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This systematic review was conducted to answer the clinical question: Is there a superior parenteral medication or combination of medications for acute management of adult out-of-hospital or emergency department patients with severe agitation? These recommendations do not apply to pediatric, elderly (>65 years), pregnant, or out-of-hospital patients. For these groups, additional studies are needed given unique risk profiles.
When “You need to calm down” won’t work…Patients presenting with severe agitation have high morbidity and mortality. Verbal deescalation and oral or sublingual medications are, of course, preferable initial approaches. However, when these are ineffective, parenteral medications are indicated to treat agitation in order to calm the patient and create a safe environment for patients and staff to allow safe and prompt evaluation and treatment of serious underlying medical problem. Obviously, treatment of underlying medical problem leading to agitation is of paramount importance. Literature on this topic is fairly heterogeneous, and more studies are needed to compare specific medications and to standardize dosing.
The current body of evidence suggests that the most effective combination of parenteral medications is droperidol and midazolam. Studies demonstrate that droperidol is likely the superior antipsychotic, though this is not always available. Atypical antipsychotics, such as olanzapine, appear to have a more favorable profile than other traditional antipsychotics such as haloperidol. When it comes to benzodiazepines, midazolam has a more rapid onset than lorazepam. While time to sedation is similar for midazolam, droperidol, and olanzapine, antipsychotics are preferred if a single agent is to be used, as benzodiazepines have more adverse effects and require more rescue medication administration.
Source
Clinical Policy: Critical Issues in the Evaluation and Management of Adult Out-of-Hospital or Emergency Department Patients Presenting With Severe Agitation: Approved by the ACEP Board of Directors, October 6, 2023. Ann Emerg Med. 2024 Jan;83(1):e1-e30. doi: 10.1016/j.annemergmed.2023.09.010. PMID: 38105109.
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