Ep 115 Emergency Management of the Agitated Patient

Managing acutely agitated patients can cause anxiety in even the most seasoned emergency doctor. These are high risk patients and they are high risk to you and your ED staff. It’s important to understand that agitation or agitated delirium is a cardinal presentation – not a diagnosis. There is pathology lurking beneath – psychiatric, medical, traumatic and toxicological diagnoses driving these patients and we just won’t know which until we can safely calm them down. An added difficulty is that most of the literature on emergency management of the agitated patient originates from psychiatric papers studying populations that do not necessarily generalize to the ED. In this podcast, Dr. Reuben Strayer and Dr. Margaret Thompson (with a special bonus appearance by guest researcher David Barbic) offer some guiding principles on the safe and effective management of the agitated patient…

Podcast production, sound design & editing by Anton Helman, voice editing by Sucheta Sinha

Written Summary and blog post by Alex Hart and Shaun Mehta, edited by Anton Helman September, 2018

Step 1: Categorize the agitation as mild, moderate or severe

Sometimes it is obvious that a patient is extremely agitated and needs to be taken down imminently in order to protect the department staff and the patient themselves. It is helpful though in cases that are less clinically obvious to have an approach to classifying a given patient’s level of agitation in order to better target sedation therapy.

Our experts recommend dividing agitated patients into the following 3 categories:

Mild: Agitated but cooperative

Moderate: Disruptive without danger

Severe: Excited delirium and/or dangerous to self and/or staff

Many scales exist, including the Sedation Assessment Tool, the Agitated Behavior Scale, the Overt Aggression Scale and the Positive and Negative Syndromes Scale. While these may be useful for research purposes, they are not practical for clinical practice. The Behaviour Activity Rating Scale (BARS) is probably the simplest scale and has good inter-rater reliability.

Excited Delirium Syndrome

Excited delirium is a life threatening medical emergency. It has several distinctive features (despite it usually being a retrospective diagnosis):

  • High degree of agitation
  • Diaphoretic, tachypneic and hyperthermic
  • Unusual “super-human” strength
  • Impervious to pain and fatigue
  • Unable to maintain attention
  • Incoherent
  • Severe metabolic acidosis

A typical clinical scenario is an obese male in mid-30’s displaying destructive/bizarre behavior leading to call to police in setting of psycho-stimulant drug or alcohol intoxication, with prior psychiatric illness. A subset of patients eventually enter a quiescent period (for less than a minute) where they suddenly stop struggling followed by a respiratory or cardiac arrest.

It is often better to err on the side of caution and assume a state of excited delirum rather than dismissing a patients behaviour as the product of a more benign cause (e.g. alcohol intoxication).

Step 2a: Non-pharmacologic de-escalatation for the mild or moderately agitated patient

Verbal de-escalation is often effective, but requires a calm and deliberate approach.

Approximately 90% of all emotional information and more than 50% of the total information in spoken English is communicated not by what one says but by body language, especially tone of voice.

  • One person delegated
  • Ensure a quiet environment
  • Don’t spend too much time
  • Monitor your own emotional and physiologic response so as to remain calm
  • Maintain at least 2 arm’s lengths of distance between you and the patient with an exit door close by and in the opposite direction of the patient
  • Hands should be visible and not clenched

It’s hard enough to interact with our fellow human in normal day to day interaction without provoking some form of social anxiety. So what do we do when those we are trying to speak to are threatening physical violence? Not sure where to start? Try the SAVE mnemonic:

Support – “Let’s work together…”

Acknowledge – “I see this has been hard for you.”

Validate – “I’d probably be reacting the same way if I was in your shoes.”

Emotion naming – “You seem upset.”

 

Step 2b: The Code White for the moderate or severely agitated patient

So you didn’t hit it off with the patient high on PCP. Don’t be hard on yourself. But also, don’t be a cowboy. Call for help. There are times when it is necessary to call that code white.

