Anyone else out there that loves haldol as much as myself?

[Zebra Hunter]

During residency, my attendings never allowed me to use it outside of the few that kept relatively up-to-date with the literature, and then they only let me use it for gastroparesis or refractory migraines. Since becoming an attending, I probably use this stuff 2-3x per shift. It is absolutely amazing how much of a life saver this medication has been. What were once frequent difficult patient interactions, now these patients leave satisfied that their pain is well controlled. I actually almost never use this for agitated delirium, surprisingly, which is the most common reason I see others use it for. It is my first-line med for chronic abdominal pain, all fibro pain complaints, "lupus flares", or any other pain complaint that clearly has a significant supratentorial component to it. I also have found that it works amazingly for tremors. It also works great at low doses for anxiolysis in Bipap patients given a lack of respiratory depression. It is also excellent for refractory nausea and vomiting. I actually have several other colleagues that have started using it more frequently. I have found the efficacy to be somewhere around 80-90% for pain relief in the population I use it on. Unfortunately the only group of patients I have found it does not work for is the chronic neck and back pain patients...although literally nothing works for this group.

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[thegenius]

During residency, my attendings never allowed me to use it outside of the few that kept relatively up-to-date with the literature, and then they only let me use it for gastroparesis or refractory migraines. Since becoming an attending, I probably use this stuff 2-3x per shift. It is absolutely amazing how much of a life saver this medication has been. What were once frequent difficult patient interactions, now these patients leave satisfied that their pain is well controlled. I actually almost never use this for agitated delirium, surprisingly, which is the most common reason I see others use it for. It is my first-line med for chronic abdominal pain, all fibro pain complaints, "lupus flares", or any other pain complaint that clearly has a significant supratentorial component to it. I also have found that it works amazingly for tremors. It also works great at low doses for anxiolysis in Bipap patients given a lack of respiratory depression. It is also excellent for refractory nausea and vomiting. I actually have several other colleagues that have started using it more frequently. I have found the efficacy to be somewhere around 80-90% for pain relief in the population I use it on. Unfortunately the only group of patients I have found it does not work for is the chronic neck and back pain patients...although literally nothing works for this group.

I use it once every 2-3 shifts but want to use it more. Can you go into more detail on how you dose it? Max dose too? Do you always get an EKG prior to giving it? Dosing IV vs IM? Ever give it PO? And so you ever send people home with an Rx?

I use it mostly for gastroparesis, chronic functional abd pain, and for psych emergencies.

 

[Zebra Hunter]

5mg either IV or IM is typically how I give it for the young and healthy depending on if the patient has an IV. I usually start with 2.5mg in the elderly with multiple medical co-morbidities. I give it as a one time dose typically. If no response, I move on to other classes of meds. I almost never get an ECG prior to administration. Average change in QTc is only about 7mS. Never given it PO.

 

[Groove]

I use it for gastroparesis on occasion. One of my partners uses it more... I generally don't give it IV. If there was anything that went wrong even remotely related to IV administration of haldol, I'd be screwed since it's not approved for IV use and we've got multiple FDA warnings for giving it that route insisting on continuous ECG monitoring. I fully realize that plenty of people give it this route.

Ironically, I rarely use it for my psych pts. I'm partial to IM Geodon or Zyprexa.

Interesting though, thanks for the post.

Are you giving other analgesics to your pain patients along with the haldol or using haldol alone?

 

[Fox800]

Samesies but generally reach for IV olanzapine or droperidol. Amazing stuff.

 

[GonnaBeADoc2222]

I would not give haldol iv

 

[BoardingDoc]

I would not give haldol iv

I use it (or droperidol) IV for refractory headache fairly often. 1-2mg a dose. No idea what the fear about giving it IV is. They're are tons of meds that we use on a daily basis that are for "off-label" indications. If you're concerned about the QT, just get an EKG and keep them on a monitor after giving it.

 

[Zebra Hunter]

I would not give haldol iv

I would, given that all the literature on its use for pain is based on IV administration. The case series that the black box warning was based on demonstrates multiple cases of its use with individuals that have received multiple doses of QT prolonging drugs within a short span of time, or had significant electrolyte abnormalities, or used doses that far exceeded recommendations. Off-label use shouldn't be a concern unless you are also not giving zofran to any of your patients. Interestingly, zofran also has about the same likelihood of causing Torsades as Haldol (which is minimal), but I never see anyone bat an eye about giving it to patients.

