Author:

Lee A.Replogle

Signs and Symptoms

A detailed history and physical exam are critical in differentiating between medical and psychiatric causes of agitation

Test Interpretation

The diagnostic work up is directed by the history, physical exam, and underlying suspicion of for a medical etiology of the agitation

Essential Workup

At minimum all patients should have:

• A full set of vital signs
• A complete physical exam, including a detailed neurologic exam and tests of cognition and attention
• Blood glucose testing

Diagnostic Tests & Interpretation

Diagnostic tests should be directed on the basis of the suspicion of a medical etiology for the patient's agitation, and history and physical exam findings

Differential Diagnosis

Agitation may be the presenting symptom of an underlying medical illness, substance abuse or withdrawal, or a psychiatric illness

Prehospital

Prehospital providers frequently encounter agitated or violent patients and should:

• Follow regional protocols regarding physical restraints and chemical sedation
• Provide prenotification when transporting an agitated or violent patient so that the receiving hospital can mobilize necessary resources
• Obtain a fingerstick glucose if feasible

Initial Stabilization/Therapy

• Airway, Breathing, Circulation, Disability, and Exposure (ABCDE)
• Treat life-threatening medical/traumatic conditions as appropriate
• Severely agitated patients may become violent:
  • Patients should change into hospital gowns and be searched for weapons
  • Physical restraints and parenteral chemical sedation should be used when necessary to ensure safety of patient(s) and staff

ED Treatment/Procedures

When a medical etiology is suspected or diagnosed:

• Treatment should be directed at underlying cause

When a psychiatric etiology is suspected or diagnosed:

• Emergency psychiatric referral is indicated

Management of agitation:

• Verbal de-escalation techniques are first line for mild or moderate agitation
  • Consider the “Ten Steps” for verbal de-escalation:
    • Respect personal space
    • Do not be provocative
    • Establish verbal contact
    • Be concise
    • Identify wants and feelings
    • Listen closely to what the patient is saying
    • Agree or agree to disagree
    • Lay down the law and set clear limits
    • Offer choices and optimism
    • Debrief the patient and staff
• Chemical sedation options include:
  • Benzodiazepines:
    • First-line therapy for undifferentiated agitation, alcohol withdrawal
    • Lorazepam or midazolam (shorter half-life)
    • Side effects: Respiratory depression, excessive somnolence, paradoxical disinhibition (rare):
      • Geriatric consideration: May precipitate or worsen delirium in geriatric patients
  • Antipsychotics:
    • First line for patients with psychiatric etiology of agitation/psychosis
    • First generation: Haloperidol or droperidol (shorter half-life)
    • Second generation: Olanzapine, risperidone or ziprasidone (less sedation and fewer instances of extrapyramidal symptoms)
    • Side effects: QTC prolongation and extrapyramidal symptoms:
      • Low dose can be used in delirious geriatric patient when verbal de-escalation is unsuccessful
  • Ketamine:
    • May consider in severely agitated patients when:
      • Antipsychotics and benzodiazepines have failed
      • Excited delirium syndrome is suspected
    • Side effects: Increased oral secretions, vomiting, laryngospasm (rare), hypertension, tachycardia, respiratory depression, emergence phenomenon:
      • Vital signs, mental status, and respiratory status should be closely monitored
      • Lorazepam may be simultaneously administered to prevent emergence phenomenon from ketamine
      • Use in the prehospital setting for severe agitation may be associated with high rates of ED intubation
  • Combination therapy:
    • May produce more rapid sedation than monotherapy
    • Should be considered in highly agitated/violent patient
• Midazolam, droperidol, lorazepam, and haloperidol

Physical restraint use:

• Chemical sedation should be used to facilitate early discontinuation of physical restraints
• Physician and nurses must document use and rationale for usage
• Prolonged use can result in:
  • Hyperthermia
  • Rhabdomyolysis
  • Nerve injury if extremities are kept in same position for prolonged time
  • Excited delirium syndrome

Medication

• Droperidol 2.5-5 mg IV/IM q3h prn
• Haloperidol 2-10 mg IV/IM q3h prn
• Ketamine:
  • IM: 2-4 mg/kg (max 400 mg). Consider starting dose of 2 mg/kg (max 200 mg), repeat prn × 1 in 5 min for a maximum of 4 mg/kg
  • IV: 0.5-1 mg/kg. Consider starting dose of 0.5 mg/kg, repeat prn × 1 after 5 min for a maximum of 1 mg/kg
• Lorazepam 0.5-2 mg IV/IM
• Midazolam:
  • 0.07 mg/kg IM or 1 mg IV slowly q3min up to 5 mg

Disposition

Follow-up Recommendations

Follow-up is determined by the causative medical or psychiatric condition(s)

• Factors suggestive of medical causes include:
  • New onset at age >45
  • Abnormal vital signs
  • Focal neurologic abnormalities
  • Acute onset
  • Visual hallucinations
  • Abnormalities of memory or attention on cognitive testing
  • Trauma with evidence of head injury

Pitfalls:

• Not assessing for underlying medical cause of agitation
• Not undressing patients and searching for weapons
• Inadequate dosing of sedatives/antipsychotics
• Failure to adjust extremity position in restraints to prevent nerve complications
• Inadequate documentation of the need for restraint
• Overmedication of the patient requiring intubation or reversal

• GoninP, BeysardN, YersinB, et al. Excited delirium: A systematic review . Acad Emerg Med. 2018;25(5):552-565.
• LukensTW, WolfSJ, EdlowJA; American College of Emergency Physicians Clinical Policies Subcommittee on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department . Ann Emerg Med. 2006;47:79-99.
• NordstromK, ZunLS, WilsonMP, et al. Medical evaluation and triage of the agitated patient: Consensus statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup . West J Emerg Med. 2012;8:3-10.
• RiddellJ, TranA, BengiaminR, et al. Ketamine as a first-line treatment for severely agitated emergency department patients . Am J Emerg Med. 2017;35:1000-1004.
• VilkeGM, DeBardML, ChanTC, et al. Excited delirium syndrome (EXDS): Defining based on a review of the literature . J Emerg Med. 2012;43:897-905.

See Also (Topic, Algorithm, Electronic Media Element)

• Alcohol Withdrawal
• Poisoning, Toxidromes
• Delirium
• Violence, Management of

ICD9

307.9 Other and unspecified special symptoms or syndromes, not elsewhere classified

ICD10

R45.1 Restlessness and agitation

SNOMED

• 24199005 Feeling agitated (finding)

• 47295007 Psychomotor agitation (finding)