Indications for calling a code white

  • Severe agitation
  • Immediate physical threat to you and/or your staff
  • Requiring multiple people to restrain

Pitfall: A common pitfall is to call a code white as a threat to an uncooperative patient. Calling a code white in and of itself can ramp up an already tense situation. For the moderately agitated patient who is not in imminent danger to themselves or to your staff, consider calling a concealed code white direct to security rather than using  an overhead page. Never use code white it as a threat.

EDs should ideally have a protocol for code white. Establishing roles for EMS, police, security, nursing, crisis workers, technicians and social workers in advance, preferably in simulation training, can help make code white safe and effective. Consider pre-mixed medications for sedation. Consider a plan for cardiorespiratory monitoring +/- airway management.

Step 3: Safe and effective physical restraints in the emergency management of agitated patients

There is ongoing debate as to whether or not physical restraints should be used at all in the management of the agitated patient in the ED. If you are going to use physical restraints the goal should be to use them as a last resort, only as a bridge to adequate chemical sedation, which should take no longer than 5-15 minutes with appropriate dosages of calming medications. Prolonged use of physical restraints may result in active resistance of restraint by the patient which may lead to electrolyte abnormalities, arrhythmias, and put the patient at further risk for rhabdomyolysis. 

One option is not to use physical restraints, and rather have the patient held down by security for the few minutes it takes for the claiming medications to take effect. The other option is to first place the physical restraints on the patient, immediately followed by IM calming medications and releasing the restraints as soon as the patient is calm. Physical restraint should always be followed by immediate chemical sedation.

When used properly, physical restraints can be quite safe as was demonstrated in this 2003 study by Zun. However, improper use can be lethal as shown in this 2012 study of 26 deaths presumed to be the direct result of improper physical restraints.

Restraints are not benign. Don’t restrain and walk away. Ensure the following:

Ideally, 6 trained staff with personal protective equipment (gloves, gowns, face-mask) are needed to apply physical restraints effectively: 1 for each extremity, 1 for the head and 1 to give medications and help apply restraints

Pearl: Avoid covering the agitated patient’s mouth and/or nose with a gloved hand. This can lead to asphyxia, metabolic acidosis and death. To prevent the patient spitting on staff, instead, use an oxygen mask. This may also serve to improve any oxygenation issues the patient may have.

Listen to Dr. Strayer’s Best Case Ever for more on this pearl.

Do’s and Don’t of Physical Restraints

Do

  • Use 4 or 5 point restraints
  • Use medical grade restraints
  • Supine position whenever possible
  • Restrain one arm above the head and the other below the waist
  • Elevate the head of the bed about 30 degrees
  • Tie restraints to the bed-frame (not the rails)

Don’t

  • Restrain in prone position (increases risk of airway complications)
  • Restrain to the bed rails (increases risk of injury)
  • Use two point restraints (increases risk of injury)
  • Tie knots that are difficult to undo
  • Put a pillow under the patient’s head (suffocation risk)

emergency management of agitated patient


Particular care should be given to ensuring a clear airway is maintained, as the airway can be put at risk if the patient is turned prone with pressure on the neck or shoulder to try to guard against spitting or biting.

Your responsibility does not end with the patient. Keep your team safe.

Tips to make sure the department is kept safe in a dangerous situation:

  • Never turn your back on the individual
  • Don’t walk ahead of the individual and ensure adequate personal space
  • Provide continuous observation and record behaviour changes in patient notes
  • Wear personal duress alarm if available
  • Never block off exits and ensure you have a safe escape route

Step 4: Calming medications in the emergency management of the agitated patient

The goal of calming medications is to enable rapid stabilization of the critically ill patient and to enable the expeditious search for potential life threatening diagnoses.

What is the best route of administration for calming medications?

Most departments have oral (po/sl), intramuscular (IM), intravenous (IV), and intranasal (IN) options for medication administration. The choice of route depends on how agitated your patient is. For cooperative patients, offer a po/sl medication first. For uncooperative moderate and severely agitated patients, the safest option is to start with IM.

