Just did a talk at a forensic institution on this topic. UpToDate now lists Droperidol OR Haldol as first line treatment for acute agitation.
Watch for EPS!
short takehome: works in 3minutes, peaks in 30 minutes, lasts (theoretical) for 3 hours so often dont need another dose.
-no need for benzo, TREAT EPS, far far more sedation than haldol and absorbed almost as fast as an IV rx ...its here!
Acute Agitation Treatment
First-generation (typical) antipsychotics — The older (first generation) or "typical" antipsychotics include the butyrophenones and phenothiazines. Among the multiple medications in this class, the butyrophenones
haloperidol and
droperidol are used most often to manage acute agitation. The mechanisms and general clinical use of these agents are discussed separately (
table 3 and
table 4). (See
"First-generation antipsychotic medications: Pharmacology, administration, and comparative side effects".)
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Haloperidol has been used effectively for many years to control violent and agitated patients [
81,82]. It can be given IV, IM, or orally, although its IV use is not approved by the US Food and Drug Administration (FDA). It is usually given in doses of 2.5 to 10 mg. The onset of action is within 5 to 20 minutes for IV administration. The dose should be decreased by one half in the elderly. Some clinicians give repeat doses as frequently as every 15 to 30 minutes in patients with severe agitation until the desired level of sedation is achieved.
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Droperidol is an analog of
haloperidol with a shorter half-life. It can be given IM or IV and is usually given in doses of 2.5 to 5 mg. Its onset of action ranges from 15 to 30 minutes, with a duration of six to eight hours [
83]. Multiple randomized trials have demonstrated the effectiveness of droperidol in controlling acute agitation [
73,77,78,83-87]. A pharmacokinetics study of 41 patients adapted from a larger clinical trial reported that IM droperidol is rapidly absorbed, obviating the need for IV therapy, which can place health care and security workers at risk while attempts are made to place an intravenous catheter [
88].
Several trials demonstrate the effectiveness of first-generation antipsychotics for the treatment of acute agitation. As an example, in a randomized trial of 115 ED patients with acute undifferentiated agitation, 16 of 25 (64 percent) treated with
droperidol (5 mg IM) achieved adequate sedation at 15 minutes compared with 7 of 28 (25 percent) in the first
ziprasidone group (10 mg IM), 11 of 31 (35 percent) in the second ziprasidone group (20 mg IM), and 9 of 31 (29 percent) in the
lorazepam group (2 mg IM) [
87]. In addition, the incidence of respiratory depression was significantly lower in the droperidol group; no ventricular dysrhythmias occurred.
All first-generation antipsychotics possess quinidine-like cardiac effects resulting in QT prolongation, with the potential for causing dysrhythmias, particularly torsades de pointes. In 2001, the US Food and Drug Administration gave
droperidol a "black box" warning because of the risk of QT prolongation [
89]. A warning for
haloperidol followed in 2007 [
90]. These warnings have generated substantial debate, given the drugs' long history of effectiveness and the dearth of substantial clinical evidence demonstrating harm [
91-94]. Studies performed after the warnings appeared raise doubts about their utility:
$B!|(BIn a retrospective chart review of 16,546 patient treated with
droperidol, only one patient suffered a cardiac arrest, felt to be unrelated to the medication, and five experienced ventricular dysrhythmias, including one patient with torsades de pointes who had multiple pre-existing risk factors for this dysrhythmia [
95]. Thus, the overall incidence of severe dysrhythmia in the study was 0.006 percent.
$B!|(BA prospective observational study performed in six EDs and involving 1009 patients sedated with
droperidol (median dose 10 mg) for acute agitation who received an ECG during their workup reported no episodes of torsades de pointes and only six cases of abnormal QT intervals attributable to droperidol [
96].
We believe both drugs are effective first-line agents for the sedation of violent and acutely agitated patients. They should be used with caution in those at risk for QT prolongation, such as patients taking other medications known to prolong the QT interval, patients likely to have electrolyte disorders (eg, hypokalemia and hypomagnesemia), and patients with congenital conditions associated with QT prolongation. If feasible, an electrocardiogram (ECG) should be performed prior to administration, but this may be impossible when managing a violent patient. In such cases, an ECG should be obtained once the patient is sufficiently sedated.
In patients with severe agitation secondary to alcohol intoxication,
droperidol may be the most effective antipsychotic available as monotherapy. In a retrospective review of 11,787 patients with acute agitation due to alcohol intoxication, droperidol given as monotherapy was associated with a significantly shorter median length of stay in the ED (499 minutes) compared with parental
haloperidol (524 minutes) or
olanzapine (533 minutes) [
97].
Neuroleptics, including
haloperidol and
droperidol, should be avoided in cases of alcohol withdrawal, benzodiazepine withdrawal, other withdrawal syndromes, anticholinergic toxicity, and patients with seizures. If possible, these medications should also be avoided in pregnant and lactating females and phencyclidine overdose [
29]. First generation antipsychotics can cause extrapyramidal side effects and delayed dystonic reactions. (See
"Teratogenicity, pregnancy complications, and postnatal risks of antipsychotics, benzodiazepines, lithium, and electroconvulsive therapy" and
"Management of moderate and severe alcohol withdrawal syndromes" and
"Anticholinergic poisoning".)
Link:
UpToDate
Chemistry of Droperidol:
Droperidol - an overview | ScienceDirect Topics
2022 Manufacturer:
Droperidol / Products / American Regent
