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
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/