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Midazolam and acute agitation
- Bradley KW Ng (11 October 2003)
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Response to Dr Bradley
- Gisele Huf, Evandro S.F. Coutinho, Clive E. Adams (23 October 2003)
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Bradley KW Ng, Psychiatry registrar Department of Psychiatry, Rotorua Hospital, Private Bag 3023, Rotorua, New Zealand
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I commend the TREC Collaborative Group’s study of rapid tranquillisation for acute agitation, which was recently published in the journal.[1] It has used a large, multi-site pragmatic randomised trial with few exclusion criteria to answer an important and under studied clinical issue in psychiatry, emergency medicine and public health. The use of intramuscular midazolam in clinical practice has previously been based on considerations other than the evidence in the literature, which had been restricted to case series and audits. [2 3] Despite a push by pharmaceutical companies advocating large doses of oral second generation antipsychotics in the treatment of acute agitation, there will be a continuing need for intramuscular and intravenous medications that are both safe and economical. The assessement of the severity of agitation was an overall doctor’s impression and the paper implies this was for pragmatic reasons. Was there an attempt to use a scale or rating scale by another person involved in the management of the emergency? Was there any assessment of possible variations in the impression of agitation between sites? Was the clinician’s impression of extreme agitation the same between hospitals, and how does this translate to other countires? This minor issue aside, the trial has established intramuscular midazolam as a relatively safe and effective medication for acute agitation. Given the potential acute side effects of antipsychotics, the question remains whether or not combining an antipsychotic (droperidol, haloperidol, zuclopenthixol) with a benzodiazepine confers any substantial clinical benefit over benzodiazepines alone, and in which populations this is most likely to benefit 1. TREC Collaborative Group. Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a randomised trial of midazolam versus haloperidol plus promethazine. BMJ 2003; 327: 708-13. 2. Ng B, Malesu RR. He use of intramuscular midazolam in an acute psychiatric unit. Australian and New Zealand Journal of Psychiatry 2003; 37: 111-112. 3. Wyant M, Diamond BI, O'Neal E, et al. The use of midazolam in acutely agitated psychiatric patients. Psychopharmacol Bull 1990; 26:126-129 Competing interests: None declared |
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Gisele Huf, TREC Co-ordinator Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, 21941-590, Caixa Postal 68037, Evandro S.F. Coutinho, Clive E. Adams
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We thank Dr Bradley for the very generous comments. We did choose to use only the clinical impression of agitation/aggression as recorded by the doctors and nurses. We ensured that the time of tranquillisation was accurate by use of independent observation for a proportion of participants. We had thought of using the Overt Aggression Scale to validate the clinical impression but this would have complicated the design and the study would have been less practical. We are therefore left with the reliably timed clinical impression of staff very experienced in managing aggression. We did not measure how this differed between centres. In the survey of rates of aggression preceding TREC the authors did not have the impression that severity of aggression differed between centres across Rio de Janeiro(1). Doctors working in the psychiatric emergency rooms of Rio rated most people as 'markedly' agitated. As the survey shows these clinicians work in situations where aggression is remarkably prevalent1 and accommodation to such levels of agitation would be understandable. TREC-India, using similar design and comparing haloperidol plus promethazine with lorazepam for 200 people whose aggression was thought to be due to psychosis(2) may shed further light on whether experienced clinical impressions concur with measures of aggression. This study did incorporate reliable use of simple validated rating of clinical global impression. Reference List 1. Huf G, Coutinho ESF, Fagundes HM Jr, Oliveira ES, Lopez JR, Gewandszajder M, da Luz Carvalho A, Keusen A, Adams CE. Current practices in managing acutely disturbed patients at three hospitals in Rio de Janeiro-Brazil: a prevalence study.BMC Psychiatry 2002;2(1):4. 2. Alexander J, Tharyan P, Adams CE, John T, Mol C, Philip J. TREC- INDIA: Rapid tranquilisation of violent or agitated patients in a psychiatric emergency setting: a pragmatic randomized trial of intramuscular lorazepam versus haloperidol plus promethazine. BJPsych 2003 submitted Competing interests: Collaborators on the TREC study |
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