Cryto Eth

Which method is the most restrictive for dealing with an aggressive patient who is out of control?

Summary

Agitation is a common, nonspecific symptom of many medical, psychiatric, psychosocial, and substance-related conditions. Initial management should aim to ensure the safety of the patient and staff and identify and treat critical causes of agitation. Once safety measures are initiated, deescalation techniques should be prioritized to help the patient calm down, avoid progression to aggressive and/or violent behavior, and allow a full medical and psychiatric evaluation. Stabilization, treatment of critical illnesses, alleviation of distressing symptoms, prevention of complications, and maintenance of patient dignity are major priorities for care. Calming medications [e.g., sedatives, tranquilizers] and physical restraints should be restricted to the goal of preventing harm to the patient or others if deescalation techniques are ineffective. Diagnostic studies may be required to evaluate for suspected underlying causes or complications. Optimal management requires familiarity with local institutional protocols and, in some cases, the involvement of a behavioral emergency response team.

Definition

Epidemiology

Epidemiological data refers to the US, unless otherwise specified.

Etiology

If there is no known history of psychiatric illness or current symptoms differ from previous presentations of a known psychiatric disease, suspect a medical or substance-related cause. [4][5]

Clinical features

Management

Management recommendations in this article are primarily consistent with the 2012 and 2020 American Academy of Emergency Psychiatrists [AAEP] Best Practices in the Evaluation and Treatment of Agitation [BETA] consensus statements. [2][4][6][7][8]

Be aware of the following when considering whether to treat agitation as a medical issue:

Gather as much information as possible before reaching conclusions about the etiology of agitation and be aware of provider biases, prejudices, and clinical uncertainty.

Patients with agitation may threaten their own safety or those of others. Call for help whenever possible.

Patients with agitation are often vulnerable and/or subject to neglect and abuse. Maintaining patient and provider safety while respecting patient dignity and autonomy can be very challenging and often distressing to all involved. Avoid making rushed decisions.

Patient and staff safety when managing agitated patients [1][3][6]

Follow local security protocols and call for help if patient or staff safety is under threat.

Do not approach patients alone if they have signs of potential for violence and/or multiple risk factors for violent behavior. [3]

Consider the following in patients with suspected medical causes of agitation and/or patients in need of sedation because they are endangering themselves or others.

IV access in agitated patients

Attempt IM sedation prior to IV placement in uncooperative patients. Call for help if agitation is refractory and urgent IV access is still required. Do not attempt IV placement alone.

Airway management in agitated patients

Risk assessment and mitigation

Managing critical causes of agitation

These include etiologies that are rapidly reversible and/or pose an imminent threat to life.

Immediate assessment [2][4][5]

Check vital signs, SpO2, and POC glucose.
For cooperative patients, obtain a brief history and conduct a focused medical exam.
For uncooperative patients, follow the ABCDE approach.

If an immediately life-threatening cause is strongly suspected in an uncooperative patient not responding to deescalation techniques, consider calming medication and, if necessary, physical restraint to enable further evaluation and treatment. [4]

