Psychiatric
Emergencies
Evaluation and care of the
Agitated Patient
By Ron Larsen, MD
At the end of this session you
will be able to:
 Identify
common Medical and Psychiatric
causes of agitation
 Provide verbal de-escalation of the
agitated patient
 Provide Psychiatric evaluation of the
agitated patient
 Identify psychopharmacological
treatments for the agitated patient
Agitation in emergency
settings – 1.7 million episodes
annually in the US
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Agitation is an extreme form of arousal
associated with increased verbal and motor
activity.
Agitation can lead to aggressive violent
behaviors - with harm to patients, others,
property - and is a leading cause of hospital
staff injuries
Agitation can result from a myriad of origins,
and its treatment is multifaceted, with
pharmacology playing only one part.
Starting with a case:
 Male
brought in as a John Doe found
wondering in the street by the Boise Police
 Appears to be in mid 40s and disoriented,
belligerent with the police, mildly
disheveled
 That’s all the info you have, so what could
be going on with him and what do you
want to do next?
Develop a broad differential:
 Observe
closely in a safe environment
with support and obtain collateral
information
 VS including O2 Sat and BG
 Obtain Utox, CBC, Chem panel
 PE
 MSE including orientation, memory,
speech and fluctuations in presentation
Conditions that may cause
agitation:
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General medical conditions:
Head trauma
Hypoxia
Metabolic (hyponatremia, hypocalcemia,
hypoglycemia)
Toxic level of medications (psych, anti-seizure)
Seizure (postictal)
Encephalitis, meningitis or other infection
Encephalopathy (liver or renal failure)
Thyroid disease
Environmental toxins
Conditions that may cause
agitation:
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Intoxication/withdrawal
Alcohol
Recreational drugs (cocaine, ecstasy,
ketamine, bath salts, inhalants, meth)
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Psychiatric Disease
Psychotic disorders
Mania
Agitated depression
Anxiety disorders
John Doe’s labs:
 Utox
+ cocaine
 Na: 140 K+:3.9 Mg:2.2 Creat:1.0 BUN:14
ALT:33 AST:49 ALK phos:43
 WBC:10.8 Hct:44
 BP:130/94 HR:108 Temp:37.1
 PE: psychomotor agitated, paranoid
appearing
 How to manage this patient?
Acute cocaine intoxication
 Check
EKG for evidence for MI
 Could be an exacerbation of a primary
psychotic illness such as schizophrenia
 Tx with nothing, benzos, or antipsychotics
depending on level of agitation and
paranoia
 Be aware of behavioral predictors of
violence: Past hx, circumstances,
substance abuse and dependence, ASP
The story evolves:
 When
the RN attempts to do the ECG, the
patient jumps up and screams, “Get
away from me! You are trying to stop my
heart!
Get away from me!”
 When
you enter the room he is standing,
looking at the door like he is getting ready
to bolt
How to de-escalate a patient
 Use
a calm voice
 Sit down with the patient
 Maintain adequate physical distance of
at least 6 feet, equal distance from the
door
 Attempt to establish rapport
 Listen to the patient’s concerns
 Tell the patient what you want to do
When verbal de-escalation is
not enough:
 When
there is risk of imminent harm and
verbal de-escalation has been ineffective
pharmacologic supports or physical
restraints may be needed.
 Substance abuse carries a 30X increase
risk than the general population
 Mental illness carries a 9X greater risk than
the general population
Pharmacologic Support:
Benzodiazepines
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Lorazepam is one of the most useful meds in
an emergency. In the first 24 hours, agitation is
as effectively addressed with lorazepam as
with antipsychotics, even if psychosis is
present
Usual dose is 1-2 MG IM, IV, or PO Q 1-2 hours
Can be additive with other agents, however,
resulting in excessive sedation and respiratory
depression
Pharmacologic Support:
Antipsychotics
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Antipsychotics can be quite effective in reducing
agitation
IM Antipsychotics – Haloperidol 1-5 MG IM Q 1
hour, NTE 20-30 MG/24 hours
PO Antipsychotics – Risperidone 1-2 MG PO, NTE 4
MG /24 hours (also comes in rapid melting tab
called Risperdal M-tab)
- Olanzapine 10-20 MG PO, NTE 20 MG/24 hours
(also comes in a rapid melting wafer called Zydis)
- Haloperidol 1-5 MG PO Q 1-2 hours, NTE 30 MG in
24 hours
Findings that require
immediate Evaluation:
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Symptoms
Loss of memory, disorientation
Severe headache
Extreme muscle stiffness or weakness
Heat intolerance
Psychosis (new onset)
Difficulty breathing
Findings continued:
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Signs
Abnormal vital signs: pulse, BP, or Temp
Overt trauma
One pupil larger than the other
Slurred speech
Incoordination
Seizures
Hemiparesis
Psychiatric Evaluation of the
Agitated patient
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Make visual observations before a direct
patient interview, with attention to verbal and
nonverbal interaction with the examiner
Obtain collateral information while deescalation is in process
Once it is determined that the patient does
not have an acute medical problem, the first
question if whether the patient has a delirium
Psychiatric Evaluation,
First r/o delirium:
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Examine for disorientation, altered level of
awareness, and problems directing, focusing,
or sustaining attention.
Observe for evidence of visual hallucinations
Check for signs of language impairment,
problems naming, or other cognitive deficits
Also consider evidence for a chronic
cognitive impairment that may be a
contributing factor (hx of a brain injury,
developmental disability or dementia)
Psychiatric Evaluation, Next
r/o intoxication or withdrawal
 Cocaine
intoxication with pupillary
dilation, perspiration, vomiting, confusion,
dyskinesias, dystonias, and seizures
 Opiate intoxication with pupillary
constriction and slurred speech
 Alcohol withdrawal associated with
increased BP and pulse, sweating, hand
tremor, anxiety, and transient visual or
tactile hallucinations
Psychiatric Evaluation,
Then consider Psychosis
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Agitation due to a known Psychiatric disorder
can best be assessed with the help of
collateral information
Schizophrenia is usually first diagnosed in the
late teens and early twenties
Mania and Agitated Depression have an
episodic course
Anxiety disorders also have a life-long course
starting in the late teens and early twenties
As a last resort –
Guidelines for the use of
restraints
 The
use of restraints puts patients at risk for
physical injury and death and can be
traumatic even without physical injury.
 Unless the patient is actively violent,
verbal de-escalation should be tried first.
 Medications should be offered and an
effort made to involve the patient in
decisions about medications
Restraint guidelines
 If
the patient is an immediate danger to
self or others, restraints are indicated
 If the restrained patient will engage in a
reasonable dialog, verbal de-escalation
efforts should continue, including getting
the patients input on medication.
 Medication should be administered to
calm a patient who has been placed in
restraints.
Restraints continued
 All
patients in restraints should be
monitored to assess response to
interventions and to prevent
complications from this interventions.
 Treatment should be directed toward
minimizing time in restraints and allowing
the patient to regain control
 Adhere to CMS and TJC standards for
seclusion and restraints
Management of agitation Summary
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Obtain a brief hx and VS (with O2 Sat and BG)
Consider findings that require immediate
evaluation and treatment
Balance evaluation and management of the
patient simultaneously
Whenever possible de-escalate to calmness
with a verbal approach alone
Establish a working diagnosis before instituting
appropriate pharmacologic intervention
Avoid the restraint process if at all possible