rapid sedation of the agitated or aggressive patient in the ED


sedation of the agitated patient

  • 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

elderly patients over 65 yrs

  • 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

younger patients

  • 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)
      • 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
        • 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:
      • 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

Mx of adverse effects of sedation

acute dystonia

respiratory depression

  • 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)


prolonged QTc on ECG

  • 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
sedation_rapid.txt · Last modified: 2021/03/10 08:35 by gary1