INTRODUCTION AND EPIDEMIOLOGY
EDs are the portal of access to the healthcare system for most patients with acute agitation and acute behavioral or mental health disorders.1 Agitation is one of the most common manifestations of mental health and behavioral disorders, dementia, and intoxication and withdrawal syndromes. The last consensus updates for acute agitation were published in 2006,2 prior to the release of newer therapeutic agents and prior to the recognition of QTc prolongation with acutely administered psychotropics. This review provides a general pharmacotherapeutic approach for acute agitation and acute behavioral emergencies.
GENERAL THERAPEUTIC APPROACH
Try to obtain vital signs, obtain a patient history and perform a physical examination, and obtain baseline laboratory data. Psychosis, mania, withdrawal syndromes, drug intoxication, delirium, or even depression and anxiety can cause psychomotor agitation, aggressive behaviors, or disorientation. Other causes of acute agitation include adverse effects of medications, pain, substance abuse, or worsening of a chronic underlying illness.
The most important goal in the care of the agitated patient is ensuring the safety of the patient and staff involved. Management of the patient's undifferentiated agitation ensures immediate safety and allows a more thorough evaluation for serious acute pathology.
Provide a sitter and try to address patient comfort needs. Decrease external stimuli by placing the patient in a quiet room. Remove potentially dangerous objects from the immediate environment. Use physical restraints if there is imminent harm to healthcare workers, other patients or visitors, or the patient him/herself.1,2,3,4
When considering pharmacologic treatment options, assess the underlying diagnosis, presenting signs and symptoms, and potential risks/benefits of specific agents (Tables 287-1 and 287-2), and determine the proper dose and easiest mode of administration. Because the oral and parenteral routes are equivalent for some agents,5,6,7,8 offer oral agents first, if appropriate and feasible. If repeated dosing is needed, try to wait 1 hour before the next dose to adequately assess patient behavior and medication effect. Generally, all antipsychotics have similar efficacy at comparable dosages and may be used to treat acute agitation.
TABLE 287-1Comparison of Important Adverse Effects of Agents for Acute Agitation |Favorite Table|Download (.pdf) TABLE 287-1 Comparison of Important Adverse Effects of Agents for Acute Agitation
| ||Benzodiazepines ||Typical or First-Generation Antipsychotics ||Atypical or Second-Generation Antipsychotics |
|Somnolence ||++ ||+ ||+ |
|Postural hypotension ||+ ||+/– ||+/– |
|Extrapyramidal symptoms ||– ||++ ||+ |
|Respiratory depression ||+ ||– ||+/– |
|Neuroleptic malignant syndrome ||– ||+ ||+ |
|QTc prolongation/torsades de pointes ||– ||+ ||+ |
|Paradoxical CNS disinhibition ||+ ||– ||– |
TABLE 287-2Considerations When Treating Acute Agitation |Favorite Table|Download (.pdf) TABLE 287-2 Considerations When Treating Acute Agitation
|Subgroup of Patients ||Special Considerations |
Agitation caused by alcohol/substance abuse