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Intramuscular chemical sedation is commonly used in the emergency department (ED) for severe agitation and physical assault when other attempts at de-escalation and agitation control (verbal de-escalation, space, etc) are unsuccessful. The “cocktails” people use are often institution-based. In this podcast, we review commonly used intramuscular agents along with recent papers including ketamine, droperidol, and choice of benzodiazepines.

Droperidol has been cited as working very quickly, however, several studies show that the onset is in the ballpark of 15-20 minutes (even at 10 mg IM).

1. Cole et al. A Prospective Study of Intramuscular Droperidol or Olanzapine for Acute Agitation in the Emergency Department: A Natural Experiment Owing to Drug Shortages. Ann Emerg Med. 2021 Aug;78(2):274-286. PMID: 33846015.
2. Isbister GK et al. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010 Oct;56(4):392-401.e1. doi: 10.1016/j.annemergmed.2010.05.037. PMID: 20868907.
3. Calver L et al. The Safety and Effectiveness of Droperidol for Sedation of Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2015 Sep;66(3):230-238.e1. PMID: 25890395.

A recent randomized controlled trial of ketamine versus haloperidol + midazolam by Barbic et al demonstrates impressive time to agitation control for ketamine.

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Guidelines have recommended outpatient management for patients with low-risk pulmonary embolism (PE) for many years. Despite this, few patients in the US diagnosed with acute PE are discharged from the Emergency Department (Westafer et al). Little is known about the course of patients managed exclusively or primarily in the outpatient setting. In this study, Vinson and colleagues describe the nature and course of patients diagnosed with pulmonary embolism in the primary care setting.

Vinson DR, Hofmann ER, Johnson EJ, Rangarajan S, Huang J, Isaacs DJ, Shan J, Wallace KL, Rauchwerger AS, Reed ME, Mark DG; PEPC Investigators of the KP CREST Network. Management and Outcomes of Adults Diagnosed with Acute Pulmonary Embolism in Primary Care: Community-Based Retrospective Cohort Study. J Gen Intern Med. 2022 Jan 12. doi: 10.1007/s11606-021-07289-0. Epub ahead of print. PMID: 35020167.

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The diagnostic algorithm for pulmonary embolism (PE) has evolved over the past few years to include probability or risk-adjusted D-dimer. The YEARS algorithm includes an elevated D-dimer threshold for some risk groups and has been found to be safe and reduce imaging in several studies, including in pregnant patients. Now, this multicenter trial by Freund et al evaluates the use of YEARS and age-adjusted D-dimer compared with an age-adjusted approach alone.

Freund Y, Chauvin A, Jimenez S, Philippon AL, Curac S, Fémy F, Gorlicki J, Chouihed T, Goulet H, Montassier E, Dumont M, Lozano Polo L, Le Borgne P, Khellaf M, Bouzid D, Raynal PA, Abdessaied N, Laribi S, Guenezan J, Ganansia O, Bloom B, Miró O, Cachanado M, Simon T. Effect of a Diagnostic Strategy Using an Elevated and Age-Adjusted D-Dimer Threshold on Thromboembolic Events in Emergency Department Patients With Suspected Pulmonary Embolism: A Randomized Clinical Trial. JAMA. 2021 Dec 7;326(21):2141-2149. doi: 10.1001/jama.2021.20750. PMID: 34874418; PMCID: PMC8652602.

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A single-center randomized trial in 2018 by Driver et al found an incredible 98% first-pass success for endotracheal intubation in the group randomized to a structured bougie-first approach, compared with 87% in those randomized to stylet. In this podcast, we review a multi-center study by Driver et al examining bougie vs stylet in a wider array of emergency departments and intensive care units.