Droperidol/Midazolam Combo Curbs Agitation in ED Patients

A combination of droperidol and midazolam was more effective than haloperidol plus lorazepam for achieving sedation in agitated patients in an emergency department (ED) setting in a study involving 86 adult patients at a single tertiary medical care center.

Patients with acute agitation present significant safety concerns in the emergency department, according to Jessica Javed, MD, of the University of Louisville, in Kentucky, and colleagues.

A combination of haloperidol and lorazepam has been widely used to curb agitation in these patients, but droperidol and midazolam could be more effective, owing to faster onset of action, Javed noted in a presentation at the American College of Emergency Physicians (ACEP) 2021 Scientific Assembly.

Javed and colleagues conducted a prospective study to compare time to adequate sedation in agitated patients in the ED. In the trial, 43 patients received droperidol 5 mg plus midazolam 5 mg, and 43 patients received haloperidol plus lorazepam 2 mg. The average age of the patients in the droperidol/midazolam group was 34 years; the average age of the patients in the haloperidol/lorazepam group was 38 years. Baseline demographics, including height, weight, body mass index, and baseline Sedation Assessment Tool (SAT) scores, were similar between the groups.

The SAT score scale ranges from +3 (combative, violent, or out of control) to -3 (no response to stimulation); zero indicates being awake and calm/cooperative. The median baseline SAT score was 3 for both treatment groups.

The primary outcome was the proportion of patients with adequate sedation (defined as SAT scores of ≤0) 10 min after treatment.

Significantly more patients in the droperidol/midazolam group met this outcome compared to the patients in the haloperidol/lorazepam group (51.2% vs 7%). Also, significantly more patients in the droperidol/midazolam group achieved adequate sedation at 5, 10, 15, and 30 min than in the haloperidol/lorazepam group.

Fewer patients in the haloperidol/lorazepam group required supplemental oxygen compared to the droperidol/midazolam group (9.3% vs 25.6%). However, none of the droperidol/midazolam patients required rescue sedation, compared to 16.3% of the haloperidol/lorazepam patients, Javed noted. None of the patients required endotracheal intubation or experienced extrapyramidal symptoms, she said.

The study was limited by the small sample size and inclusion of data from only a single center.

The results suggest that droperidol/midazolam is superior to IM haloperidol/lorazepam for producing adequate sedation after 10 min in agitated patients, Javed concluded.

The study received no outside funding. The researchers have disclosed no relevant financial relationships.

American College of Emergency Physicians (ACEP) 2021 Scientific Assembly: Abstract 122.

Ann Emerg Med. Published online October 1, 2021. Full text

Heidi Splete is a freelance medical journalist with 20 years of experience.

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