 

[southerndoc]

We use it like candy at my shop. Cannabinoid hyperemesis syndrome, gastroparesis, migraines, etc.

I copied one of the docs I work with for what to tell patients. "We have a great atypical pain medication that works on the dopamine receptors." The nurses have been scripted to tell them it's not an antipsychotic (being used for pain). Works wonders. Migraines literally go from 10 to 1 in 30 minutes.

We don't have a lot of Dilaudopenia at my shop. We took it off the formulary. Even sickle patients "allergic" to morphine get 25 mg diphenhydramine PO, wait 15 minutes, then they get morphine. Not a single "allergic" patient has had a reaction in the past 3 years with this approach. They get no PCA's when they go upstairs. This is our sickle cell pain protocol that physicians are highly discouraged deviating from. Our sickle cell population has decreased from me seeing about 1 every other shift to seeing 1 every other month. Before you go off on me, yes I realize sickle cell patients have pain. However, we had sickle cell patients abusing the system who were homeless and going from hospital to hospital (sometimes before taking off their wrist band from the previous hospital) getting admitted for "intractable pain."

 

[RustedFox]

I use it all the time.

I have never "had a dose", but I said to myself two days ago: "Jeez, I would probably love to take a dose of haldol and have a great nap."

Before anyone says anything about "wellness", I'm probably just extra crispy after working too many shifts because our director's wife is having a baby.

I wouldn't NOT have worked those shifts for him. Its his son. God Bless 'em.

 

[Listen2Savage]

During residency, my attendings never allowed me to use it outside of the few that kept relatively up-to-date with the literature, and then they only let me use it for gastroparesis or refractory migraines. Since becoming an attending, I probably use this stuff 2-3x per shift. It is absolutely amazing how much of a life saver this medication has been. What were once frequent difficult patient interactions, now these patients leave satisfied that their pain is well controlled. I actually almost never use this for agitated delirium, surprisingly, which is the most common reason I see others use it for. It is my first-line med for chronic abdominal pain, all fibro pain complaints, "lupus flares", or any other pain complaint that clearly has a significant supratentorial component to it. I also have found that it works amazingly for tremors. It also works great at low doses for anxiolysis in Bipap patients given a lack of respiratory depression. It is also excellent for refractory nausea and vomiting. I actually have several other colleagues that have started using it more frequently. I have found the efficacy to be somewhere around 80-90% for pain relief in the population I use it on. Unfortunately the only group of patients I have found it does not work for is the chronic neck and back pain patients...although literally nothing works for this group.

I heard about using it for pain on EM cases podcast (i think)

floated the idea to a 4 year resident when presenting a patient and he looked at me like wtf are you talking about bro?

I parrotted the shiz I hear on the podcast, 5 mg being relatively safe, the QT prolongation paper being old and crappy

Again, looked at me like

 

[Tenk]

I like to give it to the crazy abdominal pains who when your hand even comes within a foot of them start acting like you stabbed them with a knife made out of spiders.

 

[deleted836128]

I use it once in a blue moon with the intractable migraines or the “difficult” patients. It always knocks migraines out completely. I find it works well for the anxious patient with “pain all over my body.” It’s a miracle. The first time I used it, I was advised by an attending who advised it for a fibromyalgia flare up that would NOT leave the ER and kept coming up with more obscure symptoms by the minute. Wouldn’t stop crying. Gave her the shot, came back forty five minutes later and she was sitting up super straight on the stretcher and SMILING. I asked her if she was ready to go and she said verbatim, “I’ve never been more ready” in a really creepy manner. She then asked for a prescription (I don’t think I would prescribe it to be honest). I’ve never ordered it orally or intravenously... only intramuscularly. Five milligrams.

 

[GenericWhiteGuy]

Attending 1 year out here, frequent reader but infrequent poster.

Use regularly in the following scenarios, almost always IV but IM if I feel good chance of one dose and discharge. Always 5mg unless elderly.

- Chronic pain patients with a description as @southerndoc uses.
- 2nd line after Zofan for intractable vomiting.
- 1st or 2nd line for migraines
- Anxiolysis (works great on BiPap patients)

 

[TheComebacKid]

We use it a lot in residency. It's go to for significant agitation, belligerent drunks, PCP, etc. All the other patients including intractable nausea/vomiting, migraines, abdominal pain etc, works great for as well.

