Medication Options for Acute Agitation Without IV Access
For patients with acute agitation without intravenous access, intramuscular (IM) midazolam 0.07-0.08 mg/kg (approximately 5 mg for adults) is the preferred first-line treatment due to its rapid onset, effectiveness, and safety profile. 1
First-Line Options
Intramuscular midazolam: 0.07-0.08 mg/kg (approximately 5 mg for adults) injected deep into a large muscle mass. For older patients (>60 years) or those with chronic conditions, reduce dose to 0.02-0.05 mg/kg (2-3 mg). 1
Intramuscular lorazepam: 2.5-5 mg subcutaneously every 2-4 hours as needed. If frequent dosing is required (more than twice daily), consider alternative routes when IV access is established. 2
Rectal diazepam: Can be administered when IM options are not feasible. Note that IM diazepam is not recommended due to erratic absorption. 2
Special Populations
Elderly patients (>60 years): Use reduced doses of midazolam (0.02-0.05 mg/kg, approximately 1-3 mg) due to increased risk of respiratory depression. 1
Patients with severe systemic disease or debilitation: Require lower doses of benzodiazepines; start with approximately 50% of the standard dose. 1
Second-Line Options
Intramuscular haloperidol: 0.5-1 mg for initial dose in elderly patients; 1.5-3 mg for severely distressed patients. May be combined with a benzodiazepine for enhanced effect. 2
Intramuscular olanzapine: Consider when available as it has shown faster onset of action and fewer adverse effects than haloperidol in treating acute agitation. 3
Intramuscular ziprasidone: Has shown significant calming effects within 30 minutes for acutely agitated patients with psychotic conditions. 3
Monitoring and Precautions
Respiratory monitoring: All benzodiazepines carry risk of respiratory depression. Monitor respiratory rate, oxygen saturation, and level of consciousness. 2
Cardiac monitoring: When using antipsychotics, particularly ziprasidone, be aware of potential QTc interval prolongation. 3
Reversal agent: Have flumazenil available when administering benzodiazepines for potential reversal of respiratory depression. 2
Approach Based on Etiology
Undifferentiated agitation: IM midazolam is preferred due to rapid onset and short duration. 1, 3
Psychotic agitation: Consider combining a benzodiazepine with an antipsychotic (haloperidol or atypical) for enhanced effect. 3, 4
Agitation due to substance intoxication/withdrawal: Benzodiazepines are generally preferred; avoid antipsychotics in alcohol or sedative withdrawal. 5
Common Pitfalls to Avoid
Excessive sedation: Titrate medication carefully, especially in elderly or medically compromised patients. 1
Combining multiple CNS depressants: This increases risk of respiratory depression and adverse events. 2
Inadequate monitoring: Even with non-IV routes, patients require close monitoring for adverse effects. 2
Delayed reassessment: Allow sufficient time between doses to assess medication effect before administering additional doses. 2
Remember that establishing IV access should be a priority when possible, as it allows for more precise medication titration and immediate access for emergency medications if needed. 2