SGEM#328: I Can’t fight this Med Any Longer – Droperidol for Acute Agitation

Date: April 19th, 2021 Guest Skeptic: Dr. Kirsty Challen (@KirstyChallen) is a Consultant in Emergency Medicine and Emergency Medicine Research Lead at Lancashire Teaching Hospitals Trust (North West England). She is Chair of the Royal College of Emergency Medicine Women in Emergency Medicine group and involved with the RCEM Public Health and Informatics groups. Kirsty is also the creator of the wonderful infographics called #PaperinaPic. Reference: Martel et al. Randomized Double-blind Trial Intramuscular Droperidol, Ziprasidone and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department. AEM April 2021 Case: You are sitting minding your own business charting on shift when you become aware of shouting and banging from your ambulance bay.  On investigating you find a collection of nursing, EMS and hospital security personnel surrounding an obviously agitated patient with blood on his head who is attempting to punch them. The nurse wants to know what medications he can get to chemically restrain the patient. Background: We have covered the issue of excited delirium back in SGEM#218 with a systematic review which found that the evidence base for most pharmacological treatments at that point was poor. Way back in 2013 we looked at haloperidol for agitation due to psychosis (SGEM#45) and concluded that it was an effective treatment but had common side effects. Droperidol has been used widely, particularly in Australasia, for acute severe agitation. Unfortunately, an FDA Black Box warning and supply issues meant that droperidol effectively vanished from the US armamentarium from 2013-2019 and other agents were used and investigated. Clinical Question: In patients needing parenteral sedation for acute agitation, is droperidol, ziprasidone or lorazepam intramuscularly  most effective and safe? Reference: Martel et al. Randomized Double-blind Trial Intramuscular Droperidol, Ziprasidone and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department. AEM April 2021 Population: Emergency department (ED) patients 18 years or old where the treating physician determined the need for parenteral sedation for acute agitation (it needed a patient or staff safety concern, not purely a high agitation score). Exclusions: Prisoners or those in police custody, pregnant or breast-feeding, or with documented allergy to any study medications. Intervention: Droperidol 5mg IM, Ziprasidone 10mg IM or Ziprasidone 20mg IM Comparison: Lorazepam 2mg IM Outcome: Primary Outcome: Adequate sedation at 15 minutes was defined as an Altered Mental Status Scale (AMSS) of zero Secondary Outcomes: Need for additional sedation, ED length of stay, respiratory depression (SpO2<90% requiring supplemental O2, EtCO2 falling by 10mmHg or rising by 15mmHg). Dr. Marc Martel This is an SGEMHOP episode, which means we have the lead author on the show. Dr. Martel is a practicing emergency physician at Hennepin County medical center in Minneapolis, Minnesota since 2000.  He has been a nocturnist for essentially his entire career.  Dr. Martel’s research focuses on finding the safest way to care for patients with acute agitation while respecting patient's dignity, limiting restraint use, and efficiently getting them care they need. Authors’ Conclusions: “Droperidol was more effective for sedation and was associated with fewer episodes of respiratory depression than lorazepam or either dose of ziprasidone.”  Quality Checklist for Randomized Clinical Trials: The study population included or focused on those in the emergency department. Yes The patients were adequately randomized. Yes The randomization process was concealed. Yes The patients were analyzed in the groups to which they were randomized. Unsure The study patients were recruited consecutively (i.e. no selection bias). No The patients in both groups were similar with respect to prognostic factors....