The Acutely Agitated Adult ED Patient

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Rachel Rafeq
Emergency medicine pharmacist and toxicology enthusiast. Trained in medication safety and I apply that to everything. I love photography and world schooling my kids.

The Pre-brief

What do you take into consideration when you’re presented with an acutely agitated adult? Do you have a drug of choice? Or perhaps a go-to cocktail? While most of the time these patients present to the ED and require immediate decision making, there may be an opportunity to identify etiology, comorbidities, and some medical history

DETERMINE GOALS

  1. Calm the patient 
  2. Minimize dangerous and aggressive behavior 
  3. Expedite treatment of the patient’s underlying condition 

IDENTIFY RELEVANT PATIENT CHARACTERISTICS

  1. Renal and hepatic function 
  2. Age (i.e. elderly, pregnant, etc.) 
  3. Source of agitation (drug induced vs psychiatric) 

EVALUATE ROUTE OF ADMINISTRATION BENEFIT VS RISK

  1. In scenarios where patients do not require immediate therapeutic effect, oral medications are considered first line when possible as they are less interventional to the patient. Oral solutions and dissolvable tablets are preferred to prevent diversion or “cheeking”.  
  2. In acute scenarios where oral is not practical and the patient does not have an intravenous line in place, use the intramuscular route of administration. 
  3. Intravenous route is generally the least preferred option as it is associated with greater risk of adverse events inclusive of dystonia, cardiovascular or respiratory compromise. 

REVIEW AND DECIDE ON YOUR MEDICATION(S) BASED ON CHARACTERISTICS

References

  1. Baker SN. Management of acute agitation in the emergency department. Adv Emerg Nurs J. 2012;34(4):306-320. doi:10.1097/TME.0b013e31826f12d6

  2. Lexicomp Online, Pediatric and Neonatal Lexi-Drugs Online, Hudson, Ohio: UpToDate, Inc.; 2013; April 15, 201

  3. Wilson MP, Pepper D, Currier GW, Holloman GH Jr, Feifel D. The psychopharmacology of agitation: consensus statement of the American association for emergency psychiatry project Beta psychopharmacology workgroup. West J Emerg Med. 2012; 13(1):26-34. doi:10.5811/westjem.2011.9.6866

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