Few drugs blackmail me like droperidol. It is a superb and unmatched tool in our pharmaceutical hangar. It’s a sophisticated instrument, a targeted dart, a brilliant medicine to take control of a patient with agitated delirium.
The sedation of very excited and dangerous patients is always heavy. As a procedure, it has an extremely narrow therapeutic window. The ledger on the risk side is full. But we in Western Australia have a special love affair with this agent because we wear the unenviable crown of the meth capital of the world. Why that might be an entirely different story. It has, however, given us a fairly extensive experience of rapid and effective sedation.
I am old. I have been through the generational changes when it comes to emergency room sedation. All we had when I was a trainee was midazolam and occasionally thiopentone for RSI, and we only had midazolam and haloperidol for sedatives for agitated patients. A general rule of thumb has always been that it was time to think about alternatives when you hit 50 mg of each of these without success. But those were the days before methamphetamine; the drugs were paler, and a lot of people just got calm, drowsy, and a little apneic on heroin and things.
Now our sedation needs are considerably more complex. Fortunately, so are drugs. We are grateful here that droperidol did not deserve the Black Box warning it made in the United States. It was an interesting event. Droperidol as monotherapy does not and has never been shown to increase the QT interval in a clinically relevant way to induce torsades, a recent study confirms. (Ann Emerg Med. 2015; 66: 230; https://bit.ly/3bz5H37.)
This whole Black Box episode was a bit sketchy, wasn’t it? Was there more to the story than worry for Torsades? Should we follow the money? I do not know. This is not the column for such questions. I am a tortured poet wearing the skin of an emergency physician, not an investigative journalist. The problem is, however, that the stench of being defiled in this manner persists. I have no doubt that people are still wary of using droperidol or maybe unaware of its use. Maybe not sure about its benefits. Let me, as Shakespeare would say, count the paths.
An angry beast
As a first generation butyrophenone or antipsychotic, it has a tailored profile of reducing psychomotor agitation (a strong calming factor in people aroused by the sympathetic system), decreasing psychosis (as stated on the label ) and sedation without too much respiratory depression. The trifecta of calm. It can be safely administered intramuscularly or intravenously; 10 mg as a starting dose is always safe. In my shop we almost always use IV. We have a battalion of security guards to keep a limb stable and free, which allows us to jump like gazelles on the patient and insert an IV. Many (in fact, most of the world) consistently oppose this approach, claiming that MI is safer across the board, but the 20-30 minute lag for the effect is simply impossible to bear in any way. a ward with several similar patients and the patient in question displaying the strength, manners and danger of a pissed off beast.
Droperidol goes well with a benzodiazepine seasoning. We tend to dribble in midazolam as a hunter, but it is no longer the predominant agent. Data from the DORM study and others repeatedly tell us that the more benzodiazepines are used, the greater the risk of adverse events, mainly decreased respiratory function, desaturation and the need for intervention. respiratory tract. (Ann Emerg Med. 2010; 56: 392; https://bit.ly/3jZo45M.)
Ketamine is a relative newcomer to the block for IM sedation of the patient with agitated delirium. It can also be spectacularly effective, but its side effect profile is slightly worse than droperidol, plus the biological argument for not using an agent that itself causes sympathetic stimulation in the already uncontrollable sympathetic tornado of poisoning. to methamphetamine is compelling (although I admit the data does not support this so far). Four mg / kg IM are certainly effective and faster than some of the other IM agents (the average time to effective sedation is between 10 and 20 minutes).
As always, it is up to each of us to make the best decisions about treatment interventions based on the best available evidence. We know that no evidence is waterproof, and protocols, personal preferences, and patient populations vary around the world with staggering heterogeneity. This column was just my little love song to droperidol, a stylish agent that saved my skin more times than I could count.
It seems entirely appropriate to end with Sonnet 27 by the Bard himself.
Tired of toil I hurry to my bed,
The dear rest for the members tired by the trips;
But then begins a journey in my head,
To work my mind, when the work of the body has expired:
‘Cause then my thoughts (from afar where I live)
Hear a zealous pilgrimage to you,
And keep my droopy eyelids wide open,
Watching the darkness the blind see[.]
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Dr johnstonis a certified emergency doctor, so the same as you but with a weird accent. She works in a trauma center located at the old fashioned end of Perth, Western Australia. She is the author of the novel Falling dust, available on his website, http://michellejohnston.com.au/. She is also a regular contributor to the Life in the Fast Lane blog athttps://lifeinthefastlane.com. Follow her on twitter@Eleytheriusand read its columns passed tohttp://bit.ly/EMN-WhatLiesBeneath.