Safety and effectiveness of high-dose midazolam for severe behavioural disturbance in an emergency department with suspected psychostimulant-affected patients


  • David Spain, MB BS, FRACGP, FACEM, Deputy Director of Emergency Medicine; Julia Crilly, RN, PhD, Nurse Researcher; Ian Whyte, MB BS(Hons), FRACP, FRCP(Edin); Linda Jenner, MAppSci(Research), Project Officer; Vaughan Carr, MD, FRCPC, FRANCP, Director; Amanda Baker, BA(Hons), MPsychol, PhD, NHMRC Senior Research Fellow.

Dr David Spain, Gold Coast Hospital, Southport Campus, Nerang Street, Southport, Qld 4215, Australia. Email:


Objectives:  To trial high-dose midazolam sedation protocol for uncooperative patients with suspected psychostimulant-induced behavioural disorders. End-points were effectiveness and safety.

Methods:  A prospective pilot study was undertaken with a convenience sample of adult, uncooperative patients with suspected psychostimulant-induced severe behavioural disorders. The protocol was midazolam in 10 mg increments, i.m. or i.v., at 10 min intervals, up to four doses and titrated to an end-point of rousable drowsiness.

Results:  Sixty-two patients were enrolled. Two-thirds of the patients required only one dose of midazolam; 88% of the sample were sedated with two doses. Six and a half per cent of patients were not sedated after four doses. A Glasgow Coma Score of eight or less was prolonged in eight patients. Airway problems requiring an adjunct were present in four patients. Recent psychostimulant use was present in only 55% after full assessment.

Conclusions:  High-dose midazolam protocols cannot be supported as universally safe. High-dose protocols for severe behavioural disturbance are not more effective, with failures occurring even after repeated dosing.