RCT – Droperidol, Ziprasidone, and Lorazepam Walk Into a Bar…

Written by Clay Smith

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Droperidol 5mg IM was a safe, rapid way to sedate agitated patients and was more effective than IM ziprasidone 10 or 20mg and lorazepam 2mg.

Why does this matter?
Treatment of agitated patients in the ED is important for their own safety and the safety of the staff. This study was performed in 2004-2005 and was presented as an abstract but then went unpublished. Then droperidol got a black box warning followed by a nationwide shortage. Now that it’s back, the authors decided they should publish the full study.

Droperidol, ziprasidone, and lorazepam walk into a bar
This was a randomized trial comparing IM droperidol 5mg, ziprasidone 10mg, ziprasidone 20mg, and lorazepam 2mg. For the primary outcome of adequate sedation at 15 minutes, droperidol was best at 64%; compared to ziprasidone 10mg, 25%; ziprasidone 20mg, 35%, and lorazepam 2mg, 29%. The original primary outcome was difference in sedation score, which was also best with droperidol. Droperidol lasted the longest before redosing, 90 minutes. It was also just behind ziprasidone 20mg in need for additional sedation. Most of these patients were agitated because they were drunk. This study took place before K2 and bath salts, and methamphetamine use was not as common then. Mild respiratory depression, defined as a dip in SpO2 <90% or alteration of EtCO2, was common with all agents, ranging from 12-48%, but was lowest with droperidol (12%). No one needed intubation except one patient who was later found to have a subdural hematoma. None of the agents caused prolonged QTc. This study is old and out of date, but it still adds value and shows that droperidol is a safe, effective, rapid way to sedate patients with agitation.

Source
Randomized Double-Blind Trial of Intramuscular Droperidol, Ziprasidone and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department. Acad Emerg Med. 2020 Sep 5. doi: 10.1111/acem.14124. Online ahead of print.

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