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The Journal of Emergency Medicine, Vol. 31, No. 3, pp.

317–324, 2006
Copyright © 2006 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/06 $–see front matter

doi:10.1016/j.jemermed.2005.09.021

Violence: Recognition,
Management and Prevention

THE USE OF INTRAMUSCULAR BENZODIAZEPINES AND ANTIPSYCHOTIC


AGENTS IN THE TREATMENT OF ACUTE AGITATION OR VIOLENCE IN THE
EMERGENCY DEPARTMENT
Douglas A. Rund, MD,* John D. Ewing, MD,† Katherine Mitzel, DO,* and Nicholas Votolato, PharmB‡

*Department of Emergency Medicine, †College of Medicine, and ‡Department of Psychiatry, The Ohio State University,
Columbus, Ohio
Reprint Address: Douglas A. Rund, MD, Department of Emergency Medicine, The Ohio State University, 169 Means Hall, 1654 Upham
Drive, Columbus, OH 43210

e Abstract—The management of an agitated, abusive or must frequently manage the difficult behavior while deter-
violent patient is a common and challenging problem in Emer- mining the etiology. Behaviors that can precede violence
gency Medicine. Priorities include measures to ensure the include excessive motor or verbal activity, apparent irrita-
safety of the patient and the emergency staff, including pro-
bility, or vocal outbursts. Many times the patient is brought
vision of physical restraint of the patient and evaluation for
correctable medical causes of such behavior. Medications used to the Emergency Department (ED) by police, medics,
in the treatment of such patients include benzodiazepines and family or coworkers for evaluation and subsequent man-
antipsychotic agents. The newer atypical antipsychotic agents agement of such behavior. The patient may, in fact, have
seem to provide a safe and effective treatment for such pa- been violent and brought to the ED in full restraints. In the
tients. The atypical antipsychotic agents may have fewer ED, the patient must be protected from self-inflicted harm
short-term side effects than older typical antipsychotic agents, or inadvertent harm associated with physical restraint, such
such as haloperidol and droperidol. Currently available atyp- as aspiration or limb ischemia. The initial management of
ical antipsychotic medications for the treatment of acute agi-
the agitated or violent patient modifies or even supercedes
tation include ziprasidone and olanzapine, which can be ad-
ministered in an intramuscular formulation, and risperidone, the doctor-patient relationship because the patient’s behav-
which is available in a rapidly dissolvable tablet and liquid ior must be controlled by physical restraint if necessary to
formulation. © 2006 Elsevier Inc. ensure the safety of others (1). Given these challenges, a
treatment approach that provides safe, rapid and effective
e Keywords—benzodiazepines; antipsychotic agents; acute intervention to control agitation, and aggressive or violent
agitation in the emergency department; psychosis; injectable behavior is most desirable. When the undesirable side ef-
atypical antipsychotic medications; psychiatry
fects of treatment are minimized, the patient appreciates the
calming effect induced and a therapeutic relationship be-
INTRODUCTION tween the physician and patient can be established.
In one recent study regarding the management of
The management of the agitated or violent patient is a acutely agitated behavior, the recommended initial man-
common and challenging problem in Emergency Medicine. agement strategies for the imminently violent patient
As in much of emergency care, the emergency physician included talking with the patient, offering food or drink,

Violence: Recognition, Management and Prevention is coordinated by Ellen H. Taliaferro, MD, of San Francisco
General Hospital, San Francisco, California
RECEIVED: 19 June 2004; FINAL SUBMISSION RECEIVED: 29 April 2005;
ACCEPTED: 8 September 2005
317
318 D. A. Rund et al.

Agitated Patient

Focused Assessment
(vitals/H&P)

Medical Condition Substance Abuse Primary Psychiatric Distrubance


(withdrawal/intoxication)

Lab Tests as Benzodiazipine Attempt Discussion Regarding Behavior with Patient


Determined by Physician (Lorazepam 0.5 - 2 mg IV/IM) Possibly Offer Food/Drink
Possibly Barbiturate Oral Medication
**Consider Oral Medication if Possible Show of Force

Treat Medical Condition May Need Psychotropic Benzodiazipine (Lorazepam 0.5 - 2 mg IV/IM)
(glucose for hypoglycemia, Medications Typical Antipsychotic (Haloperidol 2 - 10 mg IV/IM)
BP medication for in Conjuction with Atypical Antipsychotic (Ziprasidone 20 mg IM or
hypertensive encephalopathy) Other Treatments Olazapine 2.5 - 10 mg IM) **consider oral doses if possible
Figure 1. Algorithm for the treatment of acute agitation in the ED.

