Hello there my name is angela tuttle and i am one of the pharmacists here at ut mc and i would like to talk to you about the management of acute agitation in the emergency department my objectives for this presentation are to outline the possible causes of agitation delirium in the emergency department assess when it is necessary to administer pharmacological agents
For the treatment of agitation delirium and determine an appropriate agent based on the underlying cause so causes of agitation delirium could be due to medical conditions intoxication withdrawal mental health conditions and other reasons medical conditions to consider head trauma and cephalopoda especially if we’re considering from we know renal failure or hepatic
Failure some metabolic conditions to consider would be hyponatremia hypocalcemia and hypoglycemia there’s also hypoxia seizures acute delirium and dementia behavior or psychological symptoms so the important thing to consider is that we need to make sure that we are recognizing and treating the underlying cause and rather than just assuming that it’s a psychiatric
In nature when we’re talking about a toxication or thrall we’re talking about alcohol hallucinogen stimulants cannabis especially when we consider the legalization of marijuana there’s a lot of intoxication related to edibles because patients consume much more than they normally would because the onset is slower there’s also the possibility of synthetics opioids and
Benzodiazepines mental health conditions to consider psychiatric disorders mania agitated depression anxiety borderline personality and antisocial personality other things to consider developmental disabilities situational crisis impulse control disorders and pain in patients with intellectual disabilities again this is important to make sure that we are recognizing
The underlying cause because if we have a patient that’s in pain and acting out because of their pain and they don’t have the ability to communicate if we can treat their pain we don’t need to treat with an anti-psychotic factors that we need to consider regardless of the cause of the agitation we need to make sure that we are maintaining safety that we’re waiting
Safety for the patient the staff and others we want to make sure there’s enough people around to restrain if we need to we need to be aware of the environment and make sure that we remove any potential items that could be used to harm the patient or other people and we need to make sure that we are learning security and mental health to triage if necessary and make
Sure that we have someone available for one-to-one observation if it’s necessary safran and the emergency department should have some training on de-escalation we want to make sure that we are approaching the patient in a calm confident non-threatening manner that we’re using short clear sentences and that we’re not using medical jargon the patient is in a very high
Agitation state and so the patient probably doesn’t have the capacity to understand completely which is why we need to speak slowly and calmly with a steady voice and make sure that we’re not raising our voice we want to make sure that we’re empathetic and non-judgmental and that we’re actually listening to the patient’s concerns we want to introduce ourselves and
Our role and also try and lead the discussion and engage the patient we want to use clear study voice again and not raise our voice if the patient raises their voice we want to make sure that we’re pausing and letting them speak and vent if needed which can be difficult when you have a patient getting agitated to keep yourself calm but it’s important to make sure
That you are the rational voice in the situation and that you remain calm so that you can hopefully not need to go to medications so we want to emphasize the desire to help and to listen the patient’s worries and their fears and their unmet needs again we want to avoid provocative statements we don’t want to say calm down if you don’t settle down xx will happen
If if we think about it one of the surest ways to fire someone up is if we tell them to calm or if we threaten them with you better stop or else this will happen so we don’t want to we want to make sure that we are not escalating that behavior or that and we want to make sure that we are not perceived as a threat to the patient so while there may be other staff
Members there really only one staff member should be engaging the patient we should entrust relatives or staff to help if needed to de-escalate this situation some general recommendations to consider the use of medication as a restraint in order to restrict the patient’s movement should be discouraged so the joint commission actually requires the same level of
Scrutiny and medical evaluation and record-keeping for medication as a restraint as they do for physical restraint so we need to consider that if we are going that measure for for medications of the restraint again it’s highly discouraged non pharmacological approaches should be attempted first before medications are administered when we are medicating patients we
