Elsevier

The Journal of Emergency Medicine

Volume 16, Issue 4, July–August 1998, Pages 567-573
The Journal of Emergency Medicine

Original Contributions
Chemical restraint for the agitated patient in the emergency department: lorazepam versus droperidol

https://doi.org/10.1016/S0736-4679(98)00045-6Get rights and content

Abstract

Patients presenting to the emergency department with acute agitation frequently require physical and chemical restraint. To determine the efficacy of lorazepam vs. droperidol, we conducted a prospective, randomized study of violently agitated patients requiring chemical restraint. Patients were randomized to receive either lorazepam or droperidol i.v. A six-point sedation scale was used. Sedation scores were recorded at time 0, 5, 10, 15, 30, and 60 min. Vital signs were compared at time 0 and at 60 min. Repeat dosages of each drug could be given at 30 min. Toxicology screen, ethanol and creatinine phosphokinase levels were obtained. A total of 202 patients were evaluated. One hundred patients received lorazepam and 102 patients received droperidol. Agitation was attributed to methamphetamine toxicity in 146 patients (72%), cocaine toxicity in 28 (14%), psychiatric illness in 20 (10%), and ethanol withdrawal in 8 (4%). Ethanol intoxication was present in 98 patients (49%). Both drugs had similar sedation profiles at 5 min. Patients receiving droperidol had significantly lower sedation scores at times 10, 15, 30, and 60 than lorazepam. More repeat doses of lorazepam were given (40) than droperidol (8) at 30 min. We conclude that droperidol produces a more rapid and better sedation than lorazepam at the doses used in this study in agitated patients requiring chemical restraint. Lorazepam is more likely to require repeat dosing than droperidol. Methamphetamine toxicity was present in the majority of patients in this study.

Introduction

Violent, agitated patients are frequently brought to the emergency department (ED) for evaluation and treatment of potential toxicologic, psychiatric, traumatic, and medical problems. Emergency physicians must often restrain these patients in order to protect both patient and staff, and to determine the cause of the agitated behavior. Physical restraint may not be adequate for these patients and may actually cause harm if their agitation accelerates (1). Chemical restraint provides a logical, humane alternative (2). Benzodiazepines such as lorazepam and diazepam have been used for chemical restraint with good efficacy 3, 4, 5. Neuroleptics, such as the butyrophenone haloperidol, have also been highly effective 6, 7, 8, 9, 10, 11. Droperidol is a butyrophenone that, like haloperidol, has a rapid onset, but has a shorter half-life than haloperidol 12, 13, 14. Prior studies comparing benzodiazepines to butyrophenones for control of agitation exist, but were done in the setting of a psychiatric inpatient facility 15, 16. Only one study exists comparing haloperidol and lorazepam in the ED (17). We conducted a randomized, prospective trial comparing lorazepam to droperidol for the chemical restraint of violent, agitated patients presenting to the ED.

Section snippets

Materials and methods

This study was conducted in a large urban university ED, with an average 65,000 patient visits per year, from January 1995 through January 1997. All adult patients who presented to the ED acutely agitated were considered candidates for the study. Acute agitation included patients with violent, controlled or uncontrolled muscular movement putting both themselves and staff at danger and requiring constant supervision. All patients were placed on a cardiac monitor with automatic blood pressure

Results

A convenience sample of 259 patients were considered for the study. A total of 220 patients met entry criteria and were entered into the study. Thirty-nine patients were excluded for the following reasons (n): head trauma (12), age <18 (6), pregnancy (5), hypoglycemia (5), prior psychotropic medication (5), SBP <90 (3), anticholinergic syndrome (2), droperidol allergy (1). There were 10 missing or incomplete data sheets for the lorazepam group and 8 for the droperidol group. Thus, the final

Discussion

The use of droperidol in the ED has been previously described in only one study by Thomas et al. in which it was prospectively compared to haloperidol and demonstrated to have comparable sedation properties (9). In a double-blind placebo study, van Leeuwen and colleagues demonstrated excellent sedation in acutely agitated patients with no side effects (11). This was confirmed in a more recent study by Szuba et al. (14) Our results correlate well with these studies and indicate droperidol

Conclusion

Administration of droperidol provides a more rapid and greater sedation than lorazepam in agitated patients requiring chemical restraint at the doses chosen for this study, and lorazepam is more likely to require repeat dosing than droperidol. Agitation resulting from methamphetamine toxicity requiring chemical restraint was present in the majority of patients in this study.

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