offering oral medication, and displaying a show of force. Within the past several years, however, the Food and
If such measures are ineffective or not possible to im- Drug Administration (FDA) has issued a black box
plement, the second tier of approach involves the use of warning regarding prolongation of QTc intervals, cardiac
emergency medication with or without physical restraint dysrhythmia and death in patients treated with droperi-
(1). dol; and droperidol is no longer routinely recommended
The categories of emergency medication, typically for such patients.
given intramuscularly, for the immediate treatment of The selection of an intramuscular medication depends,
acute agitation or violent behavior include the benzodi- to some extent, on the cause of the agitation. Such causes
azepines, conventional high potency antipsychotics (of- generally fall into one (or more) of three major categories:
ten termed “typical”) and, more recently, atypical anti- a general medical condition, substance intoxication or with-
psychotics. The specific agents used most frequently by drawal, or a primary psychiatric disturbance (usually
intramuscular injection in the ED are a benzodiazepine, schizophrenia or mania) (2). The categories form major
lorazepam (Ativan®), a conventional high potency anti- branches of the decision tree shown in Figure 1.
psychotic, haloperidol (Haldol®), or one of the atypical The management of a patient with a general med-
antipsychotic medications such as: ziprasidone (Ge- ical condition involves a medical assessment including
odon®), and most recently olanzapine (Zyprexa®). Two vital signs, appropriate history, physical examination,
atypical antipsychotics available in an oral disintegrating and laboratory testing, as directed by the clinical as-
tablet are Risperidone (Risperdal®M-TAB™) and olan- sessment. This process is sometimes described as
zapine (Zyprexa® Zydis®). To use an oral tablet in any “medical clearance” (3). The specific treatment ap-
form there must be at least minimal cooperation by the proach may directly treat a medical condition (such as
patient. A conventional high potency antipsychotic, giving some form of glucose to the hypoglycemic
Droperidol (Inapsine®), was (and in some centers still is) patient or lowering blood pressure in the patient with
a popular agent used to calm behavior in such patients; it hypertensive encephalopathy). When nonspecific
was given in both intramuscular and intravenous doses. agents are used in such conditions, benzodiazepines,
Intramuscular Benzodiazepines and Antipsychotics 319

