What is the best approach for parenteral sedation to manage severe acute behavioral disturbance in the emergency department?
Clinical toxicology (Philadelphia, Pa.) · 2025-12-08 · Guideline / consensus
Abstract
INTRODUCTION: Patients with severe acute behavioural disturbance commonly present to the emergency department. Differing expert opinion dominates treatment strategies. We describe an evidence-based approach to parenteral sedation for the management of emergency department patients with severe acute behavioural disturbance. APPROACH TO MANAGING SEVERE ACUTE BEHAVIOURAL DISTURBANCE WITH PARENTERAL SEDATION: The most common cause of severe acute behavioural disturbance in the emergency department setting is alcohol and drug intoxication, both being relatively short-lived. The goal of parenteral sedation is to provide safe observation until the effect of any intoxication wears off and allow time for further clinical investigation and treatment as required. A validated scoring tool, such as the sedation assessment tool score, is useful to guide objective assessment of behavioural disturbance. We recommend the intramuscular route initially, unless intravenous access is already available (i.e., placed by first responders), as it allows rapid administration and requires less physical restraint. We recommend droperidol, or olanzapine where droperidol is unavailable, as the preferred first-line parenteral agent, due to strong evidence of effectiveness and safety. When rescue therapy is required or in extremely dangerous circumstances, we recommend using ketamine. We do not routinely recommend benzodiazepines, such as midazolam, except for treating specific causes of agitation which respond well to benzodiazepines, such as alcohol withdrawal or stimulant intoxication. We recommend avoiding combination therapy (antipsychotic and benzodiazepine) due to an increased adverse effect profile, without clear evidence for increased effectiveness. MONITORING FOLLOWING SEDATION FOR ACUTE BEHAVIOURAL DISTURBANCE: Following sedation, we recommend close observation in all patients, including at a minimum regular monitoring of vital signs, level of sedation, and continuous pulse oximetry without supplemental oxygen. End-tidal carbon dioxide monitoring should be used when available. CONCLUSIONS: There is a good evidence base to recommend a standardized approach to the management of severe acute behavioural disturbance in the emergency department. We recommend using intramuscular droperidol (or olanzapine if droperidol is not available) as a first-line therapy, which can be repeated at 15 min if effective sedation is not achieved. If rescue sedation is required or in extremely dangerous scenarios when immediate control is required, we recommend ketamine. We do not routinely recommend benzodiazepines as first-line therapy, unless specifically treating a condition likely to benefit from benzodiazepines, such as alcohol (or sedative hypnotic) withdrawal or stimulant intoxication. We do not recommend combination therapy (antipsychotic and benzodiazepines).
Tags
Anaesthetics · Capnography · Intravenous access · Ketamine · Midazolam · Sedatives & anxiolytics