Pitfall: A common pitfall is to attempt an IV start on a severely agitated patient. Protect your nursing staff. Do not attempt IVs in agitated, thrashing patients. It is much safer to calm them with an IM medication first, and then attempt to start an IV once the patient is calm.

Calming medication options include ketamine, benzodiazepines and antipsychotics

Several regimens exist. Our experts suggest the following based on optimal route, pharmacologic mechanism of action, and patient/staff safety.emergency management of pediatric seizures

Whenever possible, tailor the therapy to the underlying diagnosis (psychotic psychiatric disorder vs alcohol withdrawal vs drug intoxication etc).

Level of Agitation

1st Choice Drug, Dose, Route

Alternative or Adjunct Drug

Mild

Lorazepam 1-2 mg SL

po antipsychotic that has previously been effective for that particular patient

Moderate

Midazolam 2-5 mg IM

Haloperidol 5-10 mg IM

Severe

Ketamine 5 mg/kg IM

Haloperidol 10mg IM AND

Midazolam 10mg IM

Benzodiazepines are safe and effective calming medications in the young adult

Midazolam is the best IM option. Maximum effect is in 10 minutes, and lasts up to 2 hours. In alcohol intoxicated patients, beware of respiratory depression with benzodiazepines. All alcohol intoxicated patients who are receiving benzodiazepines for agitated should be placed on a cardiac monitor, ideally with end-tidal CO2 monitoring for earliest detection of respiratory depression.

Pearl: Place alcohol intoxicated patients who are receiving benzodiazepines for moderate agitated on end tidal CO2 monitoring for early detection of respiratory depression.

Diazepam is poorly absorbed by the IM route and lorazepam is erratically and slowly absorbed; additionally, lorazepam requires refrigeration, which can impose acquisition delays. When a benzodiazepine is required urgently–for any indication–our experts recommend midazolam, which is quickly and reliably absorbed IM. The “M” in IM stands for Midazolam.

Haloperidol should be considered an adjunct to benzodiazepines in moderate and severe agitation and may be appropriate as monotherapy in moderately agitated intoxicated patients that cannot be placed on a monitor when resources are limited.

Be aware that haloperidol has a longer half life than midazolam, and can cause your patient to linger in the ED for many hours more than necessary. The mean time to sedation is 25-28 minutes and is therefore not recommended as monotherapy when immediate sedation is required for the severely agitated patient.

What about the safety of haldol?

While traditional teaching has been to avoid Haloperidol in some at risk patients because of fears of prolongation of the QT interval 

emergency management of pediatric seizuresresulting in Torsades de Pointes and concerns over lowering the seizure threshold, there is no good evidence in the literature that in real practice this risk exists according to our experts. Although we know that haloperidol prolongs the QTc, this effect is very unlikely to be clinically consequential at the doses typically used for emergency agitation. However caution is advised in patients who are already on multiple QTc-prolonging agents. Consider obtaining a baseline ECG first in these higher risk patients, when possible. It is also very unlikely that patients will suffer extrapyramidal symptoms from one dose of haloperidol in the ED, so this potential side effect should not dissuade the use of haloperidol in the severely agitated patient.

 

Ketamine 5mg/kg IM may be the first line medication for excited delirium and the severely agitated patient

Ketamine is an NMDA-receptor antagonist, providing rapid sedation and analgesia. Of the available options, time to sedation is the fastest, usually less than 5 minutes with appropriate dosing, and it has a predictable dose-response relationship. While the weak sympathomimetic properties of ketamine may increase heart rate and BP in the calm patient, these effects of ketamine are not of concern in the severely agitated patient who is in sympathomimetic overdrive already. Rather, ketamine will have a predictably calming effect and may lower the heart rate and blood pressure. Current evidence for the effectiveness and safety of ketamine in calming the severely agitated patient is promising, yet not definitive. A large single center RCT is currently underway in Vancouver comparing Ketamine 5mg/kg IM vs Midazolam + Haldol IM. Two IM injections of ketamine may be required depending on the weight of your patient and whether or not your ED carries the highly concentrated formulation or not.

