Safety and efficacy of pharmacologic agents used for rapid tranquilization of emergency department patients with acute agitation or excited delirium

Kim, Hong; Leonard, James; Corwell, Brian N.; Connors, Nicholas J.

doi:10.1080/14740338.2021.1865911

Cited by 28 publications

(19 citation statements)

References 132 publications

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“…The traditional first-line therapy for severely agitated ED patients is a benzodiazepine, haloperidol, or both [ 15 ]. However, despite the wide use of benzodiazepine and antipsychotics, they have inadequate sedative effects [ 16 ].…”

Section: Reviewmentioning

confidence: 99%

“…In contrast, ketamine has gained attention as an alternative short-acting sedative [ 17 ]. Several studies showed that ketamine exerts adequate sedative effects within 5 minutes in 90%-96% of recipients who receive 4-5 mg/kg IM ketamine [ 15 , 18 , 19 ]. In contrast, 10 mg IM haloperidol requires a median of 17 minutes to achieve sedation; however, only 65% of the recipients were adequately sedated [ 15 , 19 ].…”

Section: Reviewmentioning

confidence: 99%

“…Several studies showed that ketamine exerts adequate sedative effects within 5 minutes in 90%-96% of recipients who receive 4-5 mg/kg IM ketamine [ 15 , 18 , 19 ]. In contrast, 10 mg IM haloperidol requires a median of 17 minutes to achieve sedation; however, only 65% of the recipients were adequately sedated [ 15 , 19 ]. Ketamine was also associated with less redosing of sedative agents compared to haloperidol (5%-20%) [ 15 ].…”

Section: Reviewmentioning

confidence: 99%

“…In contrast, 10 mg IM haloperidol requires a median of 17 minutes to achieve sedation; however, only 65% of the recipients were adequately sedated [ 15 , 19 ]. Ketamine was also associated with less redosing of sedative agents compared to haloperidol (5%-20%) [ 15 ]. Ketamine PCP analog results in non-competitive NMDA antagonism, thereby decreasing the calcium influx and ultimately blocking the neuronal activation required for the conscious state [ 20 ].…”

Section: Reviewmentioning

confidence: 99%

“…In contrast, benzodiazepine and haloperidol result in extrapyramidal symptoms, respiratory depression, and long QT syndrome. Respiratory depression is a particular concern for benzodiazepines [ 15 ].…”

Section: Reviewmentioning

confidence: 99%

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A Comparative Analysis Between Ketamine Versus Combination of Midazolam and Haloperidol for Rapid Safe Control of Agitated Patients in Emergency Department: A Systematic Review

Zaki¹,

Shaban²,

Bashir³

et al. 2022

Cureus

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We aim to discuss the efficacy and adverse effects of using ketamine in agitated patients in the emergency department (ED) compared with the combination therapy of haloperidol with benzodiazepine. This systematic review followed Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. An electronic search from PubMed/Medline, Cochrane library, and Google Scholar was conducted from their inception to 30 th April 2022. We included agitated patients in ED who were given infusion with ketamine only. Our comparative group was patients infused with combined therapy of haloperidol and benzodiazepine. We did not include letters, case reports, abstracts, conference papers, appraisals, reviews, and studies where full text was unavailable. We did not put any language restrictions. Three studies were selected in our manuscript (one cohort and two randomized controlled trials). All three studies showed that ketamine was used to achieve sedation in less time than the other group. However, two studies reported significantly more adverse effects in ketamine-infused groups.We concluded that ketamine use is superior when its primary focus is to sedate the patient as quickly as possible, but it carries some side effects that should be considered. However, we still need more studies assessing the efficacy of ketamine in agitated patients presenting in the ED.

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Section: Reviewmentioning

confidence: 99%

Section: Reviewmentioning

confidence: 99%

Section: Reviewmentioning

confidence: 99%

Section: Reviewmentioning

confidence: 99%

Section: Reviewmentioning

confidence: 99%

See 3 more Smart Citations

A Comparative Analysis Between Ketamine Versus Combination of Midazolam and Haloperidol for Rapid Safe Control of Agitated Patients in Emergency Department: A Systematic Review

Zaki¹,

Shaban²,

Bashir³

et al. 2022

Cureus

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Effect of Sublingual Dexmedetomidine vs Placebo on Acute Agitation Associated With Bipolar Disorder

