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Prehospital Agitation and Sedation Trial (PhAST): A Randomized Control Trial of Intramuscular Haloperidol versus Intramuscular Midazolam for the Sedation of the Agitated or Violent Patient in the Prehospital Environment

Published online by Cambridge University Press:  01 September 2015

Derek L. Isenberg  and
Dorian Jacobs
Derek L. Isenberg*
Affiliation:
Department of Emergency Medicine, Crozer-Chester Medical Center, Upland, Pennsylvania USA
Dorian Jacobs
Affiliation:
Department of Emergency Medicine, Crozer-Chester Medical Center, Upland, Pennsylvania USA
*
Correspondence: Derek Isenberg, MD Crozer-Chester Medical Center Department of Emergency Medicine 1 Medical Center Boulevard Upland, Pennsylvania 19013 USA E-mail: Derek.isenberg@crozer.org
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Abstract

Introduction

Violent patients in the prehospital environment pose a threat to health care workers tasked with managing their medical conditions. While research has focused on methods to control the agitated patient in the emergency department (ED), there is a paucity of data looking at the optimal approach to subdue these patients safely in the prehospital setting.

Hypothesis

This study evaluated the efficacy of two different intramuscular medications, midazolam and haloperidol, to determine their efficacy in sedating agitated patients in the prehospital setting.

Methods

This was a prospective, randomized, observational trial wherein agitated patients were administered intramuscular haloperidol or intramuscular midazolam to control agitation. Agitation was quantified by the Richmond Agitation and Sedation Scale (RASS). Paramedics recorded the RASS and vital signs every five minutes during transport and again upon arrival to the ED. The primary outcome was mean time to achieve a RASS less than +1. Secondary outcomes included mean time for patients to return to baseline mental status and adverse events.

Results

Five patients were enrolled in each study group. In the haloperidol group, the mean time to achieve a RASS score of less than +1 was 24.8 minutes (95% CI, 8-49 minutes), and the mean time for the return of a normal mental status was 84 minutes (95% CI, 0-202 minutes). Two patients required additional prehospital doses for adequate sedation. There were no adverse events recorded in the patients administered haloperidol.

In the midazolam group, the mean time to achieve a RASS score of less than +1 was 13.5 minutes (95% CI, 8-19 minutes) and the mean time for the return of normal mental status was 105 minutes (95% CI, 0-178 minutes). One patient required additional sedation in the ED. There were no adverse events recorded among the patients administered midazolam.

Conclusions

Midazolam and haloperidol administered intramuscularly appear equally effective for sedating an agitated patient in the prehospital setting. Midazolam appears to have a faster onset of action, as evidenced by the shorter time required to achieve a RASS score of less than +1 in the patients who received midazolam. Haloperidol offers an alternative option for the sedation of an agitated patient. Further studies should focus on continued investigation into appropriate sedation of agitated patients in the prehospital setting.

IsenbergDL , JacobsD . Prehospital Agitation and Sedation Trial (PhAST): A Randomized Control Trial of Intramuscular Haloperidol versus Intramuscular Midazolam for the Sedation of the Agitated or Violent Patient in the Prehospital Environment. Prehosp Disaster Med. 2015;30(5):491–495.

Keywords

agitationpsychomotorambulanceemergency careprehospitalemergency servicepsychiatric
Type
Brief Reports
Information
Prehospital and Disaster Medicine , Volume 30 , Issue 5 , October 2015 , pp. 491 - 495
Copyright
© World Association for Disaster and Emergency Medicine 2015 