Future options for calming medications in the agitated patient may include nebulized loxapine and dexmedetomidine IM, but strong evidence is pending.

  

Pharmacologic options in the older agitated patient

Elderly patients are at increased risk of respiratory depression and delirium from benzodiazepines. Our experts recommend avoiding benzodiazepines whenever possible, the exception being alcohol/sedative-hypnotic withdrawal. Haldol 0.5mg IM is a reasonable first line medication for the agitated older patient. Consider atypical antipsychotics such as risperidone, quetiapine or olanzapine starting at the lowest dose and titrating slowing to effect.

Avoid benzodiazepines

Use antipsychotics (consider atypicals)

Start low, go slow

 

 

Step 5: Treat immediate life threats and persue underlying diagnosis in the emergency management of the agitated patient as soon as calming medications take effect

Agitation, agitated delirium and excited delirium are not diagnoses, but rather cardinal presentations of a variety of life-threatening underlying diagnoses.

Mild to moderately agitated patients

Collect as much corroborating history as possible from police, family and any social supports. A head-to-toe physical exam with the patient completely disrobed is essential so as not to miss obvious pathology that is concealed by clothing. Cast a wide differential diagnosis including space occupying CNS lesions, toxiciologic, psychiatric, traumatic and metabolic causes with appropriate laboratory and imaging testing as required.

Severely agitated patients

In the severely agitated patient the history and physical exam are more limited, so it is important to be organized in your approach.

A) First few minutes

1. Place the patient in a resuscitation room and apply cardiorespiratory monitoring, capnography and oximetry

2. Place 1-2 large bore IV lines

3. Assess for and start to treat:

Hypoxia  – place supplemental O2

Hyperthermia obtain rectal temperature and initiate cooling measures 

Hypoglycemia – obtain capillary glucose and administer D50W

Hypovolemia – most severely agitated patients will be volume depleted and acidotic; initiate crystalloid 1L bolus on speculation

 

B) Next few minutes

Hyperkalemia and acidemia – send a blood gas with lytes and consider calcium gluconate, insulin with glucose and sodium bicarb

CNS lesions – CT head

Monitoring – ideally vitals q5min for the first 30 mins

 

C) Next hour

Consider primary diagnoses such as: sepsis, neuroleptic malignant syndrome, thyrotoxicosis, meningitis/encephalitis

Rule out consequences of agitation: rhabdomyolysis, traumatic injuries

Airway considerations in the emergency management of the severely agitated patient 

The primary airway issues in the severely agitated patient are often inadequate preparation and preoxygenation secondary to patient combativeness. For this reason, our experts recommend avoiding rapid-sequence intubation (RSI) and instead perform a delayed-sequence intubation (DSI)Initiate a dissociative dose of ketamine, adequately preoxygenate your patient, and then, if necessary, administer the paralytic and perform endotracheal intubation. Moderate hyperventilation prior to intubation to at least the patient’s resting elevated respiratory rate may improve acidemia and avoid a precipitous rapid drop in blood pressure after intubation. Maintain high ventilatory rates after intubation.

If a paralytic is used, our experts suggest avoiding succinylcholine because of potential side effects such as hyperkalemia, hyperthermia and acidemia.

 

