Point-Counterpoint | IV Haloperidol Should be Avoided in the Emergency Department

February 15, 2023

Written by Nickolas Srica

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Here are the counterpoints for why these authors think intravenous (IV) haloperidol (Haldol) should be avoided in the emergency department setting.

Why does this matter?
There are a host of medication options for both sedation and refractory vomiting, of which haloperidol is one. Given its potential for adverse effects, should it be our first choice?

Haldol, schmaldol…
These authors had the following key points to make for why IV haloperidol should NOT be used in the ED:

• Despite frequent use of IV haloperidol over the years for many different indications, there are safer and more effective alternative medications and routes of administration.
• Intravenous administration increases the risk of QT prolongation and torsades de pointes, which prompted an FDA boxed warning.
• In a 2010 retrospective review of case reports, though 97% of cases of QT prolongation/torsades had another risk factor, no specific risk factor adequately predicted risk, and 24% of the patients were under 40 years of age.
• A 2018 randomized controlled trial for IV haloperidol using up to 20 mg daily for delirium showed no increase in QT prolongation/torsades, but it was limited to critically ill and already risk-stratified patients in the ICU, making it difficult to generalize these findings to an ED setting often filled with unknowns.
• A cross-sectional study looking at 1,017 otherwise medically healthy patients with schizophrenia did show even low dose (2 mg) IV haloperidol was associated with QTc prolongation, where oral administration was not.
• Dystonic reactions and extrapyramidal symptoms occur at a lower incidence when using droperidol instead of haloperidol and can be avoided entirely with benzodiazepines, barbiturates, or NMDA antagonists instead (though the elderly population is one area haloperidol may still offer an advantage).
• Overall, it would be best to check for electrolyte abnormalities, a baseline ECG, and other QT-prolonging medications prior to administering IV haloperidol. Given the difficulty of obtaining this information quickly and safely when facing an undifferentiated agitated patient in the ED, we should consider reaching for other more appropriate medications instead of IV haloperidol when able.

Source
Intravenous Haloperidol Has a Limited Role in the Modern Emergency Department. Annals of Emergency Medicine. 2023;81:96-98. doi: 10.1016/j.annemergmed.2022.07.008