Safety and Efficacy of Pharmacologic Agents Used for Rapid Tranquilization of Emergency Department Patients with Acute Agitation or Excited Delirium

Division

South Atlantic

Hospital

Trident Medical Center

Document Type

Manuscript

Publication Date

12-16-2020

Keywords

acute agitation, rapid tranquilization, excited delirium, emergency department, patient safety

Disciplines

Emergency Medicine | Pharmacy and Pharmaceutical Sciences | Psychiatry and Psychology

Abstract

Introduction

Management of patients with acute agitation or aggressive behavior can pose a significant challenge to health care providers in emergency departments.

Areas covered

This article provides a comprehensive review of the pharmacologic properties, efficacy, and safety profiles of select intramuscular (IM) sedative agents (i.e., antipsychotics, benzodiazepines, and ketamine) for rapid tranquilization.

Expert opinion

Using antipsychotics and benzodiazepines—whether a single agent or combined—will have similar efficacy in producing sedation. But there are differences in the time to sedation depending on which agent is used. Based upon the available studies, droperidol (5-10 mg IM) and midazolam (5-10 mg IM) have the fastest onset of sedation when either is used as a single agent. When combination therapy is used, using midazolam with an antipsychotic agent, instead of lorazepam, may result in faster sedative effect. QT prolongation and torsades de pointes are uncommon adverse drug effects of antipsychotic administration. Ketamine is often reserved as a second-line agent when antipsychotics and benzodiazepines fail to produce the desired tranquilization. However, ketamine (5 mg/kg IM) is more frequently associated with airway compromise requiring endotracheal intubation. A low-dose of ketamine (2 mg/kg IM) may reduce the risk of airway compromise while providing adequate sedation.

Publisher or Conference

Expert Opinion on Drug Safety

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