1. Take a chill pill: An approach to the agitated ED patient
Alan Sazama, MD
Avera Medical Group
Emergency Medicine
Sioux Falls, SD

2. Disclosures
None

3. Objectives Differentiate causes of acute agitation in the ED
Discuss pharmacologic treatment options for agitated patients
Review evidence behind treatment of agitated patients
Discuss treatment of special populations of agitation patients

7. Agitation:
Excessive verbal and/or motor behavior in addition to feelings of unease
Loss of impulse control
Involuntary behaviors
Potential to hurt self or others
Citrome, L. Postgrad Med. 2002

9. Who is agitated? Waiting patients Psychiatric history
Toxins(drugs/alcohol/withdrawal)
Patients in trouble with the law
Medical patients (hypoxia, infection, medications)

10. Why do we care? Patient safety Staff safety Government regulations
It’s common!

11. Medical causes

12. Can’t miss diagnoses Infection Toxins Meningitis/encephalitis UTI
Sepsis
Toxins
Drugs
Withdrawal
Carbon monoxide

13. Can’t miss diagnoses Hypoxia Trauma CNS Metabolic
Electrolytes (sodium, calcium)
Hepatic encephalopathy
Uremia
Hypothermia/hyperthermia

14. What do we need to work up?
H&P of most importance
Labs unless directed by H&P are usually unhelpful (ACEP clinical policy Level B recommendation)
Urine drug screens

15. Strategy

16. Project Beta
Best Practices for Evaluation and Treatment of Agitated Patients
Series of 6 articles in the Western Journal for Emergency Medicine
Excellent resource for information on treating agitated patients

17. Verbal De-escalation

18. The verbal de-escalation 10 commandments

19. The verbal de-escalation 10 commandments
1. Thou shall be non-provocative
2. Thou shall respect personal space
3. Thou shall establish verbal contact
4. Thou shall be concise
5.Thou shall identify wants and feelings

20. The verbal de-escalation 10 commandments
6. Thou shall lay down the law
7. Thou shall listen
8. Thou shall agree or agree to disagree
9. Thou shall have a moderate show of force and be prepared to use it
10. Thou shall debrief with patients and staff

21. Chemical restraints

22. Considerations Indications Side effects Toxicities
Medical Hx of patient
Drug interactions
Time of onset

23. Important ED factors Time of onset Reliability of delivery
Interaction with other medications
Patient preference

24. Side effects Antipsychotics Movement disorders (acute dystonia)
Sedation
Dysphoria
Postural hypotension
QTc prolongation

25. Side effects Benzodiazepines Sedation, ataxia, dysarthria
Dysphoria, euphoria
Hypotension
Abuse potential
Respiratory depression

27. Benzodiazepines
Versed (midazolam), Ativan (lorazepam), Valium (diazepam) are the most common used in the acute setting
Fast onset
Multiple mechanisms of delivery

28. Benzodiazapines Drug Onset Peak Duration Versed (Midazolam) IN: 5 min
IM: 15 min
IV: min
10 min
30-60 min
rapid
2-6 hr
Ativan
(Lorazepam)
PO: min
IM: min
IV: min
1-6 hr
1-2 hr
15-20 min
8-12 hr
Valum
(Diazepam)
PO: min
IM: 20 min
IV 1-5 min
30 min-1.5 hr
15-30 min
Up to 24 hr
Unknown
15-60 min

29. Droperidol

30. Haloperidol Titratable (2 mg/5mg increments)
Can be combined with ativan for synergism
Works in min
Dopamine blocker– extrapyramidal side effects

32. Atypical Antipsychotics
Olanzapine (zyprexa), ziprazadone (geodon), aripiprazole (abilify), quetiapine (seroquel), risperdone (risperdal)
Effects seen in about 25 minutes
Comparable QTc effects
Less extrapyramidal side effects

