Agitated or combative patient: Difference between revisions

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==Background==
==Background==
* '''Violence may occur without warning'''
*'''Violence may occur without warning'''
* Positive predictors of violence
*Positive predictors of violence
** Male gender
**Male gender
** History of violence
**History of violence
** Substance abuse
**Substance abuse
** Psychiatric illness
**Psychiatric illness
*** Schizophrenia, Psychotic depression
***[[Schizophrenia]], Psychotic [[depression]]
*** Personality disorders - lack remorse for violent actions
***[[Personality disorders]] - (e.g. antisocial personality disorder patients may lack remorse for violent actions_
*** Mania - unpredictable because of emotional lability
***[[bipolar disorder|Mania]] - unpredictable because of emotional lability
** Increased '''waiting''' duration (for evaluation, results, treatment, etc)
**Increased waiting duration (for evaluation, results, treatment, etc)
* Factors that '''do not''' predict violence
*Factors that '''do not''' predict violence
** Ethnicity, diagnosis, age, marital status, and education
**Ethnicity, diagnosis, age, marital status, and education
** Evaluation by psychiatrist, '''regardless of experience'''
**Evaluation by psychiatrist, regardless of experience


==Clinical Features==
==Clinical Features==
* Escalation behaviors include progression through:
*Escalation behaviors may include progression through:
** anger, resistance, aggression, hostility, argumentativeness, violence
**Anger, resistance, aggression, hostility, argumentativeness, violence


==Differential Diagnosis==
==Differential Diagnosis==
* FIND ME (functional, infectious, neurologic, drugs, metabolic, endocrine)
''FIND ME (functional, infectious, neurologic, drugs, metabolic, endocrine)''
* Psychiatric
*Psychiatric
** Schizophrenia
**[[Schizophrenia]], paranoid ideation, catatonic excitement
** Paranoid ideation
**[[Bipolar disorder|Mania]]
** Catatonic excitement
**Personality disorders ([[borderline personality disorder|borderline]], [[antisocial personality disorder|antisocial]])
** Mania
**Delusional [[depression]]
** Personality disorders (Borderline, Antisocial)
**Post-traumatic stress disorder
** Delusional depression
**Decompensating obsessive-compulsive disorders
** Post-traumatic stress disorder
*Situational Frustration
** Decompensating obsessive-compulsive disorders
**Mutual hostility
** Homosexual panic
**Miscommunication
* Situational Frustration
**Fear of dependence or rejection
** Mutual hostility
**Fear of illness
** Miscommunication
**Guilt about disease process
** Fear of dependence or rejection
*Antisocial Behavior
** Fear of illness
**Violence with no associated medical or psychiatric explanation
** Guilt about disease process
*Organic Diseases
* Antisocial Behavior
**[[Head trauma]]
** Violence with no associated medical or psychiatric explanation
**[[Hypoxia]]
* Organic Diseases
**[[Hypoglycemia]] or [[hyperglycemia]]
** Trauma (head)
**[[Electrolyte abnormality]]
** Hypoxia
**Infection
** Hypoglycemia or Hyperglycemia
***CNS infection (eg, herpes [[encephalitis]])
** Electrolyte abnormality
***[[AIDS]]
** Infection
**Endocrine disorder
*** CNS infection (eg, herpes encephalitis)
***[[Thyrotoxicosis]]
*** AIDS
***[[Hyperparathyroidism]]
** Endocrine disorder
**[[Seizure]] (eg, temporal lobe, limbic)
*** Thyrotoxicosis
**[[CNS tumor]] (limbic system)
*** Hyperparathyroidism
**Autoimmune Disease
** Seizure (eg, temporal lobe, limbic)
***[[Limbic encephalitis]]
** Neoplasm (limbic system)
***[[Multiple sclerosis]]
** Autoimmune Disease
**[[Porphyria]]
*** Limbic encephalitis
**[[Wilson's disease]]
*** Multiple sclerosis
**Huntington’s disease
** Porphyria
**Sleep disorders
** Wilson’s disease
**[[Vitamin deficiencies]] (e.g. folate, B12, niacin, B6)
** Huntington’s disease
**[[Delirium]]
** Sleep disorders
**[[Dementia]]
** Vitamin deficiency
**[[Cerebrovascular accident]]
*** Folate
**Vascular malformation (e.g. [[AVM]])
*** Vitamin B12
**[[Hypothermia]] or [[hyperthermia]]
*** Niacin
**[[Anemia]]
*** Vitamin B6
*Tox
*** [[Wernicke-Korsakoff syndrome]]
**Adverse reaction to prescribed medication
** Delirium
**[[Alcohol]] (intoxication and withdrawal)
** Dementia
**[[Amphetamines]]
** Cerebrovascular accident
**[[Cocaine]]
** Vascular malformation
**[[Sedative/Hypnotics]] (intoxication or withdrawal)
** [[Hypothermia]] or hyperthermia
**[[Phencyclidine]] (PCP)
** Anemia
**[[Lysergic acid diethylamide (LSD)]]
* Drugs
**[[Anticholinergics]]
** Adverse reaction to prescribed medication
**Aromatic [[hydrocarbons]] (eg, glue, paint, gasoline)
** Alcohol (intoxication and withdrawal)
**[[Steroids]]
** Amphetamines
** Cocaine
** Sedative-hypnotics (intoxication or withdrawal)
** Phencyclidine (PCP)
** Lysergic acid diethylamide (LSD)
** Anticholinergics
** Aromatic hydrocarbons (eg, glue, paint, gasoline)
** Steroids


