Laboratory findings in emergently medicated psychiatry patients

Schillerstrom, Tracy L.; Schillerstrom, Jason E.; Taylor, Sally

doi:10.1016/j.genhosppsych.2004.06.004

Cited by 14 publications

(7 citation statements)

References 11 publications

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“…Agitation can be caused by many medical problems, such as delirium, and agitated patients may also have significant medical problems that do not directly relate to the agitated presentation but may complicate its management. One study 14 reviewed the lab results of people who had received IM injections over a 1-month period in a PES versus those who had not. It was found that those who received IM injections had abnormal levels of potassium, glucose, aspartate aminotransferase, and alanine aminotransferase, as well as longer mean QTc interval on electrocardiogram.…”

Section: Medical Assessmentmentioning

confidence: 99%

Managing the Acutely Agitated and Psychotic Patient

Nordstrom¹,

Allen²

2007

CNS Spectr.

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Agitation can present as an emergency in the course of numerous psychiatric conditions including intoxication, schizophrenia, bipolar disorder, and delirium. This article reviews relevant literature regarding the definition, etiology, measurement, and management of episodic agitation and pays particular attention to intramuscular treatments. The impact of changes in methodology between the era of first- and second-generation antipsychotics, the implications of those changes for external validity of studies of second-generation studies, and the recent evolution of expert consensus are discussed.

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Section: Medical Assessmentmentioning

confidence: 99%

Managing the Acutely Agitated and Psychotic Patient

Nordstrom¹,

Allen²

2007

CNS Spectr.

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“…It is frequently impossible in emergency settings to determine which medications patients may have taken. Moreover, recent investigations 33 indicate that severely agitated patients requiring emergency IM medication tend to have significantly more laboratory abnormalities, including QTc prolongation, than nonagitated patients who present in the ED. Both of these factors underscore the need for agents with a low likelihood of drug-drug interactions in the treatment of acutely agitated patients.…”

Section: Drug-drug Interactionsmentioning

confidence: 99%

“…The randomized clinical trials described in this monograph provide data demonstrating the safety and efficacy of ziprasidone IM to support regulatory approval for marketing. However, subjects in randomized clinical trials are not necessarily representative of patients in real-world clinical practice, 33 as these studies must exclude severely agitated individuals unable or unwilling to consent to participation, as well as others with a recent history of alcohol or substance abuse. To address this issue, panelists from a large PES, a medical ED, and an ICU, provided data from naturalistic studies conducted in real-world treatment settings.…”

Section: Postmarketing Experience In the Psychiatric Emergency Servicementioning

confidence: 99%

“…According to a majority of the panelists, one justification for choosing a conventional over a second-generation agent is if the patient has a history of responding well to conventional agents and specifically requests one. The need to select the safest medication possible was highlighted by recent findings that patients treated with antipsychotics in the PES are likely to be older and to have more abnormal laboratory values than other adult patients in emergency settings, 33 and are thus at higher risk of drug side effects and drug-drug interactions.…”

Section: Choice Of Initial Im Agent: Atypical Versus Conventionalmentioning

confidence: 99%

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Best Clinical Practice With Ziprasidone IM: Update After 2 Years of Experience