Management of critical causes of agitation

Suggestive findingsImmediate intervention

Hypoxia

Hypercarbia

Hypoglycemia

Hypothermia

Hyperthermia

Shock

Pain

Sepsis

Seizure

Wernicke encephalopathy

Acute urinary retention

↓ SpO2 Dyspnea	Start oxygen therapy. Manage underlying cause of hypoxemic respiratory failure: e.g., pneumonia, acute asthma exacerbation, acute exacerbation of COPD, acute heart failure, CO poisoning.
PaCO2 > 45 mm Hg Dyspnea or hypopnea	Manage underlying cause: e.g., hypercapnic respiratory failure of any cause, substance-related respiratory depression [due to opioid intoxication, severe salicylate toxicity]. Consider mechanical ventilation.
Serum or fingerstick glucose ≤ 70 mg/dL [≤ 3.9 mmol/L]	Give oral glucose or IV dextrose . Evidence of chronic alcohol use and/or poor nutritional status Consider concurrent prophylactic IV thiamine. [16][17][18][19] Higher doses of thiamine are indicated if there is a concern for active Wernicke encephalopathy. See also “Alcoholic ketoacidosis.” See “Treatment of hypoglycemia” for further management details.
Core body temperature < 35.0°C [95.0°F]	Initiate active and/or passive rewarming, as indicated. See “Treatment” in “Hypothermia.”
Elevated body temperature History of heat exposure and/or excessive physical activity Clinical features of drug-induced hyperthermia	Initiate cooling measures. Discontinue potentially offending drugs. See “Treatment” in “Heatstroke” and in “Drug-induced hyperthermia.”
Clinical features of shock History of trauma, bleeding, diarrhea, vomiting, or reduced oral intake Clinical features of underlying cause, e.g., bleeding, clinical signs of hypovolemia signs of sepsis, symptoms of heart failure, or clinical features of pulmonary embolism	Consider IV fluid resuscitation and/or vasopressors. Provide immediate hemodynamic support as needed.
High score on subjective and/or objective pain assessment. See “Pain intensity scale,” “Behavioral pain scale,” and “Critical care pain observation tool.”	Initiate treatment for pain.
History of infectious symptoms ≥ 2 positive SIRS or qSOFA criteria	Check serum lactate and obtain 2 sets of blood cultures. Initiate fluid resuscitation and start antibiotic therapy for sepsis. See “Sepsis management.”
History of seizure disorder Ictal or postictal signs of generalized seizures or complex partial seizures	Initiate pharmacological interruption of ongoing active seizures. See “Management of acute seizures and status epilepticus.” If alcohol withdrawal seizures are suspected, consider treatment for alcohol withdrawal.
Evidence of chronic alcohol use or poor nutritional status Confusion, oculomotor dysfunction, or gait ataxia [20]	Start treatment with full-dose IV thiamine . Consider treatment for alcohol withdrawal.
History of BPH, pelvic surgery, pelvic cancer, urinary stones, or spinal disease/injury Suprapubic pain/discomfort Palpable bladder	Perform urgent bladder catheterization. See “Treatment” in “Urinary retention.”

Diagnostic approach

Obtain the following as soon as safely possible:

Patients with a known psychiatric disorder, with no concerning history or physical exam findings, and whose symptoms are consistent with those of their preexisting psychiatric disease are unlikely to require further diagnostic workup. [2][4][5]

Basic studies

Routine laboratory studies are not recommended. Diagnostic testing should be tailored to each patient based on clinical features, history, and physical examination findings. [21]

Additional studies

Consider a more extensive diagnostic workup in patients with: atypical presentations of known psychiatric illnesses, age > 45 years without prior psychiatric illness, or immune deficiency. [2]

Deescalation

Noncoercive verbal and nonverbal techniques are used to help the patient calm down and cooperate with medical evaluation and treatment. This approach can relieve the symptoms of agitation, decreasing the need for coercive measures and potential for violence and associated harm to patients and staff. [1][6]

Involuntary medications or physical restraint should only be used if a serious attempt at deescalation has failed to ensure the safety of the patient and staff. [6]

Pharmacotherapy

Consider calming medication if there is an insufficient response to nonpharmacological measures, with the overarching goal of relieving distress, treating underlying conditions, and permitting a safe medical and psychiatric evaluation.

Do not administer medication involuntarily unless it is to prevent imminent self-harm or harm to others, or it is mandated by a valid court order. [4][23]

Calming medications of all classes can potentially cause oversedation, hemodynamic instability, and respiratory compromise, especially if used in combination.

Repeated dosing of intramuscular medication can lead to overdose due to less predictable absorption and drug accumulation. Obtain IV access in the agitated patient as soon as safely possible.

For severe agitation consider combining IM typical antipsychotics [e.g., haloperidol] with short-acting IV benzodiazepines [e.g., midazolam] under careful observation. [2]

Benzodiazepines

The following suggested agents and dosages are consistent with the 2012 and 2020 AAEP best practices and expert reviews in the literature. Follow local hospital policy whenever available as dosage recommendations vary widely. [1][2][7][31]

General principles [2][7][31][32][33]

Benzodiazepines are preferred as first-line treatment of agitation of unknown etiology and agitation due to alcohol withdrawal, benzodiazepine withdrawal, or intoxication with CNS stimulants.
Consider dose reduction for at-risk patients: e.g., older age, impaired drug metabolism, cardiac disease, high risk of hypotension.
Consult a clinical pharmacist if the optimal agents and dosages are uncertain.
Midazolam has a faster onset and time to maximal concentration [Tmax], but a shorter duration of action compared to lorazepam.
IV benzodiazepines are typically effective within a few minutes.
PO and IM benzodiazepines have slower and more variable kinetics.
Duration of effect can vary widely depending on patient factors and agitation etiology and severity.