==Evaluation==
==Evaluation==
* '''Screen for acute medical conditions that may contribute to the patient's behavior.'''
*Screen for acute medical conditions that may contribute to the patient's behavior.
** Always obtain:
**Always obtain:
*** Blood glucose
***Blood glucose
*** Vitals, including pulse oximetry
***Vitals, including pulse oximetry
** Consider:
**Consider:
*** Metabolic panel: serum electrolytes, thyroid function
***Metabolic panel: serum electrolytes, thyroid function
*** Toxicology screen and blood alcohol levels
***Toxicology screen and blood alcohol levels
*** Lumbar puncture (CNS infection)
***Ammonia level
*** Aspirin and acetaminophen levels (intentional ingestion)
***Urine analysis
*** Medication levels (sub- vs super-therapeutic)
***[[Lumbar puncture]] (CNS infection)
*** Electrocardiogram (elders, intentional ingestion).
***Aspirin and acetaminophen levels (intentional ingestion)
*** Cranial imaging
***Medication levels (sub- vs super-therapeutic)
*** Electroencephalography
***[[Electrocardiogram]] (elders, intentional ingestion).
* '''Unnecessary diagnostic testing prolongs ED stay and delays definitive psychiatric care.'''
***Cranial imaging
** '''Organic cause unlikely''' → ''may not'' require further workup
***Electroencephalography
*** Younger than 40 years
*Unnecessary diagnostic testing prolongs ED stay and delays definitive psychiatric care.
*** Prior psychiatric history
**Organic cause unlikely → ''may not'' require further workup
*** Normal physical examination
***Younger than 40 years
**** Normal vital signs
***Prior psychiatric history
**** Calm demeanor
***Normal physical examination
**** Normal orientation
****Normal vital signs
**** No physical complaints
****Calm demeanor
** '''Organic cause more likely''' → ''does'' require further workup
****Normal orientation
*** Acute onset of agitated behavior
****No physical complaints
*** Behavior that waxes and wanes over time
**Organic cause more likely → ''does'' require further workup
*** Older than 40 years with new psychiatric symptoms
***Acute onset of agitated behavior
*** Elders (higher risk for delirium)
***Behavior that waxes and wanes over time
*** History of substance abuse (intoxication or withdrawal)
***Older than 40 years with new psychiatric symptoms
*** Persistently abnormal vital signs
***Elders (higher risk for delirium)
*** Clouding of consciousness
***History of substance abuse (intoxication or withdrawal)
*** Focal neurologic findings
***Persistently abnormal vital signs
***Clouding of consciousness
***Focal neurologic findings


==Management==
==Management==


===Risk assessment===
===Risk assessment===
* Screen for weapons and disarm prior to entrance to ED
*Screen for weapons and disarm prior to entrance to ED
* '''Violence may occur without warning'''
*'''Violence may occur without warning'''
* '''Be aware of surroundings'''
*Be aware of surroundings
** Signs of anger, resistance, aggression, hostility, argumentativeness, violence
**Signs of anger, resistance, aggression, hostility, argumentativeness, violence
** Accessibility of door for escape
**Accessibility of door for escape
** Presence of objects that may be used as weapons
**Presence of objects that may be used as weapons


