Management of Acute Agitation in the Emergency Department First Generation Antipsychotics

Lesson 5 of 9

In Progress

First Generation Antipsychotics

Jimmy October 25, 2021

Butyrophenones

Mechanism
- Dopamine receptor inhibition

Drug	Onset (IM)	Onset (IV)
Haloperidol 5-10 mg	20-60 min	3-5 min
Droperidol 5-10 mg	15-30 min	1-2 min

Effects
- Reduces psychotic symptoms
Adverse Effects
- QTc prolongation, sedation, dystonia, akathisia
  - Akathisia – restlessness 🡪 “worsening agitation”
  - Dystonia – torticollis, tongue protrusion, laryngeal dystonia (respiratory sx, stridor, dysphagia)
Caution
- Neuroleptic malignant syndrome, Parkinson’s disease

Controversies
- How significant is the QTc prolongation? Studies show…4-8 ms
- Combination therapy needed?

Calver et al, 2015

ECG within 2 hours of droperidol in 1009 patients
- 1.3% of patients had abnormal QTc
- Of the 13 patients, 7 had pre-existing prolongation or other causes
No cases of TdP

Harrigan et al, 2004

Open-label, randomized, parallel-group trial of 183 patients
Haloperidol increased QTc interval by 7.1 ms