Acute agitation and rapid tranquillisation — structured clinical viva

Reject the proposed combination. IM olanzapine must not be given with a parenteral benzodiazepine (midazolam). Risk is profound respiratory depression and hypotension. This is a non-negotiable viva fail if missed.^[1]

Assessment. Scene safety, ABCDE, glucose, vitals, ECG QTc before or ASAP with antipsychotics, exclude medical mimics, emergency MSE (threat/command content), capacity for treatment decisions, legal status.^[1]

Safer RT plan. Prefer single IM agent: lorazepam 1–2 mg IM, or olanzapine 5–10 mg IM alone (then wait ≥1 h before any parenteral BZD), or aripiprazole ~9.75 mg IM, or haloperidol 5 mg IM + promethazine 25–50 mg IM (TREC-backed). In ANZ ED undifferentiated SBD, droperidol 5–10 mg IM is a common evidence-supported first-line with monitoring. Endpoint calm and rousable; observations every 15 minutes for ≥1 hour.^[1][3]

If standard RT fails. Senior review; environmental control; do not stack banned combinations. In ED with airway readiness, ketamine rescue for difficult-to-sedate SBD has evidence under local governance — not default general-ward first-line.^[2]

Legal/ethics. Capacity is decision-specific; document least-restrictive rationale; apply local Mental Health Act without inventing foreign section numbers.^[4]