haloperidol, and more recently, ziprasidone or olanza- to some other benzodiazepines, it is rapidly absorbed
pine are the agents of choice. after intramuscular injection. A dose of 0.5 to 2 mg every
In the case of agitated violent behavior associated 1 to 6 h, administered intramuscularly, has a rapid onset
with acute withdrawal from alcohol, benzodiazepines or of action and a relatively short duration of action (half-
barbiturates are generally the preferred treatment. They life 10 to 20 h). In contrast to haloperidol, lorazepam is
may be used alone or in combination with primary psy- associated with no extrapyramidal side effects or other
chiatric medications, depending on the patient’s circum- neurological problems such as neuroleptic malignant
stance. A recent meta-analysis of nine prospective con- syndrome (8,9). Risks associated with its use are usually
trolled trials discussing the treatment of acute alcohol minimal for a single dose or short-term administration
withdrawal demonstrated that “sedative-hypnotic agents (10).
are more effective then neuroleptic agents in reducing Intramuscular midazolam (Versed®) also has been
duration of delirium and mortality” (4). Statistically sig- shown to reduce agitation. It is rapidly absorbed when
nificant differences between various benzodiazepines administered intramuscularly. In a study evaluating the
and barbiturates were not found. In all cases reviewed, effectiveness of midazolam in treating agitation, 5 mg of
no cases of death were reported with the use of either intramuscular midazolam was superior to 10 mg of hal-
benzodiazepines or barbiturates. operidol (11). In a study comparing the use of intramus-
For all agents oral administration is preferred to an cular midazolam, haloperidol, and lorazepam in restrain-
intramuscular injection if the patient accepts it. Currier ing violent and severely agitated patients, midazolam
and Simpson found that oral treatment with risperidone was found to more quickly control patients than loraz-
and lorazepam were as well tolerated and effective as epam or haloperidol (12). Although acute onset of action
intramuscular haloperidol and lorazepam for short-term is ideal, one potential drawback with midazolam may be
treatment of acute agitation (5). Patients may improve its relatively short half-life. In healthy individuals, the
quickly after the administration of an oral dose of med- elimination half-life is approximately 1.5–2.5 h. To ad-
ication, and this, in part, results from the patient’s feeling equately control the acutely agitated patient, a medica-
that their needs have been addressed (6). The acutely tion with a longer duration of action may be preferred to
agitated patient is often unwilling or unable to take any reduce the need for frequent re-dosing.
oral medication, making intramuscular administration a Benzodiazepines have been associated with excessive
necessary and essential alternative. sedation and, less frequently, paradoxical disinhibition,
The goal of treatment for the emergency physician is which can pose a significant problem in the treatment of
to rapidly control agitated behavior and cause the fewest some agitated patients (10). Furthermore, excessive som-
side effects possible. In addition, some consideration nolence can be negatively viewed by the patient, and
ought to be given as to which agent will be most easily possibly deter them from seeking medical attention in the
switched to an oral form (7). An ideal medication would future. The potential abuse, dependence, and tolerance of
be used in both the acute and long-term setting, it would these agents are some of the features that limit the
be well tolerated by the patient and therefore have a good usefulness of benzodiazepines to short-term use in the
compliance rate, and the change from parenteral to oral treatment of agitation.
form would be relatively easy.
The patient and the physician will benefit from a drug
that will calm the agitated patient without causing ex- CONVENTIONAL ANTIPSYCHOTICS
cessive sedation. This will allow the patient to rest while
still participating in the treatment process and will enable Intramuscular forms of a variety of neuroleptics are
the physician to obtain an appropriate history, initiate a currently in use. Haloperidol, a high potency conven-
work-up to identify etiologies of the patient’s agitation, tional antipsychotic, is most often used in the Emergency
and begin treatment. Excessive somnolence frequently Department. Haloperidol causes less hypotension, fewer
hinders this evaluation process (8). anticholinergic side effects, and less decrease in seizure
than lower potency “conventional” antipsychotic agents
such as chlorpromazine (6). Patients receiving haloperi-
BENZODIAZEPINES dol, however, can experience acute dystonias (13). A
sigmoidal dose-effect curve has been described between
Lorazepam (Ativan®) is the most frequently used ben- 2.5 mg to 15 mg for intramuscular haloperidol given
zodiazepine for treatment of acute agitation. A 2-mg within the first 4 h of treatment. Doses exceeding 15 mg
dose of intramuscular lorazepam has been found to be as are not associated with any additional benefit and actu-
effective in treating agitation and aggressive behavior as ally yield lesser degrees of improvement. Higher doses
a 5-mg intramuscular dose of haloperidol (9). In contrast also lead to an increased risk of adverse effects (14).
320 D. A. Rund et al.

