Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Agents that may prove helpful include benzodiazepines and traditional antipsychotics. Titration of benzodiazepines may be indicated to control agitation; administer phenothiazines only when indicated by severe psychotic reaction. Do not administer phenothiazines to patients with signs of sympathomimetic overstimulation.

Class Summary

Decrease agitation or combative behavior when patients are at risk of harming themselves or others.

Lorazepam (Ativan)

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Sedative hypnotic with fairly rapid onset of effects (15-20 minutes) and relatively long half-life.

By increasing the action of gamma-aminobutyric acid (GABA), which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation.

Haloperidol (Haldol)

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Completely blocks postsynaptic dopamine receptors. Drug of choice for patients with acute psychosis when no contraindications are present. Has high potency and low potential for causing orthostasis. Downside is the high potential for extrapyramidal symptoms/dystonia, lowering of the seizure threshold, and QT-interval prolongation..

Parenteral dosage form may be admixed in syringe with 2-mg lorazepam for better anxiolytic effects.

Diazepam (Valium)

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Depresses all levels of CNS (eg, limbic and reticular formation) by increasing activity of GABA.

Individualize dosage and increase cautiously to avoid adverse effects. Absorption is unpredictable with intramuscular administration, so should be used intravenously when possible.

Midazolam (Versed)

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Sedative hypnotic with rapid onset and relatively short duration of effects.

By increasing the action of gamma-aminobutyric acid (GABA), which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation. Because water soluble, takes approximately 3 times longer than diazepam to peak EEG effects. Thus, clinician must wait 2-3 min to fully evaluate sedative effects before initiating procedure or repeating dose. Has twice the affinity for benzodiazepine receptors than diazepam. May be administered IM if unable to obtain vascular access.

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Author

Joseph L D'Orazio, MD, FAAEM, FACMT Director, Division of Medical Toxicology, Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University; Consulting Staff in Medical Toxicology, Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Philadelphia

Joseph L D'Orazio, MD, FAAEM, FACMT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, American Society of Addiction Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Robert Bassett, DO, FAAEM Fellow in Medical Toxicology, Department of Emergency Medicine, Einstein Medical Center; Clinical Assistant Professor of Emergency Medicine, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Robert Bassett, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

William J Boroughf, DO Fellow in Medical Toxicology, Attending Physician, Department of Emergency Medicine, Einstein Medical Center

William J Boroughf, DO is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

John G Benitez, MD, MPH Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Undersea and Hyperbaric Medical Society, Wilderness Medical Society, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Chief Editor

Sage W Wiener, MD Assistant Professor, Department of Emergency Medicine, State University of New York Downstate Medical Center; Director of Medical Toxicology, Department of Emergency Medicine, Kings County Hospital Center

Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

David C Lee, MD Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School

David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Joseph A Salomone III, MD Associate Professor and Attending Staff, Truman Medical Centers, University of Missouri-Kansas City School of Medicine; EMS Medical Director, Kansas City, Missouri

Joseph A Salomone III, MD is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.