Welcome to UH EMS-I’s Pharmacy Phriday. In this installment, we will focus on not one medication, but two of the listed medications in your UH protocols. These two medications, haloperidol and droperidol, are used for cases of the agitated patient and can be found referenced in the “Behavioral/Agitation/Combative” algorithm.
Several options exist in the protocol for the provider to use when sedating the agitated patient. The choice of medications used can be based on many factors, including:
- the specifics of the situation
- the severity or degree of agitation
- the possible cause of the agitation
- expectations and/or preferences of your individual medical director
- the level of certification of the provider
Haloperidol has been the main medication recommended in cases of moderate agitation. This includes patients who are a risk to themselves or others but are not necessarily violent (not in Hulk mode). Haloperidol has also been the recommended sedative when the primary cause of the agitation is, or the patient has a history of, psychiatric psychosis. An alternative medication, droperidol, is now listed in the protocol and has been added to our agencies’ most recent drug licenses.
Haloperidol is a first-generation antipsychotic medication that dates to the 1950s. The medication is believed to work by blocking dopamine receptors in the brain that control mood and behavior. It also provides a major tranquilizing effect for treatment of the combative patient and use of the drug is considered a form of chemical restraint.
Droperidol is in the same drug class as haloperidol. It also acts to block dopamine receptors, producing antiemetic and sedative-hypnotic effects. It is not a newly developed medication but has been around and even used in the prehospital setting before. An FDA warning over twenty years ago regarding cardiovascular side effects (prolonged QT intervals, a listed contraindication in our protocol) caused the medication to fall out of favor. Since that time, there have been studies and debatesthe that seem to conclude there are no differences in adverse effects when using droperidol or other first-generation antipsychotics like haloperidol.1
A distinct advantage of droperidol is that, compared with haloperidol, it has a much faster onset time (3-10 minutes as compared to 30-45 minutes). For this reason, some doctors use droperidol as a monotherapy (without benzodiazepines). This approach has sometimes led to shorter ED stays for these patients.
Regardless of the agent recommended, approved, and provided by your local medical direction, be sure that the criteria established within your protocol for chemical restraint is met before using one of these medications. These considerations include an adult patient who cannot be calmed, who is out of control, or a danger, and that the medication can be administered safely. It is worth noting that in cases where a patient poses a “significant” risk (Hulk mode) to the provider, ketamine is the preferred choice for chemical restraint.
Though protocol indicates haloperidol and droperidol may be used as the single medication in a behavioral emergency, they may be used in conjunction with a benzodiazepine, Midazolam being our first-line choice. Due to haloperidol’s longer onset time, a benzo agent is often given to calm the patient until the haloperidol takes effect. Remember that droperidol has a shorter onset time and may not necessitate the quick-acting benzo.
When using either of these medications, remember that the use of physical restraints is also suggested. Chemical and physical restraints should generally be used in combination with each other.
Dosing of haloperidol and droperidol are the same, being 5 mg IM (preferably in the anterolateral thigh), given just once in the prehospital setting. In patients over 65 years of age, the dose is reduced to 2.5 mg.
Neither haloperidol nor droperidol are used in the pediatric patient within the UH protocols and should only be used in the pregnant or breastfeeding patient after a careful risk-benefit assessment. Neither is approved for dementia-related psychosis, and they are contraindicated in cases of Parkinson’s disease, CNS depression, severe cardiac disease, or liver disease. Care should be exercised in patients with a seizure history or disorder.
Both medications have some notable side effects. Some of the more common side effects include extrapyramidal effects (EPS). Symptoms of EPS include an inability to sit still, involuntary muscle contraction, tremors, stiff muscles, and involuntary facial movements. Treatment of these adverse effects are managed with the use of diphenhydramine.
Other side effects, such as Parkinsonism, tardive dyskinesia, neuroleptic malignant syndrome, and even cardiac symptoms such as QTc prolongation or hypotension can occur from higher doses.
Use of haloperidol and droperidol is considered sedation and thus requires thorough monitoring of the patient and transport by EMS. If we can monitor it, we should! These should include heart rate, EKG, blood pressure, SpO2, ETCO2, Glucose, GCS, MSPs, etc. As you are monitoring the patient, look for possible causes of the agitation and treat appropriately during transport to a medical facility.
Most behavioral emergencies do not require medication administration in the prehospital setting. However, when the use of non-pharmacological measures such as de-escalation, removing the patient from the stressful environment or situation, and/or establishing a good rapport with the patient does not ensure their safety or your crew’s safety, sedation with medications can provide a medical benefit and result in better patient care.
With proper training, decision making, and patient monitoring, sedation can be very effective and advantageous in treating the agitated patient.
Sincerely,
The UH EMS-I Team
University Hospitals
Download a PDF of this email HERE.
Source:
- Moore, M. J., & Im, D. The acutely agitated or violent adult: Pharmacologic management. UpToDate. https://www.uptodate.com/contents/the-acutely-agitated-or-violent-adult-pharmacologic-management#H2332403236