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The Acutely Agitated Patient

Andrew A. Galvin, ENP-BC, ACNP-BC, CEN

Objectives

Describe and discuss a variety of selected medical and/or psychiatric conditions which may present to the Emergency Department (ED) in an acutely agitated state

Discuss the appropriate management of the acutely agitated patient in the Emergency Department setting

Case scenario

21-yr-old male presented to ED via Law Enforcement, screaming and yelling that the “government is bugging my phones” Law enforcement were called because he was

yelling profanity and saying that the “aliens were coming to take me away”

Alert, agitated adult male w/normal vital signs and no fever

No reported medical or psychiatric history

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SAFETY!!!!

“The primary goal of the management of agitation is to maintain a safe environment for everyone in the ED” (Baker, S. 2012)

General concepts It is always preferred to have EARLY

recognition and apply de-escalation strategies to defuse situation

Always consider staff, patient & visitor safety Never block off exits and ensure there is an

escape route Never turn your back on patient Ensure adequate personal space Don’t walk ahead while escorting to room

Provide ongoing observation (LOS)

Behavioral Activity Rating Scale (BARS)

1 = Difficult or unable to rouse 2 = Asleep but responds normally to verbal or

physical contact 3 = Drowsy, appears sedated 4 = Quiet and awake (normal level of activity) 5 = Signs of overt (physical or verbal) activity,

calms down with instructions 6 = Extremely or continuously active, not require

restraint 7 = Violent, requires restraint

From: Medical Evaluation and Triage of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation West J Emerg Med. 2012 Feb;13(1):3-10.

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Require immediate evaluation by clinician

Symptoms Signs

Loss of memory, disorientation

Severe headache Extreme muscle stiffness

or weakness Heat intolerance Unintentional weight loss Psychosis (new onset) Difficulty breathing

Abnormal vital signs Overt trauma One pupil larger than the

other Slurred speech Incoordination Seizures Hemiparesis

Clinical pearl

“Its never a good look to have charted Midazolam 5mg, Midazolam 5mg, and then amp of dextrose 50%. Always look for medical causes”! Accessed at:

http://lifeinthefastlane.com/behavioural-emergencies/

Assessment of Agitation1. New onset at age > 45

years2. Abnormal vital signs3. Focal neurologic findings4. Evidence of head injury 5. Substance intoxication6. Substance withdrawal7. Exposure to toxins or drugs8. Decreased awareness with

attentional problems

From: Medical Evaluation and Triage of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation West J Emerg Med. 2012 Feb;13(1):3-10.

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Medical clearance Substance/ETOH abuse or intoxication Hypoxia Metabolic disturbances Head injury Infections Underlying mental illness Hyperthermia or hypothermia Seizures: post ictal or status epilepticus Vascular: stroke or subarachnoid

hemorrhage

Reversible causes of psychosis

“DEMENTIA” mnemonic D = Drug toxicity E = Emotional disorder M = Metabolic disorder E = Endocrine disorder N = Nutritional disorder T = Tumors & trauma I = Infection A = Arteriosclerotic complications

Assessment

History & physical examination can provide clues that point to a non-psychiatric source of agitation

Observe vital signs, neurologic status New-onset agitation > 45 is less likely to

represent psychiatric condition as most of these conditions tend to present at younger age

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Assessment

Abnormal vital signs, abnormal physical exam findings, overt substance/ETOH intoxication, confusion/disorientation indicate higher likelihood of medical source of agitation Decreased awareness and attention

problems may point to delirium Assess for trauma

Medical clearance

Complete physical exam Get an accucheck! Hypo/hyperglycemia

and hypoxia are easily reversible causes of agitation

Check pulse oximetry with vital signs Consider thyrotoxicosis if markedly

tachycardic Observe for known toxidromes

Medical clearance

Lab analysis CBC, BMP, Acetaminophen, Salicylate &

alcohol level, UA, Urine drug screen Diagnostic imaging Brain CT / MRI

Lumbar Puncture

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Behavioral issues

May include first-episode or exacerbation of psychiatric disease

Substance and/or alcohol ingestions Substance and/or alcohol withdrawal Situational crises Self-harm behaviors

Assessment of Potential Violence:

Appearance Physiologic indications of impending aggression

General appearance Current medical status Any previous psychiatric

History (history of violence)

What are current medication

Are they oriented (time, place, person)

Flushing of skin Dilated pupils Shallow rapid

respirations Excessive perspiration

Behavioral indicators Overall general behaviors

Are they intoxicated, anxious, hyperactive Are they displaying?