Over time, however, many emergency physicians have threatening cardiac events” (23). A more definitive study
adopted a dosing technique called “rapid tranquilliza- is probably warranted before a final judgment regarding
tion” that utilizes an initial dose of 5 mg of intramuscular droperidol’s safety can be established.
haloperidol, patient reassessment in 30 min for resolution
of agitation, and an additional 5 mg dose at that time if
needed. This technique frequently overestimates the dos- COMBINATION THERAPY: CONVENTIONAL
ing requirements necessary for the control of agitated ANTIPSYCHOTICS AND BENZODIAZEPINES
behavior. An alternative technique begins with a 2-mg
intramuscular dose. The dose is doubled for the second A commonly used regimen for treatment of acute
injection in 30 – 45 min if necessary (15). The cumulative agitation is 5 mg of intramuscular haloperidol and 2
dose needed to resolve the target symptoms suggests the mg of intramuscular lorazepam given simultaneously.
oral dose that may be needed when the patient is treated This combination can be mixed together in the same
with oral medication. syringe if used immediately (1). The combination ap-
Numerous studies have implicated parenteral use of proach was initially proposed to minimize the likeli-
antipsychotics and QTc prolongation. The degree of QTc hood of producing extrapyramidal effects and mini-
prolongation caused by specific antipsychotics is con- mizing the need for additional doses of haloperidol.
stantly in debate. A recent article showed an increase in The combination approach does control the patient but
“QTc prolongation ranging from 4 – 6 ms for haloperi- increases the risk of side effects of two agents com-
dol” (16). The study notes that the amount of prolonga- pared with one. The added sedation caused by this
tion is dependent on the individual and therefore it may combination may delay additional assessment by in-
be more appropriate to measure the patient’s mean terview and mental status evaluation.
change from baseline QTc. Although it has yet to be
determined what degree of increase is clinically danger-
ous, most feel that patients with a QTc ⬍440 ms are at NEWER ATYPICAL ANTIPSYCHOTIC
low risk of dysrhythmia. AGENTS
Droperidol is a butyrophenone neuroleptic closely
related to haloperidol. Intramuscular droperidol had the Atypical antipsychotics have replaced conventional an-
reputation of being a more rapid and reliable agent for tipsychotics in the long-term treatment of chronic disor-
the control of acute agitation compared with haloperidol ders such as schizophrenia. They are also playing an
(17). It has a rapid onset of action and produces greater increasingly important role in the control of symptoms of
sedation than haloperidol. The shorter serum half-life of the acutely psychotic patient. Their unique pharmacol-
droperidol, 2.2 h, after intramuscular injection is thought ogy has a broader spectrum of response with a lower
to be an advantage in many patients over haloperidol, side-effect burden. This improved side-effect profile is
which has a half life of 10 to 19 h (18). Patients treated better accepted by patients acutely leading to enhanced
with droperidol have significantly lower sedation scores levels of satisfaction and compliance with regard to
than those treated with lorazepam within the first hour long-term treatment. Therefore, the preliminary studies
(19). Originally thought to have few undesirable side show that there is a greater probability that the patient
effects compared with haloperidol and lorazepam, will continue to take such agents if long-term therapy is
droperidol was once considered a popular choice for needed (24). Olfson et al. found that patients treated with
control of agitation and sedation in the ED. Droperidol newer atypical antipsychotics tended to be less likely to
has been associated with dose-dependent prolongation of become medically noncompliant than those treated with
the QTc, however, which has led to a black box warning conventional antipsychotic agents (25).
in the United States and withdrawal from use in the Currently, ziprasidone (Geodon®) and olanzapine
United Kingdom (20 –22). Recent literature has critically (Zyprexa®) are available in intramuscular forms, making
questioned the validity of the black box warning. A them reasonable choices for treatment of acute agitation
review article by Kao et al. contends, “The recent black in the ED. Both olanzapine (Zyprexa® Zydis®) and
box warning appears to have originated from post- risperidone (Risperdal®M-TAB™) are available in dis-
marketing surveillance data rather then data reported solvable oral tablets. The time to peak concentration
in the peer-reviewed medical literature . . . although between these two formulations is significantly shorter
droperidol has been associated with prolonged QT inter- for risperidone compared with olanzapine and should be
vals, clinically significant adverse cardiovascular events the preferred treatment when rapid control of agitation is
appear to be rare” (23). The review maintains, “The required and an oral form is to be given. Dissolvable
evidence is not convincing for a causal relationship be- forms do not have a faster onset of action compared with
tween therapeutic droperidol administration and life- any other orally dosed medication.
Intramuscular Benzodiazepines and Antipsychotics 321