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References

1. Isbister, GK, Calver, LA, Page, CB, Stokes, B, Bryant, JL, Downes, MA. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010;56(4):392-401 e1.CrossRefGoogle ScholarPubMed
2. Martel, M, Sterzinger, A, Miner, J, Clinton, J, Biros, M. Management of acute undifferentiated agitation in the emergency department: a randomized double-blind trial of droperidol, ziprasidone, and midazolam. Acad Emerg Med. 2005;12(12):1167-1172.Google ScholarPubMed
3. Resnick, M, Burton, BT. Droperidol vs. haloperidol in the initial management of acutely agitated patients. J Clin Psychiatry. 1984;45(7):298-299.Google ScholarPubMed
4. Rund, DA, Ewing, JD, Mitzel, K, Votolato, N. The use of intramuscular benzodiazepines and antipsychotic agents in the treatment of acute agitation or violence in the emergency department. J Emerg Med. 2006;31(3):317-324.CrossRefGoogle ScholarPubMed
5. Thomas, H Jr., Schwartz, E, Petrilli, R. Droperidol versus haloperidol for chemical restraint of agitated and combative patients. Ann Emerg Med. 1992;21(4):407-413.CrossRefGoogle ScholarPubMed
6. Wilson, MP, MacDonald, K, Vilke, GM, Feifel, D. A comparison of the safety of olanzapine and haloperidol in combination with benzodiazepines in emergency department patients with acute agitation. J Emerg Med. 2012;43(5):790-797.CrossRefGoogle ScholarPubMed
7. Richards, JR, Derlet, RW, Duncan, DR. Chemical restraint for the agitated patient in the emergency department: lorazepam versus droperidol. J Emerg Med. 1998;16(4):567-573.CrossRefGoogle ScholarPubMed
8. Chan, EW, Taylor, DM, Knott, JC, Phillips, GA, Castle, DJ, Kong, DC. Intravenous droperidol or olanzapine as an adjunct to midazolam for the acutely agitated patient: a multicenter, randomized, double-blind, placebo-controlled clinical trial. Ann Emerg Med. 2013;61(1):72-81.CrossRefGoogle ScholarPubMed
9. Knott, JC, Taylor, DM, Castle, DJ. Randomized clinical trial comparing intravenous midazolam and droperidol for sedation of the acutely agitated patient in the emergency department. Ann Emerg Med. 2006;47(1):61-67.CrossRefGoogle ScholarPubMed
10. Li, SF, Kumar, A, Thomas, S, et al. Safety and efficacy of intravenous combination sedatives in the ED. Am J Emerg Med. 2013;31(9):1402-1404.CrossRefGoogle ScholarPubMed
11. Sessler, CN, Gosnell, MS, Grap, MJ, et al. The Richmond Agitation–Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338-1344.CrossRefGoogle ScholarPubMed
12. Schulz, KF, Altman, DG, Moher, D, Group, C. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. BMJ. 2010;340:c332.CrossRefGoogle Scholar
13. Rosen, CL, Ratliff, AF, Wolfe, RE, Branney, SW, Roe, EJ, Pons, PT. The efficacy of intravenous droperidol in the prehospital setting. J Emerg Med. 1997;15(1):13-17.CrossRefGoogle ScholarPubMed
14. Hick, JL, Mahoney, BD, Lappe, M. Prehospital sedation with intramuscular droperidol: a one-year pilot. Prehosp Emerg Care. 2001;5(4):391-394.CrossRefGoogle ScholarPubMed
15. Martel, M, Miner, J, Fringer, R, et al. Discontinuation of droperidol for the control of acutely agitated out-of-hospital patients. Prehosp Emerg Care. 2005;9(1):44-48.CrossRefGoogle ScholarPubMed
16. Macht, M, Mull, AC, McVaney, KE, et al. Comparison of droperidol and haloperidol for use by paramedics: assessment of safety and effectiveness. Prehosp Emerg Care. 2014;18(3):375-380.CrossRefGoogle ScholarPubMed
17. Weiss, S, Peterson, K, Cheney, P, Froman, P, Ernst, A, Campbell, M. The use of chemical restraints reduces agitation in patients transported by emergency medical services. J Emerg Med. 2012;43(5):820-828.CrossRefGoogle ScholarPubMed
18. Ho, JD, Smith, SW, Nystrom, PC, et al. Successful management of excited delirium syndrome with prehospital ketamine: two case examples. Prehosp Emerg Care. 2013;17(2):274-279.CrossRefGoogle ScholarPubMed
19. Burnett, AM, Salzman, JG, Griffith, KR, Kroeger, B, Frascone, RJ. The emergency department experience with prehospital ketamine: a case series of 13 patients. Prehosp Emerg Care. 2012;16(4):553-559.CrossRefGoogle ScholarPubMed
20. Keseg, D, Cortez, E, Rund, D, Caterino, J. The use of prehospital ketamine for control of agitation in a metropolitan firefighter-based EMS system. Prehosp Emerg Care. 2015;19(1):110-115.CrossRefGoogle Scholar
21. Le Cong, M, Gynther, B, Hunter, E, Schuller, P. Ketamine sedation for patients with acute agitation and psychiatric illness requiring aeromedical retrieval. EMJ. 2012;29(4):335-337.CrossRefGoogle ScholarPubMed