122 Haloperidol Plus Lorazepam Versus Droperidol Plus Midazolam for the Treatment of Acute Agitation in the Emergency Department

A combination of an intramuscular (IM) antipsychotic and benzodiazepine is often utilized for treatment of undifferentiated acute agitation in patients presenting to the emergency department (ED). Haloperidol plus lorazepam represents a relatively safe and effective combination treatment. When given separately, droperidol or midazolam both have faster onset of action than haloperidol or lorazepam, respectively. This study aims to compare if IM droperidol/midazolam is superior to IM haldol/lorazepam at producing adequate sedation at 10 minutes. This prospective cohort study enrolled subjects from November 2020 through May 2021 at a single academic trauma center in a mid-sized metropolitan area. In an effort to standardize practice, the study site implemented a quality improvement alternating month protocol assigning patients with undifferentiated acute agitation to receive either haloperidol 5mg/lorazepam 2mg IM or droperidol 5mg/midazolam 5mg IM. The protocol used the following inclusion criteria: acute undifferentiated agitation requiring security activation, at least 18 years old, refractory to verbal de-escalation, and lacking intravenous access. Exclusion criteria included known acute alcohol withdrawal, additional sedative drug administration before or at enrollment, hemodynamic instability, or allergies to any of the study medications. The primary outcome was adequate sedation at 10 minutes defined as ED Sedation Agitation Tool (SAT) score of 0 or less. Secondary outcomes included change in ED SAT score at 5, 15, 30, and 60 minutes, the administration of oxygen after study drug administration, and the need for any airway interventions. A total of 78 patients were enrolled between November 2020 and May 2021, with 43 patients receiving droperidol/midazolam and 35 patients receiving haloperidol/lorazepam. Ten minutes after receiving medication, 51.2% of patients in the droperidol/midazolam group were adequately sedated compared to 5.7% of patients in the haloperidol/lorazepam group (OR 17.3; 95% CI 3.7, 81.2). Results showed significant differences in each of the first four time periods (5, 10, 15, 30 minutes). Median time to adequate sedation was 10 minutes for the droperidol/midazolam group and 30 minutes for the haloperidol/lorazepam group. Eleven patients (25.6%) in the droperidol/midazolam group received oxygen supplementation compared to five patients (14.3%) in the haloperidol/lorazepam group. No study patients required endotracheal intubation or experienced extrapyramidal symptoms. Intramuscular droperidol/midazolam was superior in efficacy to haldol/lorazepam at achieving adequate sedation at 10 minutes. However, patients sedated with droperidol/midazolam were also more likely to receive oxygen supplementation. This medication combination is an effective treatment for acute agitation in the ED.