March 22, 2024

Welcome to this edition of Pharmacy Phriday. This month’s Prehospital Paradigm podcasts focus on psychiatric emergencies and include some discussion on various medications used within those emergencies. Over the next few weeks of this column, we will review some of the medications specific to those emergencies. 

This week, we focus on Olanzapine. Olanzapine is a second-generation antipsychotic medication that is one of two choices when the paramedic provider is treating an agitated, non-combative patient within the “Behavioral/Agitation/Combative” algorithm. The other choice is the use of a benzodiazepine. 

The decision of which agent to use can be based on many factors. The decision may hinge on the possible history related to the agitation, be it a medical cause or a psychiatric, if that can even be determined early on in the call. Another may be influenced by the level of certification of the provider. Olanzapine is outside the scope of practice for the AEMT. An additional consideration may be the severity of the patient’s presentation. Decision points for the use of various agents can also vary by medical directors. Make sure you know what your medical director’s expectations are. It is important to remember that the use of both these medications together is outside of the protocol. 

Olanzapine works by blocking neurotransmitters like serotonin, dopamine, and norepinephrine in the brain and is useful in calming a patient experiencing agitation and acute psychosis. It is not approved for dementia-related psychosis and is not the preferred medication if the patient is combative (more on this in the next edition!). Olanzapine is recommended in the adult patient as a single dose of 10 mg. It is not recommended for the pediatric patient. 

Possible side effects from the use of Olanzapine can include hypotension and sedation. The provider must monitor the patient, including their vital signs, ECG, and capnography. Another potential side effect, although less likely with Olanzapine than other antipsychotic medications, is extrapyramidal symptoms (EPS) such as involuntary facial tics, etc. In cases where EPS does occur, the provider can administer 25-50 mg of Diphenhydramine (Benadryl).  

When administering Olanzapine, caution should be taken with an elderly patient or patient with a known cardiac history. The medication can affect the heart and cause hypotension. It is yet another medication for which the provider should watch for a prolonged QT. Caution is also advised for the pregnant or breastfeeding female patient. Consulting medical direction to discuss the risk/benefit analysis would be advisable. 

Another caution to consider with Olanzapine, as with any medication, is to ensure the proper medication is given. The medication is supplied as an oral dissolving tablet and is a look-alike, sound-alike medication within our drug boxes. It has been mistaken for Ondansetron in some cases. Olanzapine, because it is used less often than Zofran, is packaged and labeled in an additional sealed bag to help prevent any medication errors.

Once the patient is medicated, the provider should continue further assessment, searching for any possible causes of the agitation and provide appropriate care for any medical conditions. Documentation of the patient’s level of agitation before and after the use of medications using the Richmond Agitation Sedation Score (RASS), as referenced in the current UH protocol, is also recommended to provide justification for the sedation. 

For more on this topic, tune in to the Prehospital Paradigm episodes from this month. The live interactive episode with the panel will be this upcoming Monday, March 25th @ 7:00 PM. Previous episodes are archived and can be accessed by clicking here. 

Finally, remember that safety is always a priority, especially for calls of this nature! Have a great week!

Sincerely,



The UH EMS-I Team

University Hospitals

September 16, 2022

Dear Colleagues,

Welcome to this edition of Pharmacy Phriday.  This edition focuses on ZyPREXA, an Oral Dissolving Tablet (ODT) listed for possible use by the paramedic provider in cases of a behavioral emergency.  ZyPREXA is one of two ODTs found in the UH drug box, both typically on the top shelf of the box.  Do you recall the other ODT provided for your use? It also starts with a “Z”!  ZyPREXA is often placed in a zip-lock bag that is marked clearly but always check to be sure you have the right drug!

ZyPREXA is a rapid-acting antipsychotic that blocks neurotransmitters like serotonin, dopamine, and norepinephrine that is useful in calming a patient experiencing agitation and acute psychosis.  It is not approved for dementia-related psychosis.  ZyPREXA is recommended in the adult patient at a dose of 10 mg, given once, for the behavioral patient that is agitated with psychosis. Psychosis is generally defined as a situation where thoughts and emotions are so impaired that contact is lost with external reality.

An important point to note is that ZyPREXA is only used for the patient who is not combative, violent, or a threat to themselves or others.  In those circumstances, the provider should consider other treatments or medications.  Also, note that ZyPREXA is not given in conjunction with other medications. Under the protocol, it is ZyPREXA or a benzodiazepine.  Zyprexa and benzodiazepine can cause severe orthostatic hypertension and cardiac and respiratory depression. 

Before giving ZyPREXA or any other medication under the behavioral emergency algorithm, the provider should consider some important points first.  These might include:

• Safety is always first. In these types of cases, patient behavior can change rapidly. For your safety, it is advisable to summon law enforcement for additional assistance.  

