The Effect of the FDA Vvarning on the Use of Droperidol by U.S. Emergency Physicians

The Californir! Journai of Ealer~eiicvMedicine IV: I.San-Rlar 1003

Methods: An internet-based survey was designed with ORIGINAL RESEARCH y~~eslionsregarding droperidol use in the emergency department (ED).Data coiiected included EP demographics, use of droperidcd before and ~ifierthe FDA warniiig, use of The Effect sf the FDA VVBrning alterilative drugs, and incidence of arrhythmias. A repre- sentative sample of EPs were contacted by e-!nail and asked on the Use of Droperidol by U.S. to complete the survey. Results: A total of 2,000 e-mails resulted in 506 (25%) com- Emergency Phy sisians plered surveys. There was no aecond mailing. Respond- ers" average years practicing was 12.6 2 9.2. EP responders worked in pivatelcommunity (n=278, 55%). academic/ John R, Richards, M.D. county jn=187,37%), and HMO (i1=41,89) hospitals. The Steven 9. PNeiss. M.D. ~~~ajority(11~455, 90%) used droperidol and were aware of Stephen W. Bi'etz, M.D. the FDA warning (n=460.9 i %). Droperidol was no longer Aaron B. Schneir, M.D. avaiiable at i 22 (24%) ofthe respondents' EDs as aresult of Dauna Rinetti the FDA warning. Prior to the FDA warning EPs who had Roberz W. D~rler.M.D. used droperidcli used it as an antiemetic jn=408,90%), for conrroi of agiiaticm (n=330.73%); for treatment of headache Division of E~nerge~lcyMedicine (JRR. SJW, DR: RUJD), (n=247, 54%), and for treatment of vertigo jn=106. 23%). University of California, D;lvis Meiiical Center After the FDA warning, 387 (85%) of EPs reported their use Szcramento. California of droperidol had decreased or ceased altogether, and 68 (158) always oh~btinedan elecrrocardiogra~nprior to ad- Depaitr~xntof Erncrgci~cy1b:Icciicinc (SWB). ministraiion. Of' tilose who used droperidol fix agitation: San Francisco Generai Hohpiiai 137 (42%) felt there were no other drugs with greater effi- San Franciscc. California cacy. Haloperidol was the most cited alternative agent in=160, 79%) fc>c;i!o\+ed by benzodiazepines (it=223,68%). Del7au~1ierlioi'Ei~lergency Medicine !ASS). Of those wl~ousecl cira>peridoifor antiernesis; 116 (28%) felr Divisinil of h!l;tciicai Tc3xicoEogy there were no other drugs with grealer efficacy than liriirersiiy olraiifoniit, Siln Diego Medical Ceni-,- droperidoi: promethazine was rhz most cited alternative San Diego Divisioii, Califorriiz. Poison Contrcl Syscciii agent (n=2OO. 64%). 'Two (0.4% j EPs reported 21-rhythxnias San Diegil, Ca'iiIomia in patients who received droperidol. Only 37 (8%) EPs reported they were unconcerned with potential loss of droperidol frol-i~the nlaritet, Address for relirii~ts: Conc%iasion: Basecl 031 this survey EP use of droperidol has decreased cirarnaticaliy as a result ofthe FDA warning. John R. Richards; M.D. However. EPs he!ieve that there are fevv:or no alternative Division of Ei-i;ergci~cy ?~fedicine anriernelic drugs that have an improved adverse ePfecl pro- 23 1.5 Stocktori Borrievard file, Sacrsmciito; CA 9581 7 (916'j 734-1537 Tax (9 16) 734-7950 Key words: droperidol. Ii~zpsine.emergency medicine: FDA e-mall: jrrichards@ucdir~~is.ed~.r avarnilag

