Rapid tranquillisation of violent or agitated patients in a psychiatric emergency setting. Pragmatic randomised trial of intramuscular lorazepam v. haloperidol plus promethazine.
BACKGROUND
The pharmacological management of violence in people with psychiatric disorders is under-researched.


OBJECTIVE
To compare interventions commonly used for controlling agitation or violence in people with serious psychiatric disorders.


METHODS
We randomised 200 people to receive intramuscular lorazepam (4 mg) or intramuscular haloperidol (10 mg) plus promethazine (25-50 mg mix).


RESULTS
At blinded assessments 4 h later (99.5% follow-up), equal numbers in both groups (96%) were tranquil or asleep. However, 76% given the haloperidol-promethazine mix were asleep compared with 45% of those allocated lorazepam (RR=2.29,95% CI 1.59-3.39; NNT=3.2,95% CI 2.3-5.4). The haloperidol-promethazine mix produced a faster onset of tranquillisation/sedation and more clinical improvement over the first 2 h. Neither intervention differed significantly in the need for additional intervention or physical restraints, numbers absconding, or adverse effects.


CONCLUSIONS
Both interventions are effective for controlling violent/agitated behaviour. If speed of sedation is required, the haloperidol-promethazine combination has advantages over lorazepam.
Alexander
Jacob
J
Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India. dralexander_in@yahoo.com
Tharyan
Prathap
P
Adams
Clive
C
John
Thomas
T
Mol
Carina
C
Philip
Joncy
J
D014150:Antipsychotic Agents / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D004630:Emergencies; D004636:Emergency Service, Hospital; D005260:Female; D006220:Haloperidol / Q000627:therapeutic use; D006634:Histamine H1 Antagonists / Q000627:therapeutic use; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use*; D008140:Lorazepam / Q000627:therapeutic use; D008297:Male; D001523:Mental Disorders / Q000188:drug therapy* / Q000523:psychology; D011398:Promethazine / Q000627:therapeutic use; D011595:Psychomotor Agitation / Q000188:drug therapy*; D013997:Time Factors; D014754:Violence
D014150:Antipsychotic Agents; D006634:Histamine H1 Antagonists; D006993:Hypnotics and Sedatives; D011398:Promethazine; D006220:Haloperidol; D008140:Lorazepam