THE MORNING REPORT

The Best in FOAM Education

  • Jia Jian Li, MD

Acute Agitation

Differential Diagnosis

Tox

-Alcohol intoxication or withdrawal

-Stimulant

-Other drugs and drug reactions

Metabolic

-Hypoglycemia

-Hypoxia

-Hypo/hyperthermia

Neurologic

-Stroke

-Intracranial lesion

-CNS infection

-Seizure

-Dementia

Other medical conditions

-Hyperthyroid

-Shock

-AIDs

Psychiatric causes


Verbal Techniques

A consensus statement from the American Association for Emergency Psychiatry De-escalation Workgroup for verbal deescalation:

Respect personal space

Do not be provocative

Establish verbal contact

Use concise, simple language

Identify feelings and desires

Listen closely to what the patient is saying

Agree or agree to disagree

Lay down the law and set clear limits

Offer choices and optimism


Verbal de-escalation of the agitated patient. Chapter 1: Identification and assessment of agitation


Chemical Restraints

Lorazepam

-Usual dose is 0.5 to 2 mg IV or IM

-Half-life is 10 to 20 hours

Midazolam

-Usual dose is 2.5 to 5 mg IV or IM

-Duration of action = 1-2hrs

Side effects

-Respiratory depression

-Excessive somnolence

-Paradoxical disinhibition


First-Generation Antipsychotics

Haloperidol

Can be given IV, IM, or orally

Doses of 2.5 to 10 mg

-Should be decreased by one half in the elderly.

The onset of action is within 5 to 20 minutes for IV administration

Droperidol

Can be given IM or IV

Doses of 2.5 to 5 mg.

-Onset 15 to 30 minutes

Duration of 6-8 hours

Clinical trial reported that IM droperidol is rapidly absorbed, obviating the need for IV therapy


Side effects

Quinidine-like cardiac effects resulting in QT prolongation,

-Potential to cause dysrhythmias

--Torsades de pointes

Can cause extrapyramidal side effects and delayed dystonic reactions

Should be avoided in cases of alcohol withdrawal, benzodiazepine withdrawal, other withdrawal syndromes, anticholinergic toxicity, and patients with seizures.

-Should also be avoided in pregnant and lactating females and phencyclidine overdose.


Second-Generation Antipsychotics

Reportedly cause fewer extrapyramidal side effects and less sedation than first generation antipsychotics

Limited studies involving its use in acute agitation in the ED

Growing and preliminary studies suggest that they are effective


Olanzapine

Initial IM = 10 mg

Onset of action is 15 to 45 minutes

Half-life is two to four hours.

IV olanzapine must be closely monitored as there is a risk of respiratory depression, and clinicians

-Off label


Risperidone

Generally used for schizophrenia

Data for its use in acute agitation are limited

Oral and IM = 1 to 2 mg


Ziprasidone

Treat agitated schizophrenic and bipolar patients

IM dose of 10 to 20 mg

-IM has on onset of action of 15 to 20 mins

Half-life of two to four hours


Side effects

Cause some degree of QT prolongation

-Ziprasidone most likely to cause this effect.

Similar side effects as in for first generation antipsychotics



Ketamine

Useful when:

-Initial treatments such as benzodiazepines or antipsychotics have failed

-Patients with excited delirium

Initial dose of 1 to 2 mg/kg IV, or 4 to 6 mg/kg IM

Onset of action is ~1-2 mins with IV administration, but 4-5 or longer with IM administration

Duration of action is approximately 10 to 20 minutes


Side effects (may be more common with rapid IV administration)

-May include hypertension and tachycardia (usually mild and transient)

-Laryngospasm (uncommon

-Emergence reactions

-Vomiting

--Avoid ketamine in patients experiencing agitated delirium who are older, have known heart disease, or are at increased risk of heart disease

--Can exacerbate schizophrenia

--Greater need for endotracheal intubation compared to other medications depending upon the dose required to achieve adequate sedation


Take Away #1

For severely violent patients requiring immediate sedation:

-Give a rapidly acting first generation antipsychotic

-Benzodiazepine alone

-A combination of a first generation antipsychotic and a benzodiazepine

For patients with agitation from drug intoxication or withdrawal, give a benzodiazepine.

For agitated patients with a known psychotic or psychiatric disorder, give antipsychotics


Take Away #2 Emcrit

Haldol 5mg and Lorazepam 2 mg given IM will take a long time for full effect and even then, may not provide adequate sedation.

Droperidol monotherapy 5-10 mg IM or 5 mg IV

Droperidol 5 mg + Midazolam 2mg IM or IV in the same syringe

Olanzapine 10 mg IM (Needs Resp Monitoring)

Olanzapine 5 mg + Midazolam 2 mg IM or IV (Needs Resp Monitoring)

Haldol 5 mg + Midazolam 2 mg IM or IV (will be slower than the other choices)

References:

https://www.uptodate.com/contents/assessment-and-emergency-management-of-the-acutely-agitated-or-violent-adult?search=agitation&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H19


https://emcrit.org/emcrit/dangerous-and-disruptive/