E'rescntcd at the Arncricd~iCalllcge i>f Eiiiesgeilcy Pliysi- INTRODUCTION: ciims Research Fcrum, October 2002 In December 2001 the FDA :ssued a %Jack box uars~ing~'(E~glitc 11, ils most sersous alert, c3n the use WBST&\CT: of dropendoi, ;u~dthis bx, a\ tollowed soon thereafter Objective: To determine if emergency phq iiciatls~IEP) by 21 s~rmilar\wa.r,arng by the Canadfan Hedth Protec- UFG o!'drcq7eridr>! i-12s chiingrri sirice 1112 United Scales Food a.nd Driig Aclniinihzratio~:(FDA) warning of December 2001 t1si-i Erarich ' ' This walnang w a\ sn respocce kc3 con- coxicerning QT irikrrt al proiorgatioi:, iorsarie Je poi~tes, rems s\ el pot? -ti;s,l prolonga~ios,~of t5e QT Imiterb al. 2nd s~~cidciide:.r",l: and ro qu:.r> EP nl,ii?iofij rcgzrding twwde de poineb, ;lid s~iddeudeath after adminis- droy?eri:'.cl hefclre 2nd ~iftertli~ FDA. i;var.r,ing aiid regarding tratlm 239 dr~pendoi.'~Prior to theie warnings, potcx"lal aItcrilbt:il;c drugi. dnspei:nol was zxtensrvclj uscd 11: the ED fot myralad mdlc;it~ons,~~sludmg co-2 ti ol of agdt~itiolaand p\yrlao- Cases of QT prolongation and/or torsades de pointes have been reported in patients receiving INAPSINE at doses at or below recommended doses. Some cases have occurred in patients with no known risk factors for QT prolongation and some cases have been fatal.

Due to its potential for serious proarrhythmic effects and death, INAPSINE should be reserved for use in the treatment of patients who fail to show an acceptable response to other adequate treatments, either because of insufficient effectiveness or the inability to achieve an effective dose due to intolerable adverse effects from those drugs (see Warnings, Adverse Reactions, Contraindications, and Precautions).

Cases of QT prolongation and serious arrhythmias (e.g., torsades de pointes) have been reported in patients treated with INAPSINE. Based on these reports, all patients should undergo a 12-lead ECG prior to administration of INAPSINE to determine if a prolonged QT interval (i.e., QTc greater than 440 msec for males or 450 msec for females) is present. If there is a prolonged QT interval, INAPSINE should NOT be administered. For patients in whom the potential benefit of INAPSINE treatment is felt to outweigh the risks of potentially serious arrhythmias, ECG monitoring should be performed prior to treatment and continued for 2-3 hours after completing treatment to monitor for arrhythmias.

INAPSINE is contraindicated in patients with known or suspected QT prolongation, including patients with congenital long QT syndrome.