Take Home Points on The Emergency Management of Agitated Delirium

  • There are 5 steps to the emergency management of the agitated patient:
  1. Categorize the agitation as mild, moderate or severe,
  2. Employ de-escalation techniques in the mild-moderate agitated patient and/or call a code white in the moderate-severe agitated patient,
  3. Physically restrain the moderate-severe agitated patient safely with either limbs held down by security personnel or by physical restraints
  4. Administer calming medications as soon as possible
  5. Treat immediate life threats and pursue the underlying diagnosis
  • Agitation or agitated delirium is a cardinal presentation, not a diagnosis. There is pathology lurking beneath. Cast a wide differential diagnosis.
  • If physical restraints are used, they should be used as a last resort for the the shortest possible time, only until calming medications have taken effect and according to safe procedural protocol.
  • Severely agitated patients require immediate attention to potential life threats and a thorough assessment and work-up including a head to toe physical exam and consideration for disease specific laboratory and imaging testing. A step-wise approach should start with identification and treatment of hypoxemia, hyperthermia, hypoglycemia and hypovolemia.
  • Most agitated patients in the ED are moderately agitated and first line medications include midazolam 2-5mg IM and haloperidol 5-10mg IM. Medications should be tailored to the suspected underlying cause.
  • Benzodiazepines should be avoided in older patients whenever possible. Instead consider antipsychotic medications, start low and go slow.
  • For the rarer very severe agitated Ketamine 5mg/kg is considered first line for calming of the severely agitated patient by our experts, however evidence is not definitive.
  • Delayed sequence intubation with specific peri-intubation management of severe acidosis is recommended in the airway management of severely agitated patients.

References

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  2. Coburn, V. & Mycyk, M. (2009). Physical and Chemical Restraints. Emergency Medicine Clinics of North America. 27, 655-667.
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  4. New A, Tucci VT, Rios J. A Modern-Day Fight Club? The Stabilization and Management of Acutely Agitated Patients in the Emergency Department. Psychiatr Clin North Am. 2017 Sep;40(3):397-410.
  5. Nice.org.uk. (2018). Violence and aggression: short-term management in mental health, health and community settings | Guidance and guidelines | NICE. [online] Available at: https://www.nice.org.uk/guidance/ng10.
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  7. Swift, RH, Harrigan, EP, Cappelleri, JC, et al, Validation of the behavioural activity rating scale (BARS): a novel measure of activity in agitated patients. Journal of Psychiatric Research, 2002. 36: p. 87‐95.
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  10. Glezer A, Brendel RW. Beyond emergencies: the use of physical restraints in medical and psychiatric settings. Harv Rev Psychiatry. 2010 Nov-Dec;18(6):353-8.
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  14. Zun LS. A prospective study of the complication rate of use of patient restraint in the emergency department. J Emerg Med. 2003 Feb. 24(2):119-24.
  15. Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clin North Am. 2009 Nov. 27(4):655-67, ix. 
  16. Zun LS. A prospective study of the complication rate of use of patient restraint in the emergency department. J Emerg Med. 2003 Feb. 24(2):119-24.
