POV you’re on south and a patient in chairs wakes up and starts running around the doc box yelling and throwing their apple sauce everywhere. Security and psychiatry are no where to be found and you already attempted to verbally deescalate.
ED sedation is goal-directed, not one-size-fits-all. Medication choice should be based on the clinical goal (calm vs dissociate vs procedural), patient physiology, and airway risk. Rapid control of severe agitation is critical for the safety of the patient, staff, and surrounding patients.
Ketamine
Indications: Severe agitation, excited delirium, trauma, need to preserve airway reflexes
• IV: 0.5–1 mg/kg (procedural: 1–2 mg/kg)
• IM: 3–5 mg/kg
• Onset: IV 1–2 min | IM 3–5 min
Pearls: Dissociation + analgesia
Watch for: Hypersalivation, vomiting, emergence reactions
Tip: Position upright when feasible to reduce aspiration risk
Midazolam
Indications: Anxiolysis, mild–moderate agitation, alcohol withdrawal
• IV: 1–2 mg q2–5 min (usual max 5 mg)
• IM: 5 mg
• IN: 0.2 mg/kg (max 10 mg)
• Onset: IV 2–3 min | IM 10–15 min | IN 5–10 min
Watch for: Respiratory depression especially with opioids or alcohol, avoid in elderly patients
Haloperidol
Indications: Psychosis-related agitation
• IV/IM: 2.5–5 mg (may repeat; typical max 10 mg)
• Onset: IV 5–10 min | IM 20–30 min
Pearls: Minimal respiratory depression
Watch for: QT prolongation, dystonia
Droperidol
Indications: Acute agitation
• IV/IM: 2.5–5 mg
• Onset: IV 5 min | IM 5–10 min
Pearls: Rapid, reliable calming
Watch for: QT prolongation (risk low at ED doses)
Olanzapine
Indications: Agitation related to psychosis, bipolar disorder, delirium
• IM: 5–10 mg (max 20 mg/day)
• PO/ODT: 5–10 mg
• Onset: IM 15–30 min | PO/ODT 30–60 min
Pearls: Effective calming with low EPS risk
Dexmedetomidine
Indications: Cooperative sedation, ICU-bound agitation
• IV infusion: 0.2–0.7 mcg/kg/hr
• Onset: 10–20 min
Pearls: Preserves respiratory drive
Watch for: Bradycardia, hypotension
Propofol
Indications: Procedural sedation (full monitoring and airway readiness required)
• IV: 0.5–1 mg/kg bolus, then 10–20 mg PRN
• Onset: 30–60 seconds
Pearls: Rapid on/off
Watch for: Hypotension, apnea
The classic haloperidol 5 mg + lorazepam 2 mg works- however, evidence suggests faster alternatives exist with similar or better safety profile including:
Droperidol 5 mg + midazolam 5 mg IM, or
Ketamine when safety concerns are immediate
https://pubmed.ncbi.nlm.nih.gov/34353650/
https://www.ncbi.nlm.nih.gov/books/NBK551685/