When Talk Just Don’t Cut It: Intramuscular medications for the acutely agitated ED patient
When the acutely agitated patient walks (or rolls) into the emergency department, there are multiple levels of de-escalation that physicians, nurses, and staff go through to control the situation. Verbal de-escalation is first-line and preferable. But, when the patient is acting in a manner dangerous to those taking care of him or her, medications must be used. Intramuscular medications are preferably deployed as they do not require a physician or nurse to place an IV line first. The goal is to safely calm the patient down while minimizing danger to others.
The Article: Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department by Lauren R. Klein, MD, MS, et al. Annals of Emergency Medicine, 2018.
The Takeaway: Midazolam performed the best in time to sedation, and had the shortest half-life. That’s a double-edged sword- you regain your patient’s mental status quickly to conduct your exam, but you also may need rescue medication if the patient is still acutely agitated. Olanzapine is a fine alternative. Haloperidol 10mg had better sedation than haloperidol 5mg, but we rarely give it alone due to time of onset… And ziprasidone is hard to mix up in the ED and has limitations as to who can give it (i.e. pregnant women need “a gown, nitrile gloves, and face protection”). Not great for a chaotic situation with an agitated patient. Lastly, there was no mention of ketamine at all in this article!
Methods: The authors conducted a prospective observational study where a single center rotated which medication was used for any presenting acutely agitated patient. Data gathered included Altered Mental Status Scale scores at intervals starting at 15 minutes and adverse events during the ED stay.
Results: Patients receiving midazolam had the most sedated AMSS score at 15 minutes, compared to patients receiving the other medications. 40% of those patients needed rescue medications by 120 minutes from initial dose. Almost no adverse events were recorded for any medications, and they were not significantly different between the medications. Pairwise comparison between medication groups of % adequately sedated was completed, even though this severely increases the risk of making a false discovery.
Thoughts: This article was fine for confirming what many practicing physicians already do- give midazolam to agitated patients. We knew H5A2 is out- we don’t want to snow our patients. Ketamine is “in”, but wasn’t included in this study. And 15 minutes seems like an extremely long time to deal with an acutely agitated patient. An earlier time point could have helped optimize treatment of the agitated patient even more thoroughly.