Beware of drug accumulation with frequent dosing; respiratory suppression can occur if benzodiazepines are prescribed at high doses or when used in patients exposed to other CNS depressants [e.g., alcohol]. [7][31]

Lorazepam dosage [2][7][31][32][33]

Mild agitation
- Adults: 1–2 mg PO once; may repeat after 2 hours
- Older adults: 0.25–0.5 mg PO; may repeat after 2 hours
Moderate–severe agitation
- Adults: 1–2 mg IM/IV once; may repeat after 2 hours
- Older adults: 0.25–0.5 mg IM/IV once; may repeat after 2 hours
Maximal dose
- Adults: 10–12 mg/day
- Older adults: 2 mg/day

Midazolam dosage [2][7][31][32][33]

Moderate agitation
- 2.5–5 mg IM once; may repeat after 5–10 minutes
- OR 1–2.5 mg IV once; may repeat after 3–5 minutes
Severe agitation
- 10 mg IM once; may repeat after 5–10 minutes
- OR 2–5 mg IV once; may repeat after 3–5 minutes
Maximal dose
- Not clearly defined
- Respiratory support may be required at doses > 0.15 mg/kg.
Specific considerations: Use in older adults is not well established and parenteral routes may be harmful in these patients. [34]

Antipsychotics

General principles

Consider dose reduction for at-risk patients: e.g., older age, impaired drug metabolism, cardiac disease, high risk of hypotension.
Consult a clinical pharmacist if the optimal agents and dosages are uncertain.
IM antipsychotics and are usually effective within an hour
Compared to IM antipsychotics, PO antipsychotics have a slightly slower onset, but a much slower Tmax.
IV antipsychotics have the fastest effect but may be associated with a higher risk of adverse effects.
The duration of action of antipsychotics in agitated patients is unclear and may be highly variable.

Anticipate common adverse effects of all antipsychotics such as extrapyramidal symptoms [e.g., akathisia, acute dystonia], QTc prolongation, and orthostatic hypotension.

Beware of drug accumulation with frequent dosing; Avoid repeat dosing before the expected time to effect of each drug.

Second-generation antipsychotics [1][2][7][32]

Preferred over first-generation antipsychotics as first-line treatment of agitation due to delirium and psychosis.

Olanzapine dosage

Older adults: 2.5–5 mg PO/IM once; may repeat after 2 hours
Adults with mild agitation: 5 mg PO/SL once; may repeat after 2 hours
Adults with moderate agitation: 5–10 mg PO/SL once; may repeat after 2 hours
Adults with severe agitation: 10 mg IM once; may repeat after 2 hours
Maximal dose
- PO: 20 mg/day
- IM: 30 mg/day
Specific considerations
- Avoid within 1 hour of benzodiazepine intake if possible. [1][2]
- Most significant adverse effects
  - Hypotension
  - Anticholinergic effects
  - QTc prolongation
  - Extrapyramidal symptoms

Risperidone dosage

Mild agitation: 1 mg PO/SL once; may repeat every 4–6 hours
Moderate agitation: 2 mg PO/SL once; may repeat every 4–6 hours
Maximal dose: not clearly established [7]
- Generally should not exceed > 6–10 mg/day
- Older adults: 3 mg/day
Specific considerations
- Often used for psychotic symptoms due to schizophrenia or mania in bipolar disorder
- Most significant adverse effects
  - Orthostatic hypotension
  - Extrapyramidal symptoms

Ziprasidone dosage [35][36]

Severe agitation: 10–20 mg IM once; may repeat after 2–4 hours
Maximal dose: 40 mg/day
Specific considerations
- Avoid in patients with:
  - Cardiac disease
  - QTc prolongation or exposure to other drugs that cause QTc prolongation
- Most significant adverse effect: QTc prolongation. [2]

First-generation antipsychotics [1][2][7][32]

Preferred as first-line treatment of agitation caused by a CNS depressant [e.g., alcohol]
Can be considered as a first-line antipsychotic in combination with a benzodiazepine for treatment of very severe or refractory agitation
Avoid in patients with:
- Cardiac disease
- QTc prolongation and/or exposure to drugs that cause QTc prolongation
- High risk of seizures
Significant adverse effects
- Orthostatic hypotension
- Extrapyramidal symptoms
- QTc prolongation and torsade de pointes
Obtain an ECG before administration or as soon as possible. [1]

Haloperidol dosage

Older adults: 0.25–0.5 mg PO/IM once; may repeat after 0.5–4 hours [2][7]
Adults with mild agitation: 2.5 mg PO once; may repeat after 0.5–4 hours [2][7]
Adults with moderate agitation
- 5 mg PO once; may repeat after 0.5–4 hours
- OR 2.5 mg IM once; may repeat every ≥ 15 minutes until adequate effect, then every 0.5–6 hours
Adults with severe agitation
- 5 mg IM once; may repeat every ≥ 15 minutes until adequate effect, then every 0.5–6 hours
Extreme situations [controversial]: 2–5 mg IV once; consider repeating in 0.5–6 hours [7][37][38][39]
Maximal dose [7]
- PO/IM: 20–30 mg/day
- IV: 10 mg/day
- Older adults: 3 mg/day
Specific considerations
- Keep dosage to the minimum required.
- If IV therapy is needed, ensure continuous cardiac monitoring during and after administration.
- Consider adding a drug to prevent extrapyramidal symptoms, e.g., benztropine, diphenhydramine, lorazepam, or promethazine.