While we theoretically aren't supposed to see much respiratory depression, we have intubated a couple of patients who in hindsight shouldn't have gotten it. Most of them of morbidly obese people with underlying bad OSA. I suspect it wasn't a direct a haldol effect, and more than likely is related to any sedating med.

I'll still be using it fairly liberally because it works well in the majority of patients.

Sometimes I've given PO more for anxiolysis in otherwise cooperative patients, but for any pain or other off label indications i'm exclusively giving IV. IM for the agitated patient that is getting taken down. It's usually second line for migraines i5mg in 500ml of saline) if they don't get controlled with toradol/benadryl/compazine/IVF cocktail.

One of the best medications we can use in the ED

 

[deleted109597]

I would not give haldol iv

I've done it thousands of times. It's really quite safe.

I use it probably 5x a shift at minimum. Headaches, abdominal pain, nausea, complex regional pain syndrome, cannabanoid related anything, and then again the occasional psych patient. It turns out that a lot of pain is supratentorial, and if you smooth out those spikes their pain also gets better.

 

[Groove]

For those of you giving IV, just make sure this doesn't become you:

Giving Haldol Intravenously | Emergency Physicians Monthly

A 68-year-old male was brought to the emergency department several times over the past month after being found intoxicated in public. On one occasion, he was found sleeping in the bathroom at a restaurant. On another occasion he was sleeping in the ATM lobby of a bank. On a third occasion, he...

epmonthly.com

It's not that we don't give other QT prolonging meds through IV. The problem is that there is a preponderance of cases involving TdP with haloperidol, much more than other medications with equally QT prolonging effects and the risk is greatest with IV administration at any dose. Nobody is entirely sure why which is what led the FDA to giving multiple warnings regarding IV administration. I would worry about it more with patients with risk factors such as: concomitant antipsychotics, electrolyte abnormalities, structural heart dz, drug interactions, age/comorbidities, etc..

If you happen to have the rare pt that ends up with TdP, have a bad outcome and get sued...just write a blank check because you've got absolutely no defense with current guidelines right now. If you're going to do it anyway, I'd recommend having them on a monitor and getting an EKG first.

The FDA extended warning for intravenous haloperidol and torsades de pointes: How should institutions respond?

Ask yourself though, Is it worth the trouble and risk to save 15 mins for effect?

 

[deleted109597]

For those of you giving IV, just make sure this doesn't become you:

Giving Haldol Intravenously | Emergency Physicians Monthly

A 68-year-old male was brought to the emergency department several times over the past month after being found intoxicated in public. On one occasion, he was found sleeping in the bathroom at a restaurant. On another occasion he was sleeping in the ATM lobby of a bank. On a third occasion, he...

epmonthly.com

It's not that we don't give other QT prolonging meds through IV. The problem is that there is a preponderance of cases involving TdP with haloperidol, much more than other medications with equally QT prolonging effects and the risk is greatest with IV administration at any dose. Nobody is entirely sure why which is what led the FDA to giving multiple warnings regarding IV administration. I would worry about it more with patients with risk factors such as: concomitant antipsychotics, electrolyte abnormalities, structural heart dz, drug interactions, age/comorbidities, etc..

If you happen to have the rare pt that ends up with TdP, have a bad outcome and get sued...just write a blank check because you've got absolutely no defense with current guidelines right now. If you're going to do it anyway, I'd recommend having them on a monitor and getting an EKG first.

The FDA extended warning for intravenous haloperidol and torsades de pointes: How should institutions respond?

Ask yourself though, Is it worth the trouble and risk to save 15 mins for effect?

TdP is easily treated.
70 cases in 186 years of literature review identified (2009 article)

Error - Cookies Turned Off

onlinelibrary.wiley.com

Nobody is telling you that you have to give it.

