The Agitated Patient

Objectives

Upon finishing this module, the student will be able to

  • Recognize the agitated and potentially dangerous patient
  • Describe the initial evaluation of an agitated patient
  • Define agitated behavior and differentiate delirium, dementia and psychosis
  • Describe appropriate methods for de-escalation and restraint

Introduction

Agitation complicates the presentations of many ED patients. Examples include changes in mood, orientation, and level ofconsciousness as well as violence. Agitation may be a symptom of delirium, dementia or psychosis. The duty of the emergency physician is to ensure safety for the patient and staff while distinguishing underlying medical causes from those which are functional or psychiatric in nature. As around one third of teaching hospitals report daily verbal threats and at least one fourth restrain at leas one patient daily, it is essential to rapidly assess and intervene upon agitate and potentially violent patients.

Initial Actions and Primary Survey

After assessment of the ABCs, initial treatment is focused on attempting to calm the patient to facilitate further evaluation.Techniques avoiding sedation are preferred to allow gathering further history. Vital signs, measures to assure safety of patient and others, and early containment (including physical or chemical restraint, as appropriate) are the first steps. A good history including one from collateral sources is essential. Blood glucose should be attained as soon as is safe to do so as hypoglycemia is a fatal cause of altered mental status. Whenever head and neck trauma is a possibility, the provider should also consider safely placing a cervical collar on the patient. Always consider safety of both the patient and examiner before approaching a potentially dangerous patient and see detailed discussion of approaching such a patient below.

Presentation

An agitated patient may present anywhere on the spectrum from slightly anxious to combative. Due to this patients may be tachycardicand hypertensive upon presentation. Clinically significant agitation may include explosive and unpredictable anger; intimidating behavior; physical or verbal self-abusiveness; demining or hostile verbalbehavior; or signs of impatience like restlessness, pacing and excessive movement. Violent actions do not usually occur without warning.Watch for signs of anxiety including pacing, clenching of fists, pressured or angry speech, defensiveness, verbal threats, or yelling.

Agitated behavior may occur in the context of substance abuse, personality disorder, and psychiatricor physical illness. Below we will discuss key features of delirium, dementia and psychosis.

Delirium

Delirium is an acute confusional state due to an organic disturbance in the brain. These patients require complete workup for a medical cause of the agitation. Key features include change in level of consciousness (agitation to drowsiness) and change in cognition (memory, orientation, attention or speech). Usually, the course is acute but fluctuatesin severity. Patients are often elderly and usually hallucinations are non-auditory.An example would be a newly combative elderly patient sent for evaluation from a nursing home found to have a UTI.

Dementia

Dementia is an organic brain disturbance with progressive mental status changes including intellectual abilities, behavior and personality. May present with an acute delirium in a patient with a chronic, progressive decline.

Psychosis

Psychosis is a dysfunction in processing of information or thought capacity that may present as a feature of a personality disorder, schizophrenia, mania, acute stress reactions, or depression with psychotic features. Patients may have delusions, hallucinations, disorganized speech or behaviorand negative symptoms. Patients with acute psychosis are usually not disoriented.

Diagnostic Testing

Investigations should focus on identifying and treating life-threatening diagnoses presenting as agitated behavior and general medical conditions causing symptoms. A complete set of vital signs and blood glucose should be acquired for all agitated patients and additional workup tailored based upon the patient’s presentation. After ensuring respiratory and hemodynamic stability, the next steps are to obtain a complete history and physical.

Collateral information from family members, witnesses, paramedics, and other providers is essential. Often, aPCP or psychiatrist can attest to the patient’s baseline behavior or provide additional information about precipitants of patients’ agitation.

Differential diagnosis for delirium can be remembered with the mnemonic DIMTOPS:

  • Drugs-intoxication, poisoning or withdrawal
  • Infections-UTI, pneumonia, meningitis/encephalitis, and others
  • Metabolic Disturbance-Glucose and other endocrine derangements as well as electrolyte disorders
  • Trauma-Head injury
  • Oxygen-Hypoxia
  • Postictal State
  • Space Occupying Lesion-Intracranial Tumor

Suggests Psychiatric Etiology

Suggests Organic Etiology

Oriented

Disoriented

Alert

Depressed Level of Consciousness

Gradual Onset

Sudden Onset

Psychiatric History

No Psychiatric History

Normal Vital Signs

Abnormal Vital Signs

Normal Physical Exam

Abnormal Physical Exam

Age < 40 years Age > 40 years (Without Psychiatric History)

Auditory Hallucinations

Visual Hallucinations

Flattened Affect

Emotional Lability

Able to Redirect

Unable to Sustain Attention

Physical exam should include a complete neurological exam including assessment mental status and evaluating for meningeal signs, signs of trauma, evidence of toxidromes (assess pupils, heart, bowelsounds, skin) or intoxication. Sepsis can also affect mental status and as such, a thorough exam including assessment of the neck, skin, lungs, abdomen and potentially genitalia should be completed.