Haloperidol administered intravenously [IV] may be associated with high rates of adverse effects [e.g., extrapyramidal symptoms, QTc prolongation, torsades de pointes] and is likely best reserved for extreme situations. Alternate routes [PO or IM] are generally considered safer. [7][37][38][39]

Droperidol dosage [40][41]

Severe agitation: 5 mg IM or IV once in combination with midazolam [2]
Maximal dose: 10–20 mg/day
Specific considerations
- Faster control of agitation, shorter duration of action, and lower incidence of extrapyramidal symptoms compared to haloperidol [1]
- There is currently an FDA black box warning regarding QTc prolongation, however, this is controversial. [7]

Dissociative anesthetics

Ketamine [1][2][21][28][30]

Consider dose reduction for at-risk patients: e.g., older age, impaired drug metabolism, cardiac disease, high risk of hypotension. Consult a clinical pharmacist if the optimal agents and dosages are uncertain.

Clinical application: rapid short-term control of severe refractory agitation and/or violence. [1][42][43]
Dosage
- 4–5 mg/kg IM once; may repeat once at 2–3 mg/kg IM if no initial effect after 10–25 minutes
- OR 1–2 mg/kg IV once; if no initial effect after 5–10 minutes, may repeat 0.5–1 mg/kg IV once
Pharmacokinetics
- Ketamine is effective within minutes.
- IM ketamine has a comparable onset, but slower Tmax than IV ketamine. [44]
- The duration of action, when used for agitation, is ∼ 20 minutes. [1][42][43]
Specific considerations
- Avoid in patients with:
  - Advanced age
  - Known or suspected schizophrenia
  - Risk of morbidity exacerbated by ketamine-induced increases in blood pressure
- Significant adverse effects
  - Hypertension
  - Tachycardia
  - Emesis
  - Laryngospasm
  - Respiratory failure [45]
- To reduce the risk of respiratory depression, administer IV bolus doses slowly over > 30–60 seconds. [28]

Physical restraints

The following recommendations are consistent with the 2008 Joint Commission standards on restraints and seclusion [and their 2020 revision], the 2008 Centers for Medicare & Medicaid Services [CMS] restraint and seclusion guidelines, the 2012 AAEP BETA consensus statement, and the 2020 American College of Emergency Physicians [ACEP] policy statement on the use of restraints. [8][23][46][47][48]

Physical restraints can cause significant harm, including long-term psychological trauma and death. They should only be considered to enable crucial diagnostics and treatment and/or prevent harm to the patient and others. They should never be used for punishment, discipline, retaliation, or provider convenience! [23][50]

Use calming medications before or immediately after applying restraints to reduce the risk of injury, complications from the patient's efforts to resist restraints, and the negative psychological consequences of restraint and coercion. [2][51]

Preparation

If possible, the treating clinician should avoid actively applying the restraints in order to preserve the clinician-patient relationship. [1]

Approaching the patient

Procedure

Do not restrain patients in the prone position, as this can result in asphyxiation and death. If chest restraints are used, ensure that they do not impede chest expansion and adequate ventilation. [1]

The level of monitoring should be decided based on an individual risk assessment in accordance with local hospital protocols and regional laws.

Always follow regional laws and local hospital protocol. Hospitals are obligated to have specific policies on restraint and seclusion that must be in accordance with regional law, including regulating authority to order restraints, patient monitoring, and circumstances that allow the discontinuation of restraints.

