The Agitated Patient

Educational Objectives

The goal of this program is to improve the prevention, identification, and management of agitation. After hearing and assimilating this program, the clinician will be better able to:

1. De-escalate situations involving an agitated patient.

2. Choose among medication options for treating patients with agitation.

3. Anticipate possible adverse effects of medications used to treat patients with agitation.

Summary

Lack of training: psychiatric and behavioral problems often not considered medical issues and thus not included in training; paradigm change needed to treat these problems; intervention in early phase, excellent bedside manner, and shared decision making yield better results in less time

Cycle of assault: beginning phase (patient stable), escalation (patient encounters trigger), fulminant agitation (behavioral manifestation of brain failure), and gradual improvement; risk for assault of medical staff high if patient agitated and restrained; recognize escalation and intervene; warning signs — angry appearance (eg, clenching side rails of bed, rocking, internal preoccupation, talking loudly); previous history of agitation with poor outcome; warning signs may not be present; prevention of worsening agitation — transport patient to safe environment (eg, room cleared of potential weapons, area with security personnel present); see patient as soon as possible (clinicians tempted to delay encounter because of anticipated difficult interaction, but delay worsens situation [similar to alcohol withdrawal])

Techniques for De-escalation

Goals: develop therapeutic relationship; ease suffering; relieve symptoms; help patient regain control over self

Respect patient’s personal space: to avoid being hit, maintain distance of ≥2 arm’s lengths; if paranoia suspected, double distance; stand to side of doorway to maintain clear line of egress for patient and ability to step out of patient’s way; if patients desire to leave, do not stop them

Avoid provocation (iatrogenic escalation): avoid impulse to respond to personal insults from patient

Establish verbal contact: attempt to bring patient from state of agitated nonfocused activity and language to problem solving; start with introduction (eg, name, role); ensure only one clinician speaking during de-escalation (avoids excess stimuli); replace person handling de-escalation only if necessary; use concise speech, short sentences, and repetition; use “capture pacing” to match patient’s initial level of energy while repeating short phrase (eg, “you’re safe here”) and gradually slowing to calmer cadence

“Talk to me”: listen to patient to determine cause of agitation; address cause, if possible; patient may only need to “vent”; use active listening skills (eg, avoid talking over patient, listen, reflect back); feeling that someone listening therapeutic; never argue with agitated patient; agree, if possible (eg, “I believe you are seeing that, but I don’t see it”); having choices gives patient agency, opportunity to act rationally, and comfort (eg, choice of food, medicine, blankets)

Set clear limits: choose battles; avoid escalation in response to minor infractions; ensure that show of force nearby, and use it if patient crossing unsafe boundaries; if “takedown” required, debrief staff; determine whether anyone injured and how encounter could have been better handled

Medications

Timing and route: early administration (eg, haloperidol [Haldol], intramuscular [IM] sedation) may prevent greater requirement later; use de-escalation skills to persuade patient to take oral medication (offer control and strengthen therapeutic relationship); use elixirs or dissolving tablets to ensure delivery (tablets dissolve on contact with tongue, so “cheeking” impossible); oral medication can be administered to patients in restraints (use tongue blade to avoid biting); fast-acting medications available (eg, elixirs); onset of oral medications only slightly slower than that of IM forms; patients prefer oral pills and capsules (IM delivery least preferred)

Medications for undifferentiated patient with agitation: benzodiazepines; first-generation antipsychotic agents (eg, haloperidol, droperidol); anticholinergic agents (often part of “cocktails”; eg, benztropine [Cogentin], diphenhydramine [Benadryl]); second-generation (atypical) antipsychotic agents (eg, ziprasidone [Geodon], olanzapine [Zyprexa, Zyprexa Zydis dissolving formulation], risperidone [Risperdal], aripiprazole [Abilify], quetiapine [Seroquel]); dissociative agents (ketamine)

Guidelines: American College of Emergency Physicians (ACEP) — recommendations level B and C; administer benzodiazepines, conventional antipsychotic agents, or droperidol (sedation more rapid, but drug has black-box warning for prolonged QTc interval); oral benzodiazepines and antipsychotic agents; onset of haloperidol, lorazepam (Ativan), and benztropine (Cogentin; HAC) fast; patient with agitation of unknown cause — expert consensus guideline recommends benzodiazepines; patient with known disorder (eg, schizophrenia) — according to ACEP, if methamphetamine or alcohol toxicity not suspected, use antipsychotic agent alone or with oral benzodiazepine; according to consensus recommendation, in patient with pure psychiatric disease (eg, decompensated schizophrenia, bipolar disorder) use second-generation antipsychotic agents; Project BETA (consortium of emergency physicians, emergency psychiatrists, and social workers) recommends second-generation antipsychotic agents (eg, oral risperidone or olanzapine, IM ziprasidone or olanzapine); haloperidol not recommended