  17. Annas GJ. The last resort–the use of physical restraints in medical emergencies. N Engl J Med. 1999 Oct 28. 341(18):1408-12.
  18. Currier GW, Simpson GM, Risperidone liquid concentrate and oral lorazepam versus intramuscular haloperidol and intramuscular lorazepam for treatment of psychotic agitation. J Clin Psychiatry, 2001. 62(3): p. 153‐7.
  19. Currier GW, Chou JC, Feifel D, Acute treatment of psychotic agitation: a randomized comparison of oral treatment with risperidone and lorazepam versus intramuscular treatment with haloperidol and lorazepam. J Clin Psychiatry, 2004. 65(3): p. 386‐94. 
  20. Nobay F, Simon BC, Levitt MA, Dresden GM. A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Acad Emerg Med. 2004;11(7):744-9.
  21. Richards JR, Derlet RW, Duncan DR, Chemical restraint for the agitated patient in the emergency department: lorazepam versus droperidol. J Emerg Med, 1998. 16(4): p. 567‐73.
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  23. Isenberg DL, Jacobs D. Prehospital Agitation and Sedation Trial (PhAST): A Randomized Control Trial of Intramuscular Haloperidol versus Intramuscular Midazolam for the Sedation of the Agitated or Violent Patient in the Prehospital Environment. Prehosp Disaster Med. 2015 Oct;30(5):491-5.
  24. Kroczak S et al. Chemical Agents for the Sedation of Agitated Patient in the ED: A Systematic Review. Am J Emerg Med. 2016. (34); 2426-2431.
  25. Gottlieb M, Long B, Koyfman A. Approach to the Agitated Emergency Department Patient. J Emerg Med. 2018;54(4):447-457.
  26. Zun LS. Evidence-Based Review of Pharmacotherapy for Acute Agitation. Part 1: Onset of Efficacy. J Emerg Med. 2018;54(3):364-374.
  27. Gottlieb M, Schiebout J. What Is the Efficacy of Droperidol for the Management of Acute Psychosis-Induced Agitation?. Ann Emerg Med. 2018;71(1):141-143.
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  29. Bieniek SA, Ownby RL, Penalver A, Dominguez RA. A double-blind study of lorazepam versus the combination of haloperidol and lorazepam in managing agitation. 1998 Jan-Feb;18(1):57-62.
  30. Hui D, Frisbee-Hume S, Wilson A, et al. Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial. 2017 Sep 19;318(11):1047-1056.
  31. Le Cong M, Humble I. A Ketamine Protocol and Intubation Rates for Psychiatric Air Medical Retrieval. Air Med J. 2015 Nov-Dec;34(6):357-9.
  32. Cole JB, Moore JC, Nystrom PC, et al. A prospective study of ketamine versus haloperidol for severe prehospital agitation. Clin Toxicol (Phila). 2016 Aug;54(7):556-62.
  33. Riddell J, Tran A, Bengiamin R, Hendey GW, Armenian P. Ketamine as a first-line treatment for severely agitated emergency department patients. Am J Emerg Med. 2017 Jul;35(7):1000-1004.
  34. Isbister GK, Calver LA, Downes MA, Page CB. Ketamine as Rescue Treatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2016;67(5):581-587.e1.
  35. Vrana B. Use of Intranasal Ketamine for the Severely Agitated or Violent ED Patient. J Emerg Nurs. 2016;42(3):198-9.
  36. Lahti AC, Koffel B, LaPorte D, Tamminga CA. Subanesthetic doses of ketamine stimulate psychosis in schizophrenia. 1995 Aug;13(1):9-19.
  37. Peisah C, Chan DK, McKay R, Kurrle SE, Reutens SG. Practical guidelines for the acute emergency sedation of the severely agitated older patient. Intern Med J. 2011 Sep;41(9):651-7.
  38. Aftab A, Shah AA. Behavioral Emergencies: Special Considerations in the Geriatric Psychiatric Patient. Psychiatr Clin North Am. 2017 Sep;40(3):449-462.
  39. Kruse WH. Problems and pitfalls in the use of benzodiazepines in the elderly. Drug Saf. 1990 Sep-Oct;5(5):328-44.
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FOAMed Resources on The Agitated Patient

