Art of the Chemical Takedown

An unruly, intoxicated and violent patient rolls into the ED. The situation and the patient are both in need of control. How do you go about it? Redirection? Calming words? Sometimes those things aren’t quite enough and chemical sedation is in order. When it comes to choice of sedating agent, everyone seems to have their secret formula. We canvassed the planet to see how chemical takedowns are done across the globe.


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Our Panel

ZdoggMD Art of the chemical takedown FOAMed World Premier

Scott Weingart  5mg of droperidol and 2mg of midazolam mixed together in a syringe with 11⁄2 inch needle and jabbed into whatever large muscle is available. Wait a few minutes. If necessary, will repeat once. Then establish IV

Minh Le Cong Ketamine  IV, IM, or IO.

Cliff Reid Ketamine

Chris Nickson Benzo, olanzipine or droperidol

Sean Nordt The B-52.  5mg Haldol, 2mg Ativan and 50mg of benadryl mixed together in a single syringe and given IM

Katrin Hruska abusive patients are asked to leave the emergency department

Amit Maini 5mg of IM droperidol. Repeat in 5-10 minutes if needed

Sa’ad Lahri: lorazepam (4 to 8 mg IV) and haloperidol (5mg IV)

Yosef Leibman midazolam, droperidol. Starting to use clotiapine –  a dibenzothiazepine anti-psychotic and a phenothiazine with anti-anxiety properties.

Gerry O’Malley Burly security guards and a show of force. If that doesn’t work- benzodiazepine

Ray Moreno:  Toxin related or sympathomimetic: midazolam 5 – 10mg IM. Psychiatric related- olanzipine. No idea what’s causing the agitation- midazolam

Chris Richards- The B-52.  5mg Haldol, 2mg Ativan and 50mg of benadryl mixed together in a single syringe and given IM

Bonus section:

Droperidol,  QTc prolongation, and the Black Box with toxicologist Sean Nordt….

When droperidol was ‘black boxed’ in the US, it sent shockwaves across the emergency medicine community because this drug was, for many of us, the go to agent for sedation of combative and agitated patients. Over the past several years, the pendulum has swung away from the black box and toward increasing use of droperidol. Why is that? Have we all gone mad? Are we putting patients in danger?

The history (or the conspiracy, depending on how you look at it) is expertly explained in the below article. It involves big pharma, outlier case reports of patients given much higher doses than are used in the ED for either nausea or sedation, and suspicious timing. There is no doubt that butyrophenones can influence the QTc, but so can a lot of other meds we use (that are not black boxed).

Sean Nordt’s approach to giving droperidol in the agitated patient

  1. Give the med
  2. When the patient has calmed, get an EKG.
  3. If the QTc is prolonged, put the patient on a cardiac monitor

Horowitz, B. Zane, Kenneth Bizovi, and Raymond Moreno. “Droperidol—behind the black box warning.” Academic Emergency Medicine 9.6 (2002): 615-618.


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  1. Jenny

    Great!!! In regards to the droperidol prolonging the QTc, it was discussed to get an EKG to check the QTc . When you give geodon (ziprasidone), do you also check an EKG since it also can cause QT prolongation? Thank you!

  2. Sue

    My first ever term as an intern was inner city Psychiatry, so I soon became an expert at the Chemical Takedown -- then it was Diazepam and Haloperidol (“Serenace and Valium”), in increments of “5 and 5” IVI, depending on size and predicted tolerance. I still use this today, though I might modify to Droperidol and Midazolam. I have always been fairly slick at doing this.

    What I am finally learning later in my career, though, is how NOT to sedate, even in the acutely disturbed. It’s a real art. Our ED-MH CNC is an ex-ED NUM in the UK -- he excels at talking down even violent patients and getting them to take oral meds, therefore no airway probs or delays in transfer to psych service.

    OF course, this doesn’t work in all cases, but I’m encouraged to try more often. Hold down for IV take-down is much less sophiscticated, though sometimes needed.

  3. Sarah Moodie

    I want to know what chemical take-down is going to keep us all under control in Mexico… Can’t wait for cabo cme!

  4. Pingback: Research and Reviews in the Fastlane 090 | LITFL: Life in the Fast Lane Medical Blog

  5. Rasmus Aagesen

    As an Swedish critical care and anaesthesiologist resident I don’t completely agree about the picture of Sweden. I have done several chemical takedowns in the emergency department. It’s true that we have a lot of laws how to treat psycpatients who come in and are agitated- but we stil see the septic, Hypoxic patient that tries to creat wwIII in the department. Trauma patients are also sometimes impossible to handle in Sweden without an adequate sedation. The main difference I think in Sweden is that we don’t have ED docs that can intubate and sedate patients- Common practice is that the critical care on call doc gets involved in these cases.

    1. Rasmus Aagesen

      My method of choice is ketamine IV/IM for the majority of cases. Some times ketofol. The Critical care patient/ post op usually get Haloperidol and benzo

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