Preskorn

Zeller

Citrome

et al. 2022

JAMA

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IMPORTANCEAcute agitation is common in patients with bipolar disorder and requires urgent management to relieve distress and to prevent escalation to aggressive behavior.OBJECTIVE To evaluate the effect of orally absorbed, sublingual dexmedetomidine, a selective α 2A -adrenergic receptor agonist on symptoms of acute agitation in patients with bipolar disorder.DESIGN, SETTING, AND PARTICIPANTS Phase 3, randomized, double-blind, placebo-controlled trial conducted in 15 sites in the US with enrollment between February 24, 2020, and April 27, 2020, and final follow-up on May 21, 2020. A total of 380 adults with bipolar I or II disorder were randomized and 362 completed the study. INTERVENTIONS Participants were randomized to 3 groups: sublingual dexmedetomidine 180 μg (n = 127), sublingual dexmedetomidine 120 μg (n = 127), or placebo (n = 126). MAIN OUTCOMES AND MEASURESThe primary efficacy end point was the mean change from baseline at 2 hours for the Positive and Negative Syndrome Scale-Excited Component (PEC) total score. The range of possible total scores is 5 (absence of agitation) to 35 (extremely severe). The secondary end point was the earliest time of a statistically significant change in PEC total score from baseline for the drug vs placebo. On the primary efficacy end point, to account for multiplicity associated with comparing 2 sublingual dexmedetomidine doses with placebo, the 2-sided significance level for each dose vs placebo was set at .025. RESULTSOf 380 patients randomized (mean age, 45.6 years; 54.8% women; and 56.1% Black individuals), 378 (99.5%) self-administered the study medication and completed the study. Baseline agitation was mild to moderate, with an overall mean PEC total score of 18.0. Two hours after taking the medication, the mean changes from baseline in PEC total score were −10.4 for sublingual dexmedetomidine 180 μg, −9.0 for sublingual dexmedetomidine 120 μg, and −4.9 for placebo. Least-square mean differences from placebo in the sublingual dexmedetomidine groups at 2 hours were −5.4 (97.5% CI, −6.6 to −4.2) for 180 μg and −4.1 (97.5% CI, −5.3 to −2.9) for 120 μg (both doses P < .001 vs placebo). Treatment effects began 20 minutes after taking the medication among patients in the sublingual dexmedetomidine groups (least-square mean difference for 180 μg, −1.1 [97.5% CI, −2.0 to −0.2]; P = .007; for 120 μg, −1.0 [97.5% CI, −1.9 to −0.1]; P = .009). Adverse events occurred in 35.7% of patients taking 180 μg of dexmedetomidine, 34.9% taking 120 μg, and 17.5% taking placebo. The most common adverse events (Ն5%) in the respective 180 μg, 120 μg, and placebo groups were somnolence (21.4% and 20.6% vs 4.8%); dry mouth (4.8% and 7.1% vs 0.8%); hypotension (6.3% and 4.8% vs 0%); and dizziness (5.6% and 5.6% vs 0.8%).CONCLUSIONS AND RELEVANCE Among patients with mild to moderate agitation associated with bipolar disorder, treatment with a sublingual film formulation of dexmedetomidine 120 μg or 180 μg, compared with placebo, resulted in significantly greater reduction in the agitation score...

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Schizophrenia and Related Psychoses

2021

The Maudsley Prescribing Guidelines in Psychiatry

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Despite disagreements about nomenclature, patients who develop schizophrenic or schizophrenialike symptoms in later life are often seen in clinical practice. Questions about the etiology of late-life psychotic disorders and about their similarities or differences from early-onset disorders remain unanswered. Neuroimaging techniques have been used to study patients with late onset of psychosis, and in substantial subgroups of patients (from 25% to 100% in various studies) compared with agematched control subjects, structural and functional abnormalities have been found. We review the literature on imaging in late-life schizophrenia and related psychotic disorders, and we present data from our own investigations of patients with these disorders. We discuss the potential usefulness of imaging evaluations in patients with late-onset disorders, and we offer suggestions for future investigations.

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Safety and efficacy of pharmacologic agents used for rapid tranquilization of emergency department patients with acute agitation or excited delirium

Cited by 28 publications

References 132 publications

A Comparative Analysis Between Ketamine Versus Combination of Midazolam and Haloperidol for Rapid Safe Control of Agitated Patients in Emergency Department: A Systematic Review

A Comparative Analysis Between Ketamine Versus Combination of Midazolam and Haloperidol for Rapid Safe Control of Agitated Patients in Emergency Department: A Systematic Review

Effect of Sublingual Dexmedetomidine vs Placebo on Acute Agitation Associated With Bipolar Disorder

Schizophrenia and Related Psychoses

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