Irritability, agitation Hostility, anger Impulsivity Restlessness, pacing Suspiciousness Rage Intimidating non-verbal behaviors (clenched

fists) Has there been any property damage

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Conversation

Do they admit to? Owning a weapon A previous history of violence Significant anger Thought of violent/harmful behaviors

towards others Substance use / abuse Command hallucinations

Have they made threats to harm another

Risk factors for violence in ED Male gender Younger age Lower income, unemployed Previous history of violence, juvenile

detention History of physical abuse by parent or

guardian Substance dependence Comorbid mental health and substance

disorder History of recent victimization

Please

Attempt verbal de-escalation techniques Genuine sense of concern Speak softly rather than shouting or threatening Ask patient about their needs Eye contact – can establish rapport OR produce

discomfort Minimize external stimuli (lights & sounds) Are your psychiatric patients in hallway

stretchers?

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Verbal de-escalation “Calming the patient” has a dominant-

submissive connotation, while “helping the patient calm himself” is considered more collaborative Ensure safety of patients, staff and others Assist patient with management of emotion

and distress and maintenance or control of behavior

Avoid the use of restraints Avoid coercive interventions

Verbal de-escalation rationale

When physical restraints are used, it can reinforce the patient’s idea that violence is necessary to resolve conflict

Patients placed in restraints more likely to admitted to psych facility and have longer inpatient LOS

JCAHO and CMS consider low restraint rates a quality indicator

10 Domains of De-Escalation1. Respect personal space2. Do not be provocative3. Establish verbal contact4. Be concise5. Identify wants and feelings6. Listen closely to what the patient is saying7. Agree or agree to disagree8. Lay down the law and set limits9. Offer choices and optimism10. Debrief the patients and staff

From: West J Emerg Med. 2012 Feb; 13(1): 17–25.

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General principles

Be polite Explain your role as one there to provide

safety for patient and staff Use short sentences & simple

vocabulary May require repetition Appropriate body language Offer choices that are seen at comfort

Inviting patient ideas What helps you in times like this?

Stating a fact I think you would benefit from medication

Persuading I really think you need a little medicine

Inducing You’re in a terrible crisis. Nothing seems to be helping.

I’m going to get you some emergency medicine. It works well and it’s safe. Let me know if you have any concerns.

Coercing (last resort) I’m going to have to insist

From: West J Emerg Med. 2012 Feb; 13(1): 17–25.

Clinical Pearl

“You can’t change someone’s personality; but you can obliterate it

with drugs”.- Dr. Billy Mallon

Accessed at http://lifeinthefastlane.com/behavioural-

emergencies/

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Why consider restraint?

In order to Prevent harm to the patient or other patients

in the ED Prevent harm to caregivers or other ED staff Prevent damage to the

environment/department Assist with assessment and management of

patient NOT for convenience of staff!

Considering restraints? The order (physical, chemical) in which

restraints are ordered should be determined by safety and clinical evaluation

Get as much of exam and assessment completed as possible before medicating

Consider discussing w/psychiatry prior to initiation of as consultant may want to examine patient

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Pharmacologic choices Treatment guidelines published by ACEP,

National Institute for Health & Clinical Excellence and Expert Consensus Guidelines discuss How and when to initiate pharmacologic measures Optimal agents for degrees of agitation Individualization of therapy for special populations

GOAL of medications are to calm patient w/o affecting airway to provide for better assessment

Pharmacologic choices

No type of medication is considered “best”

Typically classes of medications used most frequently for agitation include benzodiazepines, first & second-generation anti-psychotics

May be provided orally, intra-muscular or intravenous routes

Remember

When treating the undifferentiated patient especially one reluctant to use oral agents – IV access should be obtained May provide IM agent while attempting IV Once you have chosen this path….you are

responsible for maintenance of airway, breathing, circulation, hydration and toileting needs

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There is always risk

Intramuscular route may have more rapid onset of action but are often associated with higher rates of adverse effects

Intravenous administration may provide faster onset and resolution but can precipitate orthostasis, dystonia, cardiac and/or respiratory compromise