Want to do this to calm patients not to induce sleep if we take them to the point where they’re snowed we’re not going to be able to help with their underlying medical condition so we want to make sure that we’re calming them down without putting them to sleep patients whenever possible should be involved in the process to choose what medication to use so hopefully
In in this manner we can help the patient decide whether we want an oral medication in term us term a neuromuscular medication etc if the patient is able to cooperate and take oral medications we want to make sure that we are doing that before we are giving anything parentally so what medications do we use we have the first generation antipsychotics droperidol and
Hale pair at all i have to repair it all still listed here because you might hear about it still a lot droperidol has actually been removed from the market due to risk of qt prolongation and this risk actually may be controversial although there there is some data to support that there were some patients that had qt prolongation which are paradol it may have been
Overblown so is the possibility with some push that this drug made may come back so he’ll paradol also has the risk of qt prolongation especially with larger doses and especially if we’re giving it iv so if we do need to give help here at all iv we need to make sure that we are using ecg monitoring during the administration extrapyramidal symptoms are eps such
As dystonia or neuroleptic syndrome may occur if they do occur we can give lorazepam diphenhydramine or promethazine but we need to realize if we if we are treating the eps that it’s also going to increase the sedative risk of the help here at all if we give high doses of help here at all it can also cause catatonic reactions due to the central dopamine blockade
Second-generation antipsychotics s seen here cannot be given iv per the fda guidelines there is some data to support olanzapine and sub-period own as iv in the critical care population but no data that i have seen for use in the emergency department and the fda only has it approved for i am and oral administration ere peppers all is highlighted in red here because
Although it does have a indication for agitation it appears to be less effective and it is no longer available in an iamb formulation it’s only available in oral it used to be available in the i am formulation for immediate release now it is only available in a long-acting the oral second-generation antipsychotics we have risperidone in quetiapine quetiapine is
In red because it has a high risk of orthostatic hypotension especially in patients that are volume depleted so again not a good choice for the emergency department but risperidone seems to have a good use there is less risk of eps with a second-generation antipsychotics benzodiazepines can be used and we’re all very familiar with benzodiazepines they can be over
Sedating and they have the potential for respiratory depression or hypotension we need to especially consider this in patients that are already having underlying respiratory conditions or if they are already on other cns depressants such as alcohol this risk for respiratory depression actually increases other medications that are sometimes used to help with agitation
We have diphenhydramine and hydroxyzine and clonidine may also be used for alcohol withdrawal and we will discuss that later so this slide is just here for your reference these are medications that are readily available in the accu dose in the emergency department at utmc so as you can see we have some haloperidol some second-generation antipsychotics the benzos
And other medications available if needed that are readily available in the accu doses in the emergency department any other medications would be available at utmc they just would need to be sent up from the central pharmacy if we have a patient who we expect their agitation is due to intoxication most of the time we’re going to choose a benzodiazepine to help
Calm the patient down there are some patients that are chronic and fun amine users that will actually develop psych psychiatric and psychotic symptoms so if we have psychotic symptoms we want to treat with an anti-psychotic which should be added to the benzodiazepine if we have a patient that’s intoxicated from alcohol which again remember is a cns depressant we
Want to most of the time just let let the alcohol wear off on its own and medication should be used very sparingly benzodiazepines as we discussed before should be avoided because of the increased risk of respiratory depression if we need to treat we should use haloperidol as our first choice in olanzapine and risperidone could be an alternative agent if we have
A patient that is in an agitated state due to withdrawal if it’s due to an alcohol or benzodiazepine a benzodiazepine is the drug of choice when you have withdrawal from alcohol or benzos you have rapid loss of gaba receptor inhibition and it’s implicated in producing delirium clonidine may be helpful in reducing the sympathetic overdrive of alcohol or benzotine
Withdrawal and it may ease the delirium and agitation associated with our draw withdrawal for other agents it’s best to replace with a agent that has some similar pharmacological properties so if we have nicotine we’re gonna replace with nicotine if we have opioids it’s actually best to get an expert in detox for the management of the opioid withdrawal so there’s
