An 18-year-old football player presents to the Emergency Department after an episode of transient numbness, tingling, and inability to move his right upper extremity after making a tackle. He continued playing without recurrence. The above imaging was obtained (Figure 1. Lateral cervical spine x-ray. Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 32505).
A 91-year-old female patient presented with her family after concern for multiple new lesions on her face and hands. The patient thinks the lesions grew over the course of a few months. There is no pain at the sites, no erythema, and no pruritis. She has caught the lesions on clothing and bedding, which has irritated the lesions on occasion, and the family is concerned/embarrassed by the growths on her face, which are harder to conceal than those on her hand.
A 27-year-old male with no significant past medical history presented to the emergency department with one week of progressively worsening, non-pruritic, and intermittently painful rash to his bilateral dorsal and plantar feet. The patient also described lesions to his left inguinal region and scrotal sac. There was no fever, chills, nausea, vomiting, chest pain, or shortness of breath. The patient was sexually active with men and women, with inconsistent condom use.
The ability to safely and effectively sedate agitated patients in the emergency department (ED) is paramount to provide prompt medical care and protect ED staff. Intravenous (IV) antipsychotics are frequently utilized, instead of other routes, given their more rapid onset of action. Similar to haloperidol, olanzapine can be used safely via the IV route despite both being FDA-approved for intramuscular (IM) administration only.
The table below summarizes the primary data evaluating IV olanzapine in the ED [1-5]. While IV olanzapine is a safe option for some agitated patients, some of these studies report a higher risk of respiratory complications or respiratory depression with the IV route compared to IM olanzapine or other IV treatment options. An Annals of Emergency Medicine commentary argues IV olanzapine might not be necessary for non-emergent cases of agitation or non-agitation indications and the IM route may suffice [6].
| Study | Olanzapine Dose | Adverse Event Rate – Olanzapine | Adverse Event Rate – Comparators | Notes |
|---|---|---|---|---|
| Chang 2013 (N=336) | 10 mg | 8.3% | IV Droperidol: 10.7% Placebo: 15.7 % | |
| Martel 2016 (N=713) | 1.25-20 mg | Minor: 11.4% Major: 2.6% | N/A | Adverse events were respiratory complications; 7 patients intubated |
| Taylor 2017 (N=92) | 5-10 mg | 20% | IV Midazolam + Droperidol: 22% IV Droperidol: 16.2% | |
| Yap 2017 (N=92) | 10 mg | 21.4% | IV Midazolam + Droperidol: 20.6% IV Droperidol: 6.7% | Methamphetamine-induced agitation |
| Cole 2017 (N=784) | 1.25-20 mg | 3.7% | IM olanzapine: 2.0% | Adverse events were respiratory depression |
Table: Adverse Events from IV Olanzapine for Agitation in the ED [1-5]
Treatment of agitated patients in the ED can be complex. Respiratory complications after medication administration may be related directly to the medication(s), the reduction of sympathetic drive, or both. All agitated patients should be monitored after receiving medications for sedation. The exact time course of this monitoring is not known and likely medication specific. Patients at high risk of neurologic, cardiovascular, or hemodynamic compromise should be monitored even more closely. This could include an ECG, pulse oxygenation, vital signs, and direct observation, as appropriate based on the patient-specific factors.
Medication selection for treating agitation in the ED requires thoughtful consideration of factors such as onset time (read more about “Onset of IM Medications for Severe Agitation“), duration, adverse events, and patient-specific variables. IV olanzapine is an option and monitoring should be commensurate with the situation and medication(s) chosen.
For further information, please read this in-depth literature review of IV olanzapine for the management agitation [7].
Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.
A 63-year old female presents to your ED with positional dizziness since rising out of bed from a nap this afternoon. She says she had a similar episode in the past and reports, “they took the stones out of my ear by making me lay down and move my head a few times.” Based on your assessment of the patient’s history and physical exam you determine she has peripheral vertigo, likely BPPV. However, despite multiple attempts with the Epley Maneuver, the patient is still symptomatic. What next steps could you consider?
Benign paroxysmal positional vertigo (BPPV) is a type of peripheral vertigo caused by a cluster of otoconial fragments that are displaced into the involved semicircular canal. The classic presentation is brief episodes of dizziness reported with position changes, commonly with rolling or arising from bed. The condition is more common in females and with advanced age (>40). BPPV should be differentiated from central vertigo and other types of peripheral vertigo including Meniere’s disease, vestibular schwannoma, vestibular neuritis, and labyrinthitis among others. Displaced otoliths are most commonly located in the posterior or horizontal semicircular canals. The strongest positive predictors of BPPV include dizziness lasting <15 seconds and onset with turning over in bed [1]. Episodes occur more frequently in the ear that is habitually dependent while sleeping [2], most commonly the right ear [3]. Regarding canal involvement, a retrospective review of 253 patients demonstrated the following [4]:
There exist many different diagnostics and therapeutic positional techniques for addressing BPPV. Below we discuss the commonly taught techniques and several viable alternatives to consider when initial evaluation and/or treatment are unsuccessful.
Posterior Canal
1. Diagnostic: Loaded Dix-Hallpike Test
A Dix-Hallpike test is the most commonly taught and used diagnostic technique. However, providers may consider the “loaded” Dix-Hallpike.
