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

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