When negotiations break down with an undifferentiated agitated patient, before you reach for your trusty 5:2, consider ziprasidone (Geodon).
Martel et al. concluded that droperidol or ziprasidone achieved better sedation of the undifferentiated agitated ED patient than midazolam. But the onset of sedation was delayed with ziprasidone relative to the other agents. Details of the study follow:
– Prospective, randomized, double-blind trial of undifferentiated agitated ED patients requiring emergent sedation
– 50 patients received droperidol 5mg IM
- Rescue sedation medication required in 5/50 patients
– 46 patients received ziprasidone 20mg IM
- Rescue sedation medication required in 9/46 patients
– 48 patients received midazolam 5mg IM
- Rescue sedation medication required in 24/48 patients; significantly higher (p<0.05) than other 2 groups
– 15 min after administration, more patients who remained agitated in ziprasidone versus droperidol & midazolam groups (p=0.01)
– 30 min after administration, no difference in number of patients who remained agitated among all groups (p=0.08)
– 45 min after administration, more agitated patients in the midazolam group versus the droperidol & ziprasidone groups (p=0.03)
– No cardiac dysrhythmias or intubations noted in any treatment group
– No significant difference (p=0.20) in respiratory depression (measured as change in ETCO2 > 10mmHg or SaO2 < 90%) among treatment groups
Note: Droperidol has fallen out of favor since in 2001 the FDA issued a black box warning stating that droperidol has the potential for cardiac dysrhythmias. However since then there have been numerous studies challenging this warning. Read more about this from references listed in ACEP’s “Clinical Policy: Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the ED” chaired by none other than our very own Dr. Andy Jagoda.
Martel M, Sterzinger A, Miner J, Clinton J, Biros M. Management of acute undifferentiated agitation in the emergency department: a randomized double-blind trial of droperidol, ziprasidone, and midazolam. Acad Emerg Med. 2005 Dec;12(12):1167-72. Epub 2005 Nov 10. Erratum in: Acad Emerg Med. 2006 Feb;13(2):233.