INAPSINE should be administered with extreme caution to patients who may be at risk for development of prolonged QT syndrome (e.g., congestive heart failure, bradycardia, use of a diuretic, cardiac hypertrophy, hypokalemia, hypomagnesemia, or administration of other drugs known to increase the QT interval). Other risk factors may include age over 65 years, alcohol abuse, and use of agents such as benzodiazepines, volatile anesthetics, and PV opiates. Droperidol should be initiated at a low dose and adjusted upward, with caution, as needed to achieve the desired effect. Figure I. FDA Black Box Warning for Use of Droperidol (InapsineB). sis,"12 nausea and emesis,13l8 headache,lS" ver- academic/universiQ>countyipt~b- tigo,?*-"and atypical pain syndr~mes.~"~~Dmperidol lic, p~ivate/communi@>md health maintenance orga- was commonly used by anesthesiologists for treat- nizatioi~(mO) EDs. A questionnaire was de\ieloped ment of postoperahive nausea and vorniting (POW), in hyper text makup language (HTNIE) format tasii~g constihtting 30% of the POWmarket, with over 25 Dreamweaver (Macromedia, Sari Francisco. Califor- million units sold in 2000.2Vnits oral form, dsoperidol nia), and a survey world wide web (WWW) page was used as an antipsychotic agent by psychiatrists, was set up on a dedicated server. Upon completion especially in Europe.' Before the FDA wa~ng,only of the HTML survey, data was collected using doses greater than 25 mg were col~cideredto be at ColdFusion (Macromedia, San Francisco. Califor- risk for QT interval proBongation and arrhythmia. nia) in an Access (Microsoft, Wedmsnd, Washing- Across the world, EPs. anesthesiologists, psychia- ton) database for hi-ther andysis. This study was ap- hists, and pl~amacistsreacted with skepticism to there proved by the hsdtk~tionalReview Board of the Uni- new rertrictions on the use of droperidol.' 2s-35 The versity of California, Davis Medical Centeir. purpose of this survey study war to determine if droperidol use by EPs has changed since the FDA Survey Content and Administration warning. The first section of the survey contained questions regauding El? demogr;~p%nics,includil~g type of hospi- METHODS tal staffed, surrounding population sewed, and years Study Design and Population practicing emergency medicine. We obtained re- This survey study was specifically designed for, and sponses on howledge of the FDA waning and prior addressed to practicing EPs in the United States, in- use of dropendo1in the ED. Culrent availability of droperidol in the respondent's particular ED and dis- Table 1. Clinlczl lndrcatiolls for Droperidol use 111 !he ED. continuation after the FDA walling were also que- -n 6%) ried. The next section of the s~~~veyinvolved ody those EPs who uie or used Droperidol 455 (100) physicians who use or had used droperado1 in the ED. Specific indicaeioras such as nausea and emesis, agitation. and headache were listed, and frequency of Emesis use of ciroperidol before and after the FDA war~~ing Nausea was detemined. Emergency physicians who contin- Agitation Psychosis ued to use drope6dol despite the FDA !yarning were Headache aslced if they now obtained an eelctrocxdioga-mprior Anxiety to administration. 3pinion regarding efficacy of Vertigo droperidol and preferred alternative pharmaceutical Abdominal pain agents for tl~eBndics?'bions of agitkltlon and psychosis, Chronic musculoskeletal pain Co~~scioussedation as well as nausea and emesis, were queried. In addi- Amnesia tion, adverse outcomes in the fom~of arrhythmia or Chest pain sudden death from droperidol administration were tabulated. Finally, EP opinion of the validity of the From 2,080 e-mails iient out there were 506 (25%) g and concern regarding loss of drope:r;ldol fully completes$ surveys. There were 122 (6%) in- avi6lability altogether were also i~acludedin the ques- 17alid e-man1 addresses, and one EP returned the e- tio~~raire. mail u~~willmgto pafl~cipate in the seirvey, Respocd- ers' ak7erageyears practicing was 12.6 + 9.2, Elmer- A;? e-r-mil conea~ningLa solacttation letter deialilng the gency phy\ician responders worked ira plrt atei~orn- pu~yos: of tbc stvdy a hy perllnh lzrading to the mut~~fy(n=27S, 55%). 3cadem1clci3untj {n= 187, xeeah web page v as wit:o a SB\I of2,000EPc). E%cG- 37%),anci HMO bn=4 1, 8%) i-~osp~taals.One 11~1i.8- uonlc in21izddre4ces were obta~nedraxadoady rn pro- dred twes7ty four (25%j dejcrlbed :heir pract~ceset- pol-tlon ko xnembsrahlp nulxber Lcrn published direc- iing as inner city, 299 (59%) a\ urban. and 83 ( 16%) ti;nes of clx -4mesncdn Colkeg of Emergencq Pnj sl- as r~iral. The mkajo~itg'(11~455. 90%) had u\ed crars. Socsety of Academic Enxrgency Medicme. and droperidol and were av,are of the FDA warning Amersia~~Aii?dt:my oEEmergency Mcd~csne.A sangle (n=460,91%). Droperidol war i?o longer available broadcast nnailing was perfornied In the Spnng of in 122 (24%) ofthe respondents ED3 following the 2002, and there were no repeat e-mails To emure FDA warning. Pnor to the FDA warnzing 90% pnvacy and freedom ofopls~~o~~,no adenlifaer$ were (n--408) of EPs who had used droperidol, used it as s~.iedfoi respondent<.such aa Hogging ori~~ternetpro- an antiemet~c.and 73% (11x330) for ccsntsol of agita- vider (IP) s;- e-mail acldresses, ccjok~es,ol survey tion. Eble H l~stsall ~Iinicdindications for si-soper'rdol coding ac indicated by the respondents.

