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Open Access Highly Accessed Research article

The impact of a standardised intramuscular sedation protocol for acute behavioural disturbance in the emergency department

Leonie A Calver12*, Michael A Downes123, Colin B Page24, Jenni L Bryant15 and Geoffrey K Isbister12

Author Affiliations

1 Discipline of Clinical Pharmacology, University of Newcastle, New South Wales, Australia

2 Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, New South Wales, Australia

3 Emergency Department, Calvary Mater Newcastle, New South Wales, Australia

4 Emergency Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia

5 Department of Liaison Psychiatry, Calvary Mater Newcastle, New South Wales, Australia

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BMC Emergency Medicine 2010, 10:14  doi:10.1186/1471-227X-10-14

Published: 28 June 2010

Abstract

Background

Acute behavioural disturbance (ABD) is an increasing problem in emergency departments. This study aimed to determine the impact of a structured intramuscular (IM) sedation protocol on the duration of ABD in the emergency department.

Methods

A historical control study was undertaken comparing 58 patients who required physical restraint and parenteral sedation with the structured IM sedation protocol, to 73 historical controls treated predominantly by intravenous sedation, according to individual clinician preference. The primary outcome was the duration of the ABD defined as the time security staff were required. Secondary outcomes were the requirement for additional sedation, drug related-adverse effects and patient and staff injuries.

Results

The median duration of the ABD in patients with the new sedation protocol was 21 minutes (IQR: 15 to 35 minutes; Range: 5 to 78 minutes) compared to a median duration of 30 minutes (IQR: 15 to 50 minutes; Range: 5 to 135 minutes) in the historical controls which was significantly different (p = 0.03). With IM sedation only 27 of 58 patients (47%; 95% CI: 34% to 60%) required further sedation compared to 64 of 73 historical controls (88%; 95%CI: 77% to 94%). There were six (10%) drug-related adverse events with the new IM protocol [oxygen desaturation (5), oxygen desaturation/airway obstruction (1)] compared to 10 (14%) in the historical controls [oxygen desaturation (5), hypoventilation (4) and aspiration (1)]. Injuries to staff occurred with three patients using the new sedation protocol and in seven of the historical controls. Two patients were injured during the new protocol and two of the historical controls.

Conclusion

The use of a standardised IM sedation protocol was simple, more effective and as safe for management of ABD compared to predominantly intravenous sedation.