Episode 197: Acute Agitation

We discuss an approach to the acutely agitated patient and review medications commonly used. Hosts: Jonathan Kobles, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Agitation.mp3 Download Leave a Comment Tags: Agitation, psychiatry, Toxicology 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.   Read More