Intended for healthcare professionals

Rapid response to:


Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a randomised trial of midazolam versus haloperidol plus promethazine

BMJ 2003; 327 doi: (Published 25 September 2003) Cite this as: BMJ 2003;327:708

Rapid Response:

Midazolam and acute agitation

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

Competing interests: No competing interests

11 October 2003
Bradley KW Ng
Psychiatry registrar
Department of Psychiatry, Rotorua Hospital, Private Bag 3023, Rotorua, New Zealand