Excited delirium controversy

Excited delirium [or agitated delirium] is recognized by the American College of Emergency Physicians [ACEP] and National Association of Medical Examiners as a medical syndrome characterized by: [55][56][57][58]
- Clinical features such as:
  - Altered mental status
  - Uncontrollable inappropriate or violent behavior
  - Sympathetic hyperarousal
  - Unexpected strength
  - Sudden unexplained death
- Often associated with:
  - Younger age
  - Male gender
  - Sympathomimetic drug use
  - Traumatic encounters with law enforcement
- Complex and poorly defined underlying pathophysiology
- A need for physical restraints and sedative agents [e.g., ketamine, benzodiazepines] administered by health providers
Several authorities, including other medical societies, e.g., the American Psychiatric Association [APA] and American Medical Association [AMA], have questioned its validity based on the following: [59]
- Imprecise definition and poor evidence base [60][61]
- Poorly attributable mortality risk [50]
- The potential for misuse of this label in legal and out-of-hospital contexts [57][62]
- Allegations of bias in the literature [58][63]
See “Tips & Links” for the full report of the AMA's Council of Science and Public Health [CSAPH] on this issue.

Related One-Minute Telegram

Interested in the newest medical research, distilled down to just one minute? Sign up for the One-Minute Telegram in “Tips and links” below.

