II. Management: General Approach in All Cases
- See Agitated Delirium
- See Calming the Agitated Patient
- See Physical Restraint
- Isolate patient with a safe room (with minimal stimulation)
- Be prepared with strong, large, burly security guards at the ready in case of dangerous Agitation
- Make use of facility security, and police as needed
- At least 5 responders should be present if patient requires restraint
- Remove all unnnecessary equipment from the room
- Remove all items that could be used as weapons
- Staff should maintain a safe distance from patient until patient contained or adequate help available
- Maintain closest access to door for safe exit
- Be prepared with strong, large, burly security guards at the ready in case of dangerous Agitation
- Consider alternatives to sedation or restraints (see Verbal Deescalation below)
- Approach Agitated Patients with plans for each of three presentations (see below)
- Agitated but cooperative
- Disruptive, but not dangerous
- Agitated Delirium
III. Management: Verbal De-escalation approach (for agitated, but non-dangerous patients)
- One person initiates de-escalation
- Maintain a safe distance for both patient and provider (2 arms lengths)
- Stand with hands visible and at an angle to patient (less confrontational)
- Introduce yourself and call the patient by their preferred name
- Maintain a calm voice and ask open-ended questions
- Speak in clear, concise sentences and use simple vocabulary
- Tell the patient you wish to help them
- Agree with the patient when possible
- Listen patiently and approach with kind demeanor
- Avoid a confrontational, demeaning, coersive approach
- Do not threaten the patient (e.g. with restraints)
- Set clear limits of what behaviors will not be tolerated (e.g. assault)
- Tell the patient that their behavior is frightening to the staff and others
IV. Management: Agitated but cooperative patients (Agitation in Dementia, or drunk teen)
- Assign a volunteer to talk to the patient and distract them
- Provide a calm, quieter, comfortable setting with dimmed lights to help de-escalate Agitation
- Offer food, drink, warm blanket, phone call and other comforts to those able to reason
- Offer Nicotine Replacement as needed
- Benzodiazepines for Alcohol Withdrawal Protocol or anxiety
- Apologize for delays (in some cases, days for boarding psychiatric patients)
- Express empathy and compassion
V. Management: Disruptive patients who are not dangerous (agitated drunk, acute Psychosis)
- See Sedation of the Violent Patient
- Have staff available in case of escalation and need for Physical Restraint
- Consider non-medication options used above for cooperative patients
- Common calming agents (adult doses), primarily if concurrent Psychosis (see descriptions below)
- Midazolam 5 mg IM
- Olanzapine (Zyprexa) 10 mg ODT or IM
- Ziprasidone (Geodon) 10-20 mg IM
- Risperidone 2 mg orally
- Haldol 5 mg with Midazolam 2 mg and Benadryl 25 mg IM (may be repeated once in 30 minutes)
- Alcohol Withdrawal (B52)
- Droperidol 5 mg with Midazolam 2 mg IM (and may be repeated once in 3-5 minutes)
VI. Management: Dangerously Combative Patients or Agitated Delirium
- See Agitated Delirium
-
Physical Restraint allows access to patient for IM Injection
- Requires at least 5 strong responders (one for each limb and one for head)
- Consider applying an oxygen mask at face to block spit and supply oxygen
- Intramuscular Chemical Restraint
- See Chemical Restraint
- Ketamine 2 mg IV or 5 mg IM
- Allows for Intravenous Access and maintained chemical sedation
- Then administer Benzodiazepines after IV Access is available
- Consider Rapid Sequence Induction and intubation for a sick or injured, Agitated Patient
VII. References
- Shanks, Ginsburg and Leaf (2023) Crit Dec Emerg Med 37(9): 4-10
- Strayer in Herbert (2017) EM:Rap 17(6):10-11