As routine laboratory testing is not particularly useful in the assessment of agitated patients, it is essential to tailor the diagnostic testing based upon history, physicaland vital signs. Consider head CT for patients with significant agitation after trauma and investigate potential sources of infection in patients, for example, with immunocompromise or fever with agitation. When history is limited, keep a low threshold to orderdiagnostic tests.

Treatment

Management relies upon controlling agitation for safetyof patient and others in the department as well. This allows improvement of the patient’s comfort and an evaluation of the etiology of the agitation. Calming an agitated patient allows the provider to establish a more normal patient-physician relationship and obtain informed consent where needed. Remember thatearly attention to agitation and escalating violence allows better safety for both patients and staff. Do not be embarrassed to ask for help and do not trivialize any threats.

All weapons must be removed. When approaching an agitated patient, it is essential to remain calm and to approach with adequate assistance (including security or police if needed). The patient should beevaluated in a safe place with a clear escape route for the examiner. (Do not position the patient between yourself and the door.) Leave the room immediately if you feel in any danger.

It is essential for medical students to communicate with the supervising team before evaluating a potentially dangerous patient. Note in the video of the agitated patient that the medical student informed the attendingphysician that she was going to interview a psychiatric patient and indicated which room she would be in.

Verbal De-escalation

The most important concept in verbal de-escalation is for the physicianto convey professional concern and respect for the patient. Avoid threatening the patient by speaking in a calm and reassuring manner and respecting personal space. Pay attention to your body language and avoid potentially threatening stances such as crossed armsor waving a finger. Acknowledge thepatent’s discomfort but speak in a controlled manner and put clear limits on disrupted and dangerous behaviors. The patient should be advised of consequences for such continuedbehavior. Often, verbal de-escalation is all that is needed to calm an agitation. In some cases, approaching as a group with a show of force may calm an agitated patient.

Non-Pharmacological Restraint

When attempts at de-escalation are unsuccessful, restraints may be required. They may be utilized alone or in conjunction with other interventions for agitated behavior. A physical restraint is a devise that restricts freedom of movement of one’s body including soft wrist or ankle restraints, and torso vests attaching to the patient’s gurney. Upon the decision to utilize physical restraints, the team should continuously explain what is happening to the patient without confrontation or threats. The patient should be placed in a calm, quiet area. Always use physical restraints for the briefest possible time until less restrictive measures are effective.

Five Point Immobilization

Five Point Immobilization is utilized to ensure patient and team safety utilizing at least 5 team members. Restraints shouldbe soft and easy to remove if needed (e.g. in case of seizure). Never apply restraints over neck, chest or head and do not use gags.

  • Team leader talks to the patient and may control the head
  • One person per limb at a major joint
  • Grasp all extremities at the same time
  • Place the patient supine on the bed
  • Apply restraints to each ankle and wrist—attach to bedframe, not rails

Restrained patients cannot move toprotect themselves and medications have sedating effects. Thus, fortheir safety restrained patients should have a provider in the room constantly and have continual monitoring of vital signs. Seclusion shouldbe initiated only in consultation with a senior emergency physician and in an area without hazards for the patient and where staff can see the patient at all times. Sedated patients should not be placed in areas where they are not well monitored by staff.

Whenever placing a patient in restraints it is essential to comply with safety procedures and document appropriately and an attending should evaluate the patient soon after restraints are placed, usually in less than one hour. Monitoring and documentation are required including those that comply with the policies set forth by the Joint Commission and theCenters for Medicare and Medicaidservices and any local hospital policy. Oftenthere is a specific local form or electronic documentation set required. A plan for removal of the restraints should be communicated with the team.

Chemical Restraint (Rapid Tranquilization)

In patients who are agitated to the degree that they are unable to participate in less restrictive alternatives, medications may be used to rapidly allow for evaluation of the patient. Chemical restraint is used to control violent and potentially dangerous behavior rather than confining bodily movement, as a strict definition might suggest. The decision to utilize chemical restraint is clinical. It is neveracceptableto initiate its use for staff convenience or patient punishment. Endpoints ofrestraint are to resume a more normal patient-physician interaction, to obtain informed consent and the secure patient and staff safety. When choosing a therapy, consider the objective of reducing agitation with minimal sedation to allow for timely assessment and treatment of any underlying condition requiring immediate medical intervention.

A variety of options are available and should be weighed based on the patient’s history and presentation. Vital signs should be monitored frequently until the patient is ambulatory. Historically, benzodiazepinesand antipsychotics are the most common pharmocotherapeutic options. The table shows common choices for chemical restraint. Emergencyphysicians should be familiar with the use of these medications, their side effects and how to address complications of their use. Anticholinergic medications such as benztropine and diphenhydramine may be used for prophylaxis against extrapyramidal symptoms caused by some antipsychotic administrations.

