Written by John Korducki
New research on droperidol shows that it is a safe and effective medication for a multitude of common ED presentations, despite an FDA black box warning for QTc prolongation in 2001.
Why does this matter?
Droperidol had seen a sharp decline in use in the ED due to the black box warning it received over 20 years ago but has seen a resurgence in use recent years. It has a rapid onset (3-10 min) with no significant difference whether administered IV or IM. Though it may increase QTc by about 30 msec, the significance of this is not clear and is comparable to current standard pharmacotherapy at conventional dosing for nausea/vomiting, agitation, and headache.
Drop(eridol) it like it’s hot
Review of the literature demonstrates this black box warning stemmed from data showing adverse cardiac events occurred at doses far outside (1) (i.e. 50+ mg) what is commonly administered today. Additionally, studies have shown a similar mean QTc prolongation in droperidol compared to ondansetron (2). ED based studies with a median dose of 5mg IM demonstrated no episodes of torsades de pointes in over 4,900 patients receiving droperidol (3). While there are some side effects such as akathisia, anxiety, dizziness, and rarely tachycardia and hypotension, the literature review demonstrates no increased rate of these side effects and is as effective or better than conventional therapies for headache, nausea/vomiting, and agitation.
The article notes that the EM societies AAEM and ACEP have recently advocated for the use of droperidol, particularly in the setting of agitation. They have even stated that at doses of 2.5 mg or less, or 5-10 mg in an agitated patient does not require an EKG for a QTc check for most patients.
Take home: We should “drop” droperidol’s bad reputation and should feel comfortable utilizing this Swiss Army knife of a medication to provide safe, effective care of our patients.
Emergency medicine updates: Droperidol. Am J Emerg Med. 2022 Jan 14;53:180-184. doi: 10.1016/j.ajem.2022.01.011. Online ahead of print.
- van Zwieten K, Mullins ME, Jang T. Droperidol and the black box warning. Ann Emerg Med. 2004;43(1):139-140. doi:10.1016/j.annemergmed.2003.05.006
- Charbit B, Albaladejo P, Funck-Brentano C, Legrand M, Samain E, Marty J. Prolongation of QTc interval after postoperative nausea and vomiting treatment by droperidol or ondansetron. Anesthesiology. 2005;102(6):1094-1100. doi:10.1097/00000542-200506000-00006
- Klein LR, Driver BE, Horton G, Scharber S, Martel ML, Cole JB. Rescue sedation whentreating acute agitation in the emergency department with intramuscular antipsy-chotics. J Emerg Med. 2019;56(5):484–90