Data Analysis As a direct result of the FDA wafing, 85% (n=387) Gompaa-isonsbetween drope~doluse before and af- oEEPs reported theh use of dropekdol had decreased ter the FDA warning werc made asmg fne two-sample or ceased akogether (Figure 21, and this decline in frequency of use was significant (P < 0.1400%).The Vi~lcoxonEU& sum test for non-pa arnetric v;viables. Statibtical signlficai7ce is ascumed at a level of P < remaining 15% of EPs who still use droperidoi al- was s obtained an electrsc~~diogrampsior to admin- 0~05~Data are rcpdried a

250- =Before FDA Warning nAfter FDA Warning 200

Respondents 150 in)

!00

0- never 1 -4lmonih I-4lweek I -4lshi% Frequency of Use Figare 2, Frequency of Droperidsl Use before and after the FDA Warning

79% (r-r=260)foliorn7ed by benzodiazepines m 68% The results of this survey demonstrate the impact the (n=223) (Table 2). Or" tho% who used ctroperidol FDA warning on dl-operidoi has had on prac"rcing for antierz~esis,28% ((n= 1I&) felt there were no other EPs' use of the drug. Those paaicipating in the bur- &XI~Swith greater efilcacy, md promethalzine was the vey now use droperidol rn~lchless frequeaztly or not most cited alterxlative agent by 63% in=%68)(Table at all, and many now have no access to Qoper;dol. h 3). TWO(0.4%) EFs repor-ted arI~yt'ranGasin patitie~~ts also outlines the skepticism many EPs harbor towad who received droperidol, but no cleat115 were repomd. the validity and ;113pmpnaateness of the FDA wm~ing, md that alternative naedicaiions may not be perceived Opinion regarding overall utiiity of droperidol as a to be as effective as dropesidol for a variety of indi- drug in the ED declined sig~ficantlyas a result of the cations. The ackrraI practice experience of EPs does FDA warning (P < 0.009),tvith ZOO (44%) EPs rating droperidol as "extremely rascful'' prim to the U~~ITI- ing. and just 69 (15%) giving it the s;mx rating after Table 2. Equal or More Effectwe Alterndt~ze Drugs than Droper~dnlfor Aglratlon in i11e ED the warning. Tlaree huladred and four respondents -11 @i?-) (67%) aaaswered that the FDA tc arning had a direct EP\ vl ho use or uced dropelidol affect on their ability to ireat patients in the ED Emer- for agitation 330 (100) gency physicians were q~~e~ledsn their opm?on of the FDA warning, and 242 (53%) felt it was ur~justified. Alternative agents Twenty (4%) EQs felt the warning was completely Haloperidol (HaldolO) appropriate, and two (0.4%) felt droperidol should Benzodiazepines be banned altogether. Onzly 37 (8%) EBs reported Chlorpro~nazine(Thorazine@) they were unconcerned with potential loss of Barbiturates droperidol from the market, as has occurred in Eu- Propnfol (Diprn an@) R~speridoilciRisperdalO) rope. 01 anzapine (ZyprexaO) Thioridamne (Me!larilO) DISCUSSION Fluphenazine (Prolixin@) Diphenhydramine (BenadrylO) "one of the most used emergency medications now," Table 3. Equal or More Effective z41ternahve Drugs than suggested the link between droperidol and QT inter- Droperidol for Nausea and EmeGs in the ED. val prolongation. torsade de pointes, and sudden c;~- -n IC/c) EPs t\ no use or used