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Original Research

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Prehospital drugs for sedation in psychomotor agitation, friends or foes? An observational retrospective study

  • Serena Tomasino1
  • Giulio Trillo'2
  • Annarita Tullio3
  • Elena Querena4
  • Emiliano Fattori1,5
  • Chiara Molinari1,5
  • Francesco Meroi1,5,*,
  • Tiziana Bove1,5

1Department of Anesthesia and Intensive Care Medicine, ASUFC University-Hospital of Central Friuli, 33100 Udine, Italy

2E.M.S.-SUEM-118, AULSS 1 Dolomiti, Pieve di Cadore Hospital, 32044 Pieve di Cadore, Italy

3Epidemiology and Public Health Unit, ASUFC University-Hospital of Central Friuli, 33100 Udine, Italy

4Department of Anesthesia and Intensive Care Medicine, A.O.U.I. University Hospital of Verona, 37126 Verona, Italy

5Department of Medicine (DAME), University of Udine, 33100 Udine, Italy

DOI: 10.22514/sv.2023.110 Vol.19,Issue 6,November 2023 pp.160-167

Submitted: 14 March 2023 Accepted: 26 April 2023

Published: 08 November 2023

*Corresponding Author(s): Francesco Meroi E-mail:


Altered mental status (AMS) describes an undifferentiated presentation of disorders of mentation. It represents a common problem for prehospital and hospital providers and may be found in 5% to 10% of patients admitted to the Emergency Department (ED). Psychomotor Agitation (PMA), a state of motor restlessness and mental tension associated with a variety of psychiatric conditions, is one of the most frequent manifestations of AMS. In this observational retrospective study we included all the patients who presented PMA, treated by the out-of-hospital Emergency Medical System (EMS), and transported to the ED of the University Hospital of Udine, Italy. The objectives were to determine the incidence of patients with PMA treated by EMS in the area of investigation, the evaluation of pharmacologically treated patients considering the most commonly administered drugs, the intubation rate, the fraction of inspired oxygen (FiO2) needs, the length of hospital stay (LOHS), the adverse drug reactions (ADRs), and the excited delirium syndrome (ExDS). From January 2017 to December 2018, 319 patients were enrolled. The prevalence of PMA was 2.5% and 0.5% were the cases of PMA managed by the EMS. The predominant drugs used for sedation were midazolam (19.75%) and ketamine (9.09%), alone or in association; patients with consistent PMA required more than one sedative. Statistically significant differences were found in FiO2 supplementation for ketamine-sedated psychiatric patients and midazolam-sedated psychiatric patients with chronic home therapy, in the LOHS >24 hours (h), with a longer stay in case of midazolam and ketamine use, and in LOHS and FiO2 supplementation due to polypharmacy administration with more than one sedative drug. PMA is a frequent and widespread phenomenon and in the prehospital setting requires rapid assessment and management. Therapeutical strategies with benzodiazepines, ketamine, and rarely associations of drugs are safe, do not increase hypoxia and intubation rate.


Psychomotor agitation; Ketamine; Midazolam; Emergency medical system; Prehospital care

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Serena Tomasino,Giulio Trillo',Annarita Tullio,Elena Querena,Emiliano Fattori,Chiara Molinari,Francesco Meroi,Tiziana Bove. Prehospital drugs for sedation in psychomotor agitation, friends or foes? An observational retrospective study. Signa Vitae. 2023. 19(6);160-167.


[1] Gottlieb M, Long B, Koyfman A. Approach to the agitated emergency department patient. The Journal of Emergency Medicine. 2018; 54: 447–457.

[2] Kanich W, Brady WJ, Huff JS, Perron AD, Holstege C, Lindbeck G, et al. Altered mental status: evaluation and etiology in the ED. The American Journal of Emergency Medicine. 2002; 20: 613–617.

[3] Battaglia J. Pharmacological management of acute agitation. Drugs. 2005; 65: 1207–1222.

[4] Miner JR, Klein LR, Cole JB, Driver BE, Moore JC, Ho JD. The characteristics and prevalence of agitation in an urban county emergency department. Annals of Emergency Medicine. 2018; 72: 361–370.

