Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a randomised trial of midazolam versus haloperidol plus promethazine

doi:10.1136/bmj.327.7417.708

Cited by 157 publications

(28 citation statements)

References 17 publications

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“…40, 45, 46, 49-56 Of the additional studies included, eight had intramuscular SGA treatment arms, while four of the additional studies examined haloperidol plus promethazine (an antihistamine with anticholinergic properties). Among these studies, one study had a treatment arm using intramuscular haloperidol alone.…”

Section: Resultsmentioning

confidence: 99%

“…50, 55, 56 Notably, all four trials of haloperidol in combination with promethazine were randomized but were not blinded. 40, 45, 49, 52 Subjects receiving 2 mg ziprasidone were not included. 51, 53 Most patients carried a diagnosis of a primary psychotic disorder (60%), while a sizable minority of patients (30%) were from studies that did not require a diagnosis for study entry beyond symptomatic agitation.…”

Section: Resultsmentioning

confidence: 99%

“…51, 53 Most patients carried a diagnosis of a primary psychotic disorder (60%), while a sizable minority of patients (30%) were from studies that did not require a diagnosis for study entry beyond symptomatic agitation. 40, 45, 49, 52, 56 …”

Section: Resultsmentioning

confidence: 99%

“…We addressed this issue to some degree in the second analysis by including many studies that did not require prospective informed consent. 40, 45, 49, 52, 55, 56 …”

Section: Discussionmentioning

confidence: 99%

“…While these four trials 40, 45, 49, 52 have been noted to be of very high methodological quality, 93 they were randomized but were not double-blind. The combination of promethazine and haloperidol is frequently used internationally, 52 but it is not commonly used in the United States.…”

Section: Discussionmentioning

confidence: 99%

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A Meta-Analysis of the Risk of Acute Extrapyramidal Symptoms With Intramuscular Antipsychotics for the Treatment of Agitation

Satterthwaite¹,

Wolf²,

Rosenheck³

et al. 2008

J. Clin. Psychiatry

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OBJECTIVE We examined the evidence for a decreased risk of extrapyramidal symptoms (EPS) with intramuscular second-generation antipsychotics (SGAs) versus intramuscular haloperidol alone or in combination with an anticholinergic agent. DATA SOURCES We searched MEDLINE, EMBASE, and the Cochrane Registry for studies published in English of intramuscular SGAs and intramuscular haloperidol alone or in combination with an anticholinergic agent. Initially, we included only randomized controlled trials (RCTs). To obtain more data comparing SGAs to the combination of haloperidol and an anticholinergic, we conducted a second analysis including studies of any methodology. STUDY SELECTION Seven RCTs that compared SGAs to haloperidol alone were identified. However, we found only one RCT of haloperidol plus an anticholinergic. In the second analysis, we identified 18 studies, including four using haloperidol combined with promethazine (an antihistamine with anticholinergic properties). DATA EXTRACTION The primary outcome measure was acute dystonia; secondary outcomes included akathisia, parkinsonism, or additional anticholinergic medication. For RCTs, risk ratios (RR) and 95% confidence intervals (CI) were calculated for each outcome. When all studies were included in the second analysis, we calculated the risk of acute dystonia. DATA SYNTHESIS Among RCTs (N=2032), SGAs were associated with a significantly lower risk of acute dystonia (RR 0.19, CI 0.10-0.39), akathisia (RR 0.25, CI 0.14-0.45), and anticholinergic use (RR 0.19, CI 0.09-0.43) compared with haloperidol alone. When all trials were considered (N=3425), rates of acute dystonia were higher for haloperidol alone (4.7%) than SGAs (0.6%) or haloperidol plus promethazine (0%). CONCLUSIONS Intramuscular SGAs have a significantly lower risk of acute EPS compared to haloperidol alone. However, intramuscular haloperidol plus promethazine has a risk of acute dystonia comparable to intramuscular SGAs. The decision to use SGAs should consider other factors in addition to the reduction of EPS, which can be prevented by the use of an anticholinergic agent.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

“…We addressed this issue to some degree in the second analysis by including many studies that did not require prospective informed consent. 40, 45, 49, 52, 55, 56 …”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 3 more Smart Citations

A Meta-Analysis of the Risk of Acute Extrapyramidal Symptoms With Intramuscular Antipsychotics for the Treatment of Agitation

Satterthwaite¹,

Wolf²,

Rosenheck³

et al. 2008

J. Clin. Psychiatry

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Clotiapine for acute psychotic illnesses

Berk

Rathbone

Mandriota‐Carpenter

2004

Cochrane Database of Systematic Reviews

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Droperidol for psychosis-induced aggression or agitation

Khokhar

Rathbone

2016

Cochrane Database of Systematic Reviews

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Background People experiencing acute psychotic illnesses, especially those associated with agitated or violent behaviour, may require urgent pharmacological tranquillisation or sedation. Droperidol, a butyrophenone antipsychotic, has been used for this purpose in several countries. Objectives To estimate the effects of droperidol, including its cost-effectiveness, when compared to placebo, other 'standard' or 'non-standard' treatments, or other forms of management of psychotic illness, in controlling acutely disturbed behaviour and reducing psychotic symptoms in people with schizophrenia-like illnesses. Search methods We updated previous searches by searching the Cochrane Schizophrenia Group Register (18 December 2015). We searched references of all identified studies for further trial citations and contacted authors of trials. We supplemented these electronic searches by handsearching reference lists and contacting both the pharmaceutical industry and relevant authors. Selection criteria We included all randomised controlled trials (RCTs) with useable data that compared droperidol to any other treatment for people acutely ill with suspected acute psychotic illnesses, including schizophrenia, schizoaffective disorder, mixed affective disorders, the manic phase of bipolar disorder or a brief psychotic episode. Data collection and analysis For included studies, we assessed quality, risk of bias and extracted data. We excluded data when more than 50% of participants were lost to follow-up. For binary outcomes, we calculated standard estimates of risk ratio (RR) and the corresponding 95% confidence intervals (CI). We created a 'Summary of findings' table using GRADE. Main results We identified four relevant trials from the update search (previous version of this review included only two trials). When droperidol was compared with placebo, for the outcome of tranquillisation or asleep by 30 minutes we found evidence of a clear difference (1 RCT, N = 227, RR 1.18, 95% CI 1.05 to 1.31, high-quality evidence). There was a clear demonstration of reduced risk of needing additional medication after 60 minutes for the droperidol group (1 RCT, N = 227, RR 0.55, 95% CI 0.36 to 0.85, high-quality evidence). There was no evidence that droperidol caused more cardiovascular arrhythmia (1 RCT, N = 227, RR 0.34, 95% CI 0.01 to 8.31, moderate-1 Droperidol for psychosis-induced aggression or agitation (Review)

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Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a randomised trial of midazolam versus haloperidol plus promethazine

Abstract: Both treatments were effective. Midazolam was more rapidly sedating than haloperidol-promethazine, reducing the time people are exposed to aggression. Adverse effects and resources to deal with them should be considered in the choice of the treatment.

Cited by 157 publications

References 17 publications

A Meta-Analysis of the Risk of Acute Extrapyramidal Symptoms With Intramuscular Antipsychotics for the Treatment of Agitation

A Meta-Analysis of the Risk of Acute Extrapyramidal Symptoms With Intramuscular Antipsychotics for the Treatment of Agitation

Clotiapine for acute psychotic illnesses

Droperidol for psychosis-induced aggression or agitation

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