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Current practices in managing acutely disturbed patients at three hospitals in Rio de Janeiro-Brazil: a prevalence study
© Huf et al; licensee BioMed Central Ltd. 2002
Received: 25 October 2001
Accepted: 22 January 2002
Published: 22 January 2002
The medical management of aggressive and violent behaviour is a critical situation for which there is little evidence. In order to prepare for a randomised trial, due to start in the psychiatric emergency rooms of Rio de Janeiro in 2001, a survey of current practice was necessary.
A seven day survey of pharmacological management of aggressive people with psychosis in the emergency rooms of all four public psychiatric hospitals in Rio de Janeiro, Brazil.
In one hospital data were not available. Of the 764 people with psychosis attending these ERs, 74 were given IM medication for rapid tranquillisation (9.7%, 2.1/week/100,000). A haloperidol-promethazine mix (with or without other drugs) was used for the majority of patients (83%).
The haloperidol-promethazine mix, given intramuscularly for rapid tranquilization, is prevalent in Rio, where it is considered both safe and efficient. However, scientific evaluation of all pharmacological approaches to rapid tranquilization of psychotic people is inadequate or incomplete and a randomized trial of IM haloperidol-promethazine is overdue.
Agitated or violent patients constitute 10% of all emergency psychiatric treatment . The majority of these people have severe psychiatric problems such as schizophrenia, affective disorder or substance abuse. Less frequently, organic illness or serious psychological stresses underlie the aggression. The medical management of aggressive and violent behavior by people with schizophrenia or other serious mental illnesses is of continuing central concern to clinicians .
In order to gain an overview of the evidence underlying current practice, the authors first undertook a search of the Cochrane Library. The search strategies used for all databases mentioned are available from the authors. Relevant randomised clinical trials seem few, small and of debatable clinical utility . For example, we found only one randomised trial (n = 40) comparing haloperidol (IV) with placebo for acutely disturbed psychiatric patients . Only one statistically significant difference was found (RR unimproved by 2 hours 0.19 95% CI 0.04 to 0.9). A very small (n = 12) randomised trial compared benzodiazepines with placebo for acutely disturbed people , and, unsurprisingly, found no clear differences. Seven trials (total n = 206), compared benzodiazepines versus typical antipsychotics. Benzodiazepines are statistically significantly more likely to produce an 'improvement' by 1.5 hours (RR 1.6 95% CI 1.02 to 2.5), but patients may also be at greater risk of needing additional injections (RR 0.66 95% CI 0.42 to 1.02). On the other hand, more patients given haloperidol are asleep by three hours than those allocated to benzodiazepines (RR 1.6 95% CI 0.99 to 2.5). Ninety-six people were randomised to trials investigating the value of a benzodiazepine-haloperidol mix versus haloperidol alone for acutely disturbed people . The combination, largely with lorazepam, is no better than haloperidol for all the outcomes measured (eg. unimproved by 1.5 hours RR 0.7 95% CI 0.3 to 1.7), except for being asleep by 3 hours, favouring the mix (RR 2.0 95% CI 1.1 to 3.5). A systematic review of droperidol for acutely disturbed people, now withdrawn from use because of cardiac problems with prolonged use, shows it to be of unclear advantage when compared with placebo (1 RCT, n = 41, RR needing additional injection by 30 minutes 0.46 95% CI 0.2 to 1.2) or haloperidol (1RCT, n = 27, RR needing additional injection by 30 minutes 0.45 95% CI 0.2 to 1.01) . A systematic review of zuclopenthixol acetate (5 RCTs, total n = 413), found no statistically significant differences for outcomes such as 'not sedated by two hours' (RR 0.6 95% CI 0.3 to 1.3) and 'needing another injection' (RR 1.5 95% CI 0.8 to 2.9), when compared to haloperidol, chlorpromazine or clothiapine.
Pharmacological treatments and outcomes favoured by clinicians
Number of Doctors
USA 1999 
Haloperidol + lorazepam +/- benztropine
Benzodiazepine (unspecified) alone
Droperidol + lorazepam + diphenhydramine
Haloperidol + benztropine
Use of physical restraints
Usually not used
Route of administration
Preferred IM or IV
UK 1994 
Haloperidol + chlorpromazine
Haloperidol + diazepam
Haloperidol + lorazepam
Desired end point
Sedated but mobile
Not sedated but calm
Route of administration
Studies of clinical practice
Ratio of means of administration IV : IM
Drug of choice
Frequency of use
mean dose in mg (range)
Complications / comments
1 cardiorespitory arrest (60 mg haloperidol + 80 mg DZ)
1 tachycardia, 1 hypotension
1 respiratory distress
2 with acute dystonia
Mostly people with substance abuse (study in General Emergency Room)
In the UK, intravenous treatments were common, and the doses employed, high. In France, where aggression due to intoxication was common, loxapine IM was largely used. Other less informative surveys were identified.
