In this episode, I’ll discuss which IM medication is the best first-line treatment for acute agitation in patients presenting to the emergency department.
The authors of a study published in October 2018 in Annals of Emergency Medicine compared 5 or 10 mg haloperidol, 10 mg olanzapine, 5 mg midazolam, and 20 mg ziprasidone to treat agitation.
Medications were administered according to protocol in which the initial medication given was predetermined in consecutive 3-week blocks.
The primary outcome was adequate sedation at 15 minutes, as assessed by the Altered Mental Status Scale.
At 15 minutes, midazolam resulted in a greater proportion of patients adequately sedated compared with all other agents. Olanzapine resulted in a greater proportion of patients adequately sedated at 15 minutes compared with either dose of haloperidol as well as ziprasidone.
Adverse events were rare and there was no difference in events between groups. There were 2 patients out of 737 that experienced extrapyramidal adverse effects, 5 patients that experienced hypotension, 10 patients that experienced hypoxemia, and 5 patients that required intubation.
Based on the results of this study, midazolam appears to be the best first line agent for undifferentiated agitation in patients that present to the ED, followed by olanzapine.
I’ve updated my free visual critical care antibiotic guide for 2019. To download this guide and easily remember spectrum of activity, go to pharmacyjoe.com/abx.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.