Droperidol in
mg
0.625 im
or iv: nausea
1.25 im or iv, nausea
2.5 im or
iv, migraine
5.0 im or iv, psychosis and agitation
10.0 im or
iv, psychosis, extreme violence
The IM
doses are great in that an IV is not needed with droperidol for rapid
action.
A large study shows no change in rates of sedation related death or TdP despite no use of droperidol (Anesth 2007;107:531)
Nobay F, Simon BC, Levitt MA, Dresden GM. A prospective,
double-blind, randomized trial of midazolam versus
haloperidol versus lorazepam in the chemical restraint of violent and severely
agitated patients. Acad Emerg Med.
2004 Jul;11(7):744-9.
Time to onset Time to
arousal
Lorazepam (2 mg IM) 32.2 min 217.2 min
Haloperidol (5 mg IM) 28.3 min 126.5 min
Midazolam (5 mg IM) 18.3 min 81.9 min
Battaglia, J. et al. "Haloperidol, lorazepam, or both for psychotic
agitation? A multicenter, prospective, double-blind, emergency department
study." Am.J.Emerg.Med. 15.4 (1997): 335-40.
This is the classic article that compared haloperidol, lorazepam and the
combination of the two in agitated patients in the ED. All three treatment
groups showed a decrease in agitation as measured by the Agitated Behavior
Scale, Brief Psychiatric Rating Scale and the Clinical Global Impressions scale.
The combination of haloperidol and lorazepam was more effective at decreasing
agitation when compared with haloperidol alone or lorazepam alone. The only
negative side effect noted with this combination of medications is an increased
length of time that patients were asleep.
Hill, S. and J. Petit. "The violent patient." Emerg.Med.Clin.North Am. 18.2
(2000): 301-15, x.
This is an excellent review article by an emergency physician about the overall
care of the violent patient in the ED. It provides a comprehensive algorithm for
assessing violent behavior and providing interventions in a stepwise manner. The
review includes a discussion of patient's rights and the various methods of
restraints.
Currier, G. W. "Atypical antipsychotic medications in the psychiatric emergency
service." J.Clin.Psychiatry 61 Suppl 14 (2000): 21-26.
This article provides a brief review of the atypical antipsychotics. It
concentrates on the comparison between haloperidol and risperidone. The author
concludes that risperidone is as efficacious at treating psychosis as
haloperidol with significantly less side effects, particularly EPS.
Miller, C. H. et al. "The prevalence of acute extrapyramidal signs and symptoms
in patients treated with clozapine, risperidone, and conventional antipsychotics."
J.Clin.Psychiatry 59.2 (1998): 69-75.
This article provides a comparison of the EPS effects of two atypical
antipsychotics, clozapine and risperidone, and conventional antipsychotics. 106
patients were treated for at least 3 months. The prevalence of akathisia in the
clozapine group was 7.3%, 13% in the risperidone group and 23.8% in the group
treated with conventional antipsychotics. There is a very good explanation about
how the ratio of 5-HT2 receptor blockade to D2 receptor blockade may determine
the incidence of the EPS side effects in the atypical antipsychotics.
Head to head randomized study of 5-10 mg Haldol vs. 7.5-15 mg versed given IM.
Both effective Midazolam was quicker to work. Low side effects. (BMJ
327:27, Sept 2003)
(Annals 2004 43:1) 3 cases of droperidol death at normal doses:
1. 48 hrs after 5 mg drop while on many other drugs
2. .625 mg drop on numerous card meds c other PMH
3. 5 mg in an illicit drug user
Review by James Roberts (Emerg Med News Sept 2007)
(Can Med J 1998;158(12):1603)
21 deaths
all were in prone/hogtie or with pressure applied to neck
patients die a bradycardic, hyperthermic, acidotic death
? administer large amounts of bicarb if they code?
Am J Emerg Med 2001;19:187
18 cases
all were in prone/hobble, all had excited delerium, all were struggling against their restraints
Am J Forensic Med Pathol 1998;19(3):201)
body position alone is not enough to cause death, though frc and hypoxia is certainly worse in this position