• Allison Schneider, Samuel Mullinax, Nathanael Hall, Ashley Acheson, Alison H Oliveto, and Michael P Wilson.
• Division of Research and Evidence-Based Medicine, Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America.
• Am J Emerg Med. 2021 Aug 1; 46: 193-199.

BackgroundSeverely agitated patients in the emergency department (ED) are often sedated with intramuscularly-administered medications. The evidence base underlying particular medication choices is surprisingly sparse, as existing reviews either have methodological limitations or have included data collected outside of emergent settings.ObjectivesThe objective of this review was to examine all controlled trials in emergent settings that have used standardized scales to measure the effectiveness of intramuscular medication for the treatment of acute agitation.MethodsThis review was registered in Prospero as CRD42018105745. PubMed, International Pharmaceutical Abstracts, Web of Science, PsycINFO, and clinicaltrials.gov were searched for prospective controlled trials investigating intramuscular antipsychotics for agitation. Articles were assessed for bias across five domains using the revised Cochrane Risk of Bias Tool.ResultsEight studies were eligible for inclusion in the systematic review, none of which had a low risk of bias. Five studies had a moderate risk of bias with heterogenous designs, populations, and treatments. These studies seemed to suggest that second generation antipsychotics (SGAs) likely reduce agitation as effectively as first generation antipsychotics (FGAs) plus an adjunctive medication with similar or lower risk of side effects.ConclusionsExisting trials on the use of intramuscular antipsychotics in the ED/psychiatric ED setting were small, heterogenous, and at a moderate or high risk of bias. Given the clinical importance of this topic, further prospective investigations are desperately needed but are currently unfeasible under Food and Drug Administration Exception From Informed Consent regulations.Copyright © 2020 Elsevier Inc. All rights reserved.

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