 

[Zebra Hunter]

For those of you giving IV, just make sure this doesn't become you:

Giving Haldol Intravenously | Emergency Physicians Monthly

A 68-year-old male was brought to the emergency department several times over the past month after being found intoxicated in public. On one occasion, he was found sleeping in the bathroom at a restaurant. On another occasion he was sleeping in the ATM lobby of a bank. On a third occasion, he...

epmonthly.com

It's not that we don't give other QT prolonging meds through IV. The problem is that there is a preponderance of cases involving TdP with haloperidol, much more than other medications with equally QT prolonging effects and the risk is greatest with IV administration at any dose. Nobody is entirely sure why which is what led the FDA to giving multiple warnings regarding IV administration. I would worry about it more with patients with risk factors such as: concomitant antipsychotics, electrolyte abnormalities, structural heart dz, drug interactions, age/comorbidities, etc..

If you happen to have the rare pt that ends up with TdP, have a bad outcome and get sued...just write a blank check because you've got absolutely no defense with current guidelines right now. If you're going to do it anyway, I'd recommend having them on a monitor and getting an EKG first.

The FDA extended warning for intravenous haloperidol and torsades de pointes: How should institutions respond?

Ask yourself though, Is it worth the trouble and risk to save 15 mins for effect?

Yes let’s stop giving an effective medication due to adverse reactions that happen 1 in 10,000+ times of administration. Thankfully we have opiates that have a much better side effect profile...

We should probably stop basing practice patterns based off one off lawsuits. IV haldol has essentially become standard of care in multiple institutions for an alternative method of pain control. If you are uncomfortable using it, then don’t use it.

 

[GeneralVeers]

Yes let’s stop giving an effective medication due to adverse reactions that happen 1 in 10,000+ times of administration. Thankfully we have opiates that have a much better side effect profile...

We should probably stop basing practice patterns based off one off lawsuits. IV haldol has essentially become standard of care in multiple institutions for an alternative method of pain control. If you are uncomfortable using it, then don’t use it.

My institution literally REFUSES to give IV Haldol even if I order it. I've been called by pharmacy and told they are going to refuse to dispense it to the ED unless I change the order to IM.

 

[thegenius]

My institution literally REFUSES to give IV Haldol even if I order it. I've been called by pharmacy and told they are going to refuse to dispense it to the ED unless I change the order to IM.

I too have had that problem. They will only allow 2mg IV max.

So it makes that part difficult.

5 IM is OK though




I was thinking of ordering 1mg IV q1 min PRN pain up to 5 doses
See what the pharmacist thinks of that

 

[TooMuchResearch]

We have IV Haldol built into order sets and IV Zyprexa is approved by P&T.

My institution literally REFUSES to give IV Haldol even if I order it. I've been called by pharmacy and told they are going to refuse to dispense it to the ED unless I change the order to IM.

 

[scummie]

I like to give it to the crazy abdominal pains who when your hand even comes within a foot of them start acting like you stabbed them with a knife made out of spiders.

I laughed out loud way too hard at this.

Always trying to decide how to make it sound ridiculous but also not mesenteric ischemia bad.

Have a friend that will ask them if their teeth hurt. Positive sign for end stage fibro.

 

[BoardingDoc]

I laughed out loud way too hard at this.

Always trying to decide how to make it sound ridiculous but also not mesenteric ischemia bad.

Have a friend that will ask them if their teeth hurt. Positive sign for end stage fibro.

I know someone that does similar, but asks if their teeth itch. I feel like a yes answer to dental pain is still potentially ambiguous, whereas a yes answer to dental itching is pathognomonic for a supratentorial problem.

 

[Groove]

Just out of curiosity, how are most of you sneaking in your haldol? My histrionic chronic pain patients are virtually all drug seekers and paying VERY close attention to what meds they are (or are not) receiving. How are you slipping in an IM haldol dose for "pain"? For those giving IV, I guess it might get lost in all the other meds being administered and the pt wouldn't recognize it but for those of you giving IM, how are you explaining it?

I get it if some of you are explaining that you are going to try an "atypical pain med" but are all of you doing that?

I usually give them benadryl 25mg IV, toradol 15mg IV and ativan 1-2mg IV and most are nice and chilled out by that point and cleanly separated from their initial psychogenic component.

 

[Zebra Hunter]

I tell them “we are going to give you a dose of haldol which is an antipsychotic medication but has been found to be very effective for pain and nausea. It is not because we think you are crazy.” Why try to sugar coat it? If you don’t tell them it’s an antipsychotic, many will find out when they go home and google it and then become pissed.