Benzodiazepines: universally recommended as part of cocktail; safe; history of use long; titration curve known; may cause mild respiratory suppression; do not provoke seizures or prolong QT interval; preferred medication to treat toxicity due to methamphetamine or cocaine, postictal or seizure state, and alcohol withdrawal; effective for psychosis and stabilization of mood; prevent extrapyramidal symptoms (EPS); generally preferred by patients; survey found combination of lorazepam and antipsychotic agent ranked second, and single-agent antipsychotic agent last (dysphoria results from blocking dopamine); midazolam (Versed) — time to sedation and to arousal short; often used in ambulances (refrigeration not required); lorazepam — preferred by speaker because of few respiratory issues, low need for rescue medication, reliable IM absorption rate, and easy titration

First- vs second-generation antipsychotic agents: first-generation agents — provide powerful dopamine blockade; history of use long; inexpensive; treat narrow range of symptoms (not ideal for negative symptoms of psychosis); patients report dysphoria; long-term use contraindicated because of EPS (eg, tongue “catching,” dyskinesia, acute dystonia, akathisia); dystonic reaction may be mistaken for seizure; oculogyric crisis and akinesia possible; akathisia resembles “tweaking”; parkinsonism with tardive dyskinesia possible with long-term use; second-generation agents — effective for broad range of symptoms; exhibit γ-aminobutyric acid, serotonin, and anticholinergic activity; effective as single agents; incidence of EPS low; may cause metabolic problems (eg, weight gain, diabetes mellitus, hypercholesterolemia); history of use short; long-term effects unknown; generic versions only slightly more expensive than first-generation agents

Characteristics: haloperidol — risk for diabetes mellitus or weight gain minimal; provides powerful dopamine blockade; causes EPS and tardive dyskinesia (not with intravenous [IV] administration [first-pass metabolism]); useful for elderly patients with delirium (does not cause respiratory suppression); may cause prolonged QTc interval (true for all antipsychotic agents); speaker’s institution requires baseline electrocardiography (ECG) and cardiac monitoring if >2 mg IV used; aripiprazole — partial dopamine agonist; IM formulation discontinued; olanzapine — causes weight gain and sedation; effective in decompensated bipolar disease; IM coadministration with benzodiazepine contraindicated (excess respiratory suppression); quetiapine — causes sedation; popular with patients; used for Parkinson disease with agitation or psychosis; risperidone — often used by emergency psychiatrists; inexpensive; effective; provides good dopamine blockade; works well with lorazepam; ziprasidone — IM formulation popular alternative to haloperidol (20 mg); oral form contraindicated in emergency department (food required for absorption); ziprasidone, droperidol, and haloperidol — if repeated doses anticipated, perform ECG; avoid use if QT interval >500 milliseconds; ketamine — good option when others have failed, rhabdomyolysis suspected, or paralysis with intubation may be required; patients retain respiratory reflexes; respiratory suppression minimal, but monitoring of airway and observation required

Choice of medication: antipsychotic agents — antidopaminergic activity effective for psychosis of any cause (eg, methamphetamine toxicity, schizophrenia, schizoaffective disorder, depression with psychotic features); effective for agitation without psychosis; benzodiazepines — effective for agitation (unless paradoxical reaction present) and psychosis; combination of agents — often used if diagnosis unknown; takedown — lorazepam with ziprasidone or haloperidol alone effective

Readings

Abou-Setta AM et al: First-generation versus second-generation antipsychotics in adults: comparative effectiveness [internet]. AHRP Comparative Effectiveness Reviews 2012 Aug;Report No:12-EHC054-EF; Citrome L: New treatments for agitation. Psychiatr Q 2004 Fall;75(3):197-213; Garriga M et al: Assessment and management of agitation in psychiatry: expert consensus. World J Biol Psychiatry 2016;17(2):86-128; Glick RL et al, eds: Emergency Psychiatry: Principles and Practice. Philadelphia, PA: Lipincott Williams & Wilkins;2008; Leucht S et al: How effective are second-generation antipsychotic drugs? A meta-analysis of placebo-controlled trials. Mol Psychiatry 2009 Apr;14(4):429-47; Nobay F et al: 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 2014 Jul;11(7):744-9; Nordstrom K et al: Medical evaluation and triage of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup. West J Emerg Med 2012 Feb;13(1):3-10; Richmond JS et al: Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry project BETA De-escalation Workgroup. West J Emerg Med 2012 Feb;13(1):17-25; Wilson MP et al: The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West J Emerg Med 2012 Feb;13(1):26-34; Zeller SL et al: Managing agitation associated with schizophrenia and bipolar disorder in the emergency setting. West J Emerg Med 2016 Mar;17(2):165-72.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Hardy was recorded at High Risk Emergency Medicine San Francisco, presented by the University of California, San Francisco, School of Medicine, Department of Emergency Medicine, and Office of Continuing Medical Education and held June 9-11, 2016, in San Francisco, CA. For information about upcoming CME conferences from the University of California, San Francisco, Office of Continuing Medical Education, please visit www.cme.ucsf.edu. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

EM340801

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.