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Therapeutics: Agitation in the ED

Providers will frequently use “5 & 5”, a combination of 5 mg haloperidol and 5 mg midazolam, or a B52, a combination of 50mg diphenhydramine, 5mg haloperidol and 2mg midazolam, both options for the sedation of agitated patients. Evidence supports this combination approach. For both haloperidol and droperidol, there is good evidence that the combination of these drugs with a benzodiazepine such as lorazepam or midazolam is more effective than either alone. This increase in efficacy is not associated with an increase in adverse events. Using a combination of both medications also frequently leads to a more rapid onset of sedation. Combining these medications may also lead to a reduction in side…

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Featured

 emDocs Cases: ED Approach to Agitation

Acute agitation and altered mental status can be due to a wide variety of conditions, ranging from a dangerous medical condition to primary psychosis or intoxication In the ED, alcohol or drug intoxication are the most common etiologies.

 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.

 Geriatrics - TIPS for Managing the Acutely Agitated Patient

All benzodiazepines and antipsychotics (both FGA and SGA) carry an FDA warning against their use in elderly patients with dementia-related psychosis due to increased risk of death. However, these may be needed for the safety of the patient. Data is limited on which drugs are best; in general, it is recommended to use much lower doses than in the general population, as older adults are more susceptible to adverse events. PO medications are preferred over IV, with the recommendation to start with olanzapine 2.5-5 mg, Haldol 1-2 mg PO, or risperidone < 1 mg PO.

 Should Diphenhydramine be included in an Acute Agitation Regimen?

Acute agitation in the emergency department is a common issue that frequently requires the use of chemical sedation to preserve safety for patients and healthcare workers. A commonly employed treatment regimen is the combination of haloperidol 5 mg + lorazepam 2 mg + diphenhydramine 50 mg (B-52). Diphenhydramine is included in this treatment regimen primarily to prevent extrapyramidal symptoms. However, the incidence of extrapyramidal symptoms (EPS) with haloperidol is quite low when treating agitation in the emergency department (ED). Therefore, the excessive and prolonged sedation from adding prophylactic diphenhydramine may outweigh the intended benefit and should be reserved for treatment of EPS if symptoms occur.

 The Acutely Agitated Adult ED Patient

What do you take into consideration when you’re presented with an acutely agitated adult? Do you have a drug of choice? Or perhaps a go-to cocktail? While most of the time these patients present to the ED and require immediate decision making, there may be an opportunity to identify etiology, comorbidities, and some medical history

 The Agitated Patient in the ED: Moderate & Severe Agitation

There is a lot of adrenaline associated with the severely agitated patient. Likely because of that, the emergency medicine and critical care FOAM world has been exceptionally good at writing about it! Rather than attempt to reinvent the wheel by getting into the subtleties of this topic, I have decided to summarize the conclusions of some of the FOAMites that have already done so.

 The Art of the ED Takedown

On a daily basis, emergency physicians encounter challenging patients that are acutely agitated, violent, or psychotic. Patients can behave this way for a variety of reasons, which include: intoxication, underlying mental illness, head injury, metabolic disturbances, infection, or a host of other organic and social reasons. Regardless of the cause, it’s imperative that the emergency physician rapidly identify these patients in order to ensure the well being of all healthcare providers, family members, and the patient. This is where the ED take down comes into play.

 TIPS for Managing the Acutely Agitated Patient

The standard treatment regimen for most patients presenting with acute agitation consists of three classes of medication: benzodiazepines, first-generation antipsychotics (FGA), and second-generation antipsychotics (SGA). In general, the majority of violent or agitated patients will receive a combination of an FGA and a benzodiazepine, or an SGA alone.

 To B or Not to B: B52 v 52 for Acute Agitation

The addition of diphenhydramine may not be necessary to prevent EPS in patients receiving haloperidol for agitation and is associated with increased length of stay and adverse events, likely due to its additive sedative properties.

Articles of Interest

Approach to the Agitated ED Patient

Drugs are NOT benign, use with caution in already intoxicated, pregnant, elderly, young, those with comorbidities.

Chemical Restraint in the ED

Chemical restraint via antipsychotic and benzodiazepine medication, used in an eort to facilitate medical workup and patient safety, enjoys a long standing safety and ecacy record.

Chemical Sedation of the Agitated Patient

Coaxing agitated patients out of an aggressive and often altered state with verbal and environmental modification is often fruitless.

Chemical Sedation of the Agitated Patient in the ED

This is a wonderful infographic from Dr. Schmitz discussing the various tools at the disposal of the emergency physician regarding agitated patients. Unfortunately, this type of encounter in the Emergency Department occurs rather frequently.

Emergency Management of the Agitated Patient

Disruption, danger and droperidol...

Episode 56.0 – Sedation of the Agitated Patient

This week we discuss pearls from a talk from Reuben Strayer on sedation of the agitated patient focusing on patient and staff safety.

Excited Delirium: Acute Management in the ED Setting

Excited delirium syndrome is a common yet poorly characterized ED presentation with a wide differential diagnosis. Patients are often identified initially by law enforcement, but attempts to control individuals experiencing ExDS via physical, chemical, or electrical restraints are associated with an exceedingly high rate of morbidity and mortality.

Management of Acute Agitation in the Emergency Department

Special consideration is given to the treatment of acutely agitated geriatric patients suffering from delirium and/or dementia. Management of these patients should be guided by etiology and patient characteristics to obtain maximum therapeutic benefit.

Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool

Behavioral changes in older adults can be a manifestation of underlying medical problems, mental health concerns, medication adverse effects, substance abuse, or dementia.

Managing Delirium In The Emergency Department: Tools For Targeting Underlying Etiology

Delirium is a complex neuropsychiatric disorder that often manifests secondary to a discrete medical condition.

Multiple RCTs on ketamine for severe agitation

However, it is important to note that neither of these trials is a clear win for ketamine. There appears to be a bit of a trade off, with ketamine providing more rapid sedation, but also more adverse events.

Rapid Agitation Control With Ketamine in the Emergency Department

The bottom line is that the use of ketamine appears to be a safe and attractive alternative with a good safety profile for severe psychomotor agitation in the emergency department.... Intramuscular Ketamine: 5 mg/kg

The Agitated Patient

When the patient is agitated, re-address the reason why the patient has been brought to the emergency department in the first place. If the patient did not show up agitated but has become so during their stay, often the agitation is related to a decompensation of their medical condition (think: worsening respiratory status, sepsis run amok, etc.)

The Decision to use Ketamine – Disruptive and Dangerous with Reub Strayer

I frequently see both residents and attendings inappropriately using ketamine for agitated patients. Inappropriately both by giving it when it is unecessary and giving it in poor fashion when it is indicated.

The Evolution of Ketamine for Severe Agitation

While we do not recommend ketamine as a first line agent for the treatment of mild to moderate agitation, it does have a role in the treatment of the combative excited delirium patient. In patients for whom rapid sedation is imperative, consider giving at least 1 mg/kg IV or 5 mg/kg IM.

Resources

WikEM

Screen for acute medical conditions that may contribute to the patient's behavior.