Ep 115 Emergency Management of the Agitated Patient

Managing acutely agitated patients can cause anxiety in even the most seasoned emergency doctor. These are high risk patients and they are high risk to you and your ED staff. It’s important to understand that agitation or agitated delirium is a cardinal presentation – not a diagnosis. There is pathology lurking beneath - psychiatric, medical, traumatic and toxicological diagnoses driving these patients and we just won’t know which until we can safely calm them down. An added difficulty is that most of the literature on emergency management of the agitated patient originates from psychiatric papers studying populations that do not necessarily generalize to the ED. In this podcast, Dr. Reuben Strayer and Dr. Margaret Thompson (with a special bonus appearance by guest researcher David Barbic) offer some guiding principles on the safe and effective management of the agitated patient… Podcast production, sound design & editing by Anton Helman, voice editing by Sucheta Sinha Written Summary and blog post by Alex Hart and Shaun Mehta, edited by Anton Helman September, 2018 Cite this podcast as: Helman, A, Strayer, R, Thompson, M. Emergency Management of the Agitated Patient. Emergency Medicine Cases. September, 2018. https://emergencymedicinecases.com/emergency-management-agitated-patient/. Accessed [date] Step 1: Categorize the agitation as mild, moderate or severe Sometimes it is obvious that a patient is extremely agitated and needs to be taken down imminently in order to protect the department staff and the patient themselves. It is helpful though in cases that are less clinically obvious to have an approach to classifying a given patient’s level of agitation in order to better target sedation therapy. Our experts recommend dividing agitated patients into the following 3 categories: Mild: Agitated but cooperative Moderate: Disruptive without danger Severe: Excited delirium and/or dangerous to self and/or staff Many scales exist, including the Sedation Assessment Tool, the Agitated Behavior Scale, the Overt Aggression Scale and the Positive and Negative Syndromes Scale. While these may be useful for research purposes, they are not practical for clinical practice. The Behaviour Activity Rating Scale (BARS) is probably the simplest scale and has good inter-rater reliability. Excited Delirium Syndrome Excited delirium is a life threatening medical emergency. It has several distinctive features (despite it usually being a retrospective diagnosis): * High degree of agitation * Diaphoretic, tachypneic and hyperthermic * Unusual "super-human" strength * Impervious to pain and fatigue * Unable to maintain attention * Incoherent * Severe metabolic acidosis A typical clinical scenario is an obese male in mid-30’s displaying destructive/bizarre behavior leading to call to police in setting of psycho-stimulant drug or alcohol intoxication, with prior psychiatric illness. A subset of patients eventually enter a quiescent period (for less than a minute) where they suddenly stop struggling followed by a respiratory or cardiac arrest. It is often better to err on the side of caution and assume a state of excited delirum rather than dismissing a patients behaviour as the product of a more benign cause (e.g. alcohol intoxication). Learn more about Excited Delirium in Episode 2: Excited Delirium Step 2a: Non-pharmacologic de-escalatation for the mild or moderately agitated patient