Guidelines

Low-potency antipsychotics (Iablei28.2-1) such as chlorpromazine (Thorazine) and thioridazine (Mellaril) may cause significant hypotension and thus are rarely used in emergency medicine. High-potency antipsychotics such as haloperidol (Haldol) and fluphenazine (Prolixin) have relatively few anticholinergic and alpha-blocking effects and are remarkably safe, even at high doses. They are the emergency antipsychotic agents of choice.

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TABLE 282-1 Commonly Used Antipsychotic Agents

Optimal pharmacologic management of acute agitation or psychosis is to use a high-potency neuroleptic such as haloperidol intravenously. Oral or intramuscular dosing is also acceptable if intravenous administration is not possible. In most patients, the initial drug is haloperidol. The initial dosage of 2 mg is doubled every 45 min until the symptoms are controlled, the patient is calmed, or the behavior is stabilized. The best approach is not to think of the dosages as cumulative but rather to find the one single dosage that effectively treats the symptoms. Once this is accomplished, use this particular effective dose on an "as needed" basis each time the patient's symptoms reappear. Some clinicians augment this strategy with a dose or two of a benzodiazepine (e.g., 1 or 2 mg lorazepam) to control the symptoms. This proves useful in certain circumstances, such as with an agitated psychotic or manic patient, because there is a synergistic effect between the two medications. Additionally, the benzodiazepine may prevent potential extrapyramidal problems that occasionally occur with neuroleptic use. These are easily managed if they do occur, however, as discussed in the following section. One advantage to using haloperidol intravenously is an exceptionally low incidence of extrapyramidal side effects compared with the incidence seen with intramuscular or oral routes of administration. Dosages may need to be half those described or less if the patient is elderly, debilitated, brain-injured, or has AIDS.

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