orders head injury (none, injury, injury with negative head given and completed), chief complaint, primary computed tomography [CT], injury with positive and secondary discharge diagnoses, medications/ head CT), under the in¯uence of cocaine, and sei- Յ ¯uids, dose and route of delivery, disposition, and zure. A p-value 0.05 was considered signi®cant. vital signs (heart and respiratory rate, blood pres- Chart review was attempted for 945 patients who sure, and temperature). appeared (by EmSTAT) to have a highest likelihood All patients treated in the ED with intramuscular of being at high risk for adverse events following (IM) or intravenous (IV) DROP were identi®ed DROP, or who had apparently experienced a side through EmSTAT, and summary data (see above) effect suggested by subsequent ED interventions were collected. In addition, all patients receiving (i.e., IV ¯uids, benztropine mesylate, diphenhydra- DROP were cross-referenced with patients who also mine). Of these 945 cases, 933 charts were available received benztropine mesylate (Cogentin) or di- for review. After review, 50 patient visits did not phenhydramine (Benadryl) at the same or next ED meet our criteria for high risk and, therefore, are visit as an index of dystonic reactions. not included. None of the 50 charts had an adverse event. Only one of the 12 missing charts was of a hospitalized patient; he was admitted for alcohol Study Protocol. Complete patient charts were ob- withdrawal and his medical record could not be tained and reviewed if the patient had received found. DROP in the ED and EmSTAT review indicated signs of head trauma, recent or remote seizure, cocaine RESULTS use, a dystonic reaction, hypotension (systolic blood pressure [SBP] Յ90 mm Hg) and the use of A total of 2,468 ED patients received DROP in our alcohol. Head trauma was de®ned liberally as any ED in 1998. Indications for its use are summarized contusion, laceration, or any other injury to the in Table 1. Approximately half (46%) of these pa- head or face documented in the physician's physi- tients had documented ingestion of ethyl alcohol by cal examination. Patients who were diagnosed as breath alcohol levels (BALs). The largest percentage having recent seizures or were noted as having a of patients receiving DROP were sent home (55.8%), previous history of seizures were categorized as followed by admission to the hospital (19.7%), be- seizure patients. Cocaine was noted if the patient ing sent to the crisis intervention center (10.6%) or admitted to using it just prior to ED arrival or if a detoxi®cation centers (10.7%), or being taken to jail positive urine drug screen for cocaine was found. (3.2%). (The crisis intervention center is the HCMC Level of intoxication was usually determined by emergency psychiatry department, and the detoxi- 1404 Chase, Biros · DROPERIDOL USE IN THE ED TABLE 1.
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