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Droperidol offers advantages for quelling violent behavior in the ED

Clinical Question:
Is midazolam or droperidol more effective for sedating violent or aggressive patients in an emergency department?

Bottom Line:
Droperidol (Inapsine), a highly sedating antipsychotic that has fallen out of favor because of concern for arrhythmia, was as effective as midazolam (Versed) in sedating violent or aggressive patients and was less likely to require a second sedative dose. Droperidol also caused less oversedation than midazolam. Although the authors measured QT prolongation (the concern with droperidol), the study was too small to accurately assess the risk. (LOE = 1b)

Reference:
Isbister GK, Calver LA, Page CB, Stokes B, Bryant JL, Downes MA. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: The DORM study. Ann Emerg Med 2010;56(4):392-401.  [PMID:20868907]

Study Design:
Randomized controlled trial (double-blinded)

Funding:
Government

Allocation:
Concealed

Setting:
Emergency department

Synopsis:
Conducting this study in a busy, urban emergency department, these researchers enrolled 91adults whose violent and acute behavior was assessed by a treating clinician and defined as requiring physical restraint and pharmacologic sedation. The patients were randomized, using concealed allocation, to receive a single intramuscular dose of midazolam 10 mg, droperidol 10 mg, or the combination of midazolam 5 mg and droperidol 5 mg. Patients' autonomic signs (pulse, blood pressure, respiratory rate, and oxygen saturation) were monitored every 5 minutes for the first 30 minutes, every 15 minutes for the next 90 minutes, and hourly for the next 3 hours. The Altered Mental Status Scale was used to assess agitation and sedation. Additional sedation could be administered if deemed necessary. The primary outcome was a little softer: The duration of violent and acute behavior as measured by the time that the security staff was required to be present as part ot their standard protocol. This duration, on average, was similar in all 3 groups (average = 20-25 minutes). Patients who received midazolam were approximately twice as likely as those who received droperidol to require additional sedation (hazard ratio = 2.31; 95% credible interval, 1.01 - 4.71). Oversedation was more common with midazolam.

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