In terms of affinity for neuroreceptors, ziprasidone Table 1. Factors Associated with Increased Risk of QT
Prolongation and Torsades de Pointes
has the highest serotonin-2A/dopamine-2 ratio, which
gives it a unique characteristic compared with conven- Pre-existing prolonged QTc
tional typical agents, which probably contributes to the Female sex
Eating/drinking
lower incidence of extrapyramidal symptoms and en- Athletic training
hanced therapeutic efficacy (26 –28). Ziprasidone has a Obesity
high affinity for several other serotonin receptor subtypes Sleeping
Hypothyroidism
including 5-HT2C, 5-HT1A, and 5-HT1D, which may Alcoholism
also contribute to its effects (29). Hypoglycemia
Blockage of the postsynaptic dopamine receptors in Advanced age
Bradycardia
the nigrostriatal pathway produces movement disorders, Hypokalemia/hypomagnesemia
such as dystonia. The potent 5HT2A antagonistic effects, Genetic polymorphisms of gene coding cardiac ion channels
as well as other receptor effects, decrease the potential or enzymes in liver metabolizing drugs
Congestive heart failure
for extrapyramidal symptoms, including dystonia and Cardiac dysrhythmias
akathisia, which can appear acutely more commonly Combination of drugs (ion channel blockers, cytochrome P450
with conventional antipsychotics. enzyme inhibitors)
The benefits of intramuscular ziprasidone in signifi-
cantly reducing acute agitation associated with psychosis
have been shown in a double-blind, randomized trial
atypical antipsychotics has failed to show a greater risk
(30). The results of the trial showed that ziprasidone in
with ziprasidone compared with other agents (35). The
the 20-mg dose did not cause extrapyramidal symptoms,
effects of all antipsychotics on QTc prolongation is mul-
akathisia, respiratory depression, tachycardia, or exces-
tifactorial. Propensity for a change in the QTc with the
sive sedation. Moderate somnolence was the most fre-
use of antipsychotics is increased when they are used in
quent adverse event reported. The effect was noted
conjunction with other medications that cause QTc pro-
within 15 min after the first dose and lasted 4 h. There
longation or if a patient has pre-existing metabolic dis-
was no evidence of any clinically relevant change in the
turbances (16). A possible genetic link for predisposition
electrocardiogram (ECG). The manufacturers of ziprasi-
done (Pfizer) report a clinical trial on patient volunteers: may also play a role in development and extent of QTc
ECGs were obtained at the time of maximum plasma prolongation. Table 1 lists factors associated with in-
concentration after two injections of ziprasidone (20 mg creased risk of QTc prolongation and development of
then 30 mg) or haloperidol (7.5 mg then 10 mg). The torsades de pointes (16,36). A clinician may choose to
QTc for the ziprasidone group produced a 4.6-ms pro- withhold antipsychotics if the patient is known to have
longation after a 20-mg dose and a 12.8-ms prolongation any of these pre-existing factors. Obviously, in the ED,
with the 30-mg dose. This QTc increase was less than not all of this information is always readily available.
that seen in the haloperidol group: a 7.5-mg dose of In comparison with intramuscular haloperidol in a
haloperidol produced a QTc prolongation of 6.0 ms; a population of admitted psychiatric patients, intramuscu-
10-mg dose produced 14.7-ms prolongation. No patient lar ziprasidone has been found to be significantly more
in this study had a QTc interval exceeding 500 ms (31). effective in reducing symptoms of acute agitation (37).
Ziprasidone has not been associated with torsade de Intramuscular ziprasidone does cause some adverse ef-
pointes, sudden death, or increased cardiac mortality, and fects such as headache, dizziness, nausea, somnolence,
only rarely produces QTc intervals above 500 ms and pain at the injection site (30). Dose-related somno-
(32,33). It is important to be aware of the associated lence has been the most frequently reported treatment-
effects on the QTc and caution should be used in imple- emergent adverse event.
menting treatment to those patients with cardiac disease Ziprasidone seems to cause less weight gain with
with this and other antipsychotic agents until safety in long-term use then other atypical antipsychotics. Many
this patient population has been better established. Some studies term ziprasidone’s effects to be “weight neutral,”
recommendations include withholding antipsychotic although some patients may experience weight gain (38).
medication if the QTc is above 500 ms or discontinuing To date there are no identified patient characteristics that
the medication if the QTc increases by ⬎25% after would suggest a patient will have weight gain with
administration. In a case study of overdose with ziprasi- chronic therapy (38). Ziprasidone has been associated
done, 2400 mg produced a QTc of 445 ms (34). Similar with few reports of new-onset diabetes. It is the FDA’s
findings were reported in other cases. Thus far, no fatal- position that the side effect of new-onset diabetes is a
ities have been associated with ziprasidone overdose class effect for all of the atypical antipsychotics, al-
(35). A review on the subject of fatalities with these though some of the medications may be associated with
322 D. A. Rund et al.

