Complications of Midazolam in the Management of Agitated Patients in the Emergency Department: A Dutch Observational Study

Background Hyperactive delirium with agitation is a medical emergency requiring rapid pharmacological treatment. Midazolam is widely used as a first-line agent, but data on its effectiveness and sedation-related complications, particularly in intoxicated patients, a common cause of agitation in Dutch emergency departments, is limited. Objective To identify risks associated with midazolam treatment in emergency department patients with hyperactive delirium and agitation and evaluate its effectiveness in achieving adequate sedation. Methodology This prospective observational study included patients aged ≥16 years presenting to OLVG Hospital, Amsterdam, with hyperactive delirium and agitation, defined as a Sedation Assessment Tool (SAT) score of 2–3, between November 2018 and March 2021. All received midazolam as the sole sedative. Primary outcomes were cumulative midazolam dose and time to adequate sedation (SAT ≤0). Secondary outcomes were sedation-related complications. Substance use was identified by urine analysis or self-report. Results 82 patients were included (median age, 30 years; 80.8% male); 76.8% were intoxicated. The median cumulative midazolam dose was 10 mg (IQR, 5–15), administered in three doses. Median time to adequate sedation was 24 minutes (IQR, 6.3–76.8). Complications occurred in 28.0%, including airway obstruction requiring manual airway maneuvres (15.9%), desaturation (SpO₂ <90%; 8.5%), and vomiting (6.1%). Conclusion Midazolam was associated with a relatively high rate of sedation-related complications among agitated patients, most of whom were intoxicated. Complications were transient, manageable with basic supportive interventions, and did not require advanced airway management or resuscitation. The frequent respiratory events and need for repeated dosing warrant further research into optimal pharmacological treatment strategies.