>From: "mcglonerg" <[log in to unmask]>
>Reply-To: [log in to unmask]
>To: "Acad-ae-med" <[log in to unmask]>
>Subject: Use of anti-emetics for opiates
>Date: Mon, 17 Apr 2000 20:37:14 +0100
>
>There was an interesting study in Emergency Medicine (1999) 11,240-43 on 
>"The role of prophylactic anti-emetic therapy in emergency department 
>patients receiving intravenous morphine for musculoskeletal trauma".
>
>The conclusion was that the routine use of prophylactic anti-emetics was 
>not indicated in trauma.
>
>Is anyone aware of any other research into this.  How about the use of 
>anti-emetics in M.I.'s prior to giving an opiate?
>
>Regards,
>
>Ray McGlone
>
>A&E Department
>Lancaster
>UK


A quick Medline search shows that there are trials comparing antiemetics for 
postoperative nausea and vomiting after opiates, but I've not been able to 
find anything comparing antiemetics with placebo in the setting of emergency 
department-prescribed opiates.

Having personally experienced extrapyramidal side-effects in the form of 
akathisia from both i.v. metoclopramide and i.m. prochlorperazine (given for 
migraine) I'm loathe to inflict these symptoms on my patients. Most of us 
are familiar with the uncommon extrapyramidal side-effect of dystonias such 
as oculogyric crisis, which are more than obvious when they occur, but I 
suspect we under-appreciate the frequency of this other side-effect, which 
is characterised by extremely unpleasant restlessness and a feeling of 'not 
knowing where to put yourself'. See below for an abstract from an 
interesting study in a recent Annals of Emergency Medicine and for a fuller 
definition of akathisia (lifted from the same article).

Having said all that, I still routinely give antiemetics with opiates to 
trauma patients whose c.spines are immobilised, and to AMI patients who have 
had oral aspirin, since vomiting could be be hazardous and interfere with 
life-saving treatment in these two patient groups respectively.


Cliff Reid
SpR in EM







Abstract

Study objective: Prochlorperazine (PCZ), a commonly used antiemetic and 
analgesic agent, is known to cause akathisia. The incidence of akathisia 
after a single 10-mg dose of intravenous PCZ has not been prospectively 
evaluated. We determined the incidence and severity of PCZ-induced akathisia 
at 1 hour and the incidence of delayed akathisic symptoms at 48 hours.

Methods: This prospective controlled study evaluated a convenience sample of 
140 adult patients at a 400-bed, academic, tertiary-care medical center with 
an annual emergency department census of 95,000 patient visits. One hundred 
patients who received intravenous PCZ for the treatment of severe headache 
or vomiting constituted the PCZ group. Forty patients receiving nonakathisic 
intravenous therapy (eg, saline solution or antibiotics) served as control 
subjects. Patients were excluded if they had preexisting motor disorders 
(eg, restless-leg syndrome or Parkinson’s disease) or if they recently had 
received any medication with extrapyramidal, anticholinergic, sedative, or 
antiakathisic properties. All patients underwent an akathisia assessment 
before and 1 hour after receiving their respective intravenous medications. 
An established scale was used to detect the presence of akathisia and grade 
its severity as mild, moderate, or severe. The delayed development of 
akathisic symptoms within 48 hours also was measured in the PCZ group.

Results: Akathisia developed in 44 (44%) of the patients receiving PCZ 
within 1 hour (95% confidence interval, 34% to 54%). The akathisia was 
graded as mild, moderate, and severe in 14, 22, and 8 subjects, 
respectively. Delayed symptoms suggestive of akathisia developed in 3 other 
patients within 48 hours. None of the 40 control subjects developed 
akathisia.

Conclusion: Single-dose intravenous PCZ frequently induced akathisia within 
1 hour of administration. Acute akathisia was not observed in patients 
receiving intravenous saline solution or antibiotics. The delayed 
development of akathisia symptoms 48 hours after a single dose of 
intravenous PCZ was uncommon. [Drotts DL, Vinson DR: Prochlorperazine 
induces akathisia in emergency patients. Ann Emerg Med October 
1999;34:469-475.]





Akathisia, a peculiar state of mental and motor restlessness characterized 
by an intense desire to move in order to gain respite from overwhelming 
feelings of distress was first observed with the use of dopamine antagonists 
in 1947.6 Akathisic patients report restlessness and inner tension or 
discomfort, have an urge to constantly move their legs, and have difficulty 
in maintaining a posture for several minutes, such as sitting still in a 
chair or standing in one place. They display semipurposeful or purposeless 
limb movements and tend to repeatedly shift their bodily position while 
sitting and shift weight from foot to foot or pace while standing.7 In its 
milder presentation, the disorder may resemble anxiety. Akathisia in 
patients taking psychotropic or antiemetic agents may be quite 
distressing,8-11 perhaps even leading to violent behavior12,13 and suicidal 
ideation.14-17

Akathisia is not restricted to patients taking daily oral medication but 
also occurs in those who receive a single dose of parenteral dopamine 
antagonists. Agents commonly used in emergency medicine include 
metoclopramide, promethazine, PCZ, haloperidol, and droperidol. The mental 
and motor manifestations of akathisia are well described in a fascinating 
report by an expert on drug-induced movement disorders who writes of his 
experience while a medical student after receiving a single dose of 
haloperidol for a research study. He explains that “the intensity of the 
dysphoria was striking and the sense of a foreign influence forcing me to 
move was dramatic.”18 Studies of the pharmacology of intravenous PCZ have 
been short-circuited because volunteers have withdrawn themselves from 
further participation because of the development of single-dose PCZ-induced 
akathisia.19,20 On development of acute akathisia, patients undergoing 
preoperative evaluation have suddenly refused to have surgery for which they 
had previously consented. This disruption of medical care has been reported 
with both single-dose intravenous droperidol21 and single-dose intravenous 
metoclopramide.22 The effect of acute akathisia in emergency medicine has 
not been elucidated.




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