EM Psych 3: Acute Agitation Flashcards
Practices recommended for the optimum care of the agitated patient
1.) Approach the agitated patient with safety in mind
2.) Attempt verbal de-escalation in all patients
3.) If agitation, persists or worsens employ a “show of concern”
4.) Treat underlying medical problems first
5.) Restraints should be used sparingly and only to protect the staff or patient from harm
6.) Target medication to the most likely cause of agitation and se oral medicines when possible
7.) Use second-generation antipsychotics as first-line agents in most situations not involving alcohol intoxication
Sedation Assessment Tool zero and above
0 Awake and calm/cooperative; normal speech
+1 anxious/restless; normal/talkative
+2 very anxious and agitated; loud outbursts
+3 combative, violent, out of control; continual loud outbursts
Sedation Assessment Tool below zero
-1 asleep but rouses if name called; slurring or prominent slowing of speech
-2 responds to physical stimulation; few recognizable words
-3 no response to stimulation; speech nil
most common combination medications used in acute agitation in the U.S.
haloperidol and lorazepam
Oral medications for patients with agitation associated with delirium where ETOH/BZN withdrawal is not suspected
1.) 2nd-gen antipsychotics
risperidone 2 mg
olanzapine 5-10 mg
2) 1st gen antipsychotics
haloperidol (low dose) (<3.0 mg/day)
Avoid benzodiazepines
Parenteral medications for patients with agitation associated with delirium where ETOH/BZN withdrawal is not suspected
3) 2nd gen antipsychotics
olanzapine 10 mg IM
ziprasidone 10-20 mg IM
4) 1st gen antipsychotics
haloperidol (low dose) (<3.0 mg/day) IM or IV (with caution)
Avoid benzodiazepines
First-line medications for patients with agitation associated with delirium where ETOH/BZN withdrawal is suspected
1) oral benzodiazepines
lorazepam 1-2 mg
chlordiazepoxide 50 mg
diazepam 5-10 mg
2) parenteral benzodiazepines
lorazepam 1-2 mg IM or IV
First-line medications for agitation due to intoxication from a CNS stimulant
1) oral benzodiazepines
lorazepam 1-2 mg
chlordiazepoxide 50 mg
diazepam 5-10 mg
2) parenteral benzodiazepines
lorazepam 1-2 mg IM or IV
First-line medications for agitation due to intoxication from a CNS depressent (e.g., ETOH)
1) oral 1st-gen antipsychotics
haloperidol 2-10 mg
2) parenteral 1st-gen antipsychotics
haloperidol 2-10 mg IM
Oral medications for agitation associated with psychosis in patients with known psychiatric disorder
1.) oral 2nd gen antipsychotics
risperidone 2 mg
olanzapine 5-10 mg
if antipsychotic alone does not work sufficiently, add lorazepam 1-2 mg
2) oral 1st gen antipsychotic
haloperidol 2-10 mg with BZN
Parenteral medications for agitation associated with psychosis in patients with known psychiatric disorder
3.) Parenteral 2nd-gen antipsychotics
olanzapine 10 mg IM
ziprasidone 10-20 mg IM
If an antipsychotic alone does not work sufficiently, add lorazepam 1-2 mg
4.) parenteral 1st-gen antipsychotic
haloperidol 2-10 mg IM with BZN
10 principles of verbal de-escalation
- respect personal space
- do not be provocative
- establish verbal contact
- be concise
- identify wants and feelings
- 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
- Debrief the patient and staff
most of the injuries to both patients and staff occur when?
during restraint periods
also, it has many disadvantages:
- increased ED length of stay
- poorer outpatient follow-up
in elderly patients with delirium, the safest approach is
to treat the underlying cause that is producing both the delirium and agitation
If meds are needed, 2nd-gen agents and low-dose haloperidol (<3.0 mg/day) do not seem to worsen delirium
avoid benzodiazepines and antihistamines
