Are you sedating agitated psychiatric patients safely?
A man walks into your ED screaming at the top of his lungs and waving his arms wildly. It’s clear that sedation is needed, but the safety of this patient and the ED staff is very much at risk.
For scenarios like this, a new pharmacological intervention is being used to quickly and safely sedate patients in the ED. Researchers studied 110 severely agitated ED patients who received intramuscular injections of the antipsychotic drug zipradisone. Within 30 minutes, whether the patients were psychotic or had abused alcohol or drugs, their agitation scores dropped to a normal range. In addition, the patients who received the drug spent 40% less time in restraints compared with those who were given conventional antipsychotics such as haloperidol.1
"That is not only an advantage from a manpower standpoint, since you don’t have someone sitting there with the patient; it’s also a safety issue," says Horacio Preval, MD, director of psychiatric emergency services at Stony Brook University Hospital and the study’s lead author. "Most patients with bad outcomes from restraint die from asphyxia or aspiration. So if you can minimize the time spent in restraint, there is a lower likelihood of a bad outcome."
Although the drug is highly effective with minimal side effects, the vast majority of EDs still are not using it, says Preval. "They don’t use it because they’re not familiar with it. Pockets of EDs around the country are still using the typical Haldol cocktail,’ and some are even using droperidol, which is a black box’ drug right now," he says. (The FDA’s black box warning, which reports that cases of serious arrhythmias have occurred in patients treated with droperidol, can be accessed at www.fda.gov/medwatch/SAFETY/2001/inapsine.htm.)
Agitated ED patients often are given a Haldol cocktail, but this means the patients will be highly sedated for six to eight hours, says Preval. In contrast, patients sedated with ziprasidone can be aroused within 30-45 minutes. "Even though the patient appears to be asleep, you can tap them on the shoulder and they are able to talk to you, so you can do your nursing assessment and diagnostic interview," says Preval. "This has become the gold standard in our ED for management of the acutely agitated patient."
1. Preval H, Klotz SG, Southard R. Rapid-acting IM ziprasidone in a psychiatric emergency service: a naturalistic study. Gen Hosp Psych 2005; 27:140-144.
For more information on use of intramuscular ziprasidone in the ED, contact:
- Horacio Preval, MD, Director, Psychiatric Emergency Services, Department of Psychiatry, Stony Brook University Hospital, Health Sciences Center, Tower 10, Room 20, Stony Brook, NY 11794-8101. Telephone: (631) 444-2990. E-mail: firstname.lastname@example.org.