Management of acute undifferentiated agitation in the emergency department: a randomized double-blind trial of droperidol, ziprasidone, and midazolam.
OBJECTIVE
To compare the efficacy of sedation, need for rescue sedation, rates of respiratory depression, and complications of droperidol, ziprasidone, and midazolam when used for the treatment of emergency department (ED) patients requiring sedation for acute undifferentiated agitation.


METHODS
A prospective, randomized, double-blind trial of agitated ED patients requiring emergent sedation was performed. Patients were randomized to receive droperidol 5 mg, ziprasidone 20 mg, or midazolam 5 mg intramuscularly. Interval measurements were made at 0, 15, 30, 45, 60, and 120 minutes and included Altered Mental Status Scale (AMS) scores, oxygen saturations, and end-tidal carbon dioxide levels.


RESULTS
A total of 144 patients were enrolled; 50 patients received droperidol, 46 received ziprasidone, and 48 received midazolam. Adequate sedation (mean AMS score <0) was achieved at 15 minutes in patients receiving midazolam (mean AMS score, -0.81) and 30 minutes for patients receiving droperidol (mean AMS score, -1.3) and ziprasidone (mean AMS score, -0.74). Rescue medication for sedation was necessary in 38 of 144 patients (droperidol, 5 of 50; ziprasidone, 9 of 46; midazolam, 24 of 48; p < 0.05). No cardiac dysrhythmias were identified in any treatment group. Respiratory depression that clinically required treatment with supplemental oxygen occurred in 21 of 144 patients (droperidol, 4 of 50; ziprasidone, 7 of 46; midazolam, 10 of 48; p = 0.20). No patients required endotracheal intubation.


CONCLUSIONS
Acutely agitated ED patients sedated with droperidol or ziprasidone required rescue medications to achieve adequate sedation less frequently than those sedated with midazolam. The onset of adequate sedation is delayed with ziprasidone, relative to the other agents.
Martel
Marc
M
Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN 55415, USA. marc.martel@co.hennepin.mn.us
Sterzinger
Ann
A
Miner
James
J
Clinton
Joseph
J
Biros
Michelle
M
D000293:Adolescent; D000328:Adult; D000368:Aged; D014151:Anti-Anxiety Agents / Q000627:therapeutic use*; D014150:Antipsychotic Agents / Q000627:therapeutic use*; D004305:Dose-Response Relationship, Drug; D004311:Double-Blind Method; D004329:Droperidol / Q000627:therapeutic use*; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008609:Mental Status Schedule; D008874:Midazolam / Q000627:therapeutic use*; D008875:Middle Aged; D010879:Piperazines / Q000627:therapeutic use*; D011446:Prospective Studies; D011595:Psychomotor Agitation / Q000175:diagnosis / Q000188:drug therapy*; D012131:Respiratory Insufficiency / Q000139:chemically induced; D013844:Thiazoles / Q000627:therapeutic use*; D016896:Treatment Outcome
D014151:Anti-Anxiety Agents; D014150:Antipsychotic Agents; D010879:Piperazines; D013844:Thiazoles; C092292:ziprasidone; D004329:Droperidol; D008874:Midazolam