TIPS for Managing the Acutely Agitated Patient
“medical personnel are more likely to experience work-place violence than police officers or prison guards, with a full 100% of ED staff experiencing verbal violence, and 35-80% reporting a history of physical violence while at work.[1]”
INTRODUCTION
Emergency medicine practitioners commonly care for acutely violent or agitated patients, some of whom may be psychotic, intoxicated, or affected by another pathology. Consequently, medical personnel are more likely to experience work-place violence than police officers or prison guards, with a full 100% of ED staff experiencing verbal violence, and 35-80% reporting a history of physical violence while at work.[1]
The differential diagnosis for the acutely altered patient is broad. Potential causes of altered mental status can be remembered using the mnemonic AEIOU TIPS [2]:
Alcohol
Endocrine/Encephalopathy/Electrolytes
Insulin (hypoglycemia or hyperglycemia)
Oxygen (hypoxia), Opiates (drugs of abuse)
Uremia
Toxins, Trauma, Temperature
Infection
Psychiatric/Porphyria
Stroke, Shock, SAH, Space-occupying CNS lesion
While it is critical to initiate a work-up to diagnose the underlying cause of a patient’s behavioral dysregulation, it is of primary importance to control the patient’s behavior both for their safety and the safety of the patient’s caregivers.
INITIAL ASSESSMENT
Set the Stage
As part of the initial assessment, it is important to set the stage by controlling environmental factors that can aid in the evaluation of the patient. If possible, find a quiet and private location to meet with the patient. It is important to balance the patient’s privacy with the need for safety, meaning that the interview area should not be isolated and enable for easy access by security or other ED staff, while allowing the interview to be conducted in as quiet and private a place as possible.
Crowd Control
When initially evaluating a behaviorally-dysregulated patient, multiple types of hospital staff members are typically involved, including security, technicians, nurses, and physicians. While the presence of these staff members is often triggered by an automated alert (“Behavioral Team” or “Code Grey”), it is important to assess if their presence is truly warranted and helpful. In the case of a patient who is paranoid or internally stimulated, being surrounded by a large number of people can worsen their agitation. While it is important to have staff and security present in the event the patient becomes physically aggressive or a safety concern, it can be helpful to have some of these staff members remain out of the patient’s eyesight until they are needed. In contrast, in some circumstances, such as when a non-psychotic, but behaviorally dysregulated, patient is escalating or being provocative, a “show of force” with a plurality of personnel can be useful in containing the patient’s behavior.
Manage Expectations
Often, when a patient is agitated, their provider can experience pressure from other members of the care team to restrain and/or medicate the patient. This can be especially true if the patient’s presentation includes inappropriate, mean, or inflammatory statements or behaviors related to sex or ethnicity. The motivation for this pressure is simple: as the physician, you will be spending significantly less time with the patient than the security team, aide, or RN, and your team members will be exposed to most of the burden of these patient’s behaviors. While it is important to acknowledge this and to provide support to staff, it is also important all members of the team understand the goal of care is not to silence or sedate the patient. The goal is to help the patient achieve a calm state, enabling them to engage in their medical evaluation and ultimately in their treatment.
Sit Down
Positioning and body language are important: when at all possible, sit down in the room. Try to get at the same eye level of your patient. In many circumstances, a provider meets an agitated patient while they are actively being restrained by security. This generally means the patient is supine and the provider is standing up, leaning over the patient. This can be seen as intimidating and can exaggerate the patient’s agitation, particularly if feeling paranoid or out of control. Even if a patient is being restrained, it is still possible, and recommended, to pull up a chair and try to speak with the patient. Remember to ensure your safety and the safety of others by staying at least 2 arm lengths (or 3 feet) away from the patient—out of reach. Ensure that your path to the door is unobstructed. The patient should never be positioned between the provider and the door. If possible, position yourself so that both you and the patient each have access to the door, preventing both parties from feeling trapped.
