From the Guidelines
The first line treatment options for acute behavioral disturbances include benzodiazepines, such as lorazepam or midazolam, and conventional antipsychotics, such as droperidol or haloperidol, as effective monotherapy for the initial drug treatment of the acutely agitated undifferentiated patient. When considering treatment options, it is essential to prioritize non-pharmacological interventions first, including verbal de-escalation techniques, providing a calm environment, and removing potential triggers. If these fail, pharmacological options can be considered.
- Benzodiazepines, such as lorazepam 1-2mg orally or intramuscularly, are often used for their rapid onset and relatively short half-life 1.
- Alternatively, midazolam 5-10mg IM provides even faster action.
- For psychotic symptoms, haloperidol 5-10mg IM or olanzapine 5-10mg IM/orally are commonly used.
- Combination therapy with both a benzodiazepine and antipsychotic may be more effective than either alone for severe agitation.
- Vital sign monitoring is essential after medication administration, particularly for respiratory depression with benzodiazepines and cardiac effects with antipsychotics.
- The choice between medications should consider the patient's medical history, with benzodiazepines preferred for substance withdrawal and antipsychotics for psychosis, as noted in the clinical policy for critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department 1. It is crucial to exercise caution when caring for patients agitated due to medical illness, ensuring that any reversible causes are identified and treated, and being aware that antipsychotics can potentially exacerbate agitation due to their anticholinergic side effects 1.
From the FDA Drug Label
WARNINGS ... Use in Status Epilepticus MANAGEMENT OF STATUS EPILEPTICUS Status epilepticus is a potentially life-threatening condition associated with a high risk of permanent neurological impairment, if inadequately treated. ... For the treatment of status epilepticus, the usual recommended dose of Lorazepam Injection is 4 mg given slowly (2 mg/min) for patients 18 years and older.
The first line treatment option for acute behavioural disturbances, specifically in the context of status epilepticus, is Lorazepam Injection at a dose of 4 mg given slowly (2 mg/min) for patients 18 years and older 2.
From the Research
First Line Treatment Options for Acute Behavioural Disturbances
The first line treatment options for acute behavioural disturbances typically involve the use of psychotropic drugs, including antipsychotics and benzodiazepines.
- Antipsychotics such as haloperidol and risperidone are commonly used to treat acute psychotic agitation 3, 4, 5.
- Benzodiazepines like lorazepam are also used, either alone or in combination with antipsychotics, due to their sedating properties 3, 4, 5.
- The combination of haloperidol and lorazepam is often considered a treatment of choice for acute psychotic agitation, as it provides rapid tranquilization with minimal side effects 3, 5.
- Atypical antipsychotics such as aripiprazole, ziprasidone, and olanzapine are also used to treat acute agitation, with some studies suggesting they may be better tolerated than typical antipsychotics 4.
Treatment Considerations
When selecting a treatment option, clinicians should consider the individual patient's needs and medical history.
- The use of benzodiazepines in combination with antipsychotics may be beneficial for patients with schizophrenia, as it can help reduce symptoms of anxiety and behavioural disinhibition 6.
- However, the use of benzodiazepines should be carefully monitored due to the risk of dependence and withdrawal symptoms.
- The treatment of acute behavioural disturbances should always be tailored to the individual patient's needs, with careful consideration of the potential benefits and risks of each treatment option 3, 4, 7, 5, 6.