I have used IV droperidol and IV haloperidol with success following the
discussion on the Ron Walls course last year. I've had no complications so
far and anecdotal success. It has probably avoided use of RSI in a few
patients.

Walls claims Droperidol is quicker onset and shorter acting (not
referenced), but is said to have a greater alpha blocking effect (therefore
perhaps more hypotension).

Relevant case.
Regular patient in department
female 30's regularly takes "recreational" overdoses involving a combination
of
1. Baseline methadone
2. Imipramine
3. Cocaine
4. Heroin

Unfortuantely presents as GCS 3, respiratory arrest, pin point pupils, as an
effect of the opiates. She is then given naloxone IM & IV. This blocks all
opiate activity and unmasks the tricyclics and cocaine. She then becomes
grossly agitated, tachycardic etc. This has required RSI and an ICU stay on
the first few presentations to hospital. Subsequently she has been sedated
with a combination of benzodiazepines and neuroleptics (ICU interest rapidly
waned by presentation 3).

Record so far = 100mg Diazepam + 25mg Haloperidol to achieve control. She
then sleeps the OD off in resus and seems to recover well (before thanking
us profusely for our excellent skill and care, and popping off home via the
shops to buy us all presents - not)

Suffice to say we are now trying to learn the lesson and avoid large
naloxone doses at presentation thereby avoiding the problem altogether.
Still, the new SHO's have started and they don't know
her................??????????

Oh, and yes we have suggested to her primary care physician that tricyclics
may not be a great idea - but this has not changed yet.

NB. It has made us think about the rationale of treating opiate OD patients
by suddenly blocking all their opiate receptors (standard therapy was 800ug
IM + 800ug IV naloxone). No evidence, but there must be some concerns in
taking a hypoxic, hypercapnic, acidotic patient (as many are on arrival) and
suddenly removing their chronic opiate blockade. We get away with most of
the time but should we be doing it differently. Many of us have changed
practice in light of the above but any other thoughts???

Simon Carley
SpR in Emergency Medicine
Manchester Royal Infirmary
England
[log in to unmask]
Evidence based Emergency Medicine
http://www.bestbets.org

----- Original Message -----
From: john ryan <[log in to unmask]>
To: <[log in to unmask]>
Sent: Friday, February 09, 2001 2:01 PM
Subject: chemical restraint


> I am interested to know the variety of ways list members restrain agitated
> and combative patients when using pharmacological agents.
>
> Droperidol was shown in a 1992 annals paper to give more rapid control
than
> haloperidol when given IM (no difference IV) in a randomised double blind
> prospective study but droperidol is no longer available.
>
> Do list members use haloperidol or diazepam (?) or lorazepam (?) first up?
>  or another agent ?  IV or IM ?
>
> (with due respect to reversible causes such as hypoxia etc first, of
> course)
>
> John Ryan
>