the patient was well known to the local psychiatric services and our emergency department ( ed ) .
a history of frequent attendances with mania , and violent and manipulative behaviour , was well documented .
he was given the following sedation over the next 20 min : haloperidol 15  mg iv , midazolam 15  mg iv and chlorpromazine 100 mg po .
he continued to be verbally abusive and difficult to contain in the open environment of our department . over the next 23 h he received midazolam 20  mg iv , clonazepam 2  mg po and haloperidol 15  mg iv .
a collateral history of deteriorating mental state over the preceding few weeks with insomnia , elevated mood , irritability and increasing alcohol and tetrahydrocannabinol ( thc ) use was obtained from the patient s mother .
pressure of speech , elevated mood and irritability were noted . significant tolerance to benzodiazepines was noted from previous attendances .
discussion with the duty ed consultant ( the author ) then occurred regarding transport and sedation options .
it was decided that deep sedation or general anaesthesia were the only safe options to allow the safe air transport , thus necessitating skilled medical escort .
the only suitable agency qualified and able to perform the inter - hospital transfer in western australia is the royal flying doctor service .
although the distance to perth is relatively small ( 190  km ) , no road transport with skilled medical escort is available .
a rapid sequence induction of anaesthesia was deemed too hazardous to contemplate before attempting the less invasive option of deep sedation .
the patient had no known exposure to barbiturates , and the ed consultant was familiar with its use .
secure iv access was confirmed , and a 1-l bag of 0.9% saline was running in freely .
thiopentone was administered in 25-mg increments to a total of 125  mg , where the patient attained a state of unconsciousness but was still breathing spontaneously and supporting his own airway .
. a further two doses of 25  mg iv thiopentone were given over the next 2 h , during which the patient was observed to be  sleeping  and  cooperative  .
the patient was escorted to the local airstrip , a 7-min road trip by ambulance , by an experienced paramedic crew .
no intervention was required and on arrival the patient was given a further 50  mg iv thiopentone and loaded into the aircraft .
an ambulance was called to an agitated adult male with a past history of iv substance abuse walking along a rural road .
he had taken a  hand full  of diazepam tablets and an unknown quantity of promethazine tablets with the hope that he would lose consciousness and be struck by a car .
he became increasingly aggressive and was given diazepam ( total of 10  mg ) and midazolam ( total of 5  mg ) with little effect .
on arrival at bunbury ed he was promptly assessed by the ed consultant ( wjvr ) who noted a patent airway , tachypnoea with clear equal air entry and normal oxygen saturation , good peripheral perfusion , temperature 37.4c , blood sugar level 5.4  mmol / l and ecg unremarkable apart from the sinus tachycardia .
the patient was agitated and uncooperative , struggling against the physical restraints and not responding verbally in any coherent manner .
a further unsuccessful effort was made to achieve chemical restraint using titrated iv midazolam ( 24  mg total in ed ) , diazepam ( 5  mg total in ed ) and haloperidol ( 15  mg total in ed ) .
the ed consultant then proceeded with titrated doses of iv thiopentone ; 100  mg was administered slowly followed by a further 100  mg dose .
the patient became progressively more sedated allowing the medical and nursing staff to provide monitored care focussed on supportive measures . at no stage after the administration of thiopentone was there any compromise of the patient s vital functions .
once the situation was controlled staff could provide safe ongoing care whilst feeling less threatened .
eds are increasingly faced with the problem of agitated , intoxicated and confused patients [ 1 , 2 ] .
many abuse a combination of substances and have tolerance to the standard sedatives available to ed practitioners , and with which they are familiar .
frequent dosing , with little or no short - lived effects , results in ongoing risks to staff and patient .
many modern substance abusers are naive to barbiturates , but may be highly tolerant of benzodiazepines . when emergency physicians are selecting a sedative agent for an acutely agitated and violent patient they need to consider various factors including safety .
the patients had no known exposure to barbiturates , the drug was readily available , and its use and side effect profile were well known to the ed consultant .
barbiturates were frequently used historically as sedatives , induction agents , and for conscious sedation , then became less popular with the advent of agents with shorter duration of action and less lethality in overdose [ 5 , 6 ] . as a result ,
this leaves a population naive to barbiturates and gives a more predictable clinical effect for clinicians .
thiopentone is familiar to emergency physicians as an agent for the rapid sequence induction of anaesthesia in emergency situations .
catastrophic cardiovascular decompensation , and airway loss , can occur in emergency situations and practitioners need to be aware of potential complications , and how to deal with them effectively .
caution should be exercised by those practitioners unfamiliar with the drug , and standard recommendations regarding sedation practice should be followed , in particular the immediate availability of advanced resuscitation skills .
these cases highlight the stepwise increase in sedative interventions , to allow safe ed management and a safe inter - hospital transfer .
barbiturate naivety amongst the modern substance - abusing population may aid emergency physicians to select thiopentone as a suitable sedative agent in this situation .
safe sedative practices must be observed , including skilled medical availability in a suitable resuscitation environment .
further evaluation of drugs used for indications other than the sedation of agitated ed patients is warranted , as suggested by knott and isbister in a recent editorial .
 two cases of violent , drug - intoxicated patients who presented considerable problems in management , and were resistant to standard sedative agents , are described . 
 effective and safe sedation , without the need for full anaesthesia and endotracheal intubation , was achieved using titrated doses of thiopentone . 
 the merits of selecting this agent in these circumstances are discussed . 
Patient 1
Patient 2
Discussion
Conclusion