[5] Garriga M, Pacchiarotti I, Kasper S, Zeller SL, Allen MH, Vázquez G, et al. Assessment and management of agitation in psychiatry: expert consensus. The World Journal of Biological Psychiatry. 2016; 17: 86–128.

[6] Vieta E, Garriga M, Cardete L, Bernardo M, Lombraña M, Blanch J, et al. Protocol for the management of psychiatric patients with psychomotor agitation. BMC Psychiatry. 2017; 17: 328.

[7] Vilke GM, DeBard ML, Chan TC, Ho JD, Dawes DM, Hall C, et al. Excited delirium syndrome (ExDS): defining based on a review of the literature. The Journal of Emergency Medicine. 2012; 43: 897–905.

[8] Robinson BRH, Berube M, Barr J, Riker R, Gélinas C. Psychometric analysis of subjective sedation scales in critically ill adults. Critical Care Medicine. 2013; 41: S16–S29.

[9] Gaynes BN, Brown CL, Lux LJ, Brownley KA, Van Dorn RA, Edlund MJ, et al. Preventing and de-escalating aggressive behavior among adult psychiatric patients: a systematic review of the evidence. Psychiatric Services. 2017; 68: 819–831.

[10] Richmond J, Berlin J, Fishkind A, Holloman G, Zeller S, Wilson M, et al. Verbal de-escalation of the agitated patient: consensus statement of the American association for emergency psychiatry project BETA de-escalation workgroup. The Western Journal of Emergency Medicine. 2012; 13: 17–25.

[11] New A, Tucci VT, Rios J. A modern-day fight club? The stabilization and management of acutely agitated patients in the emergency department. The Psychiatric Clinics of North America. 2017; 40: 397–410.

[12] Nobay F, Simon BC, Levitt MA, Dresden GM. A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Academic Emergency Medicine. 2004; 11: 744–749.

[13] Olkkola KT, Ahonen J. Midazolam and other benzodiazepines. Handbook of Experimental Pharmacology. 2008; 182: 335–60.

[14] Wolff K, Winstock AR. Ketamine: from medicine to misuse. CNS Drugs. 2006; 20: 199–218.

[15] Linder LM, Ross CA, Weant KA. Ketamine for the acute management of excited delirium and agitation in the prehospital setting. Pharmacotherapy. 2018; 38: 139–151.

[16] Sheikh S, Hendry P. The expanding role of ketamine in the emergency department. Drugs. 2018; 78: 727–735.

[17] Mankowitz SL, Regenberg P, Kaldan J, Cole JB. Ketamine for rapid sedation of agitated patients in the prehospital and emergency department settings: a systematic review and proportional meta-analysis. The Journal of Emergency Medicine. 2018; 55: 670–681.

[18] Burnett AM, Peterson BK, Stellpflug SJ, Engebretsen KM, Glasrud KJ, Marks J, et al. The association between ketamine given for prehospital chemical restraint with intubation and hospital admission. The American Journal of Emergency Medicine. 2015; 33: 76–79.

[19] Hayes BD. Ketamine for agitation: a key cog in the prehospital treatment armamentarium wheelhouse. Clinical Toxicology. 2016; 54: 545–546.

[20] Burnett AM, Salzman JG, Griffith KR, Kroeger B, Frascone RJ. The emergency department experience with prehospital ketamine: a case series of 13 patients. Prehospital Emergency Care. 2012; 16: 553–559.

[21] Cole JB, Klein LR, Nystrom PC, Moore JC, Driver BE, Fryza BJ, et al. A prospective study of ketamine as primary therapy for prehospital profound agitation. The American Journal of Emergency Medicine. 2018; 36: 789–796.

[22] Peiró S, Gómez G, Navarro M, Guadarrama I, Rejas J. Length of stay and antipsychotic treatment costs of patients with acute psychosis admitted to hospital in Spain. Social Psychiatry and Psychiatric Epidemiology. 2004; 39: 507–513.

[23] Cots F, Chiarello P, Pérez V, Gracia A, Becerra V. Hospital costs associated with agitation in the acute care setting. Psychiatric Services. 2016; 67: 124–127.

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