Special management required for suboxone or methadone to be used along with symptomatic relief often these patients that are opioid addicted also are much more complex and have multi-system abuse if we have a patient that’s coming through the emergency department just to kind of shore up the rules for you as far as the ohio state board of pharmacy and the federal
Regulations go if we have a patient that comes in that’s already being managed for their opioid withdrawal and their being there here for any other reason so we’re treating their medical condition they have an mi that sort of situation we are legally allowed to give their suboxone or their methadone at the doses that they that they require if they come through
The emergency department and the only reason that they’re there is for their withdrawal we can administer a dose if deemed that they did not receive their doors at their treatment center we can give a one-time dose through the emergent student room and we can give it one dose at a time for a maximum of three days if the patient’s agitation is due to a psychiatric
Illness makes sense if we have a psychiatric illness that we would use an anti-psychotic generally we would use a second-generation over a first generation because there seems to be more data if the patient will accept oral we have risperidone which is the safest as and as i pointed out before the risperidone is loaded in the academia mergency department and the
Dosage form of the oral that is loaded in the accu dose is the oral dissolving so it is a rapid onset oral dissolving tablet if i am as needed the the president or olanzapine would be preferred if the initial dose of the antipsychotic is insufficient instead of giving a second dose of the anti-psychotic it’s actually preferred to give a benzodiazepine and usually
Lorazepam is used if you have agitation associated with delirium first we need to recognize the signs of delirium so we have decreased level of awareness disturbance and attention and cognition and it can fluctuate over the course of hours visit visual hallucinations visual perception disturbances when we have these signs of delirium it signals that there’s an
Underlying medical disturbance affecting the brain function or there’s a rapid change in the established environment of the brain so once delirium is identified the cause needs to be identified as soon as possible and corrected so as we’ve said before whenever possible we need to correct the cause of delirium so if it’s alcohol withdrawal benzyl withdrawal sleep
Deprivation we’re gonna treat as as discussed before we’re going to give up enso diazepam we’re gonna induce sleep if it’s caused from something else an antipsychotic may be needed especially a second-generation if you use haloperidol it should be used at low doses so we’re talking 2 milligrams 3 milligrams less than 5 milligrams benzodiazepines actually should
Be avoided because they can exacerbate the delirium so what if we have a patient that we have no idea what is causing their agitation or we it’s very complex and it’s multiple reasons causing their agitation or delirium so again if there’s psychosis present we want to give an anti-psychotic if there’s no psychosis and the etiology is unknown a benzodiazepine our
First line of treatment it is possible if we give an anti-psychotic that we could give the help here at all lorazepam and diphenhydramine together and you will often see that but again realize that we might want to use a little bit lower doses of the help here at all and lori as a pam so that we are not snowing our patients we want to make sure that we’re calming
Them without inducing the sleep listed here is just the algorithm based on the treatment protocol from the western journal of emergency medicine just outlines all that we’ve discussed i will also supply my email address at the end of this presentation you should have been supplied with a pocket card but if you have not you can email me and i will make sure to get
You a copy of this to keep in your pocket so conclusions the pharmacological treatment should be based on the cause of agitation and should only be used if attempts at de-escalation were unsuccessful calming is the goal without inducing sleep it’s very hard to complete neuro checks on the patient if the patient is sound asleep oral should be used first if ever
Possible if there is psychosis present we want to make sure that we’re using an anti-psychotic second generation is preferred in most situations unless it is due to alcohol withdrawal then haloperidol would be preferred which may also need to be administered with a benzodiazepine to reduce the risk of eps so if you have any questions you can send an email to me at
Natalie tuttle at u toledo do you and also if you would like a copy of the presentation or the pocket card if you did not already receive it you can email me that as well so i hope that you have learned something about the acute management of agitation in the emergency department and thank you for your time
Transcribed from video
Agitation Delirium in ED video By Natalie Tuttle