Be Concise
Minimize “overtalking” with the agitated patient, and keep your discussion simple. A patient who is agitated, particularly if experiencing hallucinations or paranoia, will not be able to follow long-winded and complex instructions or explanations. It is important to remember that internal stimuli can be both a source of great distress and distraction. Keep this in mind as you consider which information is essential to communicate verbally and which is not.
SEDATION
Non-pharmacological interventions should always be attempted first, including reduction of environmental stimuli and verbal de-escalation. If medication is needed, it should not be used as a restraint nor should it be used to induce sleep. The goal of giving a patient medication is to calm them, allowing for assessment, treatment, and ultimately disposition planning. Sedating a patient ultimately delays their evaluation and does little to ensure that once they awaken they won’t become agitated again.
Address the underlying cause
If possible, the choice of medication should be based upon an assessment of the likely underlying cause of agitation.
Choices
Whenever possible, involve patients in the process of selecting medications. In the event of an unsafe or behaviorally dysregulated patient requiring medication for safety, the choice you are offering is not if a medication is going to be given, but which one. Many agitated patients have been seen in the Emergency Department previously and may have a preference regarding the type and route of medication given. Patients with psychiatric illness may also know which medications are most helpful to them based on their past experiences. PO medications are preferred to IM medications for this reason as well, enabling the patient to exert some agency over their treatment. Note that psychiatric patients are especially sensitive to violations of their autonomy; many have experienced involuntary treatment, incarceration, and other forms of social disenfranchisement. Working with a patient on a shared decision such as which medications to use and by which route can communicate respect, which can be therapeutic in its own right.
Benzodiazepine + antipsychotic
The standard treatment regimen for most patients presenting with acute agitation consists of three classes of medication: benzodiazepines, first-generation antipsychotics (FGA), and second-generation antipsychotics (SGA). In general, the majority of violent or agitated patients will receive a combination of an FGA and a benzodiazepine, or an SGA alone. It is important to recall that, while utilized frequently, these medications do confer risks that must be noted and monitored, including respiratory depression, hypotension, dystonia, QTc prolongation, and neuroleptic malignant syndrome (NMS).
First-generation (“typical”) antipsychotics work predominantly via blockade of dopamine-receptors in the brain. Of the first-generation antipsychotics, Haldol (haloperidol), is most frequently used in the management of acute psychosis or agitation. Haldol is approved for IM and PO administration, but is also frequently used off-label via IV. Haldol carries an FDA warning against IV route administration and the associated increased risk of QTc prolongation and the development of torsades de pointes.
Droperidol is an analog of Haldol, with a shorter half-life and quicker onset of action than Haldol. droperidol is approved by the FDA for treatment of postoperative nausea and vomiting, but historically was frequently used in the ED setting for the management of acute agitation. In 2001, a black box warning was issued for QTc prolongation and potential for development of torsades. Included in this warning was recommendation for a screening EKG and post-administration telemetry monitoring, which can be challenging to do for an acutely agitated patient. Both the black box warning and drug shortages have led to a decreased use of droperidol in the ED. The degree and clinical significance of QTc prolongation is controversial, with multiple studies finding no significant QTc prolongation or increased risk of torsades despite the black box warning.[3] However, because of this warning, which has not been revised or removed, project BETA, an American Association for Emergency Psychiatry coalition, recommends against the use of droperidol in acute agitation, especially given it is not FDA approved for psychiatric use.[4]
As FGAs, both Haldol and droperidol have increased risk of extrapyramidal side effects (EPS) as compared to SGA. The administration of an FGA in combination with a benzodiazepine has been shown to reduce the need for re-dosing of either medication and also to reduce the risk of EPS.[5] However, the combination of these medications was also shown to result in increased time asleep, as compared to using either medication individually.[5]
The more recently developed second-generation (“atypical”) antipsychotics have more varied mechanisms of action. Of the SGA, olanzapine (Zyprexa), risperidone (Risperdal), and ziprasidone (Geodon) are the most frequently used in the management of acute agitation. Olanzapine can be given IM or PO. Off-label, it has been used via IV route, but carries an increased risk of respiratory depression. But even IM olanzapine should not be used in combination with a benzodiazepine due to increased risk of respiratory depression, excessive sedation, and hypoxia. Although used less frequently, risperidone and ziprasidone can also be given PO or IM. Project BETA recommends the use of SGA over FGA in the setting of acute agitation due to equivalent efficacy and decreased risk of EPS. The group recommends against the use of aripiprazole, quetiapine, or clozapine for acute agitation due to higher side effect risk protocol and limited data on their use in an acute setting.[4]
Treatment recommendations for acute agitation from Project BETA[4]:
SPECIAL POPULATIONS
The psychotic and/or manic patient
The mainstay of treatment for psychotic or manic patients is a combination of an antipsychotic and benzodiazepine to help address the underlying pathology while reducing agitation. Patients in this population are likely to have experience with antipsychotics and can, at times, express a preference and communicate to the team which medications have worked best for them in the past.
