Agitation

Agitation

David Ray Velez, MD

Table of Contents

Evaluation
Management

Evaluation

Interview Safety

  • Safety of Staff is Paramount
  • Call Security if Necessary
  • Patients Should Always Be Disarmed Before Any Interaction
  • No Potentially Dangerous Objects Should Be Available
  • Do Not Let Patient Sit Between the Physician and the Exit

Risk Factors for Violence

  • History of Violence
  • Male Gender
  • Alcohol/Drug Abuse

Signs of Impending Violence

  • Provocative Behavior
  • Angry Demeanor
  • Loud, Aggressive Speech
  • Tense Posturing
  • Frequently Changing Body Position/Pacing
  • Aggressive Acts (Pounding Wall, Throwing Objects)
  • Verbal Threats

Assess for Medical Causes that May Be Contributing

  • Hypoxia
  • Inadequate Pain Control
  • Hypoglycemia
  • Infection
  • Drug Overdose
  • Intracranial Hemorrhage

Management

Delirium Prevention and Treatment

General Approach

  • Initial Nonpharmacologic Attempts are Preferred, Unless Violent or a Danger to Self/Others
  • Immediate Sedation:
    • Start with a Rapid-Onset Antipsychotic or Benzodiazepine
    • Avoid Opioids and Benzodiazepines in the Setting of Delirium as Able – Can Worsen Delirium
    • First Generation (Typical) Antipsychotics Have Risk for QT Prolongation Which Should Be Monitored
  • Continued Sedation:
    • May Require Continued Sedation Once Safety is Achieved
  • Consider Physical Restraints if an Imminent Harm to Self or Others
    • Should Be Considered a Last Resort
    • Restraints May Also Worsen Delirium

Nonpharmacologic Techniques

  • Frequent Reorientation and Reassurance
  • Listen to the Patient and Be Attentive/Receptive
  • Be Honest and Straightforward
  • Avoid Arguing or Condescending
  • Respect Personal Space
  • Use Concise and Simple Language
  • Offer a Chair
  • Use of a Bedside Sitter

Immediate Sedation

  • First Generation (Typical) Antipsychotics:
    • Droperidol: 2.5-5 mg IM/IV
      • More Rapid Onset of Action and Greater Efficacy Over Haloperidol for Acute Psychosis and Agitation
    • Haloperidol (Haldol): 2-5 mg IM/IV
  • Benzodiazepines:
    • Midazolam (Versed): 2.5-5 mg IM/IV
      • More Rapid Onset of Action but Shorter Duration than Lorazepam
    • Lorazepam (Ativan): 2-4 mg IM/IV
    • *Combination Therapy (Both Antipsychotics and Benzodiazepines) Achieves More Rapid Sedation
  • Ketamine
    • Bolus: 1-2 mg/kg Over 30-60 Seconds
    • Repeat 0.5-1.0 mg/kg After 5-10 Minutes if Needed

Continued Sedation

  • Antipsychotic Medication:
    • Quetiapine (Seroquel)
    • Valproic Acid (Depakote)
    • Olanzapine (Zyprexa)
    • Risperidone (Risperdal)
    • Haloperidol (Haldol)
  • Continuous IV Sedation:
    • Dexmedetomidine (Precedex)
    • Ketamine