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Sedation in the ER: Combination therapy or monotherapy?

Agitation and aggression are common occurrences in emergency room settings, and are likely a consequence of mental illness, drug and alcohol intoxication, or both.

Parenteral benzodiazepines or antipsychotics are often used to manage acute agitation in emergency department (ED) settings, when other strategies have failed.

A randomized, double-blind, placebo-controlled, double-dummy clinical trial was undertaken to study the efficacy of and safety of antipsychotics in combination with benzodiazepines. The trial, which was recently published, found that a combination of antipsychotic medication and benzodiazepines used to sedate acutely agitated emergency patients worked more quickly than antipsychotics alone, and kept patients adequately sedated for longer without any adverse effects.

Inclusion criteria were aged 18 to 65 years and the need for parenteral drug sedation for acute agitation, as determined by a senior resident or emergency physician. Researchers enrolled 336 patients in three groups: one group received intravenous saline (the control group), one received intravenous droperidol (an antipsychotic medication), and one received intravenous olanzapine (an antipsychotic medication). All three groups received an intravenous dose of midazolam (a benzodiazepine), the most commonly used sedating drug among Australasian emergency physicians.

Patients who received antipsychotic medication - either droperidol or olanzapine - and midazolam achieved sedation 4 to 5 minutes faster than patients in the control group. More patients in the control group than in the other two groups required an additional sedation 60 minutes after the initial sedation, and continuing through discharge from the emergency department.

"For emergency patients with mental illness and/or intoxication, 4 or 5 minutes is a long time to wait for effective sedation," said David M. Taylor, MD, co-author of this study. "This drug combination is safe, fast and inexpensive and we found no negative effects warranting the 2001 'black box' warning by the FDA. Our results are good news for emergency physicians who deal with agitation and aggression among their patients on a daily basis."