Intravenous drug regimens for acute severe behavioural disturbance in adults

Managing a patient with acute behavioural disturbance is a detailed flowchart for managing a patient with acute behavioural disturbance.

The indications for intravenous sedation for acute severe behavioural disturbance in adults are detailed here.

Most emergency departments and hospitals have protocols for the safe use of parenteral sedation, especially via the intravenous route—follow local protocols or consensus state guidelines, if available. If intravenous sedation is administered, monitor the patient 1:1 for adverse drug effects; see Principles of monitoring a patient with acute behavioural disturbance.

The intramuscular route is preferred over the intravenous route for parenteral drug administration. When considering the use of intravenous sedation, always seek expert advice.

Note: When considering the use of intravenous sedation, always seek expert advice.

The aim of pharmacological management is to calm the patient with a sufficient initial dose of a sedative drug. Repeated subtherapeutic doses that are inadequate to reduce the patient’s distress and calm their behaviour can prolong the risk of harm to the patient or others. This can also result in larger cumulative doses, or multiple drug administration, both of which increase the risk of adverse drug effects.

The most common drugs used in adults to manage acute severe behavioural disturbance are benzodiazepines and antipsychotics, which are used in this setting for their sedative effects. The sedative effects of antipsychotic drugs occur much sooner than the antipsychotic effects. If the patient has had a previous paradoxical reaction to benzodiazepines, or is tolerant to benzodiazepines, avoid benzodiazepines.

When selecting a suitable dose and regimen for a sedative drug, consider patient factors, such as their level of agitation and distress (eg measured with a Sedation Assessment Tool [SAT] score, age, body size, sex, comorbidities, drug history, previous response to sedative drugs and response to treatment.

If intravenous sedation is indicatedfor an adult with acute severe behavioural disturbance, who has existing intravenous access, and in combination with nonpharmacological techniques, use:

1 droperidol 10 mg intravenously; for frail or cachectic patients use 5 mg intravenously. If required, repeat once after 15 minutes; if more than 20 mg in total is required (10 mg for frail or cachectic patients), seek expert advice1 acute severe behavioural disturbance, adult (intravenous) droperidol droperidol droperidol

OR

2 midazolam 5 mg intravenously; for frail or cachectic patients use 2.5 mg intravenously. If required, repeat the dose every 3 to 4 minutes until the patient is sedated but rousable; if more than 20 mg in total is required (10 mg for frail or cachectic patients), seek expert advice acute severe behavioural disturbance, adult (intravenous) midazolam midazolam midazolam

OR

2 diazepam 5 to 10 mg intravenously; for frail or cachectic patients use 5 mg intravenously. If required, repeat the dose every 3 to 4 minutes until the patient is sedated but rousable; if more than 60 mg in total is required (30 mg for frail or cachectic patients), seek expert advice. acute severe behavioural disturbance, adult (intravenous) diazepam diazepam diazepam

Olanzapine is not approved for intravenous use in Australia2.

If the sedative drugs above are unavailable or fail to control the situation, intravenous ketamine can be considered; however, there is a high risk of airway compromise requiring intubation if combination intravenous pharmacotherapy or rescue sedation is used—always seek advice from a senior clinician regarding the dose and safety of intravenous ketamine.

If an adult patient is being physically restrained, continue restraint until a clinical response to the sedative is apparent (ie the patient is calm but rousable).

Always monitor the patient closely for potential adverse effects after administering an intravenous sedative drug.

1 The US Food and Drug Administration (FDA) has a Black Box warning for droperidol concerning potential cardiac complications. However, there is no convincing evidence for a causal relationship between therapeutic droperidol administration in the present context and life-threatening cardiac events.Return
2 Olanzapine is not approved for intravenous use in Australia, but some research supports its use by this route. The short-acting intramuscular formulation of olanzapine can be administered intravenously.Return