Prospective study of haloperidol plus lorazepam versus droperidol plus midazolam for the treatment of acute agitation in the emergency department

• Published in: The American journal of emergency medicine Vol. 55; pp. 76 - 81
• Main Authors: Thiemann, Pauline, Roy, David, Huecker, Martin, Senn, Joshua, Javed, Jessica, Thomas, Alyssa, Shreffler, Jacob, Shaw, Isaac
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.05.2022; Elsevier Limited
• Subjects: Acute agitation; Agitation; Anesthesia; Antipsychotic Agents - adverse effects; Benzodiazepines; Clinical trials; Dihydrotachysterol - therapeutic use; Droperidol; Droperidol - therapeutic use; Drug administration; Emergency; Emergency medical care; Emergency Service, Hospital; Enrollments; Extrapyramidal system; Haloperidol; Haloperidol - therapeutic use; Humans; Intubation; Lorazepam; Lorazepam - therapeutic use; Midazolam; Midazolam - therapeutic use; Observational studies; Oxygen; Patients; Pharmacists; Prospective Studies; Psychomotor Agitation - drug therapy; Psychotropic drugs; Quality improvement; SAT assessment; Supplements; Survival analysis; Acute agitation; Lorazepam; Midazolam; Haloperidol; Droperidol
• ISSN: 0735-6757; 1532-8171; 1532-8171
• DOI: 10.1016/j.ajem.2022.02.042

The objective of this study was to compare the combination of intramuscular (IM) droperidol/midazolam to haloperidol/lorazepam regarding time to sedation in patients with acute undifferentiated agitation in the emergency department (ED). This was a prospective, unblinded observational study in the ED of a university teaching hospital. Subjects with acute undifferentiated agitation refractory to verbal de-escalation were assigned to receive a combination of either haloperidol 5 mg/lorazepam 2 mg or droperidol 5 mg/midazolam 5 mg IM. The primary outcome was the proportion of patients adequately sedated at 10 min defined as ED Sedation Assessment Tool (SAT) score of 0 or less. Secondary outcomes included change in ED SAT score at 5, 15, 30, and 60 min, the need for oxygen supplementation, and the need for airway intervention. A total of 86 patients were enrolled in the study, with 43 patients receiving droperidol/midazolam and 43 patients receiving haloperidol/lorazepam. Ten minutes after receiving medication, 51.2% of patients in the droperidol/midazolam group were adequately sedated compared to 7% of patients in the haloperidol/lorazepam group (OR: 14; 95% CI: 3.7, 52.1). Median time to adequate sedation was 10 min for the droperidol/midazolam group and 30 min for the haloperidol/lorazepam group. Eleven patients (25.6%) in the droperidol/midazolam group received oxygen supplementation compared to four patients (9.3%) in the haloperidol/lorazepam group. No study patients experienced extrapyramidal symptoms or required endotracheal intubation. Intramuscular droperidol/midazolam was superior to intramuscular haloperidol/lorazepam in achieving adequate sedation at 10 min. Patients in the droperidol/midazolam arm may be more likely to receive oxygen supplementation than those in the haloperidol/lorazepam arm.