Safety and effectiveness of high‐dose midazolam for severe behavioural disturbance in an emergency department with suspected psychostimulant‐affected patients

Spain, David; Crilly, Julia; Whyte, Ian M.; Jenner, Linda; Carr, Vaughan; Baker, Amanda

doi:10.1111/j.1742-6723.2008.01066.x

Cited by 29 publications

(25 citation statements)

References 20 publications

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“…One study comparing IM ziprasidone, droperidol and midazolam reported respiratory depression in 15% of patients[3], similar to our study. Another study of high dose midazolam in acutely agitated ED patients, where two thirds received it via the IM route, reported adverse events in eight of 61 patients (13%)[16]. The drug was not known for each patient in our study and may differ between those receiving droperidol, midazolam or both.…”

Section: Discussionmentioning

confidence: 80%

The impact of a standardised intramuscular sedation protocol for acute behavioural disturbance in the emergency department

et al. 2010

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BackgroundAcute behavioural disturbance (ABD) is an increasing problem in emergency departments. This study aimed to determine the impact of a structured intramuscular (IM) sedation protocol on the duration of ABD in the emergency department.MethodsA historical control study was undertaken comparing 58 patients who required physical restraint and parenteral sedation with the structured IM sedation protocol, to 73 historical controls treated predominantly by intravenous sedation, according to individual clinician preference. The primary outcome was the duration of the ABD defined as the time security staff were required. Secondary outcomes were the requirement for additional sedation, drug related-adverse effects and patient and staff injuries.ResultsThe median duration of the ABD in patients with the new sedation protocol was 21 minutes (IQR: 15 to 35 minutes; Range: 5 to 78 minutes) compared to a median duration of 30 minutes (IQR: 15 to 50 minutes; Range: 5 to 135 minutes) in the historical controls which was significantly different (p = 0.03). With IM sedation only 27 of 58 patients (47%; 95% CI: 34% to 60%) required further sedation compared to 64 of 73 historical controls (88%; 95%CI: 77% to 94%). There were six (10%) drug-related adverse events with the new IM protocol [oxygen desaturation (5), oxygen desaturation/airway obstruction (1)] compared to 10 (14%) in the historical controls [oxygen desaturation (5), hypoventilation (4) and aspiration (1)]. Injuries to staff occurred with three patients using the new sedation protocol and in seven of the historical controls. Two patients were injured during the new protocol and two of the historical controls.ConclusionThe use of a standardised IM sedation protocol was simple, more effective and as safe for management of ABD compared to predominantly intravenous sedation.

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Section: Discussionmentioning

confidence: 80%

The impact of a standardised intramuscular sedation protocol for acute behavioural disturbance in the emergency department

et al. 2010

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“…Frequent dosing, with little or no short-lived effects, results in ongoing risks to staff and patient. Many modern substance abusers are naive to barbiturates, but may be highly tolerant of benzodiazepines [3]. When emergency physicians are selecting a sedative agent for an acutely agitated and violent patient they need to consider various factors including safety [4].…”

Section: Discussionmentioning

confidence: 99%

Thiopentone sedation for sedation of acutely agitated, violent, intoxicated patients: Evaluation of 2 cases

Howes

Rensburg

2009

Int J Emerg Med

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“…However, to date, there are not published double-blind, randomized, placebo controlled trials comparing the efficacy and safety of benzodiazepines to neuroleptics or the combination of benzodiazepines and neuroleptics in 2C intoxication or excited delirium. Benzodiazepines can be used to treat agitation, hypertension, tachycardia, and hyperthermia [44,45]. Neuroleptics can be used in the setting of hallucinogeninduced agitation, although some controversy exists regarding their use.…”

Section: Treatmentmentioning

confidence: 99%

2C or Not 2C: Phenethylamine Designer Drug Review

et al. 2013

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New groups of synthetic "designer drugs" have increased in popularity over the past several years. These products mimic the euphoric effects of other well-known illicit drugs but are advertised as "legal" highs and are sold over the internet, at raves and night clubs, and in head shops. The 2C series drugs are ring-substituted phenethylamines that belong to a group of designer agents similar in structure to 3,4-methylenedioxy-N-methylamphetamine (MDMA, Ecstasy). Understanding the pharmacology and toxicology of these agents is essential in order to provide the best medical care for these patients. This review focuses on the pharmacology, pharmacokinetics, clinical effects, and treatment of 2C drug intoxication based on available published literature. Multiple names under which 2C drugs are sold were identified and tabulated. Common features identified in patients intoxicated with 2Cs included hallucinations, agitation, aggression, violence, dysphoria, hypertension, tachycardia, seizures, and hyperthermia. Patients may exhibit sympathomimetic symptoms or symptoms consistent with serotonin toxicity, but an excited delirium presentation seems to be consistent amongst deaths attributed to 2C drugs; at least five deaths have been reported in the literature in patients intoxicated with 2C drugs. 2C drugs are a group of designer intoxicants, many of which are marketed as legal, but may carry risks that consumers are unaware of. These drugs may be characterized by either serotonergic toxicity or a sympathomimetic toxidrome, but a presentation consistent with excited delirium is consistent amongst the reported 2C-related deaths. Treatment of 2C intoxication is primarily supportive, but immediate action is required in the context of excited delirium, hyperthermia, and seizure activity.

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Safety and effectiveness of high‐dose midazolam for severe behavioural disturbance in an emergency department with suspected psychostimulant‐affected patients

Abstract: High-dose midazolam protocols cannot be supported as universally safe. High-dose protocols for severe behavioural disturbance are not more effective, with failures occurring even after repeated dosing.

Cited by 29 publications

References 20 publications

The impact of a standardised intramuscular sedation protocol for acute behavioural disturbance in the emergency department

The impact of a standardised intramuscular sedation protocol for acute behavioural disturbance in the emergency department

Thiopentone sedation for sedation of acutely agitated, violent, intoxicated patients: Evaluation of 2 cases

2C or Not 2C: Phenethylamine Designer Drug Review

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