What is the best way to treat a patient with psychosis using medications in the Emergency Department (ED)?

From the Guidelines

The best way to treat a psychotic patient in the emergency department is to first ensure safety for the patient and staff, then administer appropriate medications, with a preference for second-generation antipsychotics like olanzapine or ziprasidone due to their potentially fewer extrapyramidal side effects, as recommended by the American Psychiatric Association 1.

Key Considerations

• Ensure patient and staff safety before administering any treatment
• Assess the patient's symptoms, medical history, and potential substance use or withdrawal
• Consider using second-generation antipsychotics like olanzapine 5-10mg orally or intramuscularly, or ziprasidone 10-20mg intramuscularly, as they may have fewer extrapyramidal side effects compared to first-generation antipsychotics like haloperidol 1
• Benzodiazepines like lorazepam 2mg can be added for sedation and anxiety control, but their use should be carefully considered due to potential risks of dependence and withdrawal 1
• Monitor vital signs and mental status every 15-30 minutes, with repeated doses given if needed after 30-60 minutes
• Transition to oral medications and arrange psychiatric consultation for ongoing management once the patient is stabilized

Medication Options

• Olanzapine 5-10mg orally or intramuscularly
• Ziprasidone 10-20mg intramuscularly
• Haloperidol 5-10mg intramuscularly (although it may have more extrapyramidal side effects)
• Lorazepam 2mg for added sedation and anxiety control

Important Considerations

• Always check for medical causes of psychosis, such as substance intoxication, withdrawal, infection, or metabolic abnormalities, before attributing symptoms solely to psychiatric illness 1
• Consider the patient's preferences and goals for treatment, as well as their cultural and social factors, when developing a treatment plan 1

From the FDA Drug Label

Olanzapine for injection is an atypical antipsychotic indicated: • Treatment of acute agitation associated with schizophrenia and bipolar I mania. IM: 10 mg (5 mg or 7. 5 mg when clinically warranted) Assess for orthostatic hypotension prior to subsequent dosing (max. 3 doses 2 to 4 hrs apart)

The best way to treat a patient with psychosis using medications in the Emergency Department (ED) is to administer olanzapine (IM) at a dose of 10 mg, with the option to use 5 mg or 7.5 mg when clinically warranted. It is essential to assess for orthostatic hypotension prior to subsequent dosing, with a maximum of 3 doses 2 to 4 hours apart 2.

• Key considerations:
  • Monitor for orthostatic hypotension
  • Assess the patient's overall clinical condition to determine the appropriate dose and frequency of administration
  • Be aware of the potential for cerebrovascular adverse events, tardive dyskinesia, and neuroleptic malignant syndrome
  • Consider alternative treatments, such as haloperidol (IM), if necessary 3.

Note: The use of antipsychotic medications, including olanzapine and haloperidol, carries potential risks and side effects, and should be carefully considered and monitored in the ED setting.

From the Research

Treatment Options for Psychosis in the Emergency Department

The treatment of psychosis in the Emergency Department (ED) involves the use of antipsychotic medications, which can be administered orally or intramuscularly. The choice of medication depends on the clinical situation, the patient's cooperation, and the presence of any medical or psychiatric comorbidities.

Oral Medications

• Liquid oral preparations can be used if the patient is cooperative, and are as effective as intramuscular formulations 4
• Haloperidol, lorazepam, and olanzapine are commonly used oral medications for the treatment of psychosis in the ED 5, 6, 7
• The combination of haloperidol and lorazepam is often used, as it provides rapid tranquilization and is effective in reducing psychotic symptoms 6, 7

Intramuscular Medications

• Intramuscular preparations are usually preferred over oral medication when the patient is not cooperative and requires rapid treatment 4
• Haloperidol, olanzapine, and ziprasidone are available in intramuscular formulations, which can provide rapid onset of action and good bioavailability 4, 5
• The combination of haloperidol and promethazine is also effective in treating psychosis in the ED, and is associated with fewer extrapyramidal side effects compared to haloperidol alone 8

Medication Selection and Dosing

• The selection of antipsychotic medication and dosing should be based on the patient's clinical situation, medical history, and current medications 4, 7
• The dose of antipsychotic medication may need to be adjusted based on the patient's response to treatment and the presence of any side effects 4, 8
• The use of benzodiazepines, such as lorazepam, should be cautious, as they can cause respiratory depression, especially when used in combination with other medications 8