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The British Journal of Psychiatry (2004) 185: 63-69
© 2004 The Royal College of Psychiatrists

Rapid tranquillisation of violent or agitated patients in a psychiatric emergency setting

Pragmatic randomised trial of intramuscular lorazepam v. haloperidol plus promethazine

Jacob Alexander, MD and Prathap Tharyan, MRCPsych

Department of Psychiatry, Christian Medical College, Vellore, India

Clive Adams, MRCPsych

Cochrane Schizophrenia Group and Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, UK

Thomas John, MD

Department of Psychiatry, Christian Medical College, Vellore, India

Carina Mol

Medical Documentation Programme, University of Ulm, Germany

Joncy Philip, MA

Department of Psychiatry, Christian Medical College, Vellore, India

Correspondence: Dr Jacob Alexander, Department of Psychiatry, Christian Medical College, Vellore 632002, Tamil Nadu, India. Tel: 91 416 2262603, ext. 4259; fax: 91 416 2261632; e-mail: dralexander_in{at}yahoo.com

Declaration of interest None.

Background The pharmacological management of violence in people with psychiatric disorders is under-researched.

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

Method 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.


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