About one percent of people suffer from schizophrenia. Over 80% of those people live in low to middle income countries. In global terms, therefore, by far the greatest burden of care of people with schizophrenia falls to those in low and middle-income countries. People whose illness precipitates aggressive or violent behavior are unlikely to be very rare in these societies, so it is reasonable to assume that most psychosis-related aggression is being managed in the developing world. Recognizing this, and that the evidence-base of management is weak, the authors undertook a survey of practice as a preliminary phase of a large, pragmatic randomised trial. This paper reports a survey of drug management of severely disturbed behavior, undertaken in one week in March 2000 in the Psychiatric Emergency Units of Rio de Janeiro, Brazil.
The county of Rio de Janeiro has about 5.8 m habitants and four public hospitals are responsible for the care of about 70% of the population (Hospital Phillippe Pinel, Centro Psiquiátrico Rio de Janeiro, Centro Psiquiátrico Pedro II, Hospital Jurandir Manfredini).
Materials and Methods
The period of the survey covered emergency consultations from Saturday 25th March 2000 to Friday 31st March 2000, inclusive.
Data collection is difficult because information is recorded differently in each institution and electronic data are not available. The principle researcher repeatedly visited the emergency rooms and short stay wards of the hospitals and collected data on everyone who had presented for an emergency consultation during the prevalence period. Emergency room notes were also inspected and medical records sought for additional information on use of emergency intramuscular sedation. The main focus of this work the management of disturbed people who were likely to suffer from a psychotic illness. Therefore, whenever a primary diagnosis of substance abuse had been made, data were not recorded.
Numbers attending for emergency care between 25th – 31st March at three hospitals in Rio de Janeiro
Sat 25 th
Sun 26 th
Mon 27 th
Tue 28 th
Wen 29 th
Thu 30 th
Fri 31 th
Drugs of choice for intramuscular sedation, doses and frequency of use in the three hospitals.
Drug of choice
Frequency of use
mean dose in mg (range)
Haloperidol + promethazine
5 (2.5–10) + 50 (25–100)
Haloperidol + promethazine + diazepam
5 (2.5–10) + 50 (25–100) + 10
Haloperidol + promethazine + chlorpromazine
5 + 50 + 25
Chlorpromazine + diazepam + promethazine
25 + 10 + 50
Chlorpromazine + promethanzine
25 + 50
diazepam + promethazine
10 + 50
Haloperidol + diazepam
5 + 10
Surveys of the emergency sedation of acutely disturbed people with serious mental illness are rare. They are difficult to undertake involve piecing together particularly fragmented records and combining these data with the recent memories of the relevant health professionals. In a Developing World environment this process may be even more problematic with vastly under-resourced services and fully paper-based record keeping of varying standards.
For a population of about 3.5 m covered by the three hospitals, we estimate that at least 74 people per week are sedated for disturbed behavior thought to be the result of serious mental illness. Eventually, a proportion of this group may not have been diagnosed as having had psychotic illness. The authors suspect, that however, because the emergency rooms are only used for psychiatric crises, and as the authors tried to screen out those suspected of abusing substances, the proportion not suffering from a psychotic illness would be very small.
According to these figures, acute sedation for this group in Rio de Janeiro seems to be less prevalent than in central London (Brazil 2.1/week/100,000 vs London 3.3/week/100,000). There may be many reasons for this discrepancy and the authors would not wish to read too much into these findings.
Emergency treatment, however, does seem more consistent in Rio de Janeiro than in London. Eighty three percent of patients receiving any drug for sedation in the emergency room of these hospitals were given promethazine in addition to haloperidol. Brazilian clinicians consider this approach both safe and efficient. The rational for this combination lies in the will to swiftly instigate antipsychotic drugs, and in the sedative and antimuscarinic properties of promethazine. Doses of promethazine are usually between 25–50 mg but, as adjunctive sedative for emergency use, could reach 100 mg IM. The onset of action is about 1–2 hours after intramuscular administration and half-life is 5–14 hours. The main adverse reactions of promethazine are gastrointestinal disturbances, dry mouth and blurred vision. Paradoxical reactions such as CNS stimulation and extrapyramidal symptoms have been reported, but are exceedingly rare.
Despite the high prevalence of use in Brazil, and we have now been alerted to wide use in the Indian Sub-continent, the authors have been unable to find any randomised studies evaluating the use of haloperidol-promethazine mix IM in the psychiatric emergency.
From the global perspective, current use of drugs in the psychiatric emergency is varied . Expert consensus differs, and systematic reviews of the best evidence produce equivocal results. Brazilian psychiatrists are consistent in favouring use of IM haloperidol-promethazine for people who are dangerously aggressive due to psychotic illnesses, but recognize that authority to recommend the use of this combination has to be supported by well-designed, conducted and reported randomized trials. The TREC study (Tranquilização Rápida-Ensaio Clínico), comparing haloperidol-promethazine IM with a benzodiazepine, now running in Brazil and India, is one such trial (protocol available from corresponding author).
The authors are grateful to Dr Stefan Leucht and Ms Sharon Cure for early access to unpublished data from their forthcoming systematic reviews. The authors also gratefully acknowledge the help and advice of peer reviewers for BioMed Psychiatry. This paper was partially supported by CAPES (Brazilian Ministry of Education) and the British Council.
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