We’re all familiar with the spike in cortisol levels we feel when faced with agitated patients in the emergency department. That’s not only because of our hard-wired fight-or-flight response but also because we know that these patients are high-risk to themselves, us, and our ED staff. Agitation or agitated delirium is not a diagnosis but rather a cardinal presentation. Pathology, such as psychiatric, medical, traumatic, and toxicological diagnoses, is lurking beneath; it is imperative that we safely and rapidly calm these patients so we can assess and manage their underlying diagnoses. Here is a five-step approach to managing agitated patients.

Step 1: Categorizing Agitation as Mild, Moderate, or Severe

It is helpful to categorize the level of agitation to better target sedation. The mildly agitated patient is able to converse and is cooperative without being disruptive, while the moderately agitated patient is disruptive to your emergency department without imminent danger to themselves or your ED staff. However, the severely agitated patient is imminently dangerous to all. This last category includes patients with excited delirium syndrome, a true emergency with a very high mortality rate. Excited delirium syndrome has several distinctive features that include unusual superhuman strength, imperviousness to pain, severe metabolic acidosis, inability to maintain attention, and hyperthermia.¹

Step 2a: Nonpharmacologic De-escalation for Mildly or Moderately Agitated Patients

Verbal de-escalation is often effective in the mildly to moderately agitated patient, but it requires a calm and deliberate approach.² Some key elements of effective de-escalation include environmental awareness and self-awareness, such as delegating one person to speak to the agitated patient, ensuring a quiet room, modulating your own emotional and physiologic responses to remain calm, avoiding clenched fists, and having your hands visible.

The SAVE mnemonic outlines scripted responses that may be helpful when faced with a violent patient:³

• Support: “Let’s work together…”
• Acknowledge: “I see this has been hard for you.”
• Validate: “I’d probably be reacting the same way if I was in your shoes.”
• Emotion naming: “You seem upset.”

Step 2b: “Code White” for Moderately and Severely Agitated Patients

Consideration should be given to calling a “code white” for the patient who is an immediate physical threat to you or your staff. A common pitfall is to call a code white as a threat to an uncooperative patient, which can inadvertently increase agitation. Consider calling a concealed code white, directly to security, rather than using an overhead page for the moderately agitated patient who is not posing an imminent danger.

Step 3: Safe and Effective Physical Restraints

There is ongoing debate as to whether physical restraints should be used at all in the management of the agitated patient in the emergency department. If you are going to use physical restraints, the goal should be to use them only as a last resort as a bridge to chemical restraint, which should take no longer than five to 15 minutes with appropriate dosing.⁴ Prolonged use of physical restraints may result in active resistance of restraints, which may lead to electrolyte abnormalities or dysrhythmias and put the patient at further risk for rhabdomyolysis.