In this episode, I’ll discuss which works better for agitation in the ED – droperidol, ziprasidone, or lorazepam?
When treating acutely agitated ED patients that need sedation because they are a physical danger to themselves or others, clinicians may have a preference for the choice of sedative based on the cause of the agitation. For example, benzodiazepines are usually preferred for agitation from medication intoxication or withdrawal while antipsychotic agents are preferred for patients with a known psychiatric disorder.
However, in the setting of acute agitation, it is not always possible to discern the patient’s past medical history before needing to give an agent for agitation.
This is usually referred to as ‘undifferentiated acute agitation’ and both benzodiazepines or antipsychotics may be given.
Researchers recently published in Academic Emergency Medicine A Randomized Double-blind Trial of Intramuscular Droperidol, Ziprasidone, and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department.
115 Agitated ED patients were randomized to either 5 mg of droperidol, 10 mg of ziprasidone, 20 mg of ziprasidone, or 2 mg of lorazepam, all given intramuscularly.
Sedation efficacy, as well as respiratory and cardiac adverse effects, were evaluated. The primary outcome was adequate sedation at 15 minutes.
Efficacy was 64% for droperidol, 25% and 35% for 10 and 20 mg doses of ziprasidone, and 29% for lorazepam.
Despite higher efficacy, the authors found no significant difference between groups in need of additional rescue sedation.
Respiratory depression was lowest with droperidol at 12% compared with 36% and 39% for both doses of ziprasidone and 48% for benzodiazepines. There were no ventricular arrhythmias and QTc durations were not significantly different between groups.
In this cohort of patients, droperidol was more effective for undifferentiated acute agitation than the other agents.
One interesting note is that this study was conducted in 2004 but only recently published. The authors mention that the study was not published due to competing priorities for the investigators’ time. However, due to renewed interest in droperidol, they decided to publish their old data. The age of the study might mean that certain intoxicants that cause agitation such as K-2 were not represented in the patient population. Otherwise, droperidol had impressive performance in the this randomized controlled trial compared to ziprasidone and lorazepam.
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