===Verbal management techniques===
===Verbal de-escalation techniques===
* Be honest and straightforward; Ask about violence directly
*Be honest and straightforward; Ask about violence directly
** Suicidal or homicidal ideations and plans
**Suicidal or homicidal ideations and plans
** Possession of weapons
**Possession of weapons
** History of violent behavior
**History of violent behavior
** Current use of intoxicants
**Current use of intoxicants
* Be nonconfrontational, attentive, and receptive
*Be nonconfrontational, attentive, and receptive
** Respond in a calm and soothing tone
**Respond in a calm and soothing tone
* '''Three Fs framework''':
**Express concern/worry about the patient
** I understand how you could '''feel''' that way.
*Three Fs framework:
** Others in that situation have '''felt''' that way, too.
**I understand how you could feel that way.
** Most have '''found''' that _____ helps."
**Others in that situation have felt that way, too.
* '''Avoid argumentation, machismo, and condescension'''
**Most have found that _____ helps."
* '''Do not ''threaten'' ''' to call security — Invites patient to challenge with violence
*Avoid argumentation, machismo, and condescension
* '''Do not ''deceive'' ''' (eg, about estimated wait times) — Invites violence when lie is uncovered
*'''Do not ''threaten'' ''' to call security — Invites patient to challenge with violence
* '''Do not ''command'' ''' to calm down — Invites further escalation
*'''Do not ''deceive'' ''' (eg, about estimated wait times) — Invites violence when lie is uncovered
* '''Do not ''downplay'', ''deny'', or ''ignore'' '''threatening behavior
*'''Do not ''command'' ''' to calm down — Invites further escalation
* '''Do not ''hesitate'' ''' — Leave and call for help if necessary
*'''Do not ''downplay'', ''deny'', or ''ignore'' '''threatening behavior
*'''Do not ''hesitate'' ''' — Leave and call for help if necessary


===Chemical Restraints (Rapid Tranquilization)===
===Chemical Restraints (Rapid Tranquilization)===
* Offer voluntary administration to patient — increased sense of control may calm patient
*Offer voluntary administration to patient — increased sense of control may calm patient
*If need to temporary physical restraint the patient: One arm up, one arm down, tie legs to opposite side of bed. [https://emcrit.org/emcrit/human-bondage-chemical-takedown/ Reference with video]
*Suggested protocol for continued agitation: antipsychotic Q5 min x 2, then ketamine IM
*Suggested protocol for continued agitation: antipsychotic Q5 min x 2, then ketamine IM
**E.g. [[Droperidol]] 10mg (or [[haloperidol]] 5mg) IM Q5 min x 2, then [[ketamine]] 300mg IM
**E.g. [[Droperidol]] 5mg (or [[haloperidol]] 5mg) IM Q5 min x 2, then [[ketamine]] 300mg IM
* Neuroleptics ([[Antipsychotics]])
*[[Ketamine]], at a dose of 4-6 mg/kg IM, achieves sedation in 2-10 minutes. Few medications, if any, reliably achieve effective sedation this quickly following a single dose. <ref> Westafer, Lauren. “Patients with Severe Agitation in the ED.” ACEP NOW, vol. 42, no. 12, https://www.acepnow.com/article/which-sedatives-are-best-for-managing-severe-agitation-in-the-emergency-department/.</ref>.
** Atypical antipsychotics
*Other protocols involve combination therapy<ref>[http://www.emdocs.net/the-art-of-the-ed-takedown/ The Art of the ED Takedown EMDocs]</ref>.
*** Less sedation and [[EPS]] (than typical)
*Neuroleptics ([[Antipsychotics]])
*** Increased mortality in elderly with dementia-related psychosis
**Atypical antipsychotics
*** [[olanzapine]], [[ziprasidone]], and [[aripiprazole]]
***Less sedation and [[EPS]] (than typical)
** Typical antipsychotics (low potency)
***Increased mortality in elderly with dementia-related psychosis
*** Greater sedation, hypotension, anticholinergic effects (than high-potency)
***[[olanzapine]], [[ziprasidone]], and [[aripiprazole]]
*** [[chlorpromazine]] and [[thioridazine]]  
**Typical antipsychotics (low potency)
** Typical antipsychotics (medium potency)
***Greater sedation, hypotension, anticholinergic effects (than high-potency)
*** [[loxapine]] and [[molindone]]
***[[chlorpromazine]] and [[thioridazine]]  
** Typical antipsychotics (high potency)
**Typical antipsychotics (medium potency)
*** Greater [[EPS]] (than low-potency)
***[[loxapine]] and [[molindone]]
*** [[butyrophenones]]: [[haloperidol]] and [[droperidol]]
**Typical antipsychotics (high potency)
** Cautions
***Greater [[EPS]] (than low-potency)
*** [[Neuroleptic malignant syndrome]] &mdash; rare
***[[butyrophenones]]: [[haloperidol]] and [[droperidol]]
*** [[Extrapyramidal symptoms]] &mdash; treat with [[diphenhydramine]] or [[benztropine]]
**Cautions
*** [[QTc prolongation]] and [[torsades de pointes]]
***[[Neuroleptic malignant syndrome]] &mdash; rare
***[[Extrapyramidal symptoms]] &mdash; treat with [[diphenhydramine]] or [[benztropine]]
***[[QTc prolongation]] and [[torsades de pointes]]
*[[Ketamine]]<ref>Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587</ref>
*[[Ketamine]]<ref>Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587</ref>
**4-6mg/kg IM or 1mg/kg IV
**4-6mg/kg IM or 1mg/kg IV
* [[Benzodiazepines]]
*[[Benzodiazepines]]
**''"There is increasing evidence that benzodiazepines alone and in combination with antipsychotics are associated with higher rates of adverse effects.''<ref>Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587</ref>
**''"There is increasing evidence that benzodiazepines alone and in combination with antipsychotics are associated with higher rates of adverse effects.''<ref>Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587</ref>
** [[Lorazepam]] &mdash; Eliminated without active metabolites
**[[Lorazepam]] &mdash; Eliminated without active metabolites
*** Onset: 5-20 min (IV), 15-30 min (IM)
***Onset: 5-20 min (IV), 15-30 min (IM)
*** Duration: 6-8 H
***Duration: 6-8 H
** [[Midazolam]]
**[[Midazolam]]
*** Onset: 15 min (IM)
***Onset: 15 min (IM)
*** Duration: 2 H
***Duration: 2 H
*Typical intramuscular dosing for adult patients:<ref>Klein LR, Driver BE, Miner JR, et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018;72(4):374-385.</ref>
**Haloperidol 5-10mg IM, ziprasidone 20mg IM, olanzapine 10mg IM, and midazolam 5mg IM.
***In order from slowest to quickest time to effect