References

Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
Roppolo LP, Morris DW, Khan F, et al. Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA [Best Practices in the Evaluation and Treatment of Agitation]. J Am Coll Emerg Physicians Open. 2020; 1 [5]: p.898-907. doi: 10.1002/emp2.12138 . | Open in Read by QxMD
Nordstrom K, Zun L, Wilson M, et al. Medical Evaluation and Triage of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup. Western Journal of Emergency Medicine. 2012; 13 [1]: p.3-10. doi: 10.5811/westjem.2011.9.6863 . | Open in Read by QxMD
Wilson M, Nordstrom K, Anderson E, et al. American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations. Western Journal of Emergency Medicine. 2017; 18 [4]: p.640-646. doi: 10.5811/westjem.2017.3.32259 . | Open in Read by QxMD
Nazarian DJ, Broder JS, Thiessen MEW, et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Ann Emerg Med. 2017; 69 [4]: p.480-498. doi: 10.1016/j.annemergmed.2017.01.036 . | Open in Read by QxMD
Merlin M, Carluccio A, Raswant N, DosSantos F, Ohman-Strickland P, Lehrfeld D. Comparison of Prehospital Glucose with or without IV Thiamine. Western Journal of Emergency Medicine. 2011; 13 [5]: p.406-409. doi: 10.5811/westjem.2012.1.6760 . | Open in Read by QxMD
Alvanzo et al.. The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management. Journal of Addiction Medicine. 2020; 14 [3S]: p.1-72. doi: 10.1097/adm.0000000000000668 . | Open in Read by QxMD
Villeneuve E, Gosselin S, Hoffman RS. There is No Contraindication to Emergent Glucose Administration. Ann Emerg Med. 2017; 69 [3]: p.376-377. doi: 10.1016/j.annemergmed.2016.10.021 . | Open in Read by QxMD
Lapoint J, Grock A, Herbert M, Jhun P. In reply: There is No Contraindication to Emergent Glucose Administration. Ann Emerg Med. 2017; 69 [3]: p.377-378. doi: 10.1016/j.annemergmed.2016.10.020 . | Open in Read by QxMD
Sinha S, Kataria A, Kolla BP, Thusius N, Loukianova LL. Wernicke Encephalopathy—Clinical Pearls. Mayo Clinic Proceedings. 2019; 94 [6]: p.1065-1072. doi: 10.1016/j.mayocp.2019.02.018 . | Open in Read by QxMD
Mash DC. Excited Delirium and Sudden Death: A Syndromal Disorder at the Extreme End of the Neuropsychiatric Continuum. Frontiers in Physiology. 2016; 7 . doi: 10.3389/fphys.2016.00435 . | Open in Read by QxMD
Vilke GM, Bozeman WP, Dawes DM, DeMers G, Wilson MP. Excited delirium syndrome [ExDS]: Treatment options and considerations. J Forensic Leg Med. 2012; 19 [3]: p.117-121. doi: 10.1016/j.jflm.2011.12.009 . | Open in Read by QxMD
Gonin P, Beysard N, Yersin B, Carron P. Excited Delirium: A Systematic Review. Academic Emergency Medicine. 2017; 25 [5]: p.552-565. doi: 10.1111/acem.13330 . | Open in Read by QxMD
White Paper Report on Excited Delirium Syndrome. //www.acep.org/globalassets/uploads/uploaded-files/acep/clinical-and-practice-management/ems-and-disaster-preparedness/ems-resources/acep-excited-delirium-white-paper-final-form.pdf. Updated: September 9, 2009. Accessed: May 14, 2021.
Position Statement on Concerns About Use of the Term “Excited Delirium” and Appropriate Medical Management in Out-of-Hospital Contexts. //www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-Use-of-Term-Excited-Delirium.pdf. Updated: December 1, 2020. Accessed: May 14, 2021.
Rimmer A. Excited delirium: what’s the evidence for its use in medicine?. BMJ. 2021 : p.n1156. doi: 10.1136/bmj.n1156 . | Open in Read by QxMD
Grant JR, Southall PE, Mealey J, Scott SR, Fowler DR. Excited Delirium Deaths in Custody. American Journal of Forensic Medicine & Pathology. 2009; 30 [1]: p.1-5. doi: 10.1097/paf.0b013e31818738a0 . | Open in Read by QxMD
Strömmer EMF, Leith W, Zeegers MP, Freeman MD. The role of restraint in fatal excited delirium: a research synthesis and pooled analysis. Forensic Science, Medicine and Pathology. 2020; 16 [4]: p.680-692. doi: 10.1007/s12024-020-00291-8 . | Open in Read by QxMD
Ranson D. Excited delirium syndrome: a political diagnosis?. J Law Med. 2012; 19 [4]: p.667-72.
Mayo K, Byju A. “Excited Delirium:” Diagnostic Contradictions and Structural Racism. ISMMS Journal of Science and Medicine. 2021; 1 [1]. doi: 10.29024/ijsm.32 . | Open in Read by QxMD
Wilson M, Pepper D, Currier G, Holloman G, 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]: p.26-34. doi: 10.5811/westjem.2011.9.6866 . | Open in Read by QxMD
Hui D. Benzodiazepines for agitation in patients with delirium: selecting the right patient, right time, and right indication.. Current opinion in supportive and palliative care. 2018; 12 [4]: p.489-494. doi: 10.1097/SPC.0000000000000395 . | Open in Read by QxMD
Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017; 377 [15]: p.1456-1466. doi: 10.1056/nejmcp1605501 . | Open in Read by QxMD
Clinical Practice Guideline for Postoperative Delirium in Older Adults. //www.archcare.org/sites/default/files/pdf/ags-2014-clinical-practice-guideline-for-postop-delirium-in-older-adults.pdf. Updated: October 10, 2014. Accessed: November 19, 2020.
