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.
One option is to avoid the use of physical restraints and instead hold the patient down by security for the few minutes it takes for the calming medications to take effect. The other option is to place the physical restraints on the patient, immediately administer intramuscular (IM) calming medications, and release the restraints as soon as the patient is calm. Physical restraints should always be followed by immediate sedation.
When used properly, physical restraints can be quite safe.5 However, improper use can be lethal. In one study, 26 deaths were presumed to be the direct result of improper physical restraints.6 Avoid covering the agitated patient’s mouth and/or nose with a gloved hand. This can lead to asphyxia, metabolic acidosis, and death. Use an oxygen mask to prevent the patient from spitting on staff. This may also serve to improve oxygenation. With the patient in the supine position with about 30 degrees head elevation, use four-point restraints tied to the bed frame (rather than the rails), with one arm above the head and the other below the waist.
Step 4: Chemical Restraint or Sedation
The goal of calming medications is to enable rapid stabilization of the acutely agitated patient and to enable the expeditious search for potential life-threatening diagnoses. The choice of route depends on how agitated your patient is. For cooperative mildly agitated patients, offer oral or sublingual medications first. For uncooperative moderately and severely agitated patients, the safest option is to start with IM medications.
Calming medication options include ketamine, benzodiazepines, and antipsychotics.
Whenever possible, tailor the therapy to the underlying diagnosis (eg, psychotic psychiatric disorder, alcohol withdrawal, drug intoxication, etc.). While the evidence for one regimen over another is lacking, current evidence-based recommendations are summarized in Table 1.
IM midazolam is the best benzodiazepine option in moderately to severely agitated patients as it is quickly and reliably absorbed. In alcohol-intoxicated patients, beware of respiratory depression with benzodiazepines and place them on a cardiac monitor, ideally with end-tidal CO2 monitoring for early detection of respiratory depression.
Haloperidol should be considered an adjunct to benzodiazepines for moderate and severe agitation and may be appropriate as monotherapy in moderately agitated intoxicated patients who cannot be placed on a monitor when resources are limited.7–9 Be aware that haloperidol has a longer half-life than midazolam, which can result in the patient staying in your emergency department for much longer than would be necessary otherwise. Although haloperidol prolongs the QTc, this effect is very unlikely to be clinically consequential at the doses typically used for emergency agitation. Nonetheless, caution is advised in patients who are already taking multiple QTc-prolonging agents. Consider obtaining a baseline ECG first in these higher-risk patients.
Ketamine is an N-methyl-D-aspartate receptor antagonist, providing rapid sedation and analgesia. Of the available options, its time to sedation is the fastest, usually less than five minutes with appropriate dosing. Current evidence for the effectiveness and safety of ketamine in calming the severely agitated patient is promising but not definitive.11–13
Step 5: Treating Immediate Life Threats and Pursuing Underlying Diagnosis as Soon as Calming Medications Take Effect
For the mildly to moderately agitated patient, corroborating the history with a head-to-toe physical exam with the patient completely disrobed is essential. Consider a broad differential diagnosis, including space-occupying central nervous system lesions as well as toxicological, psychiatric, traumatic, and metabolic causes.
For the severely agitated patient, it is important to be organized in your approach, which can be divided into the first few minutes, the next few minutes, and the next hour.
In the first few minutes, place the patient in a resuscitation room and apply cardiorespiratory monitoring, capnography, and oximetry. Initiate one to two large-bore peripheral IVs and assess for and start to treat the four Hs: hypoxia, hyperthermia, hypovolemia, and hypoglycemia. If a definitive airway is required, consider delayed sequence rather than rapid sequence intubation, including hyperventilation and sodium bicarbonate in the peri-intubation period as the patient may be severely acidotic.14,15 In the next few minutes, obtain electrolytes and blood gas and treat for hyperkalemia and acidemia. Consider a head CT scan. In the next hour, consider primary diagnoses such as sepsis, neuroleptic malignant syndrome, thyrotoxicosis, and meningitis/encephalitis. In addition, it is important to assess for consequences of agitation (eg, rhabdomyolysis and traumatic injuries).
Having a simple approach to the agitated patient in the emergency department will not only buffer your cortisol levels but also give you the tools you need to safely and efficiently uncover and manage a life-threatening diagnosis.
Special thanks to Dr. Margaret Thompson and Dr. Reuben Strayer, the guest experts on the podcast from which this column was inspired.
- Gonin P, Beysard N, Yersin B, et al. Excited delirium: a systematic review. Acad Emerg Med. 2018;25(5):552-565.
- Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25.
- Windover AK, Boissy A, Rice TW, et al. The REDE model of healthcare communication: optimizing relationship as a therapeutic agent. J Patient Exp. 2014;1(1):8-13.
- Annas GJ. The last resort—the use of physical restraints in medical emergencies. N Engl J Med. 1999;341(18):1408-1412.
- Zun LS. A prospective study of the complication rate of use of patient restraint in the emergency department. J Emerg Med. 2003;24(2):119-124.
- Berzlanovich AM, Schöpfer J, Keil W. Deaths due to physical restraint. Dtsch Arztebl Int. 2012;109(3):27-32.
- Nobay F, Simon BC, Levitt MA, et al. A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Acad Emerg Med. 2004;11(7):744-749.
- Isenberg DL, Jacobs D. Prehospital Agitation and Sedation Trial (PhAST): a randomized control trial of intramuscular haloperidol versus intramuscular midazolam for the sedation of the agitated or violent patient in the prehospital environment. Prehosp Disaster Med. 2015;30(5):491-495.
- Kroczak V, Kirby A, Gunja N. Chemical agents for the sedation of agitated patients in the ED: a systematic review. Am J Emerg Med. 2016;34(12):2426-2431.
- Battaglia J, Moss S, Rush J, et al. Haloperidol, lorazepam, or both for psychotic agitation? A multicenter, prospective, double-blind, emergency department study. Am J Emerg Med. 1997;15(4):335-340.
- Cole JB, Moore JC, Nystrom PC, et al. A prospective study of ketamine versus haloperidol for severe prehospital agitation. Clin Toxicol (Phila). 2016;54(7):556-562.
- Riddell J, Tran A, Bengiamin R, et al. Ketamine as a first-line treatment for severely agitated emergency department patients. Am J Emerg Med. 2017;35(7):1000-1004.
- Isbister GK, Calver LA, Downes MA, et al. Ketamine as rescue treatment for difficult-to-sedate severe acute behavioral disturbance in the emergency department. Ann Emerg Med. 2016;67(5):581-587.
- Weingart SD, Trueger NS, Wong N, et al. Delayed sequence intubation: a prospective observational study. Ann Emerg Med. 2015;65(4):349-355.
- Forsythe SM, Schmidt GA. Sodium bicarbonate for the treatment of lactic acidosis. Chest. 2000;117(1):260-267.
- Currier GW, Chou JC, Feifel D, et al. Acute treatment of psychotic agitation: a randomized comparison of oral treatment with risperidone and lorazepam versus intramuscular treatment with haloperidol and lorazepam. J Clin Psychiatry. 2004;65(3):386‐394.