Chapter 287: Acute Agitation

INTRODUCTION AND EPIDEMIOLOGY

Patient agitation is frequently encountered in the ED. Although exact numbers are difficult to determine, it is likely that as many as 1.7 million episodes of acute agitation are treated annually in U.S. EDs, with countless more in the prehospital setting.^1–4

Over the past several years, modern expert consensus both inside and outside the field of emergency medicine has called for improved treatment of agitated patients who need emergent treatment.^3,5–8 Broadly, the following best practices have been recommended for optimum care:

• Approach the agitated patient with safety in mind. This safety planning should start even before agitated patients arrive.

• Attempt verbal de-escalation in all patients.

• If agitation persists or worsens, employ a “show of concern.”

• Treat underlying medical problems first.

• Restraints should be used sparingly and only to protect the staff or patient from harm.

• Target medication to the most likely cause of agitation and use oral medicines when possible.

• Use second-generation antipsychotics as first-line agents in most situations not involving alcohol intoxication.

The underlying goal of treatment with every acutely agitated patient is to treat agitation in order to allow performance of a thorough medical evaluation as soon as it safe to do so.^9–11

GENERAL THERAPEUTIC APPROACH

Agitation has been defined by many experts as a “temporary disruption of the typical physician-patient collaboration which has unintended consequences for the staff or other patients.”⁹ This broad definition encompasses more than the typical aggressive or violent patient, because by the time patients are agitated to the point of violence, treatment options are usually limited to restraints and forced medication.

It is important to treat acute agitation early, because nursing staff caring for the patient may be the most vulnerable to untreated agitation. A survey by the Emergency Nurses Association in 2011 indicated that 54.5% of emergency medicine nurses had been physically or verbally abused in the past 7 days.¹² The National Emergency Department Safety Study surveyed staff at 65 U.S. EDs and found that at least 25% of ED staff felt safe at work “sometimes,” “rarely,” or “never.”¹³ In another study conducted at a medium-size university teaching hospital, university police had to respond an average of twice daily to violent incidents.¹⁴

An agitation scale may be helpful, as this provides a uniform way to communicate the level of agitation to other staff.¹⁵ There are currently nearly two dozen potential scales that have been used to rate agitation, but unfortunately, as of yet there has been no head-to-head research that has established the superiority of any of these scales.¹⁶ One scale that has been studied in an Australian ED as part of an ongoing sedation protocol is the Sedation Assessment Tool (Table 287-1).¹⁷