droperrdol diac death was not at a13 clear.' They noted many of for anuemes1s 8 (ICQ the deaths or adverse outcolnes provided by the FDA were patients who were already critically ill and/or concomitantly taking several potea~tially mhytlmoge~lic~~~edirsations. Bailey et d similzly in- Promethazine (Phei~erganO) Meroclopramide (RcglanBj vestigated the actual adverse cases used by the FDA Onclansetroll (Zofran8) to justify the wdmingand reached the same conclm- Prochiorperazi~~e(CorngazineO) sion." Can and colleagues determined the cost of Hydrosyzine (VistarilO) preventing PONV was over 40 times higher to the Ibiphei~i~ydl-amim(Bei~adrylO) Meclirine (Ailti\ ertO) patient when ondansetron was used indead of Trimethobenzamide (TiganB) droperidol. and "rat prior to ihe FDA warnirrg Dolasetiorl!A~~zernet@) droperidof had a 50% ~onarhetshare.:" Thic group Lorazepam (A:ivanO) wrote "we believe thas the recent black box warning Scopoiair~ine(Transberm ScopO) by the FDA is totally unj~~stified,"and called for the Granisetron il<.ytril,B) $'or I)examethasone (DecadmnG) FDA to lift the ban Iow-dose droperidol. Ginger root Kintear emphasized the seroto9ln type 3 antagonists, s~~has ondansetron and doiasetron, also bad poten- not seer11 to reflect the poter~tial-for adverse outcoime tial for QT mter\ al plolongat~onallhi torsade de pointes as stated by the FDA, Viihat is unique about that .ji as Iargely bekg ignored by the FDA'? An up- &opekdl;":i. if is one of the dmgs used fcj; a wide Gated Lrst of dri~gsthat prolong llle QT ~ntervalor r~l-~gei_- of sce~iinglgi ~:nreiated clinical indcal'roi.s, as 1Pldtlce torsack de pomtes may by forind on the 111ternet .~.%. refiecred 311 recent emergency mecI.~cmeiitera- ($;a, x,irMcx~a~c~~).and incidde chlorprsaraz~ne, 5.7 iC. i9-2i its ey ,.. ,\ A -,~ ~rl~~t~jmdexbeineky ihsw cost -spay ~loEase~zon,~Joperidol, nspendone. Ihiofida~ine,and also exp1i.n the outcTyf:hat accompa.~~':cd 'its loss in ~:prassdone,dl dn~~ig~I1sted31 by surtey respofidents as Europe" Mter file co~npleteavi tl~ds-k~~h~dof tboperidol potenanal altenxabtes to dr-operidok (Tables 2 and 3). 95s in Europe by rna~au&~-l,ctui~erJanssen-Giiag, Trzme~. Ma24 EPs and anestl-ies~olsgisrare concerned that arnd cofieagues emphasized the d'iscsntinurdon was t~~a,lAbiestrictior~ of droperidol and huted avaiiab~Etyoi in response to adverse events liraited with chronic, pochHoqerazln3eze forcmg them to use of more ea- 1argck or;?%~OS~S given to psvchn:'1 rii~i "-'IC p&t$iie~~tS,1109 the pensi\a: serotonin typc 3 antagonasts srach as sIqI a1qa3- bl ;ntravealo~s-. doses give11$0 POTPJ patient^.^" i~ndansetroi~."Thew drugs do not have a record of r 7 !:his grou~called for a distirsciion to be made be- extz~slveuse, 111rmaq have ssmlar adverse effects, aid +< en'= the two indications so that low-dose i111rave- are extremely expensave. niius dropefidol could be used in the perjoperative setting. I-Hiaines et a1 also emphasized this distinction, and mentioned the consequences to the national he~alth LIMITATIONS budget in the Lhnited Kh~gdomGor-n loss of &ope~idol The most important limitation ofthis study is that it is and rise of the newer serotonin type 3 antagonist^.