In conclusion – haloperidol and lorazepam combination therapy for chemical restraint remains first line for use in medically undifferentiated emergency department patients. Ziprasidone 20 mg IM can be considered first line therapy for patients with no history of prolonged QT syndrome who exhibit agitation secondary to known psychiatric disorders such as bipolar mania or schizophrenia. Newer data has begun to validate its use as a first line therapy in the undifferentiated ED patient population. As with ziprasidone, olanzapine 10 mg IM should be considered first line therapy for those patients not subject to other CNS depressants, and who have a primary psychiatric diagnosis. Though newer studies showing safety and efficacy in the undifferentiated ED population have not yet progressed to prospective, randomized, double-blinded, placebo controlled trials, the benefits described above warrant further rigorous study. Care must be taken to safeguard the elderly patient or those with severe co-morbidities from over-sedation.

Benzodiazepines are second line drugs in these instances; if absolutely necessary, they should be started at half the normal dose. Droperidol has been shown to be superior to haloperidol with a similar side effect profile; however, its use in the ED remains elusive out of continued safety concerns and FDA recommendations for pre-treatment EKG’s, and post administration cardiac monitoring (impossible in the agitated patient). Haloperidol and lorazepam combination therapy remains the most studied drug regimen for the agitated undifferentiated emergency department patient; widespread routine use of atypical antipsychotics in this patient population pends further study and improved provider familiarity.

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