Intoxication and Withdrawal
Acute intoxication from alcohol or drug use is the most common underlying diagnosis of the acutely agitated patient in the Emergency Department.[6] Project BETA recommends the use of Haldol for treatment of acute agitation in the setting of alcohol intoxication due to concern for increased respiratory depression secondary to synergistic CNS depressant effects of benzodiazepines and alcohol.[4] In the setting of a CNS stimulant ingestion or in the setting of alcohol or benzodiazepine withdrawal, benzodiazepines are first-line.[4] Otherwise, the treatment approach for agitation in the setting of substance withdrawal should be based upon the underlying agent and the patient’s specific symptoms.
Pediatrics
The general approach to agitation in pediatric patients is to treat based upon the underlying etiology.[7] Often, verbal de-escalation or seclusion techniques are more successful in pediatrics than in adults. In addition, agitation is less frequently due to intoxication and more frequently due to known behavioral or psychiatric problems. If medication is warranted, the patient’s home medications should be trialed first. It is recommended to avoid mixing medications. If the desired effect is not achieved with the first dose, it is preferred to give a second dose of the same medication to avoid drug-drug interactions.[7] Both antihistamines and benzodiazepines can have a paradoxical or activating effect on young children or in children with autism.[7] These medications should be avoided unless a home medication or known to have a calming effect.
Pediatric medication recommendations for acute agitation[7]:
Geriatrics/delirium
It is rare for an older adult to develop a new psychiatric condition resulting in presentation to the ED with agitation. More frequently, an agitated geriatric patient has an underlying medical cause contributing to their altered mental status and behavioral dysregulation. Shenvi et al created The ADEPT tool, outlining 5 core principles of caring for an older adult with agitation or delirium. ADEPT stands for Assess, Diagnose, Evaluate, Prevent, and Treat[8]:
Assess: All geriatric patients should have an initial assessment to rule out hypoxia, hypoglycemia, or STEMI. Their baseline mental status should be established and a time course of mental status changes should be clarified.
Diagnose: The patient should be screened for a diagnosis of delirium. Although a common cause of confusion and agitation in the ED, few older adults are given a diagnosis of delirium. Non-delirious patients should be screened for dementia and depression.
Evaluate: This step focuses on diagnosing the underlying cause of the delirium or agitation. The three most common causes include infection, neurologic disorders, or metabolic/electrolyte derangement. It is also important to consider medication effect, trauma, and neglect.
Prevent: The ED is a challenging environment for the agitated older adult. The patient is taken out of their normal environment and schedule, exposed to loud noises, and often given new medications. Preventing worsening delirium or development of delirium includes avoidance of deliriogenic medications (anticholinergics, benzodiazepines, polypharmacy), maintenance of a normal schedule, home medications, PO intake and hydration, and the minimization of the ED length of stay.