^' a survey based or? srzbjective answers and opinions A similar protest was heard frorn Lehot and Ferry in of a small sarnple of EPs, z~dnnay not reflect act~eal France,.Q practice. F-kar"r~ermore,those who responded may FoilovV~ingthe FDA wi~~icg,an even stronger outc~=y have been motivated to do so because of a stronger occu~~edin the United States, In an article investigat- than a-zTeragepositive or negative opinion regarding ing the actual adverse outcomes listed by the FDA, droperidoi. There were many non-responders, and Horo\vitz and associates, refenjng to droperidol as several inaccurate, invalid, of- expired e-mail addresses. The loss of these potential survey partici- pants may have affected the results of the study. In 10. Hick JE. Mahoney BD. Eappe M. Prehospital sedation order to maintain respondents' privacy, follow up sur- with intra~lzuscuiardroperidol: a one-year pilot. Preiiosp veys were not e-mailed to ~mn-i-esponders,or to those Ei'iize,;? Care 2001:5:39 1-4, 5ublnikthg hcornpiete sweys. Respo~lsientsmay have 1 1. Hameer 8,Collin K, Er,som MH, 1-ornax S. Evzluation of felt their participation in the srervey would result in droperidol in the acutely agitated child or adolescent. Carz J Ps\.ritiatg 200 1:46: 864-5. their e-mail identity being prolnulgated, 12. Stanisiav SW, Chiids A. Evaluating the usage of droperidol in ac~ltelyagitated persons with brain injury. CONCLUSION B-.ra~tz ' /irj 2000;14:26!-5. Among those EPs replying to this survey, use of 13. Eberhart EH. Morin AM, Bothner U, Georgieff M. droperidol decreased dramatically as a result of the Droperidol and 5-HT3-receptor antagonists, alone or in com- FDA warning. Over half the suwey resporsdenks feel bination, for prophylaxis of postoperative nausea ;and vom- the FDA w~l~gis u~~jusdfied and are copzcerned by iting. 4 meta-analysis ofrandomised controlled trials. Actil the pote~~tialloss or h11311er rest~jctionof drope~dolin Anae.rfi?esiolSmad 2000:44: 1252-7. the United States. Many of the d~xegslisted by EPs as l4. Macario A, Chung A, Weingel- MB. Variation in prac- alternatives to droperidol, such as hitloperidol, cMor- tice patter~lsof anesthesiologists in California for prophylaxis of postoperative nausea and vomiting. J Ciirz Ane.cti2 promazine, rispesidone, and dsIase&on also have risk 2001 ;13:353-60. of QT intenla9 prolongation. Beca~rseof limited alter- F. native therapies, as well as tlaeir side effect profile 15. Rizzo J. Berilstein D. Guess A randomized double- blind placebo-controlled trial evaluating the cost-el'fective- and expense, many EPs ,and anestl~esiologistsques- ness of dmperidol as a sedative premeditation for EUS. tion the FDRs action. Glrsfmiiztrst fkciosc 1 99:50: 178-82. 16. Hill RP. L~ib~rskyDA, Phillips-B~iteB. Fortney iT3Creed REFERENCES MR. Glass PSA, Gan TJ. Cost-effectiveness of prophylactic 1. U.S. Food and Drug Adn~lnistratioil.FDA strengthen\ antiemetic tl~erapywith ondansetron. droperidol, or placebo. warn~ngsfor dropendol. FDA Talk Paper 206 i .TO 1-62. Anesti?e.siolog~.2000;92:958-67.

