National survey of Dutch emergency physicians on pharmacological sedation practices for extreme agitation.

Background and importance: Extreme agitation in the emergency department (ED) is a high-risk scenario requiring rapid, safe sedation. International evidence and guidance on first line and rescue agents are variable, however current practice has not been systematically described. Objectives: To characterise pharmacological sedation practices reported by Dutch emergency physicians (EPs) for the management of extreme agitation in the ED, including agent selection, dosing, determinants of choice, perceived performance, and rescue strategies. Methodology: National cross-sectional web-based survey among Dutch board-certified EPs (and EPs in training), was distributed to all Dutch Society of Emergency Physicians (DSEP) members through a newsletter, at the yearly DSEP conferences, to colleagues from prior collaborations, and via LinkedIn. Results: Of the 679 eligible board-certified EPs, 293 responded (43.2%); after excluding 42 incomplete responses, 251 were analysed (37.0%). Among this group, 39.0% reported that prehospital midazolam sedation, administered by ambulance services, was often insufficient upon patient arrival in the ED. Without available intravenous (IV) access, the initial choices of sedative most often were midazolam (34.7%), droperidol (23.1%), the droperidol-midazolam combination (14.3%), and esketamine (10.4%), with intramuscular (IM) being the preferred route in these situations; The median IM doses were 10 mg for droperidol and midazolam, 5 mg each for the droperidol-midazolam combination, and 150 mg for esketamine. With IV access, the same ranking applied, with IV being the preferred route, although a small proportion of respondents still opted for alternative routes such as IM and intranasal (IN). The most cited reasons for agent choice, were the DSEP pocket card on sedation for behavioural disturbance (43.0%), perceived effectiveness (37.8%), and residency training (30.3%). When asked about personal experience with sedatives, droperidol and esketamine were frequently described as effective and rapid, whereas midazolam was more often linked to side effects. When initial sedation failed, 85.7% escalated the initial sedative to a certain dosage before switching; esketamine (32.7%) and propofol (27.5%) were the most common rescue medications. Conclusion: Dutch EPs primarily use a recommended set of sedatives based on national guidelines, but their approach to managing extreme agitation varies within that framework. Emergency physicians reported midazolam as the most frequently used first-line agent, although respondents generally rated droperidol as more effective and better tolerated. Given these perceptions and the available evidence supporting droperidol's efficacy and safety, it may be reasonable to reconsider the prominent role of midazolam, particularly since prehospital midazolam sedation was often judged to be insufficient.