Treat: All benzodiazepines and antipsychotics (both FGA and SGA) carry an FDA warning against their use in elderly patients with dementia-related psychosis due to increased risk of death. However, these may be needed for the safety of the patient. Data is limited on which drugs are best; in general, it is recommended to use much lower doses than in the general population, as older adults are more susceptible to adverse events. PO medications are preferred over IV, with the recommendation to start with olanzapine 2.5-5 mg, Haldol 1-2 mg PO, or risperidone < 1 mg PO. If unable to tolerate or take PO medications, IM administration is recommended over IV. Again, use smaller doses than in the general population. It is recommended to avoid the use of benzodiazepines and diphenhydramine unless the patient already takes them at home.[8]
Pregnancy
The dangers of agitation in the pregnant patient must be considered and weighed against the risk of medication administration.[9] Agitation in pregnancy is independently associated with outcomes that include premature delivery, low birth weight, growth retardation, postnatal death, and spontaneous abortion.[10] The majority of research on the use of antipsychotics and benzodiazepines in pregnancy is related to long-term use; however, the results of these studies can be extrapolated to one-time use in an emergency setting and urge caution:
Benzodiazepines: there is no evidence of increased risk of major malformations in neonates born to mothers on prescription benzodiazepines in the first trimester. Third-trimester exposure to benzodiazepines has been associated with “floppy-baby” syndrome and neonatal withdrawal syndrome, although these are more likely to occur in women on long-term prescription benzodiazepine therapy.[10] No study has yet assessed the risk of these outcomes with a one time exposure.
Diphenhydramine: recent studies of antihistamines, such as diphenhydramine, have not reported any risk of major malformations with first-trimester exposure to antihistamines.[9]
Antipsychotics:
FGA: No significant teratogenic effects have been documented with this drug class, although several meta-analyses have found a small increase in the relative risk of congenital malformations in offspring exposed to low-potency antipsychotics compared with those exposed to high-potency antipsychotics.[10] Mid and high-potency antipsychotics (e.g. haloperidol, perphenazine) are often recommended because they are less likely to have associated sedative or hypotensive effects than low-potency antipsychotics (e.g. chlorpromazine, perphenazine), which may be a significant consideration for a pregnant patient. There is a theoretical risk of neonatal EPS with exposure to first-generation antipsychotics in the third trimester.
SGA: found to be safe to use, without significant teratogenic effects documented.[10]
CONCLUSION
Treatment of acute agitation and behavioral dysregulation is commonplace in the Emergency Department. When treating an agitated patient, the safety of the patient and the staff is of utmost importance. Techniques to calm the patient, control the crowd, and manage team expectations can be helpful to expedite treatment and avoid over-sedation of the patient. In general, oral medication is preferred over IM or IV, and the patient’s choices and opinions should be considered when selecting a medication. In general, the medications given for acute agitation will consist of an FGA and a benzodiazepine, or an SGA alone. Certain populations require special consideration, including intoxicated, pediatric, geriatric, and pregnant patients.
Authors: Erica Lash, MD & Ayala Danzig, MD
Faculty Reviewer: Dr. Dina Gozman
References
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Boyer, E. W. (n.d.). Droperidol Is Back (and Here's What You Need to Know). Retrieved September 6, 2019, from https://www.acepnow.com/article/Droperidol-is-back-and-heres-what-you-need-to-know/?singlepage=1.
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Shenvi, C., Kennedy, M., Austin, C. A., Wilson, M. P., Gerardi, M., & Schneider, S. (2019). Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool. Annals of Emergency Medicine. doi:10.1016/j.annemergmed.2019.07.023
Wilson MP, Nordstrom K, Shah AA, Vilke GM. Psychiatric emergencies in pregnant women. Emerg Med Clin North Am 2015; 33(4):841–851.
Aftabm, A., Asim, A.D. Behavioral Emergencies Special Considerations in the Pregnant Patient. Psychiatric Clinics of North America, 2017-09-01, Volume 40, Issue 3, Pages 435-448