2026 Eastern States Conference

Authors: Samia Rahman Adity, PharmD, Sharon Janak, PharmD, BCPS, Claudia Rondon, PharmD, BCCCP, Keyur Patel, PharmD, DPLA, Melissa Rufo, PharmD, BCPS, Kasia Gejdel, PharmD, BCOP, BCPS 
 
Learning Objective: Describe safe and effective prescribing and monitoring practices for injectable haloperidol use in the emergency department.   
 
Self-assessment question: Haloperidol is associated with QT prolongation and extrapyramidal symptoms.  True/False 
 
Background: Describe current injectable haloperidol prescribing and safety monitoring practices for older adults treated for acute agitation in the emergency department at Long Island Jewish Forest Hills and identify opportunities for improvement.  
 
Methods: A retrospective chart review was conducted; patients were included if they were 65 years or older and received injectable haloperidol in the emergency department (ED).  Patients were excluded if they were treated for alcohol withdrawal, or if they received oral haloperidol or another antipsychotic prior to receiving the first dose of injectable haloperidol. Collected parameters included patient history of schizophrenia or dementia; dose and route of haloperidol; time from ED triage to haloperidol administration; time from haloperidol administration to receipt of additional haloperidol, another antipsychotic, a benzodiazepine, diphenhydramine, or benztropine, if given; baseline and post-treatment QTc, if EKGs were performed; baseline  oxygen delivery; and time to post-treatment escalation of oxygen delivery, if required.   
 
Results: A total of 215 patients were included. Dementia was common, present in 63.7% of patients treated with injectable haloperidol. Patients received initial doses between 1 and 5 mg, with 60% of patients receiving 5 mg. Overall, 42.3% of patients required repeat medication, with benzodiazepines being used most frequently (52.7%). Approximately 4.7% of patients required new supplemental oxygen, while 1.9% of patients already receiving oxygen required an increase from their baseline oxygen need. Anticholinergic rescue was needed for 4.2% of patients. Of the 7% of patients who had both baseline and post-treatment EKGs performed, 53.3% of patients experienced QT prolongation.  
 
Conclusion: Initial doses of haloperidol 5 mg were not associated with reduced need for repeat sedation, suggesting limited benefit from dose escalation alone. Coadministration with lorazepam complicated the interpretation of treatment effectiveness.  Anticholinergic use was infrequent, suggesting low rates of extrapyramidal symptoms after initial haloperidol administration.  Baseline EKGs were inconsistently ordered, indicating the possible need for a standardized protocol for QTc monitoring.