Benzodiazepines

Preferred treatment for patients with psychotic agitation with concomitant sympathomimetic or anti-depressant intoxication Diazepam (Valium) Lorazepam (Ativan) Midazolam (Versed)

Do not treat any underlying psychosis (bipolar mania, schizophrenia)

Benzodiazepine cautions

Side effects include Excessive sedation Respiratory depression Ataxia Paradoxical disinhibition

Respiratory depression is concern in presence of concomitant alcohol, opiate or other CNS depressant use

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Lorazepam (Ativan)

Can be provided orally, intramuscularly or intravenously in increments of 0.5-2 mg Very few drug-drug interactions Drug of choice for alcohol withdrawal and will

not exacerbate agitation due to sympathomimetic, antidepressant or anticholinergic intoxication

Observe for excessive sedation Equal to or superior to haloperidol (Haldol)

Lorazepam (Ativan) Typical dosing

PO: 1 – 2 mg○ Peak = 2 hr.

IM: 0.5 – 1 mg○ Onset = 15-30 min○ Peak = 60-90 min

IV: 0.44 mg/kg (typically 0.5-1mg) Caution

Known hepatic impairment Elderly (PO / IM) 1 mg Avoid in presence of CNS intoxicants

Anti-psychotics First generation (“typical”)

Classified according to their chemical profile; neuroleptic or dopamine antagonist agents

Higher risk of neurological side effects (tardive dyskinesia, dystonia)

Second generation (“atypical”) 5HT2A/D2 antagonists Equal or greater efficacy in patients with

schizophrenia, schizoaffective syndrome, and bipolar mania than typical antipsychotics

Higher risk of metabolic side effects

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Anti-psychotics *Not all-included

First generation Second generation

Haloperidol (Haldol) Prochloroperazine

(Compazine) Chlorpromazine

(Thorazine, Largactil) Droperidol (Inapsine,

Innovar) Thiothixene (Navane) Fluphenazine (Prolixin)

Aripiprazole (Abilify) Onlazepine (Zyprexa) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon)

Extrapyramidal symptoms (EPS)

Drug-induced movement disorders Acute and tardive symptoms

○ Dystonia: spasms and muscle contractions○ Akasthisia: motor restlessness and anxiety○ Parkinsonism: rigidity is common○ Bradykinesia: slowness of movements○ Dyskinesia: irregular, “jerky” motor activity

TX: diphenhydramine (Benadryl) 25-50 mg and/or benztropine (Cogentin) 1mg

Tardive dyskinesia

Difficult to treat, sometimes incurable type of dyskinesia resulting in involuntary repetitive body movements Grimacing Lip smacking, puckering, pursed lips Excessive blinking

Most frequently seen with longer-term use (> 3 mo.) of antipsychotics

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Rabbit Syndrome• Rare form of EPS with perioral tremors• Fine, involuntary rhythmic motions of the mouth

along a vertical plane• Usually seen after years of pharmacotherapy

Haloperidol (Haldol)

1st generation antipsychotic, highly-potent & selective dopamine-2 (D2) receptor Approved for oral or IM use, 2.5 – 10 mg) Very effective, but higher doses often

produce unpleasant side effects Minimize or avoid IV use

○ Not FDA approved for acute agitation

Droperidol (Inapsine)

Typical antipsychotic that was very popular until Black Box warning by FDA (2007)

Has been used IV/IM in doses from 2.5-5 mg for agitation (typically lower doses for anti-emetic effects)

Faster onset of action and greater efficacy than haloperidol (Haldol) but may produce over-sedation in higher doses

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Be aware

BOTH haloperidol (Haldol) and droperidol (Inapsine) have minimal effects on vital signs but can lengthen QTc intervals Torsades de pointes has been reported with

both agents○ A lot of controversy regarding the degree and

clinical significance of this

What about the research?