Bloch F, Karoui I, Boutalha S, Defouilloy C, Dubaele J-M. Tolerability of Midazolam to treat acute agitation in elderly demented patients: A systematic review. J Clin Pharm Ther. 2019; 44 [2]: p.143-147. doi: 10.1111/jcpt.12785 . | Open in Read by QxMD
Page CB, Parker LE, Rashford SJ, Kulawickrama S, Isoardi KZ, Isbister GK. Prospective study of the safety and effectiveness of droperidol in elderly patients for pre‐hospital acute behavioural disturbance. Emergency Medicine Australasia. 2020; 32 [5]: p.731-736. doi: 10.1111/1742-6723.13496 . | Open in Read by QxMD
Perkins J, Ho JD, Vilke GM, DeMers G. American Academy of Emergency Medicine Position Statement: Safety of Droperidol Use in the Emergency Department. J Emerg Med. 2015; 49 [1]: p.91-97. doi: 10.1016/j.jemermed.2014.12.024 . | Open in Read by QxMD
Rais AR, Williams K, Rais T, Singh T, Tamburrino M. Use of intramuscular ziprasidone for the control of acute psychosis or agitation in an inpatient geriatric population: an open-label study.. Psychiatry [Edgmont [Pa. : Township]]. 2010; 7 [1]: p.17-24.
Barak Y, Mazeh D, Plopski I, Baruch Y. Intramuscular Ziprasidone Treatment of Acute Psychotic Agitation in Elderly Patients With Schizophrenia. The American Journal of Geriatric Psychiatry. 2006; 14 [7]: p.629-633. doi: 10.1097/01.jgp.0000216325.42721.99 . | Open in Read by QxMD
Tisdale JE, Chung MK, Campbell KB, et al. Drug-Induced Arrhythmias: A Scientific Statement From the American Heart Association.. Circulation. 2020; 142 [15]: p.e214-e233. doi: 10.1161/CIR.0000000000000905 . | Open in Read by QxMD
Vanneman MW, Madhok J, Weimer JM, Dalia AA. Perioperative implications of the 2020 American Heart Association scientific statement on drug induced arrhythmias—a focused review. J Cardiothorac Vasc Anesth. 2021 . doi: 10.1053/j.jvca.2021.05.008 . | Open in Read by QxMD
Beach SR, Gross AF, Hartney KE, Taylor JB, Rundell JR. Intravenous haloperidol: A systematic review of side effects and recommendations for clinical use. Gen Hosp Psychiatry. 2020; 67 : p.42-50. doi: 10.1016/j.genhosppsych.2020.08.008 . | Open in Read by QxMD
Mo H, Campbell M, Fertel B, et al. Ketamine Safety and Use in the Emergency Department for Pain and Agitation/Delirium: A Health System Experience. West J Emerg Med. 2020; 21 [2]: p.272-281. doi: 10.5811/westjem.2019.10.43067 . | Open in Read by QxMD
Green SM, Roback MG, Kennedy RM, Krauss B. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Ann Emerg Med. 2011; 57 [5]: p.449-461. doi: 10.1016/j.annemergmed.2010.11.030 . | Open in Read by QxMD
Lin J, Figuerado Y, Montgomery A, et al. Efficacy of ketamine for initial control of acute agitation in the emergency department: A randomized study. Am J Emerg Med. 2020 . doi: 10.1016/j.ajem.2020.04.013 . | Open in Read by QxMD
Riddell J, Tran A, Bengiamin R, Hendey GW, Armenian P. Ketamine as a first-line treatment for severely agitated emergency department patients. Am J Emerg Med. 2017; 35 [7]: p.1000-1004. doi: 10.1016/j.ajem.2017.02.026 . | Open in Read by QxMD
Craven R. Ketamine. Anaesthesia. 2007; 62 [s1]: p.48-53. doi: 10.1111/j.1365-2044.2007.05298.x . | Open in Read by QxMD
Mankowitz SL, Regenberg P, Kaldan J, Cole JB. Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis. J Emerg Med. 2018; 55 [5]: p.670-681. doi: 10.1016/j.jemermed.2018.07.017 . | Open in Read by QxMD
Roca RP, Charen B, Boronow J. Ensuring Staff Safety When Treating Potentially Violent Patients. JAMA. 2016; 316 [24]: p.2669. doi: 10.1001/jama.2016.18260 . | Open in Read by QxMD
Richmond J, Berlin J, Fishkind A, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012; 13 [1]: p.17-25. doi: 10.5811/westjem.2011.9.6864 . | Open in Read by QxMD
Knox DK, Holloman GH Jr. Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup. West J Emerg Med. 2012; 13 [1]: p.35-40. doi: 10.5811/westjem.2011.9.6867 . | Open in Read by QxMD
Lachner C, Maniaci MJ, Vadeboncoeur TF, et al. Are pre-existing psychiatric disorders the only reason for involuntary holds in the emergency department?. International journal of emergency medicine. 2020; 13 [1]: p.4. doi: 10.1186/s12245-020-0265-4 . | Open in Read by QxMD
Dawson NL, Lachner C, Vadeboncoeur TF, et al. Violent behavior by emergency department patients with an involuntary hold status.. Am J Emerg Med. 2018; 36 [3]: p.392-395. doi: 10.1016/j.ajem.2017.08.039 . | Open in Read by QxMD
Saya A, Brugnoli C, Piazzi G, et al. Criteria, Procedures, and Future Prospects of Involuntary Treatment in Psychiatry Around the World: A Narrative Review.. Frontiers in psychiatry. 2019; 10 : p.271. doi: 10.3389/fpsyt.2019.00271 . | Open in Read by QxMD
Behnam M, Tillotson RD, Davis SM, Hobbs GR. Violence in the Emergency Department: A National Survey of Emergency Medicine Residents and Attending Physicians. J Emerg Med. 2011; 40 [5]: p.565-579. doi: 10.1016/j.jemermed.2009.11.007 . | Open in Read by QxMD
