It’s 1 am and things are winding down.  The trickle of patients has slowed and it actually looks like you and your team are catching up.  Suddenly, you hear yelling, swearing and crashes coming from triage.  Other patients are looking around to see what is going on.  The sound of the triage nurse comes overhead, “hospital police to internal triage please, hospital police to internal triage.”  One day working in the emergency department is enough to know what that means.


It’s not uncommon to require sedation for safety reasons in our line of work.  Acute agitation can be managed with a number of medications, but there are many choices.  Which is the best option (and don’t say droperidol, it’s off the market)?


A prospective study published in June 2018 (see reference below) compared rapidity, safety and effectiveness of haloperidol 5 mg, haloperidol 10 mg, ziprasidone 20 mg, olanzapine 10 mg, and midazolam 5 mg.  Investigators rotated using each medication in 3 week blocks in the department for agitated patients, ultimately enrolling 737 study participants.  They found that midazolam 5 mg worked best, sedating 71% of patients within 15 minutes.  Olanzapine 10 mg sedated about 61%, ziprasidone 20 mg about 50%, and haloperidol 5 and 10 mg both about 40%.  Adverse outcomes were rare and no more prominent in any one group.


Granted, 15 minutes is a long time when someone is acutely agitated.  The study looked at single agents only, not combos like the “5 and 2” or “B-52” if you really mean business, but if you do want to use a single agent, midazolam is likely going to be a better choice than haloperidol, especially since droperidol is no longer available.


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Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department.  Ann Emerg Med. 2018 Jun 6. pii: S0196-0644(18)30373-1. doi: 10.1016/j.annemergmed.2018.04.027.

May 2024