Droperidol Use in Psychomimetic Overdose
Droperidol (5 mg) is recommended as an effective treatment for agitation in psychomimetic overdose, particularly when rapid sedation is required, though it should be reserved for cases where benzodiazepines are insufficient due to its FDA black box warning regarding QT prolongation. 1
Efficacy in Psychomimetic Overdose
- Droperidol is particularly effective in treating agitation attributed to methamphetamine (32%) and cocaine (14%) toxicity, demonstrating faster and more effective sedation than alternatives 1
- Patients receiving droperidol (5 mg) require fewer repeat doses than those receiving equivalent doses of haloperidol or lorazepam, making it especially valuable in difficult-to-sedate patients 1
- In a randomized study of undifferentiated agitation in the ED setting, droperidol showed significantly better sedation than lorazepam from 10 minutes through 60 minutes post-administration 1
- Droperidol's onset of action is rapid (3-10 minutes) with a duration of effect of 2-4 hours, making it suitable for acute management 1
Dosing Considerations
- The recommended dose for psychomimetic overdose is 5 mg IV/IM, though weight-based dosing has also been studied 1
- Lower starting doses (1.25-2.5 mg IV) with cautious titration are recommended in patients with renal or hepatic dysfunction 1, 2
- Droperidol may be more effective than haloperidol at equivalent doses, requiring fewer repeat administrations 1
Safety Considerations and Cardiac Monitoring
- The FDA issued a black box warning in 2001 regarding droperidol's potential for QT prolongation and torsades de pointes 3
- Per FDA labeling, all patients should undergo a 12-lead ECG prior to administration to determine if a prolonged QT interval is present (>440 ms for males, >450 ms for females) 3
- Droperidol is contraindicated in patients with known or suspected QT prolongation, including those with congenital long QT syndrome 3
- Despite the warning, large patient series have demonstrated droperidol's safety in emergency settings:
Risk Factors Requiring Caution
- Extreme caution is advised in patients at risk for QT prolongation, including those with:
- Congestive heart failure, bradycardia, or cardiac hypertrophy
- Electrolyte abnormalities (hypokalemia, hypomagnesemia)
- Concurrent use of diuretics or other QT-prolonging medications
- Age over 65 years
- Alcohol abuse 3
Alternative Options
- Benzodiazepines (lorazepam or midazolam) are recommended as first-line alternatives for agitated patients due to their favorable safety profile 1, 2
- Atypical antipsychotics like ziprasidone (20 mg IM) have shown efficacy in reducing symptoms of acute agitation with fewer movement disorders than typical antipsychotics 1
- Combination therapy with a benzodiazepine and an antipsychotic may be effective for cooperative patients 1
Monitoring and Management
- If droperidol is used, ECG monitoring should be performed prior to treatment and continued for 2-3 hours after completing treatment 3
- Monitor for extrapyramidal symptoms, including dystonia (reported in approximately 1 patient per study) 1
- Be prepared to manage potential hypotension, which has been reported as a common side effect 1
Special Considerations for Psychomimetic Overdose
- Droperidol may be particularly valuable in stimulant overdose (methamphetamine, cocaine) where agitation can be severe and difficult to control 1
- However, two case reports have documented sudden death following droperidol use in patients with cocaine and phencyclidine intoxication, suggesting caution in these specific populations 5
- The risk-benefit assessment should consider the immediate dangers of severe agitation against the potential cardiac risks, particularly in patients with stimulant-induced cardiotoxicity 3, 5