 

[GeneralVeers]

Just out of curiosity, how are most of you sneaking in your haldol? My histrionic chronic pain patients are virtually all drug seekers and paying VERY close attention to what meds they are (or are not) receiving. How are you slipping in an IM haldol dose for "pain"? For those giving IV, I guess it might get lost in all the other meds being administered and the pt wouldn't recognize it but for those of you giving IM, how are you explaining it?

I get it if some of you are explaining that you are going to try an "atypical pain med" but are all of you doing that?

I usually give them benadryl 25mg IV, toradol 15mg IV and ativan 1-2mg IV and most are nice and chilled out by that point and cleanly separated from their initial psychogenic component.

I don't really care. I order it, and if they refuse they get discharged. Why bother trying to make a drug-seeker or malingerer happy?

 

[Groove]

I don't really care. I order it, and if they refuse they get discharged. Why bother trying to make a drug-seeker or malingerer happy?

Well it's not as easy to d/c some of these ridiculous melodramatic belly pains without a work up and as much as we all try to act like we're billy badasses that have no problem ejecting unhappy pt's from the ED at 20K feet, we all should be interested in reducing pt complaints (job security). Plus, getting called back to the room to explain medications seriously hampers my flow and slows me down. Up until now, I really don't find myself needing to give haldol that much but if I were...I was just curious how you guys avoid what I would think would be inevitable questions and refusals for a "psych" med the nurse draws up to dart them with...I would think that would actually generate more complaints than it would reduce them.

 

[dchristismi]

I use it in my hospice patients a great deal, and usually explain it to the families that this drug was originially designed for schizophrenia, and works really well for that in high doses. However, in the low dose your loved one will get, it quiets the mind and helps people think more clearly and be more relaxed. It also happens to work really well for headaches and vomiting, so you get the added benefits of those good side effects.

It's all in how you sell it. I find it's much more effective than benzos in many dementia patients (keeping in mind that the vast majority of my patients are end-of-life), and if there's any anxiety-component to nausea, bonus. The only trouble is if someone is ultimately heading to a SNF, they don't seem to mind risperdal, seroquel, etc, but flip out with haldol.

 

[thegenius]

Well it's not as easy to d/c some of these ridiculous melodramatic belly pains without a work up and as much as we all try to act like we're billy badasses that have no problem ejecting unhappy pt's from the ED at 20K feet, we all should be interested in reducing pt complaints (job security). Plus, getting called back to the room to explain medications seriously hampers my flow and slows me down. Up until now, I really don't find myself needing to give haldol that much but if I were...I was just curious how you guys avoid what I would think would be inevitable questions and refusals for a "psych" med the nurse draws up to dart them with...I would think that would actually generate more complaints than it would reduce them.

Yup I agree....

I either tell these guys up front "You came in with pain, you are going to leave in pain", and that gets right to the point. And then I say "lets try haldol", and give my reasons why. Most are willing to try it.

It may not work...but surprisingly I've never had anybody say "I had a horrible reaction to haldol, I don't want it". They just say they had it before and it didn't work.

 

[thegenius]

So does Haldol work for real pain? Like acute appendicitis, MI, cellulitis, orthopedic fractures, stuff like that? Or just supratentorial pain?

 

[thegenius]

Given all the pain we deal with, BS and real, I would think doing some real good RCTs comparing risks and benefits and potential side effects (QTc changes) would be straight forward to accomplish. Probably get enough data in 2 months we have so many pain seekers.

 

[deleted109597]

So does Haldol work for real pain? Like acute appendicitis, MI, cellulitis, orthopedic fractures, stuff like that? Or just supratentorial pain?

It works great for any pain. Especially migraines, chronic back pain, etc.

 

[Zebra Hunter]

So does Haldol work for real pain? Like acute appendicitis, MI, cellulitis, orthopedic fractures, stuff like that? Or just supratentorial pain?

Unfortunately real pain frequently has a significant supratentorial component to it. I’ve seen individuals with real, painful pathology that have responded well to haldol; however, these are typically patients that are exhibiting an exaggerated response to their real pain. I have found it much less effective in those that have a more subdued response to their pain.

