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• W4386585791 abstract "Figure: droperidol, sedationFigureFew drugs make me sing the way droperidol does. It is a superb and unsurpassed tool in our pharmaceutical shed. It is a sophisticated instrument, a focused dart, a brilliant drug for gaining control of a patient with agitated delirium. Sedating highly aroused and dangerous patients is always fraught. As a procedure, it has an extremely narrow therapeutic window. The ledger on the risk side is full. But we in Western Australia have a particular love affair with this agent because we sport the unenviable crown of methamphetamine capital of the world. Why that might be is an entirely different story. It has, however, afforded us the opportunity to gain some rather extensive experience with rapid, effective sedation. I am old. I have plodded through generational changes when it comes to sedation in the ED. All we had when I was a trainee was midazolam and occasionally thiopentone for RSI, and we only had midazolam and haloperidol for sedating agitated patients. A general rule has always been that it was time to think about alternatives when you reached 50 mg of each of those without success. But those were the pre-meth days; the drugs were paler, and many people would simply get quiet, sleepy, and a little apneic on heroin and the like. Now our sedation needs are substantially more complex. Thankfully so are the drugs. We are grateful here that droperidol did not earn itself the Black Box warning it did in the United States. That was an interesting occurrence. Droperidol as a single agent does not and has never been shown to increase the QT interval in a clinically relevant way to cause Torsades, which a recent study confirms. (Ann Emerg Med. 2015;66[3]:230; https://bit.ly/3bz5H37.) That whole Black Box episode felt kind of fishy, didn't it? Was there more to the story than the concern for Torsades? Should we be following the money? I don't know. This is not the column for such questions. I am a tortured poet wearing the skin of an emergency physician, not an investigative journalist. The problem is, though, the stench of being besmirched in this way lingers. I have no doubt people are still suspicious of using droperidol or perhaps unfamiliar with its use. Maybe unsure of its benefits. Let me, as Shakespeare would say, count the ways. A Riled-Up Beast As a butyrophenone or early-generation antipsychotic, it has a bespoke profile of reducing psychomotor agitation (a strong calming factor in the sympathetically aroused), decreasing psychosis (as it says on the label), and sedating without much respiratory depression. The trifecta of calm. It can be safely given intramuscularly or intravenously; 10 mg as a starting dose is consistently safe. We in my shop almost always use IV. We have a battalion of security staff to keep a limb steady and free, allowing us to leap like gazelles on top of the patient and insert an IV. Many (in fact, most worldwide) consistently argue against this approach, saying IM is safer all round, but the 20-30-minute lag for effect is simply not possible to endure in a department heaving with multiple similar patients and the patient in question displaying the strength, manner, and danger of a riled-up beast. Droperidol does well with a seasoning of benzodiazepine. We tend to dribble in midazolam as a chaser, but this is no longer the predominant agent. Data from the DORM study and others repeatedly tell us that the more benzodiazepines are used, the greater the risk of adverse events, primarily decreased respiratory function, desaturation, and requirement for airway intervention. (Ann Emerg Med. 2010;56[4]:392; https://bit.ly/3jZo45M.) Ketamine is a relative newcomer on the block for IM sedation of the patient with agitated delirium. It too can be spectacularly effective, but its side effect profile is slightly worse than droperidol, plus the biologic argument for not using an agent that itself causes sympathetic stimulation in the already out-of-control sympathetic tornado of methamphetamine intoxication is compelling (although I concede that data are not bearing this out so far). Four mg/kg IM is certainly effective and quicker than some of the other IM agents (mean time to effective sedation is somewhere between 10 and 20 minutes). As always, it is up to each of us to make the best decisions about therapeutic interventions based on the best available evidence. We know no single piece of evidence is watertight, and protocols, personal preference, and patient populations vary around the world with staggering heterogeneity. This column was simply my little love song to droperidol, a most elegant agent, one that has saved my skin more times than I could possibly count. It only seems fitting to finish with Sonnet 27 by the Bard himself. Weary with toil I haste me to my bed, The dear repose for limbs with travel tired; But then begins a journey in my head, To work my mind, when body's work's expired: For then my thoughts (from far where I abide) Intend a zealous pilgrimage to thee, And keep my drooping eyelids open wide, Looking on darkness which the blind do see[.] Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected]. Dr. Johnstonis a board-certified emergency physician, thus the same as you but with a weird accent. She works in a trauma center situated down the unfashionable end of Perth, Western Australia. She is the author of the novel Dustfall, available on her website, http://michellejohnston.com.au/. She also contributes regularly to the blog Life in the Fast Lane athttps://lifeinthefastlane.com. Follow her on Twitter@Eleytheriusand read her past columns athttp://bit.ly/EMN-WhatLiesBeneath." @default.
• W4386585791 created "2023-09-11" @default.
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• W4386585791 date "2022-01-01" @default.
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• W4386585791 title "What Lies Beneath" @default.
• W4386585791 doi "https://doi.org/10.1097/01.eem.0000815564.77810.e6" @default.
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