===Physical restraints===
===Physical restraints===
* '''Not for convenience or punishment'''
*Not for convenience or punishment
* Indications for seclusion or restraint
*Indications for seclusion or restraint
** Imminent danger to self, others, or environment
**Imminent danger to self, others, or environment
** Part of ongoing behavioral treatment
**Part of ongoing behavioral treatment
* Contraindications to seclusion
*Contraindications to seclusion
** Patient is unstable and requires close monitoring
**Patient is unstable and requires close monitoring
** Patient is self-harming (suicidal, self-mutilating, toxin ingestion)
**Patient is self-harming (suicidal, self-mutilating, toxin ingestion)
* Caveats
*Caveats
** Allow for adequate chest expansion for ventilation
**Allow for adequate chest expansion for ventilation
** Sudden death has occurred in the prone or hobble position
**Sudden death has occurred in the prone or hobble position


==Disposition==
==Disposition==
* Admit or commit when...
===Admit===
** Harm to self
*Admit or commit when...
** Harm to others
**Harm to self
** Cannot care for self
**Harm to others
** Uncooperative, refusing to answer questions
**Cannot care for self
** Intoxicated
**Uncooperative, refusing to answer questions
** Psychotic
**Intoxicated
** Organic brain syndrome
**Psychotic
* Consider discharge when...
**Organic brain syndrome
** Temporary organic syndrome has concluded (eg, intoxication)
** No other significant problem requiring acute intervention
** Patient is in control and no longer violent