  1. http://emupdates.com/2016/09/03/emergency-management-of-the-agitated-patient/
  2. http://emupdates.com/2017/11/02/jon-cole-on-ketamine-for-agitation/
  3. https://lifeinthefastlane.com/behavioural-emergencies/
  4. http://www.emdocs.net/emdocs-cases-ed-approach-agitation/
  5. http://www.emdocs.net/the-art-of-the-ed-takedown/
  6. http://www.emdocs.net/ketamine-agitated-violent-patient/
  7. https://canadiem.org/the-agitated-patient-in-the-ed-part-2/
  8. https://emcrit.org/emcrit/human-bondage-chemical-takedown/
  9. http://rebelem.com/chemical-sedation-of-the-agitated-patient/
  10. http://stemlynsblog.org/acute-behavioural-disturbance/

Drs. Helman, Strayer and Thompson have no conflicts of interest to declare

Now Test Your Knowledge:

1. A 34 year old male presents to your ED with agitation. He was brought in by police after being involved in a physical altercation at a bar. He appears to be quite agitated, but follows your instructions during physical exam. You categorize his agitation as mild. Which of the following is true for the mildly agitated patient?

A. Intramuscular (IM) Midazolam is the first line medication

B. An oral or sublingual low dose benzodiazepine is a reasonable first line medication.

C. Intramuscular (IM) Ketamine is a reasonable first line medication.

D. Mildly agitated patients are unable to cooperate with instructions.

Answer: B

A practical categorization of agitation is as follows:

  • Mild: Agitated but cooperative
  • Moderate: Disruptive without danger
  • Severe: Excited delirium and/or dangerous to self and/or staff

This categorization is important to help guide management, especially calming medication choices, route of administration and dose. The first line medication for mildly agitated patients is Lorazepam 1-2mg sublingual. Another reasonable first-line medication for the mildly agitated patient would be an oral antipsychotic that has previously been effective for that particular patient.

2. Which of the following is NOT a symptom of excited delirium syndrome?

A. Diaphoretic, tachypneic and hyperthermic

B. Unusual “super-human” strength

C. Unable to maintain attention

D. None of the above

Answer: D

Excited delirium is a life threatening syndrome that has several distinctive features:

  • High degree of agitation
  • Diaphoretic, tachypneic and hyperthermic
  • Unusual “super-human” strength
  • Impervious to pain and fatigue
  • Unable to maintain attention
  • Incoherent
  • Severe metabolic acidosis

3. Which of the following statements regarding physical restraints is FALSE?

A.  A reasonable option is to avoid using physical restraints altogether, and instead have the patient held down by security for a few minutes until the calming medications take effect.

B. If used correctly, physical restraints can help calm the patient without the need of using medications

C. Avoid covering the agitated patient’s mouth and/or nose with a gloved hand.

D. Prolonged use of physical restraints may lead to electrolyte abnormalities or cardiac dysrhythmias.

Answer: B

Use physical restraints as a last resort, only as a bridge to adequate chemical sedation. Then release the restraints as soon as the patient is calm, which should take no longer than 5-15 minutes with adequate doses of calming medications. Physical restraints in the agitated patient should never be used without concomitant chemical sedation. Prolonged use of physical restraints have been associated with electrolyte abnormalities, cardiac dysrhythmias and rhabdomyolysis. Improper application of physical restraints may lead to injury and death.

4. When applying physical restraints, which of the following should always be done?

A. Put a pillow under the patient’s head

B. Tie knots that are secure and difficult to undo

C. Restrain to the bed rails

D. Restrain one arm above the head and the other below the waist

Answer: D

Here are the Do’s and Don’ts of physical restraints

Do

  • Use 4 or 5 point restraints
  • Supine position whenever possible
  • Restrain one arm above the head and the other below the waist
  • Elevate the head of the bed about 30 degrees
  • Tie restraints to the bed-frame (not the rails)

Don’t

  • Restrain in prone position (increases risk of airway complications)
  • Restrain to the bed rails (increases risk of injury)
  • Use two point restraints (increases risk of injury)
  • Tie knots that are difficult to undo
  • Put a pillow under the patient’s head (suffocation risk)

5. A 25 year old female presents to your ED. She was brought in by her friends after attending a house party. She is quite agitated and is pacing back and forth and intermittently yelling in her ED room, but does not appear to be a danger to herself or the ED staff. She is unable to follow instructions when you are present. What is single best medication choice to calm this patient?

  A. Lorazepam 1-2 mg SL

  B. Midazolam 2-5 mg IM

  C. Haloperidol 5-10 mg IM

  D. Ketamine 5 mg/kg IM

Answer: B

In patients with moderate agitation (disruptive without danger), the first line medication is midazolam 2-5mg IM given its fast onset and 2 hour long duration.. Haloperidol 2-5mg IM is a second line drug or can be used as an adjunct to midazolam.

6. A 30 year old male is brought in by police. He was found wandering in the middle of a busy downtown intersection oblivious to the oncoming traffic. He is currently thrashing in the hospital bed and tries to bite anyone who tries to approach him. Which of following is the best choice to sedate this patient?

  A. Lorazepam 1-2 mg SL

  B. Midazolam 2-5 mg IM

  C. Haloperidol 5-10 mg IM

  D. Ketamine 5 mg/kg IM

Answer: D

In patients with severe agitation, ketamine is a good option given its fast onset and predictable dose-response relationship. An alternative to ketamine is giving Haloperidol 10mg IM AND Midazolam 10mg IM.

