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Acutely agitated patients in the emegency room receive single or combination of benzodiazepine (lorazepam vs. midazolam) and antipsychotic (e.g. haloperidol) agents. Recently, use of ketamine has also been advocated to sedate agitated patients.
A recently published article compared IM administration several medications to treat acutely agitated patients in the ED. According to established protocol, each medication was administered in predetermined 3 week blocks:
- Haloperidol (5 mg)
- Ziprasidone (20 mg)
- Olanzapine (10 mg)
- Midazolam (5 mg)
- Haloperidol (10 mg)
Results
N=737 with median age of 40 years, 72% men.
Midazolam resulted in greater proportion of patients with "adequate" sedation (altered mentatl status scale <1) compared to antipsychotics at 15 min post administration. Among antipsychotics, olanzapine resulted in greater proportion of patient with sedation.
- Midazolam (71%)
- Haloperidol - 5 mg (40%)
- Haloperidol - 10 mg (42%)
- Olanzapine (61%)
- ziprasidone (52%)
Adverse effect were limited
- extrapyramidal AE: 0.3%
- hypotension 0.5%
- hypoxemia 1%
- intubation 0.5%
Conclusion:
Midazolam 5 mg IM achieve more effective sedation at 15 min in agitated ED patients than antipsychotics.
References
Klein LR et al. Intramuscular midazolam, olanzapine, ziprasidone or haloperidol for treating acute agitaion in the emergency department. Ann of Emerg Med 2018 June 6. pii: S0196-0644(18)30373-1. doi: 10.1016/j.annemergmed.2018.04.027. [Epub ahead of print]