Altered Level of Consciousness


COCHRANE SYSTEMATIC REVIEW: Benzodiazepines for psychosis-induced aggression or agitation
Implications for practice: There is no evidence to support he use of benzodiazepines for reducing aggression.
Review Overview: The evidence from trials for the use of benzodiazepines alone is not good. There were relatively little good data and most trials are too small to highlight differences in either positive or negative effects. Adding a benzodiazepine to other drugs does not seem to confer clear advantage and has potential for adding unnecessary adverse effects. Sole use of older antipsychotics unaccompanied by anticholinergic drugs seems difficult to justify. Much more high quality research is needed in this area.
LINK to Cochrane Library: Issue 4, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003079.pub3/abstract


COCHRANE SYSTEMATIC REVIEW: Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children
Implications for practice: Implications for practice: Effectiveness demonstrated, intravenous lorazepam is at least as effective as intravenous diazepam
Review Overview: Grand mal seizures are medical emergencies requiring immediate treatment. The objective of this review was to compare the efficacy and safety of drugs of first choice used to treat this condition in children treated in hospital. An update of the literature suggests that intravenous lorazepam is at least as effective as intravenous diazepam and is associated with fewer adverse events in the treatment of acute tonic-clonic convulsions. Where intravenous access is unavailable, there is evidence from one trial that buccal midazolam is the treatment of choice.
LINK to Cochrane Library: Issue 3 2008 – Updated review http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001429/frame.html


COCHRANE SYSTEMATIC REVIEW: Haloperidol for psychosis-induced aggression or agitation (rapid tranquillisation)
Implications for practice: Weak evidence to suggest that haloperidol can be effective but should be used with caution when used solely.
Review Overview: If no other alternative exists, sole use of intramuscular haloperidol could be life-saving. Where additional drugs to offset the adverse effects are available, sole use of haloperidol for the extreme emergency, in situations of coercion, could be considered unethical. Addition of the sedating promethazine has support from better-grade evidence from within randomized trials. Use of an alternative antipsychotic drug is only partially supported by fragmented and poor-grade evidence. Evidence for use of newer generation antipsychotic alternatives is no stronger than that for older drugs. Adding a benzodiazepine to haloperidol does not have strong evidence of benefit and carries a risk of additional harm. After six decades of use for emergency rapid tranquillization, this is still an area in need of good independent trials relevant to real world practice.
LINK to Cochrane Library: Issue 11, 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009377.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Propofol versus thiopental sodium for the treatment of refractory status epilepticus
Implications for practice: Unclear, more research needed.
Review Overview: Persistent convulsions are a major medical emergency associated with significant morbidity and mortality. At times, these convulsions fail to respond to first- and second-line drug therapy and may be observed in up to 31% of patients suffering from persistent seizure or convulsive activities. Persistent seizure activity may become refractory to antiepileptic drugs. Anaesthetics such as thiopental sodium and propofol are frequently given for control of seizures in such situations. Both agents have inherent side effects and complications. This review appraises the evidence for the these anaesthetic drugs in controlling seizure activity in patients with RSE. There is a lack of good-quality evidence to support the choice of anaesthetic drug for the treatment of patients with RSE. Only one trial could be identified, which was terminated early due to recruitment problems. The two drugs did not show any difference among each other. The only difference noted was the requirement of prolonged mechanical ventilation for patients in the thiopental group. This could be due to the long half-life of the drug. There is a clear need for a large randomised controlled trial to study the efficacy of anaesthetic agents in the treatment of RSE.
LINK to Cochrane Library: Issue 8, 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009202.pub2/abstract;jsessionid=7B55F3C013B410F33B9F193F95A04EA3.d01t04