Safety and Efficacy of Pharmacologic Agents Used for Rapid Tranquilization of Emergency Department Patients with Acute Agitation or Excited Delirium
acute agitation, rapid tranquilization, excited delirium, emergency department, patient safety
Emergency Medicine | Pharmacy and Pharmaceutical Sciences | Psychiatry and Psychology
Management of patients with acute agitation or aggressive behavior can pose a significant challenge to health care providers in emergency departments.
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.
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
Kim HK, Leonard JB, Corwell BN, Connors NJ. Safety and efficacy of pharmacologic agents used for rapid tranquilization of emergency department patients with acute agitation or excited delirium. Expert Opin Drug Saf. 2020 Dec 16. https://doi.org/10.1080/14740338.2021.1865911