The Emergency Department is no stranger to the acutely agitated patient. Agitation remains a broad and multifactorial syndrome with a high potential for significant morbidity or mortality if not recognized and managed appropriately. This can be tricky at times when there is a lack of agreement among practitioners as what is considered first line treatment.

This post aims to provide a four-step approach to managing the acutely agitated patient in the Emergency Department based on expert consensus with the goal of ensuring safety of the patient, staff, and others, minimizing use of coercive interventions, and encouraging patients to regain control to manage their emotions.

agitated

First and foremost, ensure you are safe, be mindful of your environment and potential choking hazards (e.g., stethoscope, hair, pens, lanyards etc.) and have an exit strategy.  Don’t hesitate to call for help if at any time you feel unsafe.

Step 1a: Differential Diagnosis/Treating life threats

Agitation is an acute issue that needs to be addressed but it’s important to ensure immediate life-threatening conditions are not overlooked. At times it can be obvious, but sometimes a bit of detective work is needed. Keep a broad differential and complete a thorough history and physical exam, review medications, obtain a set of vitals and initiate investigations.

There are many mnemonics out there that can help you be more organized in your approach (e.g., AEIOU TIPS, DIMS), use what works best for you.

Step 1b: Observe and Categorize 

agitated

 

How should we categorize the degree of agitation? There are quite a few agitation scales created out there, none of which have been developed for use in the Emergency Department specifically but consensus from the American Association for Emergency Psychiatry (AAEP) identified “BARS” as a reliable and easy scale to employ, particularly in an emergency setting. For the Emergency Department, we can likely simplify the scale into 4 main categories as identified by Feng (2002):

 

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Step 2: De-escalation

If it is safe to do so, non-pharmacological interventions should be your first line approach. The goal is to help patient’s calm themselves in order to cooperate in their care. Whether we are aware of it, we utilize de-escalation techniques daily in the emergency department. Despite its potential to decrease agitation and reduce escalation to violence there is little discussion surrounding teaching regarding verbal methods.

A consensus statement put forth by American Association of Emergency Psychiatry identified 10 domains of de-escalation that assist clinician’s in providing care of agitated patients.

Highlights from the article by Richmond et al. are summarized below:

agitation

To further simplify it, Windover et al outlines responses that may be helpful by using the mnemonic “SAVE

  • Support
    • “Let’s work together…”
  • Acknowledge
    • “I see this has been hard for you”
  • Validate
    • “I’d probably be reacting the same way if I was in your shoes”
  • Emotion naming
    • “You seem upset”

Step 3: Get Help (Code White)

There are no hard-set rules when it comes to activating a code white, but there is a general agreement in things that may prompt you to activate one.

agitation

 

Keep in mind that a code white should not be used as a threat for an uncooperative patient, because the code in itself can further amp up an already tense situation and can traumatically impact both patients and staff involved. If safe to do so, a great alternative would be utilization of a “concealed code white” by paging security directly rather than overhead paging for those patient’s that you feel are moderately agitated.

 

Step 4: Restraints

Despite best efforts to calm the situation escalation in the acutely agitation patient can be unpredictable leading to imminent danger to everyone. Restraints are considered a treatment of last resort but at times they are needed to control situations that have gotten out of hand.

 

Pharmacological interventions

Agitation is quite the unique clinical situation as often treatment is initiated before we’ve identified the underlying cause. Despite substantial literature reviewing medications used in management of acute agitation, there is still no consensus on the ideal first line agent. Rather, current recommendations are drawn from expert consensus and can vary depending on practitioner and situation.  

Things to consider when selecting your agent of choice:

  • Category of agitation
  • Speed of medication onset required
  • Route of administration
  • Special considerations

Below is a table summarizing common medications used, route of administration and for what category of agitation:

agitation

 

What about Ketamine for agitation? This remains up for debate and at this time it’s dependent on clinician judgement.

 

Physical restraints

Restraint use carry an elevated risk to staff and patients when implemented. Therefore, we consider this as a “treatment of last resort”. So, if initiated, keep in mind least restrictive restraint is to be used for the shortest time to reduce harm.


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Special Populations

 

Acutely Agitated Pediatric Patient

Agitation can start with tantrums and quickly escalate to aggressive behaviour, when possible, family and caregivers may provide help, but it is important to ensure that they are not the source of the agitation. As always with any agitated patient, verbal de-escalation is first line, particularly with kids but at times chemical and physical restraints may be required.

For a review of the Approach to the acutely agitated Pediatric patient, refer to this excellent grand rounds.

 

Acutely Agitated Pregnant Patient

At the best of times, we are very cautious to administer medication to pregnant patients. This adds another level of difficulty when faced with an acutely agitated pregnant patient. There’s no surprise that there is insufficient data assessing management and treatment of agitation in this population. Based on an expert consensus conducted in 2001 by Allen et al general recommendations were provided regarding therapies.

Suggested safe therapy options:

  • Risperidone – Safe, no known teratogenic effects
  • Haloperidol – commonly used acute, short-term setting
  • Benzodiazepine – may be safe in acute setting, short-term use
  • Diphenhydramine – safe, low risk of major malformations

agitation

Also, keep in mind use of physical restraints should be considered as a last resort, particularly in pregnant patients. If physical restraints are required, consider these points:

  • Avoid 4-point restraints in 2nd & 3rd trimester for risk of IVC compression
  • Place left lateral decubitus or right hip positioned 10-12cm off bed
  • Frequent reassessments

 

Acutely Agitated Elderly Patient

Though agitation is not always present in delirium, with only 1/3 of cases of altered mental status presenting with agitation in the Emergency Department. We recognize that delirium is not only distressing to patients, caregivers, and health care providers but it can be a medical emergency with hospital mortality rates approaching 33%, as it can be under-recognized in the Emergency Department.

A general thought to keep in mind when encountering the older adult that’s agitated is “Old and altered, presumed delirium until proven otherwise”. Keep a broad differential diagnosis, obtain a complete history and thorough physical examination.

To assist providers in management of the agitated older adult, based on expert opinion and literature review ADEPT (Assess, diagnose, evaluate, prevent, and treat) tool was created in 2017 for use in the ED.

So, which treatment is best?

It can be tricky, treatment options can vary depending on clinician, environment, and patient factors. It’s important to consider a patient’s neurologic co-morbidities along with current medications when selecting a drug. As there is quite a variety of treatment options, here are some recommendations based on expert consensus:

  • Non-delirious agitation
    • 1st line: de-escalation
    • 2nd line: antipsychotics (risperidone, olanzapine, haloperidol)
  • Delirious agitation
    • 1st line: de-escalation
    • Drug choice is variable, factors to consider:
      • Dementia, heart disease, respiratory failure etc.

I recognize there will be variation in practice with preferences towards different therapy choices. Below is an overview of recommended medications and route of administration.

agitated

*smaller dosing reminder with older adults

Acute agitation is an important presentation that requires early recognition and treatment.

Older adults can be complex, so, it’s important to remember to review active medications, give what they are usually given first and be cognizant of your therapy choice to avoid unwanted drug to drug interactions. Just remember the good old saying of “start low, go slow” that way you’ll know.

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