Chemical Sedation: Haldoperidol vs. Lorazepam vs. Midazolam

Question

What single agent best manages violent, agitated patients in the ED, as measured by shortest time to sedation and shortest time to arousal?

Methodology

• Prospective, randomized, double-blinded study of 111 violent and agitated patients
• Haloperidol (5 mg IM), Lorazepam (2 mg IM), or Midazolam (5 mg IM)
• Midazolam is a water-soluble benzodiazepine – excellent IM absorption profile
• Patients were agitated because of recreational drug use, alcohol use, and prior psychiatric history and divided equally in each of the 3 arms of treatment.

Results

Haloperidol (n=42)

• Minutes to sedation: 28.3 ± 25
• Minutes to arousal: 126.5 ± 85

Lorazepam (n=27)

• Minutes to sedation: 32.3 ± 20
• Minutes to arousal: 217.2 ± 107

Midazolam (n=42)

• Minutes to sedation: 18.3 ± 14
• Minutes to arousal: 81.9 ± 66

There were no significant differences in vital signs between groups.

Lorazepam was stopped after the first 95 patients at interim analysis because of prolonged sedation times.

Patients required “rescue drugs”, which were additional sedation medications at the discretion of attending physician:

• 8 haloperidol patients (19%)
• 7 lorazepam patients (26%)
• 7 midazolam patients (17%)

Complications: 2 patients who received haloperidol

• 1 had hypotension
• 1 had transient apnea

Other IM medication options

• HAC: Haloperidol 5 mg, Ativan (lorazepam) 2 mg, Cogentin 1 mg IM all in 1 syringe
• B52: Haloperidol 5 mg, Lorazepam 2 mg, Benedryl (diphenhydramine) 50 mg IM

BOTTOM LINE

• Use midazolam 5 mg IM to chemically sedation a severely agitated patients because of its shorter time to sedation (18 min) and arousal (82 min).

References

• Nobay F et al. A Prospective, Double-blind, Randomized Trial of Midazolam versus Haloperidol versus Lorazepam in the Chemical Restraint of Violent and Severely Agitated Patients . Acad Emerg Med. 2004; 11:747-9. [PubMed]