Merelman A, Perlmutter M, Strayer R. Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine. Western Journal of Emergency Medicine. 2019; 20 [3]: p.466-471. doi: 10.5811/westjem.2019.4.42753 . | Open in Read by QxMD
Luck L, Jackson D, Usher K. STAMP: components of observable behaviour that indicate potential for patient violence in emergency departments. J Adv Nurs. 2007; 59 [1]: p.11-19. doi: 10.1111/j.1365-2648.2007.04308.x . | Open in Read by QxMD
Violence: occupational hazards in hospitals. //www.cdc.gov/niosh/docs/2002-101/default.html. Updated: April 1, 2002. Accessed: March 21, 2021.
Martínez-Raga J, Amore M, Di Sciascio G, et al. 1st International Experts’ Meeting on Agitation: Conclusions Regarding the Current and Ideal Management Paradigm of Agitation. Frontiers in Psychiatry. 2018; 9 . doi: 10.3389/fpsyt.2018.00054 . | Open in Read by QxMD
Hospitals-restraints/seclusion interpretive guidelines & update state operations manual [SOM]. //www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/SCLetter08-18.pdf. Updated: April 11, 2008. Accessed: March 16, 2021.
Nashef L, So EL, Ryvlin P, Tomson T. Unifying the definitions of sudden unexpected death in epilepsy. Epilepsia. 2011; 53 [2]: p.227-233. doi: 10.1111/j.1528-1167.2011.03358.x . | Open in Read by QxMD
Connors NJ, Alsakha A, Larocque A, Hoffman RS, Landry T, Gosselin S. Antipsychotics for the treatment of sympathomimetic toxicity: A systematic review. Am J Emerg Med. 2019; 37 [10]: p.1880-1890. doi: 10.1016/j.ajem.2019.01.001 . | Open in Read by QxMD
Richards JR, Derlet RW. Another dogma dispelled? Antipsychotic treatment of sympathomimetic toxicity. Am J Emerg Med. 2019; 37 [12]: p.2256-2257. doi: 10.1016/j.ajem.2019.05.013 . | Open in Read by QxMD
Richards JR, Albertson TE, Derlet RW, Lange RA, Olson KR, Horowitz BZ. Treatment of toxicity from amphetamines, related derivatives, and analogues: A systematic clinical review. Drug Alcohol Depend. 2015; 150 : p.1-13. doi: 10.1016/j.drugalcdep.2015.01.040 . | Open in Read by QxMD
Beck K, Hindley G, Borgan F, et al. Association of Ketamine With Psychiatric Symptoms and Implications for Its Therapeutic Use and for Understanding Schizophrenia. JAMA Network Open. 2020; 3 [5]: p.e204693. doi: 10.1001/jamanetworkopen.2020.4693 . | Open in Read by QxMD
Joint commission standards on restraint and seclusion. //www.crisisprevention.com/CPI/media/Media/Resources/alignments/Joint-Commission-Restraint-Seclusion-Alignment-2011.pdf. Updated: January 1, 2009. Accessed: March 16, 2021.
Policy statement on use of patient restraints.
Prepublication Requirements - EP Revisions Related to CMS Final Rules.
Masters KJ. Physical Restraint: A Historical Review and Current Practice. Psychiatr Ann. 2017; 47 [1]: p.52-55. doi: 10.3928/00485713-20161129-01 . | Open in Read by QxMD
Wong AH, Ray JM, Rosenberg A, et al. Experiences of Individuals Who Were Physically Restrained in the Emergency Department.. JAMA network open. 2020; 3 [1]: p.e1919381. doi: 10.1001/jamanetworkopen.2019.19381 . | Open in Read by QxMD
Stratton SJ, Rogers C, Brickett K, Gruzinski G. Factors associated with sudden death of individuals requiring restraint for excited delirium.. Am J Emerg Med. 2001; 19 [3]: p.187-91. doi: 10.1053/ajem.2001.22665 . | Open in Read by QxMD
Hick JL, Smith SW, Lynch MT. Metabolic acidosis in restraint-associated cardiac arrest: a case series.. Acad Emerg Med. 1999; 6 [3]: p.239-43. doi: 10.1111/j.1553-2712.1999.tb00164.x . | Open in Read by QxMD
Otahbachi M, Cevik C, Bagdure S, Nugent K. Excited delirium, restraints, and unexpected death: a review of pathogenesis.. Am J Forensic Med Pathol. 2010; 31 [2]: p.107-12. doi: 10.1097/PAF.0b013e3181d76cdd . | Open in Read by QxMD

When working with an angry patient it is best to do which of the following?

One of the best tactics for disarming an angry patient is to show empathy. Unlike sympathy, which is an understanding of someone else's suffering, empathy involves experiencing someone else's emotions. Take the time to hear out your patient's upsets and concerns.

How do you control aggressive behavior?

Managing aggression.

Control your body language and tone of voice..

Stay calm..

Offer a way out..

Discourage bystanders..

Don't make threats..

Don't make predictions..

Wait for the right moment..

Maintain safety..

Which approach is the best to use with an individual who is displaying aggressive behaviors?

No physical contact: Do not initiate physical contact if the resident's behavior is escalating. Touching can trigger violence in some residents. Approach: Always approach the resident from the front and not the back. Respond calmly and provide support with positive and friendly facial expressions.

Which factor is a predictor of violent behavior?

Physical factors increase the risk of violence as well. These include lack of sleep, physical exhaustion, use of drugs or alcohol, brain trauma, heat, hunger, cold, physical disability, or chronic pain. Situational Factors. Situational factors are also predictive of violence.