Important to note that haldol was originally created as a pain med (it was derived from meperidine) but was found to be ineffective in this regard. I suspect the individuals they originally studied haldol in were not our typical coked-up, meth’d up, narcotic withdrawing, generalized anxiety disorder, bipolar, borderline/histrionic/antisocial personality disorder types that we care for in the ER. I suspect, as I’m sure most others reading this thread do as well, that haldol’s mechanism of action for pain is simply its ability to alter an individual’s perception of pain. The pain never changes, the patient’s mood is just stabilized so that they may perceive the pain as it actually is. This is probably why people with legitimate painful conditions who are demonstrating a normal response to said pain, see little benefit from haldol, as their mood is already stable.

 

[thegenius]

Unfortunately real pain frequently has a significant supratentorial component to it. I’ve seen individuals with real, painful pathology that have responded well to haldol; however, these are typically patients that are exhibiting an exaggerated response to their real pain. I have found it much less effective in those that have a more subdued response to their pain.

Important to note that haldol was originally created as a pain med (it was derived from meperidine) but was found to be ineffective in this regard. I suspect the individuals they originally studied haldol in were not our typical coked-up, meth’d up, narcotic withdrawing, generalized anxiety disorder, bipolar, borderline/histrionic/antisocial personality disorder types that we care for in the ER. I suspect, as I’m sure most others reading this thread do as well, that haldol’s mechanism of action for pain is simply its ability to alter an individual’s perception of pain. The pain never changes, the patient’s mood is just stabilized so that they may perceive the pain as it actually is. This is probably why people with legitimate painful conditions who are demonstrating a normal response to said pain, see little benefit from haldol, as their mood is already stable.

excellent response zebra...makes great sense.

 

[deleted109597]

Yes, it is most effective for audible pain, audible vomiting, audible anything.

 

[Dred Pirate]

I too have had that problem. They will only allow 2mg IV max.

So it makes that part difficult.

5 IM is OK though




I was thinking of ordering 1mg IV q1 min PRN pain up to 5 doses
See what the pharmacist thinks of that

why the heck do they limit the dose to 2mg? That is crazy - 1 q 1 min is obviously kind of silly, but nothing wrong with giving 5 (I have seen 10 on occasion and never seen any issues). obviously with QTC is is not a big deal 99% of the time - but that 1% (or probably less) - ya - it can be an issue

 

[filhodeinferno]

So does Haldol work for real pain? Like acute appendicitis, MI, cellulitis, orthopedic fractures, stuff like that? Or just supratentorial pain?

I use haldol a ton for histrionics and supratentorial pain, no matter where in the body. I have learned to become nervous when I give it and it doesn't work. Once gave it to a frequent flier, known drug seeker who was screaming her butt off from abdominal pain. Didn't work. Ended up doing a CT and turns out she had free air in the abdomen, went to OR. Whoops. Honestly, if I hadn't given her haldol I may not have actually given her her 15th CT scan of the year. Not to say that Haldol doesn't work for "real" pain, but if it doesn't work, it should make you think twice.

I also work 2 diff gigs in 2 diff states. Funny how one gig it is used like candy, nurses know how to sell it, everyone gives it IV. At my other gig it's almost as if an alarm goes off overhead when I order it, and the nurses don't trust it and always come back saying "the patient refused haldol." Yeah, I'm sure they refused it after you talked them out of it.

 

[Merely]

Do you guys know the mechanism behind it’s usefulness?

 

[southerndoc]

Do you guys know the mechanism behind it’s usefulness?

Most of the time it causes an extreme case of STFU.

Works on the dopamine receptors. Same effect as droperidol, which is coming back (yay!).

 

[Dred Pirate]

Most of the time it causes an extreme case of STFU.

Works on the dopamine receptors. Same effect as droperidol, which is coming back (yay!).

its back, but on back order :-(

 

[SamtheWise]

I once gave haldol to someone with real intrabdominal pathology, I thought they were full of it until I saw the CT scan.

Worked pretty well, I actually asked them about it and they said it helped with the nausea more than the pain but was still a relief.

 

[Arch Guillotti]

I give it for recalcitrant postop N/V, usually just 1-2.5 mg though.

 

[DrGasPasser]

Most of the time it causes an extreme case of STFU.

Works on the dopamine receptors. Same effect as droperidol, which is coming back (yay!).

Yeah, we got an email from pharmacy that droperidol is back provided that the QTc is normal. For those of you who like haldol for all that ails the cortex, wait until you try the drug that begins with “D.” Tell chronic painers that you’re going to give them something so strong that you need to check their ECG first to make sure their heart can take it...