Technique: Flex the patient’s head forward 30° in the same plane as the affected posterior canal for 30 seconds before placing supine with traditional technique. The loaded Dix-Hallpike has increased sensitivity, duration of nystagmus, and severity of symptoms compared to the traditional techniques [5]. Consider using pillow/blankets under the thoracic spine to allow adequate cervical extension as an alternative to hanging the patient’s head over the end of the bed (trick of the trade). Elderly patients with severe kyphosis may need to be tested with the head of the bed tilted downward (Trendelenburg).
2. Diagnostic: Sidelying Test
This is an alternative to Dix-Hallpike in patients who cannot lie flat, such as with back pain, limited mobility, obesity, or orthopnea. It can be performed on the edge of the bed (often logistically easier in crowded ED rooms than Dix-Hallpike).
Technique: Rotate the head 45° contralateral to the posterior canal being tested. The patient descends to their side which is ipsilateral to the posterior canal being tested. This position is held for 30 seconds. If the patient experiences vertigo and the provider notices nystagmus, the test is positive. A negative test should prompt testing on the other side.
3. Therapeutic: Epley Maneuver
This is the most commonly taught and performed repositioning maneuver. The American Academy of Neurology and American Academy of Otolaryngology has given this technique a Level A Recommendation and clinical benefit demonstrated in a systematic review [6]. Consider using a “chin tuck”, similar to the loaded Dix-Hallpike, for additional success.
Epley Maneuver
4. Therapeutic: Semont Maneuver
Much like the Epley Maneuver is a continuation of the Dix-Hallpike Test, this therapeutic maneuver is a continuation of the Sidelying Test. The technique for left-sided posterior canalithiasis involves having a seated patient turn their head 45° to the left. The patient then drops their trunk to the right side, with the head turned 45° to the left (facing “up”). This position is held for 30-60 seconds. The patient then quickly sits up and lies down on the left side without stopping in the seated position. The head should still be kept 45° to the left so that the head now faces “down” and into the bed. This position is held for 30-60 seconds. Return the patient to the upright position.
Semont Maneuver desired otolith movement
Horizontal Canal
1. Diagnostic: Roll Test
The Roll Test should be considered in patients displaying symptoms consistent with BPPV but posterior canal tests (Dix-Hallpike, Sidelying) are negative or appear to demonstrate horizontal nystagmus.
Technique: Have the patient begin by lying supine with the head flexed forward 30°. The provider then rotates the patient’s head rapidly 90° to one side followed by the other side, after re-centering the head. A positive test will involve bursts of nystagmus beating towards the affected ear which are stronger when the affected ear is dependent.
2. Therapeutic: BBQ or Lempert Roll
This repositioning maneuver can be performed as a continuation of the Roll Test and has shown success rates over 90% [7].
Technique: This involves stepwise rotations of the non-tilted head starting in the supine position and ultimately rolling a full 360°, holding each incremental 90° rotation for 30 seconds, starting from the affected to the unaffected side. This can be repeated 2-4 times until symptoms improve or nystagmus disappears.
3. Therapeutic: Appiani/Gufoni Maneuver
The Appiani/Gufoni Maneuver repositioning maneuver has shown success rates comparable to other techniques in a meta-analysis [8].
Technique: Have the sitting patient descend to their unaffected side, hold this position for one minute or until symptoms subside. Then turning the head 45° towards the bed, holding this position for 1-2 minutes before sitting back up. Repeat until nystagmus is absent.
Appiani/Gufoni Maneuver desired otolith movement
Anterior Canal
The same maneuvers can be used to treat both posterior and anterior BPPV (i.e., Epley, Semont). However, there is a paucity of literature given the rarity of this condition. One small study reports success using a “reverse Epley” in 2 of 4 patients [9].
Realizing that you may have mis-identified the side and location of the dysfunction, you perform maneuvers assuming alternative locations for the provoking otoliths. To test for horizontal canal (instead of the more common posterior canal) dysfunction, you perform the roll test and notice nystagmus and worsening symptoms when facing the right side. Consequently, you have the patient perform the Lempert Roll technique, which causes her symptoms to resolve.
While you observe her for 10 minutes, there is no recurrence of her symptoms and she can ambulate without issues. You advise her to sleep on her left side. Outpatient follow-up with a physical therapist, specializing in vestibular disorders, should be strongly considered, especially if the patient is at risk for falls or if responsiveness to treatment was unclear.
The authors would like to extend a special thanks to Jeff Walter PT, DPT, NCS whose in-depth knowledge, experience, and research in the area of vestibular disorders were essential to this post. He is the creator of a FOAM blog: Vestibular Today on vestibular disorders that include many useful resources, diagrams, and videos.
The patient is a 24-year-old female who presents to the emergency department for left middle finger pain and swelling. She is right hand dominant and works in a kitchen. The patient states that ten days ago she avulsed the distal tip of the left middle finger, including the majority of the nail. At that time, the patient was evaluated at an outside hospital where the wound was cauterized with silver nitrate due to soft tissue bleeding. Since then, the patient states that she has had swelling over the dorsal distal phalanx.
A patient bitten by the pictured creature with the pictured lesion should be screened for which pathology?