===Discharge===
*Consider discharge when...
**Temporary organic syndrome has concluded (eg, intoxication)
**No other significant problem requiring acute intervention
**Patient is in control and no longer violent
<div style="display:none">
<!-- SMW MedicationDose annotations for chemical restraint medications -->
{{MedicationDose|drug=Droperidol|dose=5 mg IM q5min x2|route=IM|context=1st line antipsychotic for acute agitation|indication=Agitated or combative patient|notes=Monitor QTc}}
{{MedicationDose|drug=Haloperidol|dose=5-10 mg IM|route=IM|context=Antipsychotic for acute agitation|indication=Agitated or combative patient|notes=Risk of EPS, NMS, QTc prolongation}}
{{MedicationDose|drug=Ketamine|dose=4-6 mg/kg IM or 1 mg/kg IV|route=IM/IV|context=Rescue sedation for severe agitation|indication=Agitated or combative patient|onset=2-10 min (IM)|notes=Achieves sedation faster than most other agents}}
{{MedicationDose|drug=Midazolam|dose=5 mg IM|route=IM|context=Benzodiazepine for agitation|indication=Agitated or combative patient|onset=15 min (IM)|duration=2 hours|notes=Increasing evidence of higher adverse effects with benzodiazepines}}
{{MedicationDose|drug=Lorazepam|dose=2 mg IV/IM|route=IV/IM|context=Benzodiazepine for agitation|indication=Agitated or combative patient|onset=5-20 min (IV), 15-30 min (IM)|duration=6-8 hours|notes=No active metabolites}}
{{MedicationDose|drug=Ziprasidone|dose=20 mg IM|route=IM|context=Atypical antipsychotic for agitation|indication=Agitated or combative patient}}
{{MedicationDose|drug=Olanzapine|dose=10 mg IM|route=IM|context=Atypical antipsychotic for agitation|indication=Agitated or combative patient|notes=Increased mortality in elderly with dementia-related psychosis}}
</div>
==See Also==
==See Also==
* [[Altered mental status]]
* [[Excited delirium]]
*[[Sedation (main)]]
*[[Sedation (main)]]
*[[Altered mental status]]
*[[Excited delirium]]
*[[Acute psychosis]]


==External Links==
==External Links==
Line 211: Line 227:


==Further Reading==
==Further Reading==
* Heiner JD and Moore GP.  The Combative Patient.  In: Marx J, Walls R, Hockberger R, eds.  Rosen's Emergency Medicine: Concepts and Clinical Practice.  8th ed.  Philadelphia, PA: Elsevier/Saunders; 2014: 188: 2414-2421.
*Heiner JD and Moore GP.  The Combative Patient.  In: Marx J, Walls R, Hockberger R, eds.  Rosen's Emergency Medicine: Concepts and Clinical Practice.  8th ed.  Philadelphia, PA: Elsevier/Saunders; 2014: 188: 2414-2421.
* Moore GP, Pfaff JA.  [https://www.uptodate.com/contents/assessment-and-emergency-management-of-the-acutely-agitated-or-violent-adult Assessment and emergency management of the acutely agitated or violent adult].  UpToDate.  Feb 16, 2017.
*Moore GP, Pfaff JA.  [https://www.uptodate.com/contents/assessment-and-emergency-management-of-the-acutely-agitated-or-violent-adult Assessment and emergency management of the acutely agitated or violent adult].  UpToDate.  Feb 16, 2017.


==References==
==References==

Latest revision as of 09:37, 22 March 2026

Background

  • Violence may occur without warning
  • Positive predictors of violence
    • Male gender
    • History of violence
    • Substance abuse
    • Psychiatric illness
    • Increased waiting duration (for evaluation, results, treatment, etc)
  • Factors that do not predict violence
    • Ethnicity, diagnosis, age, marital status, and education
    • Evaluation by psychiatrist, regardless of experience

Clinical Features

  • Escalation behaviors may include progression through:
    • Anger, resistance, aggression, hostility, argumentativeness, violence

Differential Diagnosis

FIND ME (functional, infectious, neurologic, drugs, metabolic, endocrine)

Evaluation

  • Screen for acute medical conditions that may contribute to the patient's behavior.
    • Always obtain:
      • Blood glucose
      • Vitals, including pulse oximetry
    • Consider:
      • Metabolic panel: serum electrolytes, thyroid function
      • Toxicology screen and blood alcohol levels
      • Ammonia level
      • Urine analysis
      • Lumbar puncture (CNS infection)
      • Aspirin and acetaminophen levels (intentional ingestion)
      • Medication levels (sub- vs super-therapeutic)
      • Electrocardiogram (elders, intentional ingestion).
      • Cranial imaging
      • Electroencephalography
  • Unnecessary diagnostic testing prolongs ED stay and delays definitive psychiatric care.
    • Organic cause unlikely → may not require further workup
      • Younger than 40 years
      • Prior psychiatric history
      • Normal physical examination
        • Normal vital signs
        • Calm demeanor
        • Normal orientation
        • No physical complaints
    • Organic cause more likely → does require further workup
      • Acute onset of agitated behavior
      • Behavior that waxes and wanes over time
      • Older than 40 years with new psychiatric symptoms
      • Elders (higher risk for delirium)
      • History of substance abuse (intoxication or withdrawal)
      • Persistently abnormal vital signs
      • Clouding of consciousness
      • Focal neurologic findings