 

[southerndoc]

The Anesthesia folk did a FOIA request from the FDA. The number of deaths for dosages <2.5 mg was only 2. Some deaths were reported multiple times, many had dosages >25 mg (one with a 250 mg dose, one had an epidural injection of droperidol), many had sepsis/alcohol intoxication/suicide attempts, etc. I think there were only like 5 out of 250 deaths that could have been attributed to droperidol with >2 million doses being given over that time frame.

Amoxicillin probably kills more people than droperidol does. Acetaminophen certainly does.

 

[thegenius]

Do you guys know the mechanism behind it’s usefulness?

Pain and the perception of pain is a complex thing. I look at it as 1) the amount of pain the medical problem produces, and 2) the amount of distress dealing with that pain. To my knowledge Haldol does little for those in #1, but does a tremendous amount for those in #2.

Things like a fractured wrist can be painful. I've never broken my wrist, but in my mind a fractured wrist is something that is extremely painful if you manipulate it, and probably only mild, maybe moderately painful if you don't touch it.

We have all taken care of patients with a fractured wrist who are just screaming in pain and flailing about and just causing a terrible scene. Those will do quite well with a dose of Haldol. Then there are those who have a fractured wrist who are calm, don't care (or appear to care) if you gently touch their wrist and do a simple neurovascular exam, and really only have pain when you manipulate it. And when you do they don't scream and yell and thrash about in the bed, they say calmly "that really hurts." You almost don't believe them because they are calm. For those...giving Haldol won't do all that much, if anything.

Haldol is great for those who have a significant amount of distress from their pain.

 

[AlmostAnMD]

I'm rotating through an inner city hospital right now and I'm giving out more haldol in the last 3 weeks than in the last 3 years. Whoever said it's good for "audible anything"....is totally correct, that is the main use of haldol

What's interesting is one of the veteran docs here says he's been giving haldol 10 mg IV for decades without ever having a problem (on anyone normal adult size and above). I stick to 5, but I've repeated the dose to titrate to STFU

 

[DrGasPasser]

The Anesthesia folk did a FOIA request from the FDA. The number of deaths for dosages <2.5 mg was only 2. Some deaths were reported multiple times, many had dosages >25 mg (one with a 250 mg dose, one had an epidural injection of droperidol), many had sepsis/alcohol intoxication/suicide attempts, etc. I think there were only like 5 out of 250 deaths that could have been attributed to droperidol with >2 million doses being given over that time frame.

Amoxicillin probably kills more people than droperidol does. Acetaminophen certainly does.

Yeah, the story behind droperidol is pretty twisted. The Cliff’s Notes version goes something like this:

Droperidol had been used safely for some 30 years. GlaxoSmithKline was a manufacturer of droperidol under the trade name Inapsine. It turns out that GSK didn’t like the fact that droperidol, their inexpensive generic, was beating the pants off of the parenteral preparation of their patented drug, Zofran, for nausea and vomiting. So, they dropped the dime on their own drug to get it black boxed for QT prolongation and torsades. That resulted in literally billions in profits for GSK as Zofran became the default intravenous medication for vomiting.

I think there was roughly 30 cases of torsades over 30 years with virtually all of those cases being patients with a lot of reasons to have QT prolongation other than droperidol (severe electrolyte disturbance, drug overdoses, etc.). Like you said, the number of deaths is even smaller. Many of us suspect that GSK coordinated with the FDA to overstate the danger when both knew that the drug was safe.

Do I use a lot of haldol and droperidol? Absolutely- both IV and IM. I find that 5 mg of hadol IV with 25 of Benadryl puts most adults to sleep; occasionally another 5 mg dose is needed. Do I get an ECG in every patient? Absolutely not. At the same time, I don’t give it to patients with known electrolyte disturbances (K and Mg), people on multiple QT prolonging meds, or when I already know the QTc is more than 480-500ms or so. Just use common sense.

 

[TooMuchResearch]

We have it. Until I use it all.

its back, but on back order :-(

 

[TooMuchResearch]

You don't really need an ECG first.

There are a couple of papers that support not getting one.

Yeah, we got an email from pharmacy that droperidol is back provided that the QTc is normal. For those of you who like haldol for all that ails the cortex, wait until you try the drug that begins with “D.” Tell chronic painers that you’re going to give them something so strong that you need to check their ECG first to make sure their heart can take it...