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Effects of droperidol Droperldoi in the lntcilm mallagement of sex ere rnanla cace in manageinent of vestibriiar disorders. iai3.izgoscope. repolls and llteratule rev~ew Clli? Neutopl?ari?incol 1976;86:946-54. 1998.21 316-8 Resident/Student Corner 24. Irving C,Rich~s~an PB, Kaisfas C. Esltin B. Ritter A. Allegra 9. Droperidoi for the treatment of acute peripheral vertigo. Afrz J Ewer;4. Men'. 1999:17: 109-i0. Training in emergency medicine is full of fascinating encounters. Over the course of medical school and 25. Graf J, Janssens U. 'l'berapy of angina pectoris: morphine or tl~alamonal?Dtsch iVded I4bchrilschr 2001 :! 26572- residency we will amash a h~agebody of inta~agible 3. experience. Much of this we share with our imedi- ate peers, residents, and classmates, as a para of our 26, Burduk P, Guzik P. Piecl-iockaM. Bronisz M, Kozek A, Jazdon M. Jordan lVR. Comparison of fennanyl and own coping and cahloguing mecl~misms.However, droperidol mixture (neuroleptanalgesia 11) with morphine much of it is also an important part of our learning on clinical outcomes in unstable angina patients, process. I cannot begin to relay how much Y have C~~ri-Eioi~uscDntg.s ?-her 2000; 14:259-69. learned, not from books (I will never read as much as 27. Wajima Z, Shitara T9Inc;ue % Ogav~aR. Setwe lightning my residency director would like me to) bent from the pain alter subarachnoid block in a patient with. neuropaehic experience of my fellow residents. Not only have 1 pain of central origin: whicl~drug is best to treat the pain? leafned about the practice of medicine, but about the Clin JPnii~2000;: 6:265-9. practice of life as a medical professional. 28. Kocake 'ii; Matsirrnoto M, Ai K. hforisski fa-ii; Talterla .I. Additional droperidol, not butorplsi~noi,augrr~ents epidura! This ES 21 new section for this journal, As it starads fentanyl analgzsia foliowing annrectal surgery. 1 Clin there are no official boursdaries. Wc (the colh"ective Ancsih, 2800; 14:9-13, reiidentisaudent population) can fill it as we see fit. 29. Gan TJ, White PF. Scuderi PE. Vilatcha ME Koviic A, There are many o~atletsfor statishcalgy s~gniii'icantrm- FDA "Black Box" warning regarding (1st. of droperidol for domized, Minded, meta-prospective studie5 about postoperative nausea and .~omitiilg:Is ir jt.srificcl? Linus~iw- siolnLg.2!102;37:287. vasiable dosing of phenytoin in post-ictd rats. Hsw- ever, these are very few place$ to share on a wider 30. Trarner MR,iteyi~oids DJ. Goodman TW. tVliose drug front, the more nebulous. but nor necessarily less irn- is it anyway?Lai~c.e?1001n358: 1275. portant experiential aspects of our training. (Pva,7c>w. 31. Haines 3, Bnic1a.y P, ZVauchob T, Withdrawal of that sorinds abit hew-agey.') HopefuUy tkis will spark drolepran?(tiroperiiiol !. BiW.l?Od' i 322: 1603. some interesting disc~rssio~~and we can lemaad laugh 32. LeiroL JJ, Ferry S. And ilow ivc present dropcridol! Arm a little in the process. Fr Anesrii Rea!~iir120UI:20:499-5043, 33. Bailey P3 Norton R, S. 'The F&4;1, dmperiilo? nam- Submissio~~sof any kind (interesting stories, poems, ing: is it justified? Al?.w.sthesiolon 2002:97:288-289. prose, fkt, fiction, and outside-the-box research pro- 34. Scn-David B.MTebcr S, Chernus 5. Drapcridol "black posals) nnay be sent 'so Jason Quinn box'' wanling warrants scrutiny. Anesthesiolog?. 2002;97:288. jquirm@hghed~com, 35. Young D. Blii~kbox warning fix droperidol surprises phamiacists. An1 .B Hpalih S~sfPi~r~i.i712002:59:502-504. 35. Kantor CS. A~~hpthmiarisk of anticmetic agents. Afles- ~/zesiii/cig;~'7002;97:286. 37. Lenzer J7sol or no^^ RG. The droperidoi dilcm~na.ACEP ,veil,§ 2002;PPugust.