Asynchrony EM: Code Gray (The Agitated Patient)

New to Asynchrony EM? It's an asynchronous learning course in its third year at Brown EM. Digital resources and #FOAMed are curated and packaged by topic, following Brown EM's curricular calendar. In the spirit of #FOAMed, we've started putting it out there for the EM community at large. Check out the theme song, the 'extras', and the discussion questions, and other modules -- and leave us your thoughts in the comments section. Follow us on Twitter at @AsynchronyEM.
Note: Brown EM residents must complete the modules (including discussion/quiz) in Canvas to obtain credit hours.
Time to pull out your agitated patient skills!

Time to pull out your agitated patient skills!

Code Gray -- known at our local community hospital as 'behavioral team to the trauma room'!

This module contains information on management of the agitated, combative patient who will likely present to the ED during your next shift.  We deal with this type of patient encounter more often than any other medical specialty, and thus we need to be able to recognize those is psychological distress, act quickly to control the situation, and work to keep the patient, our staff and ourselves safe.  In fact I would argue that this is on of the many things that ER docs are best at; we take control of a chaotic situation.  

Before we jump into the craziness, a song to set the mood...any day may have a Touch of Grey.


When patients arrive agitated, they are often acting in this way because they feel a loss of control.  It is important that you try and engage the patient and then start of give the control back to them.  


Signs of an agitated patient include:

  • increasing tone of speech (yelling louder)
  • foul language
  • foreboding tone of voice
  • demanding content
  • verbal abuse to staff
  • inability to sit still
  • making fists or other aggressive body positioning
  • flexing of the muscles/tensing of the jaw

Recommended helpful statements include:

  • I can see you're angry.  Let's talk, and you can tell me what is troubling you.
  • I am here to help you, but you have to tell me what is going on.
  • I can see you're upset; tell me what you need to help you feel better. 
  • I'll bet you didn't plan for this ER visit; tell me how you got here.

For more tips and info keep clicking, learn & enjoy!

From Life in the Fast Lane: Behavioral Emergencies

From EM Crit and Reuben Strayer: a podcast

From the March 2017 ER Cast my effort to provide you with the most up to date evidence based medicine because I know you can't get enough of journal club:)

From EM Cases, notes and podcast

From EM Crit: don't need to do the full podcast, just focus on video for proper way to restrain the patient in the ED. 


Our work environment is better than most for agitated patients, as we have the resources to help us with these situations: nursing, security, training, and most importantly drugs !!

From EP Monthly: Understanding Haloperidol

From REBEL EM: Chemical Sedation of the Agitated Patient

From The Poison Review: Is Ketamine Safe in Excited Delirium?


If you have the time extras for you to enjoy :)

The Upset Patient Protocol, from ER Cast

Medical Clearance of the Psychiatric Patient, from Emergency Medicine Cases

Also from EM Cases: Managing the Difficult Patient


That's it! See you next time! Brown residents, make sure to complete the module in Canvas for credit.