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Letter to the Editor

Editor, – We have some concerns about the approach to sedation of patients with aggression and violence suggested by Professor Fulde and Associate Professor Preisz (Aust Prescr 2011;34:115-8). Large numbers of patients require parenteral sedation with physical containment which can be hazardous to staff and requires a standardised approach.

Recent research supports the use of different drugs and initial intramuscular sedation for most patients. One study demonstrated that the duration of acute behavioural disturbance was reduced when intramuscular sedation was employed.1 Intravenous sedation requires sufficient staff to restrain the patient, otherwise it is dangerous with the risk of needle stick or physical injury. However although intramuscular midazolam is used most commonly, recent evidence demonstrates that it is unpredictable due to over-or under-sedation.2 A controlled trial found that 10 mg intramuscular midazolam caused adverse events in 28% of patients compared to 6% with droperidol.2

Only the antipsychotics olanzapine and haloperidol were suggested for sedation in the article. Haloperidol is not very sedative and has a black box warning by the US Food and Drug Administration (FDA) for confirmed reports of QT prolongation and torsades des pointes. Parenteral olanzapine has never been shown to be effective in the emergency department setting.2 Droperidol is safer and more effective for sedation of acute behavioural disturbance in the emergency department.2 It has been used extensively and rarely causes over-sedation. There have been concerns about QT prolongation and torsades des pointes. Despite an FDA black box warning this has not been confirmed in a systematic review.4

We now routinely use 10 mg intramuscular droperidol for initial sedation and repeat the dose after 15 minutes if required. In 412 patients sedated this way, 66% became sedated with one dose. Minor adverse events occurred in 5.5% of patients but no patient had QT prolongation.

Geoffrey K Isbister
Emergency Department

Leonie A Calver
Department of Clinical Toxicology and Pharmacology

Calvary Mater Newcastle Hospital, NSW


  1. Calver LA, Downes MA, Page CB, Bryant JL, Isbister GK. The impact of a standardised intramuscular sedation protocol for acute behavioural disturbance in the emergency department. BMC Emerg Med 2010;10:14.
  2. Isbister GK, Calver LA, Page CB, Stokes B, Bryant JL, Downes MA. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med 2010;56:392-401.e1.
  3. Knott JC, Isbister GK. Sedation of agitated patients in the emergency department. Emerg Med Australas 2008;20:97-100.
  4. Kao LW, Kirk MA, Evers SJ, Rosenfeld SH. Droperidol, QT prolongation, and sudden death: what is the evidence? Ann Emerg Med 2003;41:546-58.