Letters to the Editor
Beyond Haloperidol: Teaching Emergency Medicine Residents to Manage Acute Agitation and Aggression in the Emergency Department
Dear Editor:
In emergency departments, haloperidol is the antipsychotic most frequently used to manage violent patients (1). Although psychiatrists use various typical and atypical antipsychotics for this indication (2), emergency physicians continue to favour haloperidol. It is a safe and reliable medication for acute aggression (1), but there are additional factors to consider. For example, most patients requiring an antipsychotic for ongoing treatment will be prescribed a novel or atypical antipsychotic such as risperidone, olanzapine, or quetiapine. Using the same medication for both acute and ongoing treatment improves continuity, reduces risk of relapse while switching medications, and reduces the risk of medication interactions. Moreover, alternate strategies are useful if a patient states a strong medication preference or has experienced an allergic or side effect reaction to a particular medication. Further, patients will sometimes require intramuscular (IM) antipsychotics. However, in Canada, only typical antipsychotics are available in IM formulation. In the US, ziprasidone IM has recently been approved for treatment of acute agitation in patients with schizophrenia (3), while olanzapine IM is moving toward approval in Canada and in the US (3). Many typical antipsychotics are as safe and effective as haloperidol and can be given IM. These include trifluoperazine, fluphenazine, thiothixene, and loxapine (1,2). With regard to the latter, loxapine has a 5-HT2–dopamine D2 receptor occupancy ratio more characteristic of atypical than typical antipsychotics and, thus, a lower risk of extrapyramidal symptoms (2).
Many hospitals have psychiatrists readily available to the emergency department, yet emergency physicians still regularly manage patients showing acute aggression. Emergency physicians are intermittently exposed to continuing medical education, to pharma- ceutical company presentations, and to informal discussions with psychiatry staff regarding medication management of aggression. Nevertheless, haloperidol remains the antipsychotic of choice.
At our centre, postgraduate year 1 emergency medicine (EM) residents are required to complete a 1-month psychiatry rotation. During residency year 2002–2003, EM residents for the first time completed an emergency psychiatry rotation. Each resident was specifically educated in the management of agitation and aggression. This included a didactic session, teaching focused on cases, and supervised case management. At the beginning of their rotations, all 4 EM residents were aware of the haloperidol 5 mg plus lorazepam 2 mg approach to managing aggression. By the end of the rotation, residents were comfortable with some other approaches, including use of loxapine, risperidone, and olanzapine. One resident had the opportunity in the emergency department to use loading dosages of olanzapine 20 mg for 3 different patients showing agitation, with excellent benefit (4). Moreover, in ensuing months, EM residents continued to use these strategies and to discuss them with colleagues.
EM residents benefit from a specific rotation in emergency psychiatry because it is so relevant to their future practice. Further, psychiatry patients benefit from a more patient-centred, individualized approach to medication management, even in the acute setting.
Funding and Support
Eli Lilly financially supported my attendance at the International Association of Emergency Psychiatry meeting in June 2002 and the APA Annual meeting in May 2003.
References
1. Blanchard JC, Curtis KM. Violence in the emergency department. Emerg Med Clin North Am 1999;17:717–31.
2. Buckley PF. The role of typical and atypical antipsychotic medications in the management of agitation and aggression. J Clin Psychiatry 1999;60(Suppl 10):52–60.
3. Hopkins HS. In brief report. Biological Therapies in Psychiatry 2002;25:39.
4. Karagianis JL, Dawe IC, Thakur A, Begin S, Raskin J, Roychowdhury SM. Rapid tranquilization with olanzapine in acute psychosis: a case series. J Clin Psychiatry 2001;62(Suppl l2):12–6.
Susan Finch, MD, CM, FRCPC
Kingston, Ontario
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