Abstract
Acute agitation is a common presenting symptom in the emergency ward and is also dealt with on a routine basis in psychiatry. Usually a symptom of an underlying mental illness, it is considered urgent and immediate treatment is indicated. The practice of treating agitation on an acute care basis is also referred to as rapid tranquilization. A variety of psychotropic drugs and combinations thereof can be used. The decision is usually made based on availability and the clinician’s experience, with the typical antipsychotic haloperidol (alone or in combination with antihistaminergic and anticholinergic drugs such as promethazine), the benzodiazepines lorazepam, diazepam and midazolam as well as a variety of atypical antipsychotics being used for this purpose. Haloperidol is associated with extrapyramidal symptoms (which can be controlled by co-administration of promethazine) and may control agitation without inducing sedation, while benzodiazepines have a more pronounced sedating activity. The atypical antipsychotics aripiprazole and ziprasidone are better tolerated, while olanzapine is also a powerful sedative. Clinical trials evaluating the efficacy of different treatment options have been conducted but they are extremely heterogenous and most have numerous methodological flaws, leading to a poor overall quality of evidence upon which guidelines for the appropriate treatment could be based. The combination of haloperidol and promethazine, which combines the sedative properties of the antihistamine with the more selective calming action of haloperidol (with a reduced risk of extrapyramidal effects compared to haloperidol alone because of the anticholinergic properties of promethazine) may be the best choice based on empirical evidence.
Highlights
BackgroundRapid tranquilization is a term denoting the use of pharmacological agents to calm acutely agitated or aggressive patients, both in a psychiatric as well as a general acute care setting
The purpose of this review is to examine the evidence regarding empirical options, evaluate potential novel agents suitable for rapid tranquilization and provide vital information regarding these in a manner conducive to wise clinical decision- making
Benzodiazepines are more sedating than antipsychotics bau less effective for the management of acute agitation, while the combination of benzodiazepines and antipsychotics leads to more side effects without conferring additional efficacy
Summary
Rapid tranquilization is a term denoting the use of pharmacological agents to calm acutely agitated or aggressive patients, both in a psychiatric as well as a general acute care setting. No other drug has been more intimately associated in the minds of both clinicians and patients alike with rapid tranquilization than haloperidol It is a high potency typical antipsychotic agent of the butyrophenone class, which exerts its effects primarily via antagonism of the dopamine D2 receptors. Low potency typical antipsychotics such as chlorpromazine were used for rapid tranquilization in the past, but this practice is very rare due to the side effects associated with their parenteral administration These compounds are potent a1 antagonists and cause significant hypotension in patients who have not developed tolerance. Excessive sedation is generally regarded as an undesirable effect Compared with antipsychotics such as haloperidol, benzodiazepines pose a far greater risk to the patient as they may cause respiratory depression in high doses, and may contribute to dangerous drug interactions with other depressants which the patient may have been exposed to [23]. Another concern is that its partial agonist activity, combined with its high affinity for D2 receptors may render subsequent administration of other antipsychotics ineffective by displacing them from the receptor (Table 1)
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