Management

Risk assessment

  • Screen for weapons and disarm prior to entrance to ED
  • Violence may occur without warning
  • Be aware of surroundings
    • Signs of anger, resistance, aggression, hostility, argumentativeness, violence
    • Accessibility of door for escape
    • Presence of objects that may be used as weapons

Verbal de-escalation techniques

  • Be honest and straightforward; Ask about violence directly
    • Suicidal or homicidal ideations and plans
    • Possession of weapons
    • History of violent behavior
    • Current use of intoxicants
  • Be nonconfrontational, attentive, and receptive
    • Respond in a calm and soothing tone
    • Express concern/worry about the patient
  • Three Fs framework:
    • I understand how you could feel that way.
    • Others in that situation have felt that way, too.
    • Most have found that _____ helps."
  • Avoid argumentation, machismo, and condescension
  • Do not threaten to call security — Invites patient to challenge with violence
  • Do not deceive (eg, about estimated wait times) — Invites violence when lie is uncovered
  • Do not command to calm down — Invites further escalation
  • Do not downplay, deny, or ignore threatening behavior
  • Do not hesitate — Leave and call for help if necessary

Chemical Restraints (Rapid Tranquilization)

  • Offer voluntary administration to patient — increased sense of control may calm patient
  • If need to temporary physical restraint the patient: One arm up, one arm down, tie legs to opposite side of bed. Reference with video
  • Suggested protocol for continued agitation: antipsychotic Q5 min x 2, then ketamine IM
  • Ketamine, at a dose of 4-6 mg/kg IM, achieves sedation in 2-10 minutes. Few medications, if any, reliably achieve effective sedation this quickly following a single dose. [1].
  • Other protocols involve combination therapy[2].
  • Neuroleptics (Antipsychotics)
  • Ketamine[3]
    • 4-6mg/kg IM or 1mg/kg IV
  • Benzodiazepines
    • "There is increasing evidence that benzodiazepines alone and in combination with antipsychotics are associated with higher rates of adverse effects.[4]
    • Lorazepam — Eliminated without active metabolites
      • Onset: 5-20 min (IV), 15-30 min (IM)
      • Duration: 6-8 H
    • Midazolam
      • Onset: 15 min (IM)
      • Duration: 2 H
  • Typical intramuscular dosing for adult patients:[5]
    • Haloperidol 5-10mg IM, ziprasidone 20mg IM, olanzapine 10mg IM, and midazolam 5mg IM.
      • In order from slowest to quickest time to effect

Physical restraints

  • Not for convenience or punishment
  • Indications for seclusion or restraint
    • Imminent danger to self, others, or environment
    • Part of ongoing behavioral treatment
  • Contraindications to seclusion
    • Patient is unstable and requires close monitoring
    • Patient is self-harming (suicidal, self-mutilating, toxin ingestion)
  • Caveats
    • Allow for adequate chest expansion for ventilation
    • Sudden death has occurred in the prone or hobble position

Disposition

Admit

  • Admit or commit when...
    • Harm to self
    • Harm to others
    • Cannot care for self
    • Uncooperative, refusing to answer questions
    • Intoxicated
    • Psychotic
    • Organic brain syndrome

Discharge

  • Consider discharge when...
    • Temporary organic syndrome has concluded (eg, intoxication)
    • No other significant problem requiring acute intervention
    • Patient is in control and no longer violent


Droperidol 5 mg IM q5min x2 IM — Monitor QTc Haloperidol 5-10 mg IM IM — Risk of EPS, NMS, QTc prolongation Ketamine 4-6 mg/kg IM or 1 mg/kg IV IM/IV (onset 2-10 min (IM)) — Achieves sedation faster than most other agents Midazolam 5 mg IM IM (onset 15 min (IM), duration 2 hours) — Increasing evidence of higher adverse effects with benzodiazepines Lorazepam 2 mg IV/IM IV/IM (onset 5-20 min (IV), 15-30 min (IM), duration 6-8 hours) — No active metabolites Ziprasidone 20 mg IM IM Olanzapine 10 mg IM IM — Increased mortality in elderly with dementia-related psychosis

See Also

External Links

Further Reading

References

  1. ↑ Westafer, Lauren. “Patients with Severe Agitation in the ED.” ACEP NOW, vol. 42, no. 12, https://www.acepnow.com/article/which-sedatives-are-best-for-managing-severe-agitation-in-the-emergency-department/.
  2. ↑ The Art of the ED Takedown EMDocs
  3. ↑ Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587
  4. ↑ Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587
  5. ↑ Klein LR, Driver BE, Miner JR, et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018;72(4):374-385.
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