Managing the Acutely Agitated Patient

   In September 2007, the FDA issued a similar warning for haloperidol, stating that torsade de pointes and QT prolongation had been observed in patients receiving it. In response to this warning, in January 2009 Denver went back to using droperidol rather than haloperidol. Since then, we have had the same experience as the authors of those many published reports: We've found droperidol both safe and effective. Authors from Camden, NJ, published similar experiences with safety and effectiveness earlier this year.⁷

   The care of agitated patients in the field is challenging on many levels, and chemical restraint is sometimes necessary to safely manage them. While benzodiazepines are great in many cases, they are not the ideal agent for all situations. Antipsychotics such as droperidol should be an option in some cases, such as for patients experiencing agitation related to alcohol use or an acute psychiatric condition. There is growing experience with newer, atypical antipsychotics, and these may be an option to consider in the future.

References

1. ACEP Excited Delirium Task Force. White paper report on excited delirium syndrome, 2009.

2. Martel M, Sterzinger A, Miner J, et al. Management of acute undifferentiated agitation in the emergency department: A randomized double-blind trial of droperidol, ziprasidone, and midazolam. Acad Emerg Med 12(12): 1,167-1,172, 2005.

3. Hick JL, Mahoney BD, Lappe M. Prehospital sedation with intramuscular droperidol: A one-year pilot. Preh Emerg Care 5: 391-4, 2001.

4. Rosen CL, Ratcliff AF, Wolfe RE, et al. The efficacy of intravenous droperidol in the prehospital setting. J Emerg Med 15: 13-7, 1997.

5. Chase PB, Biros MH. A retrospective review of the use and safety of droperidol in a large, high-risk, inner-city emergency department patient population. Acad Emerg Med 9: 1,402-10, 2002.

6. Szuba MP, Bergman KS, Baxter LR, et al. Safety and efficacy of high-dose droperidol in agitated patients. J Clin Psychopharmacol 12: 144-5, 1992.

7. Szwak K, Sacchetti A. Droperidol use in pediatric emergency department patients. Pediatr Emer Care 26: 248-250, 2010.

8. Thomas H, Schwartz E, Petrilli R. Droperidol versus haloperidol for chemical restraint of agitated and combative patients. Ann Emerg Med 21: 407-13, 1992.

9. Knott JC, Taylor DM, Castle DJ. Randomized clinical trial comparing intravenous midazolam and droperidol for sedation of the acutely agitated patient in the emergency department. Ann Emerg Med 47(1): 61-7, Jan 2006.

10. Dershwitz M. Droperidol: Should the black box be light gray? J Clin Anesth 14: 598-603, 2002.

11. Horowitz BZ, Bizovi K, Moreno R. Droperidol--behind the black box warning. Acad Emerg Med 9: 615-8, 2002.

12. Mullins M, Zwieten K, Blunt J. Unexpected cardiovascular death associated with droperidol: A smoking gun or just smoke and mirrors? J Toxicol Clin Toxicol 40: 600-1, 2002.

13. Kao LW, Kirk MA, Evers SJ, et al. Droperidol, QT prolongation, and sudden death: What is the evidence? Ann Emerg Med 41: 546-48, 2003.

14. Martel M, Miner J, Fringer R, et al. Discontinuation of droperidol for the control of acutely agitated out-of-hospital patients. Preh Emerg Care 9(1): 44-8, 2005.

   Christopher B. Colwell, MD, FACEP, is medical director for the Denver Fire Department and Denver Paramedic Division, and an associate professor at the University of Colorado Health Sciences Center.