higher rates of causation (39). The considerations of Due to olanzapine’s fairly recent FDA approval for the
weight gain and glucose regulation are issues that have treatment of acute agitation by means of intramuscular
little effect on the use of the medication in the acute administration, additional studies of olanzapine used in
setting, as in the ED, but large effects on choices for more severely ill patients and patients with concomitant
continuation therapy. medical illnesses are needed to determine the most ef-
The standard initial dose of ziprasidone is 10 or 20 mg fective dosing regimen, need for use of adjunctive med-
(consider the lower dose in elderly patients), and begins ications, and to obtain a comprehensive safety profile
to have an effect in 15–20 min. The time to prepare the (52).
injection may increase this time with an additional 2 min
required to place the drug into solution (40). The recom-
mended interval from the first to second injection of CONCLUSION
ziprasidone is 4 h. A second injection of ziprasidone has
been only infrequently needed in clinical evaluations. Agitation is a common and often frustrating complaint in
Another atypical antipsychotic agent, olanzapine the Emergency Department. There have been great im-
(Zyprexa®), has recently been approved for intramuscu- provements in the pharmacological treatment of the
lar use. Olanzapine has a combined serotonin and dopa- acutely agitated or psychotic patient in the past few
mine antagonist action with a greater affinity for seroto- years. Historically, older neuroleptics such as chlorprom-
nin receptors (41). The antihistaminergic potency of azine and barbiturates were commonly used. Droperidol
olanzapine is over 160 times that of diphenhydramine was a popular choice until the FDA black box warning.
(42). This may explain the associated adverse effect of The classical treatment of patients with haloperidol or
sedation and weight gain. As with other atypical antipsy- haloperidol plus lorazepam has been used effectively for
chotics, olanzapine has been associated with an increased many years. The adverse effects range from excessive
risk of new-onset diabetes or serum glucose dyscontrol sedation to extrapyramidal symptoms to potential devel-
(39). A recent review published by the FDA documented opment of neuroleptic malignant syndrome. The risks
237 reports of olanzapine-induced diabetes or hypergly- and benefits of these medications are well known due to
cemia, most of which appeared within 6 months of their vast use over a long period of time.
starting the therapy (43). These reports, along with that Newer, atypical antipsychotics are recognized as a
of weight gain over time, may be a consideration for the breakthrough for the treatment of psychosis and acute
treatment of the acute agitated patient in the ED if agitation. Intramuscular ziprasidone is used in such sit-
eventual transition to the same oral medication is uations due to its rapid onset and low incidence of side
anticipated (44). effects. The QTc prolongation has been excessively stud-
Intramuscular olanzapine has been found to be more ied and has not been linked to any life-threatening con-
effective than either haloperidol or placebo for managing ditions. Intramuscular olanzapine is also a reasonable
acute agitation in schizophrenic patients at the earliest choice for therapy. Olanzapine has been shown to be
time point measured in a double-blind study (45). Olan- effective in controlling agitation in the clinical setting.
zapine has been well tolerated in studies. No patients As more prospective studies are performed comparing
treated with olanzapine experienced the acute dystonia olanzapine with other atypical and conventional treat-
that occurred in 7% of the haloperidol treated patients ments, a more comprehensive efficacy and safety profile
(46). Olanzapine was found to have similar efficacy to can be established.
lorazepam in treatment of dementia and bipolar mania Atypical antipsychotics are generally well tolerated
(47,48). One potential drawback with the use of intra- by patients. The decreased amount of sedation caused
muscular olanzapine for acute agitation in the ED is the by atypical medications compared with conventional
possibility of the medication causing postural hypoten- medications allows the patient’s agitation to be con-
sion. In a recent study, olanzapine showed an approxi- trolled and yet still allows the patient to be able to
mate 12% increase in postural hypotension compared participate in his or her care. This leads to shorter ED
with an approximate 3% increase with haloperidol (49). stays and increased patient satisfaction. Unfortunately,
A study by Breier et al. has shown olanzapine to be a subject not always considered is management of the
effective in reducing agitation by a dose-dependent rela- patient after leaving the ED, both over the next few
tionship. The study concluded that 10 mg of i.m. olan- days and in the long-term setting. Long-term compli-
zapine was more effective then 2.5 mg. When smaller ance with atypical antipsychotics is dramatically im-
doses were given initially, the need for re-dosing was proved over conventional treatments secondary to
frequent (50). The use of olanzapine in conjunction with their improved side-effect profile. Finding a medica-
benzodiazepines has been shown to cause a hypoventi- tion that is efficacious and well tolerated for use in
latory syndrome and therefore is not recommended (51). both the acute and long-term settings would be ideal.
Intramuscular Benzodiazepines and Antipsychotics 323

Atypical antipsychotic medications offer new hope and safety of droperidol in a high-risk, inner-city emergency
department population. Acad Emerg Med 2003;10:908; author
that this type of medication is possible. A more com- reply 908 –9.
prehensive risk/benefit analysis will be possible as 21. Chase PB, Biros MH. A retrospective review of the use and safety
more research is performed and clinicians learn which of droperidol in a large, high-risk, inner-city emergency depart-
medications are the best in particular settings. ment patient population. Acad Emerg Med 2002;9:1402–10.
22. Horowitz BZ, Bizovi K, Moreno R. Droperidol— behind the black
box warning. Acad Emerg Med 2002;9:615.
23. Kao LW, Kirk MA, Evers SJ, Rosenfeld SH. Droperidol, QT
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25. Olfson M, Mechanic D, Hansell S, et al. Predicting medication
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