New in EM 003: Is IV Olanzapine safe?

15 Apr

Originally Published on RCEM Learning Podcast April 2017

As part of the RCEM Learning Podcast I record reviews of recent literature with Dave McCreary. We’ve been doing this for about a year now and you can hear them all on the RCEM Learning Podcast each month. I’d like to have them here and searchable on this site too so I’ll be posting the ones I find most relevant here. You can hear the newest ones by subscribing to the free RCEM Learning Podcast. 


Clinical Question:

Is IV Olanzapine safe?

Title of Paper:

A Prospective Observational Study of Patients Receiving Intravenous and Intramuscular Olanzapine in the Emergency Department

Journal and Year:

Annals of Emergency Medicine, 2016

Lead Author:

Jon B. Cole

Overview of study methods:

  • Prospective, observational study
  • ED patients receiving Olanzapine for any clinical indication via either the IV or IM route
  • Research nurses observed patients for the 60 minutes (0, 5, 10, 15, 30 and 60 minutes) following administration for the primary outcome of evidence of respiratory depression (multiple criteria)
  • They also observed for:
    • OAA/S Scale (5 point sedation scale)
    • Any monitoring data available
    • Any ECG performed
    • Treating physicians assessment of drug efficacy

Summary of Results:

  • 784 patients in final analysis
    • 295 in the IV group
    • 489 in the IM group
  • Respiratory depression occurred in 3.7% of the IV group and 2.0% of the IM.
    • 7 patients required intubation – 2 in IV and 5 in IM group
  • One episode of Mobitz I and one of bradycardia were observed, both were attributed to other reasonable factors.
  • 81% of the IV and 84% of the IM group did not need additional sedation
  • Median time in the ED was less for the IV group (386 vs 525 minutes)
  • The IV group generally received lower doses (5mg most commonly) than the IM group (10mg most commonly)


  • Prospective, observational data suggesting that IV Olanzapine is pretty safe in comparison to IM.
  • The peak onset in probably quicker and than the peak time of 15-45 minutes that you get with IM administration, which may lead to the higher incidence of respiratory depression.
  • The need for further sedation within an hour was similar in the IV group with its largely 5mg dose as in the IM group with its largely 10mg dose, so 5mg as an initial IV dose seems reasonable.

Clinical Bottom Line:

It’s probably safe to use IV olanzapine if you need to, just be aware that there may be a more rapid onset so as is always good with this sort of thing – start low, go slow.  As with any sedative drug in the agitated patient, be aware it sometimes doesn’t take much to ‘over-cook’ them if they’ve got lots of other ‘self-delivered’ agents on board so they should be closely monitored.

Other #FOAMed Resources:

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