33. Antipsychotics Drug Onset Peak Duration Haloperidol PO: 2 hr
IM: min
IV: seconds
2-6 hrs
30-45 min
immediate
8-12 hrs
4-8 hrs
4-6 hrs
Olanzapine
PO: 60 min
IM: rapid
6 hrs
15-45 min
10-15 hrs
2-4 hrs
Quetiapine
PO: min
1.5 hrs
7-12 hrs
Ziprasidone
PO: hours
1-3 days
60 minutes
unknown

34. Ketamine

35. Ketamine NMDA receptor antagonist
Dissociates cortical activity from brain stem activity vs just depressing CNS
VS maintained as well as airway reflexes
BP, pulse can increase
Can be a weak bronchodilator

36. Ketamine IV: 1-2 mg/kg IM: 4-5 mg/kg
Onset 1 minute, lasts minutes
Can titrate
IM: 4-5 mg/kg
Onset 5 min, lasts min

37. Ketamine Side effects Increased secretions Emergence reaction
Nausea, vomiting
Laryngospasm

40. Primary outcome: respiratory depression
Secondary outcomes: additional doses of sedative, Qtc, time to nadir sedation, adverse events, physician assessment of efficacy.
784 patients

43. Conclusion (per authors): These data suggest that, with proper monitoring, administration of olanzapine, both intramuscular and intravenous, is safe for several indications in the ED

44. Prospective open label study patient in urban EMS system
A prospective study of ketamine versus haloperidol for severe prehospital agitation JCole J, et al
Prospective open label study patient in urban EMS system
Paramedics received training on altered mental status scale
2 six month periods where ketamine or haldol was first line therapy

45. A prospective study of ketamine versus haloperidol for severe prehospital agitation J Cole et al
Primary outcome time to adequate sedation
Secondary outcomes adverse medication events
146 subjects 64 ketamine 82 haldol
Ketamine sedation: 5 minutes
Haldol sedation: 17 minutes

46. A prospective study of ketamine versus haloperidol for severe prehospital agitation J Cole et al
49% complications ketamine vs 5% haldol
Ketamine complications
Hypersalivation 38%
Emergence reaction 10%
Vomiting 9%
Laryngospasm 5%
39 % intubated on ketamine vs 4% haldol

47. Special populations

48. No official evidence based management guidelines exist for pediatric population
Lorazepam, Olanzapine often featured in hospital policies.
Similar to adults, verbal de-escalation and avoiding restraints is stressed in many guidelines

49. Tough population with respect to increased medical causes, co morbid conditions, and polypharmacy
Haldol and olanzapine with some evidence
Oral risperdal has good evidence in dementia patients
Benzodiazpines have a role, but must be used in caution in the elderly

50. Summary It’s common to encounter agitation
Must rule out organic causes
Verbal de-escalation and pharmacology are good strategies
Ketamine and IV olanzapine hold promise for the future care of our patients

51. References
Cole JB, Moore JC, Dolan BJ, et al. A Prospective Observational Study of Patients Receiving Intravenous and Intramuscular Olanzapine in the Emergency Department. Annals of Emergency Medicine. 2017;69 (3)
Cole JB, Moore JC, Nystrom PC, et al. A prospective study of ketamine versus haloperidol for severe prehospital agitation. Clin Toxicology 2016;54(7):556–62.
Hilt, RJ, Woodward, TA. Agitation Treatment for Pediatric Emergency Patients. The Journal of American Academic Child Adolescent Psychiatry. 47(2): Feb.
Levine, B. The acutely agitated patient. Christiana health care system. documents/ APNPharmacologyUpdate/Agitation.pdf
Lukens, TW. et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Annals of Emergency Medicine. 47(1): Jan.
Nassisi, D, Korc, B, Hahn, S, et al. The Evaluation and Management of
the Acutely Agitated Elderly Patient. The Mount Sinai Journal of Medicine 2006; 73 (7)
Zeller, S. Project Beta. Best Practices for Evaluation and Treatment of Agitated Patients.

52. Questions/comments