Letters to the Editor
Managing aggressive and violent patients
- Aust Prescr 2011;34:166-8
- 1 December 2011
- DOI: 10.18773/austprescr.2011.087
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Editor, – We have some concerns about the approach to sedation of patients with aggression and violence suggested by Professor Fulde and Associate Professor Preisz (Aust Prescr 2011;34:115-8). Large numbers of patients require parenteral sedation with physical containment which can be hazardous to staff and requires a standardised approach.
Recent research supports the use of different drugs and initial intramuscular sedation for most patients. One study demonstrated that the duration of acute behavioural disturbance was reduced when intramuscular sedation was employed.1 Intravenous sedation requires sufficient staff to restrain the patient, otherwise it is dangerous with the risk of needle stick or physical injury. However although intramuscular midazolam is used most commonly, recent evidence demonstrates that it is unpredictable due to over-or under-sedation.2 A controlled trial found that 10 mg intramuscular midazolam caused adverse events in 28% of patients compared to 6% with droperidol.2
Only the antipsychotics olanzapine and haloperidol were suggested for sedation in the article. Haloperidol is not very sedative and has a black box warning by the US Food and Drug Administration (FDA) for confirmed reports of QT prolongation and torsades des pointes. Parenteral olanzapine has never been shown to be effective in the emergency department setting.2 Droperidol is safer and more effective for sedation of acute behavioural disturbance in the emergency department.2 It has been used extensively and rarely causes over-sedation. There have been concerns about QT prolongation and torsades des pointes. Despite an FDA black box warning this has not been confirmed in a systematic review.4
We now routinely use 10 mg intramuscular droperidol for initial sedation and repeat the dose after 15 minutes if required. In 412 patients sedated this way, 66% became sedated with one dose. Minor adverse events occurred in 5.5% of patients but no patient had QT prolongation.
Geoffrey K Isbister
Leonie A Calver
Department of Clinical Toxicology and Pharmacology
Calvary Mater Newcastle Hospital, NSW