Approach to Agitated Patients in the Emergency Department

Show Notes

Background/Epidemiology

•Definition and Scope: Agitation encompasses behaviors from restlessness to severe altered mental states. It’s a common emergency department presentation, often linked with acute medical or psychiatric emergencies.

•Significance: Patients with agitation are at high risk for morbidity and mortality, necessitating prompt and effective management to prevent harm to themselves and healthcare providers.

A Changing Paradigm in Describing Agitation

•Terminology Shift: Move away from terms like ‘excited delirium’ due to their politicization and stigmatization. Focus on describing agitation by severity and underlying causes.

Agitation as a Multifactorial Process

•Complex Nature: Recognize agitation as a result of various factors, including medical, psychiatric, and environmental influences.

Recognizing Agitation

•Signs and Symptoms: Identify agitation early by monitoring for behaviors such as hostility, pacing, non-compliance, and verbal aggression.

Initial Evaluation

•Severity Assessment: Determine the severity of agitation and prioritize reversible causes and life-threatening conditions.

•Diagnostic Steps: Perform vital signs check, blood glucose levels, ECG, and a targeted medical screening exam.

Life Threats

•Immediate Concerns: Identify and address immediate life threats such as hypoxia, hypoglycemia, trauma, and acute neurological emergencies.

Forming a Differential Prior to Treatment

•Prioritization: Severe agitation requires immediate treatment to facilitate further evaluation and reduce risk of harm.

Physician/Staff Safety

•Safety Measures: Ensure personal and team safety by maintaining a calm environment and preparing for potential violence.

Multimodal Approach

•Self-check In: Physicians should mentally prepare and approach the situation calmly to ensure effective management.

•Verbal De-escalation: Use techniques focused on safety, therapeutic alliance, and patient autonomy to manage agitation non-pharmacologically.

Medication Administration

•Oral/Sublingual Medications: Consider oral medications for less severe cases to maintain patient autonomy and avoid invasive procedures.

•IM or IV Medications: Use intramuscular or intravenous medications for rapid control in severe cases.

Specific Medication Regimens

•PO Regimens:

•Medications: Antipsychotics like Zyprexa (olanzapine) 5-10 mg, benzodiazepines like Ativan (lorazepam) 1-2 mg.

•Benefits: Empower patients with a sense of autonomy, avoid injection-related trauma.

•Pharmacokinetics:

•Olanzapine: Onset in 15-45 minutes, peak effect in 1-2 hours, duration 12-24 hours.

•Lorazepam: Onset in 30-60 minutes, peak effect in 2 hours, duration 6-8 hours.

•IV/IM Regimens:

•Medications: Droperidol, haloperidol, midazolam, ketamine.

•ACEP 2023 Guidelines: Recommend droperidol with midazolam or an atypical antipsychotic for severe agitation.

•Pharmacokinetics (IM):

•Haloperidol: IM onset in 15, time to sedation ~25 minutes, can last for 2 hours

•Droperidol: IM onset in 5-10 minutes, duration 2-4 hours but can last as long as 12 hours

•Midazolam: IM onset ~15 minutes, , duration 20 minutes – 2 hours.

•Lorazepam: IM onset ~15-30 minutes, , duration up to 3 hours

•Ketamine: IM onset in ~5 minutes, duration 5-30 minutes.

Special Situations

•Elderly/Dementia: Optimize environment, use non-pharmacologic measures, avoid benzodiazepines to reduce delirium risk.

•Parkinson’s Disease: Avoid antipsychotics that can precipitate a Parkinsonian crisis.

•Autism/Pediatrics: Engage caregivers, create a calming environment, avoid aggressive measures.

•Alcohol Withdrawal: Utilize benzodiazepines and phenobarbital.

Re-dosing and Physical Restraints

•Re-dosing: Use the lowest effective dose, consider continuous monitoring, and reassess frequently.

•Physical Restraints: Employ as a last resort, ensuring close monitoring for any adverse effects.

Final Points

•Clinical Leadership: Physicians should lead with clear communication, planning, and support for the team.

•Continuous Learning: Regular debriefing and assessment after each incident to improve future responses.