Approach to the Agitated ED Patient
**Remember - safety for both patients and staff in ED is important!**
Interventions
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Nonpharmacological
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Verbal de-escalation
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Redirection (TV, food, magazines/toys)
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Changing environment (turning off lights, blankets, quiet area)
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Be understanding of what is frustrating them / what they want - maybe there is a compromise?
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Be concise in your goals of treatment and speak without provocation!
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Pharmacological
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Antipsychotic
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Side effects: extrapyramidal, dystonia, akathisia, prolonged QT
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First generation
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Haloperidol 5mg
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Useful as it’s available PO/IM/IV
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Fast acting
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Second generation
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Less side effects, not all available in IM so less useful in acute agitation setting without access
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Olanzapine 5-10mg
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PO/IM/IV
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Ziprasadone 10-20mg IM
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Risperadone 2mg PO
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Benzodiazepine
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Side effects: sedation, respiratory depression
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Lorazepam 2mg
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Longer acting
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PO/IV/IM
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Midazolam 5mg
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Quicker on, quicker off
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PO/IV/IM
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Other
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Ketamine
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Side effects: increased agitation, apnea, seizures
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IM: 4-6 mg / kg
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IV: 1-2 mg / kg
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Physical restraints should be used as a last resort when a patient is a danger to him/herself or others and the above cannot be used/do not work.
- Restraints should be removed as soon as safe to do so!
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Drugs are NOT benign, use with caution in already intoxicated, pregnant, elderly, young, those with comorbidities
Take into Consideration
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Do a comprehensive exam, psychiatric disease is NOT the only cause for agitation
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Infectious (check for fever, abnormal vitals, s/s of infection)
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Toxicologic (strong HPI/history, other s/s of toxidromes?)
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Metabolic (use history or exam to guide your work up)
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Neurologic (thorough neuro exam!, imaging if needed)
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Structural/Trauma (thorough physical exam, EMS/bystander reports?)
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Vital signs are vital - don’t forget that POC glucose!
References
Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012 Feb;13(1):17-25.
Emdocs cases: Ed approach to agitation. emDOCs.net - Emergency Medicine Education. http://www.emdocs.net/emdocs-cases-ed-approach-agitation/. Published February 5, 2018. Accessed August 6, 2021.
"I Don't Know What We're Yelling About!" by soukup is licensed with CC BY 2.0. To view a copy of this license, visit https://creativecommons.org/licenses/by/2.0/