Large retrospective 2002 study (n=2,456) found only 6 adverse events out of which 1 patient had cardiac arrest

Studies comparing second-generation antipsychotics to benzodiazepines and first generation antipsychotics are lacking

Olanzapine (Zyprexa)

Atypical antipsychotic in IM and PO forms (w/rapidly dissolving tablet) Dose = 10 mg PO / IM with 15-45 min onset

of action Particularly effective for control of agitation

in bipolar mania and schizophrenia Potential for orthostatic hypotension FDA Black Box warning for use in

elderly with dementia-related psychosis

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Ziprasidone (Geodon)

Atypical antipsychotic agent available in PO and IM formulations Dose = 10-20 mg PO or IM, onset of action

Another agent that is associated with QTc prolongation

FDA Black Box warning for use in elderly with dementia related psychosis

Risperdal (Risperidone)

Atypical antipsychotic with both PO and IM formulations Preferred oral use Available in oral and long-acting IM forms Dose = 1-2 mg PO / IM

More likely to cause EPS than olanzapine but less likely than typical antipsychotics

Reported to work well in elderly

Combination therapy Thought to have more rapid onset of sedation

than when either agents are used individually Common for use of one benzodiazepine and

one typical antipsychotic “B52” = (IM) Benadryl 50mg, Haldol 5mg, and Ativan

2mg “HAC” = (IM) Haldol 5mg, Ativan 2mg, Cogentin 1mg “5150” = (IM) Haldol 5mg, Ativan 1mg, Benadryl

50mg

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Ketamine (Ketalar)

Dissociative agent that acts that results in a trance-like state with both analgesic and amnestic effects

Rapidly acting with minimal effect on vital signs, preservation of airway reflexes Can be administered IM (3-5 min onset) or

IV (1-2 min onset) Should NOT be used for schizophrenia

Midazolam (Versed) Benzodiazepine sedative agent that can

be delivered PO / IV / IM & intranasal Prospective, randomized trial of 111

violent and agitated patients compared IM haloperidol (Haldol) 5mg, lorazepam (Ativan) 2mg, and midazolam (Versed) 5mg No significant changes in VS Lorazepam (Ativan) was stopped due to

increased sedation time

Age-specific considerations

Elderly patients may be more susceptible to adverse drug reactions Increased sedation w/benzodiazepines

○ Increased fall risk Exacerbation of cardiac and prostate

disease from anticholinergic side effects May worsen delirium

Hepatic or renal dysfunction may require dose adjustments

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Pediatrics

Strong clinical trials regarding pediatrics are lacking

No established guidelines for managing acute agitation in children

Physical Restraints

Be aware of facility, local, state and/or federal guidelines and laws

“Team sport” One staff per limb, one staff member to direct &

oversee process Use of physical restraints should be followed

by chemical restraints

Considering physical restraints?

Restraint devices used should be the least restrictive method, yet secure enough to restrain patient

Restraints should be able to be easily and rapidly removed by staff in the event of physical distress (vomiting, seizures)

Ensure padding is applied and frequent neurovascular assessment of extremities

Ensure appropriate documentation

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Summary

Remember that restraint and/or sedation is done for the patient benefit rather than staff convenience

PO administration is preferred Ensure appropriate monitoring for

particular medications and patient populations

Ensure staff and patient safety

References• Baker, S. (2012). Management of acute agitation in the emergency department. Adv

Emer Nurs J, Vol 34, Issue 4, 306-318.• Caine, E.D. (2006). Clinical perspectives on atypical antipsychotics for treatment of

agitation. J Clin Psychiatry; 67, Suppl 10: 22-31.• Chan, E.W., Taylor, D.M. ,Knott, J.C. et al. (2012). The pharmacoeconomics of

managing acute agitation in the emergency department. What do we know and how do we approach it. Expert Rev Pharmacoeconomics Outcomes Res, 12 (5), 589-595.

• Garriga, M. Pacchiarotti, I. et al. (2016). Assessment and management of agitation in psychiatry: Expert consensus. World J Biol Psychiatry, 17(2), 86-128.

• Gillespie, L., Gates, D., Berry, P., (2013) "Stressful Incidents of Physical Violence Against Emergency Nurses" OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 1, Manuscript 2.

• Hilt, RJ et al. (2008). Agitation treatment for pediatric emergency patients. Journal of the American Academy of Child & Adolescent Psychiatry, Vol 47 (2), 132-138.

• Hopper, A.B., Vilke, G.M., Castillo, E.M., Campillo, B.S. et al. (2015). Ketamine use for acute agitation in the emergency department. J Emerg Med; 48(6), 712-719.

• Wilson, M. P., Pepper, D., Currier, G. W., Holloman, G. H., & Feifel, D. (2012). The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. Western Journal of Emergency Medicine, 13(1), 26–34. http://doi.org/10.5811/westjem.2011.9.6866

• Emergency Department Violence Surveillance Study (2011). ENA