Medications Used in the Chemical Restraint of an Agitated Patient

Class

Drug

Dose

Route of Administration

Onset of Action

Side Effects

Benzodiazepine

Lorazepam

2-4 mg

IV/IM/PO

5-30 min

Respiratory depression, excessive sedation

Midazolam

5 mg

IV/IM/PO

10-30 min

Respiratory depression, excessive sedation

Typical Antipsychotic

Haloperidol

2.5-10 mg

PO/IM/IV

30-60 min

Extrapyramidal symptoms, Neuroleptic Malignant Syndrome

Atypical Antipsychotic

Ziprasidone

10 mg q 2 hrs or 20 mg q 4 hrs

PO/IM

15-20 min

QTc prolongation

Risperidone

2 mg q 2 hrs

PO

< 90 min

QTc prolongation, orthostatic hypotension

Olanzapine

5-10 mg q 2-4 hrs

PO/IM

15-45 min IM; 3-6 hrs PO

Orthostatic hypotension, QTc prolongation

There are some advocates for the use of ketamine and propofol in the acutely agitated patient though there is not yet sufficient literature on their use in the Emergency Department for acute agitation. Further, while the FDA has placed a black box warning on droperidol because, like many other medications, it can cause QT prolongation and an increased risk for the development of torsades de pointes and other serious dysrhythmias, some authors advocate it due to a shorter duration of sedation than some benzodiazepines and there are some studies which do not show it to have more adverse events than other ED treatments for acute agitation. Any plans to use these drugs should be discussed with an attending, preferably prior to the acute need for use on a patient.

Pearls and Pitfalls

Pearls:

  • Utilize collateral history and always attempt to gather additional history from patient after the acute agitation is controlled
  • Always ensure your own safety and make staff aware of any potentially violent patient.
  • Obtain finger stick glucose as soon as it is safe to do so.
  • Consider trauma (and the need for C-spine protection), toxidromes and infection
  • Do not ignore agitation and potential for violence

Pitfalls:

  • Failure to obtain a complete set of vital signs and glucose
  • Failure to consider medical emergencies and injury rather than psychiatric causes of altered mental status
  • Failure to obtain additional and complete history and physical exam from patient and collaterals after the acute episode of agitation is controlled (including undressing the patient)
  • Fear of asking for help or minimizing patient’s potential for violence
  • Failure to complete an assessment and plan after restraining an agitated patient

References

  • Tintinalli JE. Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill. 2010.
  • Lukens TW, Wolf SJ, Edlow JA, et al. Clinical policy: Critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006 Jan;47(1):79-99. PMID: 16387222
  • Isaacs ED, Rossi J, Swan MC. The violent or agitated patient. Emerg Med Clin N Am. 2010 (28); 235-256. PMID: 19945609
  • Zun LS. 2005. Evidence Based Evaluation of Psychiatric patients. Journal of Emergency Medicine. 28(1):35–39. PMID: 15657002

  • Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clin North Am. 2009 Nov;27(4):655-67, ix. doi: 10.1016/j.emc.2009.07.003. Review. PubMed PMID: 19932399.

  • Downes MA, Healy P, Page CB, Bryant JL, Isbister GK. Structured team approach to the agitated patient in the emergency department. Emerg Med Australas. 2009 Jun;21(3):196-202. doi: 10.1111/j.1742-6723.2009.01182.x. PubMed PMID: 19527279.
  • Martel M, Sterzinger A, Miner J, Clinton J, Biros M. Management of acute undifferentiated agitation in the emergency department: a randomized double-blind trial of droperidol, ziprasidone, and midazolam. Acad Emerg Med. 2005;12(12):1167-72. PMID: 16282517
  • Isbister GK, Calver LA, Page CB, Stokes B, Bryant JL, Downes MA. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010;56(4):392-401.e1. doi: 10.1016.j.annemergmed.2010.05.037 PMID: 20868907
  • Ketamine sedation for patients with acute agitation and psychiatric illness requiring aeromedical retrieval.Le Cong M, Gynther B, Hunter E, Schuller P. Emerg Med J. 2012 Apr;29(4):335-7. doi: 10.1136/emj.2010.107946. Epub 2011 May 12. PMID: 21565879

Credits

  • Author: Elizabeth DeVos MD, MPH, FACEP, Medical Director, International Emergency Medicine Education, Assistant Professor, Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, Director, International Educational Programs, University of Florida College of Medicine
  • Editor: Nur-Ain Nadir. MD, Medical Student Education Director, Simulation Faculty, Assistant Professor, Department of Emergency Medicine, University of Illinois College of Medicine Peoria
  • Last Updated: 2015

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