Welcome to this edition of UH EMS-I’s Pharmacy Phriday. This week, we’ll start by presenting a case scenario from our 2024 archives.
You are dispatched to a local doctor’s office for a 44-year-old male acting paranoid. Upon arrival, the staff advise the patient to go to an exam room with the doctor. He has been reportedly talking nonstop about having his identity stolen and being locked out of his personal accounts. He has a history of mental illness and is known to the staff, who state the patient is more agitated than normal, though he has not been violent. Upon exiting the exam room, the doctor advises you that he is considering “pink slipping” the patient, as he believes the patient had a break from reality.
What algorithm do you consider in treating this patient? What actions would you take? Would you request any additional assistance? What treatments might you provide or medications might you consider? How would you describe the patient’s behavior at this time? Agitated? Combative? Violent?
In this week’s Pharmacy Phriday, we focus on olanzapine. It is a medication that can be found in the “Behavioral/Agitation/Combative” algorithm of our UH protocols and is considered for patients who are agitated but not combative and are displaying psychosis, or a break from reality. It is rarely used (less than 40 times throughout the system in 2024), but in the right circumstances, it is highly effective and beneficial.
Olanzapine is a second-generation antipsychotic medication that is one of two choices the paramedic provider has when treating an agitated non-combative patient. 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, whether it is a medical or psychiatric cause, if that can even be determined early in the call. The patient’s presentation and severity of agitation should also be considered. Another factor may be influenced by the level of certification of the provider, as olanzapine is outside the scope of practice for AEMTs. 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. 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.
When administering olanzapine, caution should be taken in the elderly patient or patient with a known cardiac history. The medication can affect the heart and cause hypotension. This is yet another medication where the provider should watch for a prolonged QT. Caution is also advised for pregnant or breastfeeding female patients. 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 being given. The medication is supplied as an oral dissolving tablet and looks and sounds like another medication within our drug boxes, as 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 potential causes of the agitation and providing 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 justify the sedation.
In the case presented above, police were also requested to respond to the scene. In the end, the crew was able to talk with the patient and get him to agree to transport and treatment with olanzapine voluntarily. During transport, the patient remained cooperative with personnel, allowing them to complete a more thorough exam that was documented well. A job well done!
Remember: Safety is always a priority, especially for calls of this nature. Stay safe!
