Written by Clay Smith
Spoon Feed
Midazolam 5mg IM beat haloperidol 5 mg, ziprasidone 20 mg, olanzapine 10 mg, and haloperidol 10 mg (all also given IM), with 71% sedated at 15 minutes. Olazapine came in second.
Why does this matter?
Sedating an agitated patient is important for their own safety and that of the staff. Agents need to be rapid onset, safe, and effective. This was a study of four agents in the ED.
Midazolam with the KO
This was a prospective study that enrolled 737 patients. They had an every 3-week rotating regimen of agents set prior to study onset, and agitated patients would get one of the five IM drug regimens: haloperidol 5 mg, ziprasidone 20 mg, olanzapine 10 mg, midazolam 5 mg, or haloperidol 10 mg. They found midazolam was best at 15 minutes, with 71% of patients adequately sedated. Olanzapine 10mg was a close second at 61%, beating out both haloperidol doses (each about 40%) and ziprasidone (50%). All were equally safe, with rare adverse outcomes equally distributed among the groups. Now that droperidol is off the market, it looks like midazolam is a reasonable, safe drug to choose.
Source
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. [Epub ahead of print]
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Reviewed by Thomas Davis
Another Spoonful
- See this ED Approach the Agitation from emDOCs.
- Don’t forget, ketamine works fast and very well for agitation as well.
Did they measure duration of sedation? Would seem like the Versed would wear off quickly and you’d have to use another agent anyways.
Those in the midazolam group had lightening of sedation at 120 minutes. But the proportion determined to still have “adequate” sedation at 120 minutes was still 87%, comparable with the others.