rapid sedation of the agitated or aggressive patient in the ED

see also:

• managing violence or the aggressive patient in the ED
• Sedation Assessment Tool (SAT) for Mx of agitated patients in ED
• use of mechanical restraints
• Safer Care Victoria clinical guidance - acute behavioural disturbance Mx in the ED

• see also managing violence or the aggressive patient in the ED for further information on the possible medical causes of aggressive behaviour

• determine route and choice of sedative depending upon:
  • time critical nature of situation
  • availability of iv access
  • age of patient and likely aetiology and co-morbities to determine risk-benefit of each agent
• Australian mental health services generally utilise an agitated behaviour level and appropriate Rx for healthy young adults such as:
  • Level 1:
    • behaviour self-controlled by the patient with clinical support
    • offer an oral benzodiazepine +/- an oral antipsychotic if patient has a psychosis
  • Level 2:
    • escalation of behaviour with reduced capacity for patient to control emotions and behaviour warranting clinical intervention
    • give either:
      • olanzapine 5-10mg wafer, repeat in 2hrs if needed and again in 4hrs if needed to max. 30mg/day, or,
      • oral risperidone 2mg, repeat in 2hrs if needed and again in 4hrs if needed to max. 6mg/day
    • may also add a oral benzodiazepine if needed
  • Level 3:
    • behaviour is overt and poses imminent threat to safety requiring crisis intervention
    • give an IM medication:
      • eg. olanzapine 5-10mg plus an oral benzodiazepine
  • Level 4:
    • immediate or actual threat to staff, patients or property requiring security presence
    • give an IM medication based upon risk/benefit:
      • eg. droperidol 2.5-10mg IM PLUS lorazepam 2mg IM, repeat 4-6hrly prn, max. droperidol 20mg/d and max. lorazepam 8mg/day

• aim of management is not sedation per se, but to settle distressing & dangerous symptoms & behaviours to allow safe & effective patient management
• maximum doses are provided as a guide - if these doses do not achieve an adequate response, obtain senior clinician advice
• if PH parkinsonism or Lewy body dementia:
  • consider benzodiazepines such as oxazepam, or an antipsychotic such as quetiapine but avoid haloperidol, risperidone, or olanzapine
  • quetiapine oral 12-25mg q4h max. 100mg in 24hrs, or,
  • oxazepam oral 7.5-15mg to max. 30mg in 24hrs, or,
  • midazolam im 1-2mg maximum once only, or
  • midazolam iv 0.5-1mg initial dose, rpt 0.5mg q15-30 mins, max 2mg
• if no PH parkinsonism:
  • as for those with parkinsonism, or:
    • haloperidol oral 0.25-0.5mg q2h max. 3mg in 24hrs, or,
    • risperidone oral 0.25-0.5mg q2h max. 2mg in 24hrs, or,
    • olanzapine oral 2.5mg 0.25-0.5mg q2h max. 10mg in 24hrs, or,
    • haloperidol iv 0.5-1mg initial dose, rpt 0.5mg q30mins, max 3mg in 24 hrs

• in general, give one benzodiazepine type medication and one antipsychotic, and preferably, only ONE of these as a parenteral medication
  • combination antipsychotic/midazolam therapy for acute agitation provides faster sedation than midazolam alone.¹⁾
  • benzodiazepines:
    • midazolam iv 2.5-10mg q2h titrated to effect, max. 10mg
      • high doses may be required in those with a substance abuse history
      • NB. many hospitals have a policy which does not allow transfer of a patient to a mental health bed within 4 hours of being given iv midazolam!
    • or diazepam oral 5-10mg q2h max 20mg in 4 hrs
    • or Lorazepam iv 4mg or, oral 1-2 mg Max 8mg in 24 hrs
    • or clonazepam oral 0.5-1mg Max 4 mg in 24 hrs
  • an antipsychotic
    • olanzapine
      • usual dose for adults 10mg s/l or im (usual max. 20mg in 24hrs)
      • 5mg iv (off-label) boluses appear to be relatively safe in the ED setting and when used with 5mg iv midazolam (if > 50kg body weight), leads to adequate sedation with a median time of 14 minutes with 90% sedated by 30 minutes although most required a 2nd 5mg iv bolus of olanzapine ²⁾
      • 10mg im olanzapine acts faster than im haloperidol and with fewer adverse effects³⁾
    • or either: droperidol (Droleptan) off-label use or haloperidol
      • im: 2.5-10mg, Q4-6h max 20mg in 24hrs, or,
      • iv: 5mg initial dose repeat 2.5-5mg q5 mins max 20 mg in 4 hrs
      • nb. some prefer:
        • haloperidol im 10mg PLUS promethazine im 50mg in same syringe (appears to be as quick acting and effective as 10mg im olanzapine but longer lasting)
        • then:
          • haloperidol im 2.5-10mg, Q4-6h max 20mg in 24hrs, PLUS
          • promethazine im 25-50mg, Q4-6h max 100mg in 24hrs
    • or quetiapine oral 50-100mg, Max 200mg in 24hrs
    • or Risperidone oral 0.5-2mg, Max 2mg in 24 hrs
  • there are two main areas of concern with the use of antipsychotics for rapid tranquillisation:
    • extrapyramidal effects
      • occurs in 7% of patients given haloperidol but is rare with olanzapine
    • cardiac effects, particularly prolonged QTc
  • Sedation Assessment Tool (SAT) for Mx of agitated patients in ED

• benztropine / benzatropine (Cogentin) iv or im 0.5-2mg in adults

• give oxygen
• consider flumazenil if a benzodiazepine was given and patient not dependent upon benzos otherwise acute withdrawal seizure may occur
  • 0.2mg IV initial dose
  • then 0.1mg q60 seconds up to max 1mg
• consider naloxone (Narcan) if opiates and opioids a potential cause
  • 0.1-0.4mg IV initial dose
  • 0.4mg q60 seconds up to max 1mg

• lie patient flat
• tilt bed, head down
• ensure monitoring in place
• iv fluid bolus(es)

• with-hold antipsychotics
• consider neuroleptic malignant syndrome (NMS), see hyperthermia

• cardiac monitor until normalises
• iv access in case develops torsade de pointes VT
• avoid further medications which may cause prolonged QTc
• correct any electrolute disturbances