7. Which of the following statements regarding the management of a severely agitated patient is FALSE?

A. In the first few minutes, assess for hypoxia, hyperthermia, hypoglycemia, and hypovolemia

B. In the first hour, consider consequences of agitation such as rhabdomyolysis and traumatic injuries

C. Succinylcholine is the paralytic of choice in the agitated patient.

D. Delayed-sequence intubation (DSI) may be prefered over  rapid-sequence intubation (RSI) for the agitated patient.

Answer: C

  • If a paralytic is used, our experts suggest avoiding succinylcholine because of potential side effects such as hyperkalemia, hyperthermia and acidemia that the agitated patient is already at risk for.
  • Initiate a dissociative dose of ketamine, adequately preoxygenate your patient, and then, if necessary, administer a paralytic such as rocuronium and perform endotracheal intubation.
  • Moderate hyperventilation prior to intubation may improve acidemia and avoid a precipitous rapid drop in blood pressure after intubation. Maintain high ventilatory rates after intubation.

8. Which of the following is NOT a component of verbal de-escalation in the management of an agitated patient?

A. Validating the patients concerns

B. A team of people talking to the patient

C. If indicated, call a concealed code white

D. Acknowledging that the patient is upset

Answer: B

Verbal de-escalation is often effective, but requires a calm and deliberate approach:

  • One person delegated to speak with the patient
  • Ensure a quiet environment
  • Don’t spend too much time
  • Monitor your own emotional and physiologic response so as to remain calm
  • Maintain at least 2 arm’s lengths of distance between you and the patient with an exit door close by and in the opposite direction of the patient
  • Hands should be visible and not clenched

Not sure where to start? Try the SAVE mnemonic:

  • Support – “Let’s work together…”
  • Acknowledge – “I see this has been hard for you.”
  • Validate – “I’d probably be reacting the same way if I was in your shoes.”
  • Emotion naming – “You seem upset.”

9. Which of the following statements regarding calming medications for the agitated patient is TRUE?

A. Benzodiazepines are a safe calming medication in alcohol intoxicated patients

B. Haloperidol should be used first line as monotherapy in severely agitated patients

C. There is significant evidence that a single dose of haloperidol will cause QT prolongation leading to Torsades de Pointes and lower of seizure threshold enough to cause seizures in an otherwise healthy agitated patient

D. For older agitated patients, consider atypical antipsychotics starting at the lowest dose

Answer: D

  • In alcohol intoxicated patients, beware of respiratory depression with benzodiazepines
  • Haloperidol should be considered an adjunct to benzodiazepines in moderate and severe agitation and may be appropriate as monotherapy in moderately agitated intoxicated patients
  • There is no good evidence in the literature that supports the traditional teaching of avoiding a single dose of haloperidol due to risks of QT prolongation and lowering of seizure threshold
  • Consider atypical antipsychotics such as risperidone, quetiapine or olanzapine starting at the lowest dose and titrating slowing to effect.

10. Which of the following regarding calling a code white is FALSE?

A. Often indicated in the mild-moderately agitated patient to avoid disruption to other patients

B. Consider calling a concealed code white in the moderately agitated patient who is not in imminent danger as opposed to an overhead code white which may escalate the agitation

C. It is advisable to prepare pre-mixed medication such as Haloperidol and Midazolam in one syringe for sedation to use in a code white situation

D. It is appropriate to call a code white to help physically restrain a patient

Answer: A

Indications for calling a code white:

  • Severe agitation
  • Immediate physical threat to you and/or your staff
  • Requiring multiple people to restrain

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About the Author:

Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.

3 Comments

  1. Sandeep Saluja September 28, 2018 at 8:27 pm - Reply

    If dexmetomidine were to be used some day in which patients would you speculate it would be best used?

    Dose?

  2. Osama Elmuzamil October 14, 2018 at 4:39 am - Reply

    We owe you a great debt dr.Anton , we are always learning a good stuff and informative website ..

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