Prehospital management of acute behavioural disturbance: managing severe agitation in the prehospital setting - a systematic literature review.

Acute behavioural disturbance (ABD), formally known as excited delirium, is an under-recognised clinical picture often characterised by abnormal physiology and extreme agitation. The condition is potentially dangerous for both patients and practitioners, particularly in the prehospital setting. Our objective was to systematically review the evidence for management of ABD within the prehospital environment. A systematic literature search (PROSPERO CRD42023447238) of PubMed, Cochrane trials, Cochrane reviews, Embase, Web of Knowledge, Google Scholar and MEDLINE was performed from inception until February 2025. Any study that examined the management of ABD prehospitally was included. Randomised controlled trials, observational cohort studies and case series that were written in English were included. Methodological quality of included studies was interpreted using the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) and GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. From 6091 studies, 42 were included; none were high quality and 6 were moderate quality. Ketamine demonstrated the most effective sedation (range 79-98% of all patients included achieving adequate sedation as defined in the studies), although doses and methods of administration varied significantly. Midazolam generally showed a higher number of side effects than other drugs studied. Droperidol was not found to have a higher mortality than others, and no effect was seen on the QT interval. Ketamine was found to be the most studied drug for treatment of ABD in the prehospital setting and is likely the most effective method of sedation at a dose of 5 mg/kg intramuscularly. Midazolam appears to have a higher risk of side effects, particularly respiratory-related, in comparison to other sedative agents. Conclusions are limited by the quality of evidence currently available and additional research is required to establish the most effective mode of administration and dose for this population group, as well as better definition of the presenting condition and outcome measures. CRD42023447238.