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
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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.