• There can be many causes of a “behavioral emergency.”  Be sure to complete a thorough assessment of the patient, and not miss a possible treatable medical or traumatic cause of the emergency.  Some possible treatable causes might include medication or alcohol abuse, hypoxia, hypoglycemia, head injury, infections, sepsis, seizures, and strokes, just to name a few.

• Most behavioral emergencies do not require medication administration in the prehospital setting. Use non-pharmacological measures such as removing the patient from the stressful environment or situation and establishing a good rapport with them as you reassure and calm them.  

• If ZyPREXA is the treatment of choice, remember to handle the medication carefully.  ODTs are porous and very fragile tablets that can disintegrate easily.  Do not push the tablet through the back of the blister packaging; peel back the foil and remove the tablet with a dry, gloved hand.  The tablets are then placed on the patient’s tongue immediately (some would recommend having the patient place the tablet on their own tongue for safety concerns), which will then dissolve rapidly and be swallowed in the saliva.

When administering ZyPREXA, caution should be taken in the elderly patient or patient with known cardiac history.  The medication can affect the heart and cause hypotension.  This is yet another medication that the provider should check for and watch for a prolonged QT.  Caution is also advised for the pregnant or breastfeeding female patient.  Consulting medical direction to discuss the risk/benefit analysis would be advisable.

Possible side effects from the use of ZyPREXA can include hypotension and sedation.  The provider must monitor the patient, including vitals, ECG, and capnography.  Another potential side effect, although less likely with ZyPREXA than other antipsychotic medications, is extrapyramidal symptoms (EPS) such as involuntary facial tics, etc.  In cases where EPS does occur, the provider can administer 25-50 mg of Diphenhydramine (Benadryl). Limited data for the use of ZyPREXA in pediatrics is available, and our protocol does not recommend its use in that population. 

One last point to consider is the documentation of the patient’s agitation before and after the medication’s use. The current UH protocol references the use of the Richmond Agitation Sedation Score (RASS) to adequately document the need for and result of pharmacological intervention.

Thanks for all you do! Never forget! And as always, stay safe!

Sincerely,

The UH EMS-I Team

University Hospitals

September 9, 2022

Welcome to this edition of Pharmacy Phriday.  As we continue to review the UH “Behavioral/Psychiatric Emergencies” protocol during Mental Illness Awareness Week, we will focus on Zyprexa, another of the antipsychotic medications available to us as pre-hospital providers. 

Zyprexa is a second-generation antipsychotic medication that is one of two choices when the paramedic provider is treating an agitated patient. The other choice is the use of a benzodiazepine. The use of both these medications together is outside of the protocol and would require medical direction.

Zyprexa works by blocking neurotransmitters like serotonin, dopamine, and norepinephrine in the brain and is useful in calming a patient experiencing agitation and acute psychosis. It is not approved for dementia-related psychosis and is not the preferred medication if the patient is combative. Zyprexa is recommended in the adult patient as a single dose of 10 mg. It is not recommended for the pediatric patient. The medication is supplied as an oral dissolving tablet.

Zyprexa is a medication that is considered a look-alike, sound-alike medication within our drug boxes. It has been mistaken for Ondansetron/Zofran, another ODT found in the UH drug boxes. Zyprexa, because it is used less often than the Zofran, is packaged and labeled in an additional sealed bag to help prevent any medication errors.

Considerations before giving Zyprexa are similar to those associated with the use of any other medications under the behavioral emergency algorithm that were reviewed previously and include:

• The safety of the patient and the crew is always a priority.

• Consider any possible medical or trauma causes for the agitation/presentation.

• Ensure the criteria listed in the protocols for the use of restraints and medications have been met.

• Document the patient’s level of agitation before and after the use of medications using the Richmond Agitation Sedation Score (RASS) as referenced in the current UH protocol.

When administering Zyprexa, remember to handle the medication carefully. ODTs are porous and very fragile tablets that can disintegrate easily. Do not push the tablet through the back of the blister packaging, but peel back the foil and remove the tablet with a dry, gloved hand. The tablets are then placed on the patient’s tongue immediately (some would recommend having the patient place the tablet on their own tongue for safety concerns), which will then dissolve rapidly and be swallowed in the saliva.

When administering Zyprexa, caution should be taken in the elderly patient or patient with a known cardiac history. The medication can affect the heart and cause hypotension. It is yet another medication that the provider should check for and watch for a prolonged QT. Caution is also advised for the pregnant or breastfeeding female patient. Consulting medical direction to discuss the risk/benefit analysis would be advisable.

Possible side effects from the use of Zyprexa can include hypotension and sedation. The provider must monitor the patient, including vitals, ECG, and capnography. Another potential side effect, although less likely with Zyprexa than other antipsychotic medications, is extrapyramidal symptoms (EPS) such as involuntary facial tics, etc. In cases where EPS occurs, the provider can administer 25-50 mg of Diphenhydramine (Benadryl).

Thanks for all you do! And as always, stay safe!

Sincerely,



The UH EMS-I Team

University Hospitals