et al. 2005

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Acute agitation is a common psychiatric emergency often treated with intramuscular (IM) medication when rapid control is necessary or the patient refuses to take an oral agent. Conventional IM antipsychotics are associated with side effects, particularly movement disorders, that may alarm patients and render them unreceptive to taking these medications again. Ziprasidone (Geodon®) is the first second-generation, or atypical, antipsychotic to become available in an IM formulation. Ziprasidone IM was approved by the Food and Drug Administration in 2002 for the treatment of agitation in patients with schizophrenia. In October 2004, a roundtable panel of physicians with extensive experience in the management of acutely agitated patients met to review the first 2 years of experience with this agent. This monograph, a product of that meeting, discusses clinical experience to date with ziprasidone IM and offers recommendations on its use in various settings.In clinical trials, patients treated with ziprasidone IM demonstrated significant and rapid (within 15-30 minutes) reduction in agitation and improvement in psychotic symptoms, agitation, and hostility to an extent greater than or equal to that attained with haloperidol IM. Tolerability of ziprasidone IM was superior to that of haloperidol IM, with a lower burden of movement disorders. Clinical trials have also shown that ziprasidone IM can be administered with benzodiazepines without adverse consequences. Transition from IM to oral ziprasidone has been well tolerated, with maintenance of symptom control. The most common adverse events associated with ziprasidone IM were insomnia, headache, and dizziness in fixed-dose trials and insomnia and hypertension in flexible-dose trials. No consistent pattern of escalating incidence of adverse events with escalating ziprasidone doses has been observed. Changes in QTc interval associated with ziprasidone at peak serum concentrations are modest and comparable to those seen with haloperidol IM. Results of randomized clinical trials of ziprasidone IM have been corroborated in studies in real-world treatment settings involving patients with extreme agitation or a recent history of alcohol or substance abuse. In these circumstances, clinically significant improvement was seen within 30 minutes of ziprasidone IM administration, without regard to the suspected underlying etiology of agitation. Agents with a good safety/tolerability profile, such as ziprasidone IM, may be more cost effective long term than older agents, due to reduced incidence of acute adverse effects (eg, acute dystonia) that often require extended periods of observation. Additional trials of ziprasidone IM in agitated patients in a variety of clinical settings are warranted to generate comparative risk/benefit data with conventional agents and other second-generation antipsychotics.

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“…10,11 All aggressive patients are therefore subject to mandatory screening for a medical illness by emergency department (ED) doctors in the EDs of Addington and King Edward VIII hospitals in Durban. ED doctors argue that screening is unnecessary because:…”

mentioning

confidence: 99%

Routine pre admission laboratory screening investigations in aggressive patients who require sedation in the emergency department – necessary or unnecessary

Saloojee

2009

S. Afr. J. Psych.

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Background: The triage of aggressive patients who require sedation for behavioural control in the emergency department (ED) at our hospitals is delayed because the results of mandatory screening laboratory investigations to exclude a general medical condition (GMC) must be available prior to a psychiatric referral. The monitoring of these sedated patients in the ED is the problem.Objective: The primary objective of this study was to determine the value of the results of routine pre-admission laboratory screening investigations in the differentiation of a medical from a psychiatric cause of aggression in consecutive aggressive patients who required sedation in the EDs at King Edward V111 and Addington Hospitals. Specific objectives were to determine if there was an association between a history of past psychiatric illness, the physical examination, the results of laboratory screening investigations and the cause of the aggression.Methods: a retrospective chart review of 339 consecutive aggressive patients who required intravenous or intramuscular sedation for behavioural control in the EDs of Addington and King Edward V111 Hospitals in Kwa Zulu Natal (KZN) was conducted from 01 January 2006 to 31 December 2006. Patients who required oral or no sedation were excluded from the study. Results: 82 (24.2%) of the 339 patients in the study had a medical cause for the aggression .40 (11.7%) of these had no previous medical history. Overall the yield of clinically significant results from laboratory investigations was 9.6%. No past history of psychiatric illness, physical examination, the Full Blood Count (FBC), Urea and Electroloyte estimation (U&E) and Random Blood Glucose (RBG) had sensitivities of 28%, 63%, 57%, 40% and 21% respectively for the identification of a GMC causing the aggression. The variables that remained significantly associated with a causal GMC were an abnormal physical examination only (OR 42.151), an abnormal FBC (OR 2.363),an abnormal U & E (OR 3.531) and no past history of mental illness combined with an abnormal physical examination (OR 277.442). A previous history of a mental illness only was not significantly associated with the cause of aggression. These are adjusted odds ratios, ie they are independent of the effects of the other variables. Conclusion: The high rate of a medical cause for the aggressive behaviour and the overall yield from screening laboratory investigations emphasize the need for mandatory screening to exclude a GMC in the EDs of our hospitals. Aggressive patients with a documented past psychiatric history and a normal physical examination can be referred for a psychiatric assessment prior to the results of routine laboratory investigations becoming available.

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Laboratory findings in emergently medicated psychiatry patients

Cited by 14 publications

References 11 publications

Managing the Acutely Agitated and Psychotic Patient

Managing the Acutely Agitated and Psychotic Patient

Best Clinical Practice With Ziprasidone IM: Update After 2 Years of Experience

Routine pre admission laboratory screening investigations in aggressive patients who require sedation in the emergency department – necessary or unnecessary

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