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CHAPTER 287:  Acute Agitation      1937  INVOLUNTARY PATIENTS To consider an involuntary admission, the patient must be suffering from a severe mental disorder and must need treatment on an inpatient basis, and compulsory/involuntary treatment must be necessary in the interest of the patient’s health or safety or the protection of other persons. A crucial element that is often missed is that there must be a prospect of recovery if the patient is treated involuntarily. Thus, patients with intellectual disabilities, autism spectrum disorders, or substance use disorders may not qualify for involuntary admission no matter how dramatic their presentation. The core criteria that dictate involuntary transport to the ED are typically divided into three categories: harm to self; harm to others; and continuing deterioration without treatment. Harm to self, planned suicide, active suicidal attempt, or reason to believe the patient may harm himself or herself imminently if discharged is the first category. Although many interviewers evaluate this by asking the question “Do you feel you want to hurt yourself?” the assessment of self-harm risk is much more complex, so that suicidal ideations are usually linked to a specialized psychiatric consultation. The second category of involuntary commitment is harm to others or risk of harm to others. Frank homicidal ideations are actually fairly rare, but irritability and impulsivity are dangerous when unbridled, especially when combined with substance use, access to weapons, or personal crises that compound the situation, such as recent breakups, divorces, custody battles, and perceived need for revenge. Lastly, the third category that may allow involuntary detention of a patient in the ED is continued deterioration to the extent where self-care and self-preservation are doubtful. Such cases will lack open statement of self-harm but may include catatonia, self-starvation, eating disorders, or severe psychosis with distortion of reality. This group of patients will typically lack capacity to make full medical decisions for themselves. Table 286-6 illustrates the differences between capacity and competency. An involuntary commitment assumes (in most states) the patient lacks capacity to consent to an admission or emergency medications but is not linked to any competency determination, the latter being a legal term and decided on by the court. The rules for involuntary commitment vary by state, both in scope and in the assignment of responsibility for who should fill out the court documents. Commonalities shared by all states (and countries) are based on the principles from European Convention for the Protection of Human Rights and Fundamental Freedoms (1950), the Principles for the Protection of Persons with Mental Illness (or MI Principles, 1991), The Declaration of Hawaii (1983), and Ten Basic Principles for Mental Health Law published by the World Health Organization. Two sources of information are usually required for involuntary commitment, such as an affidavit filled by the police or physician and another filled by a family member or social worker. Psychiatric consultation is recommended for involuntary commitment situations.  EXCLUSIONARY CRITERIA FOR PSYCHIATRIC ADMISSION Once it is determined that the patient requires psychiatric admission and medical clearance/stabilization has been accomplished, various processes are used to find an inpatient psychiatric facility bed.

consultation is recommended for involuntary commitment situations.  EXCLUSIONARY CRITERIA FOR PSYCHIATRIC ADMISSION Once it is determined that the patient requires psychiatric admission and medical clearance/stabilization has been accomplished, various processes are used to find an inpatient psychiatric facility bed. In some cases, an on-site social worker will help identify local inpatient facilities TABLE 286-6 Capacity Versus Competency Capacity •   The ability to make a decision about a specific health matter at a discrete point in time. •   The concept includes the ability to understand risks and benefits of the suggested intervention, medication, or procedure; the repercussions of declining it; and alternative choices. Competency •   Legal term decided by court and extends to financial, health, and personal matters. It is not a dynamic  concept  like capacity. Absence  of competence  usually  implies the presence  of a legal guardian, either an individual or a court-appointed entity. The concept is not to be confused with power of attorney. for consideration. In other cases, a unit secretary will fax over the forms and facilitate the doctor-to-doctor calls to secure the patient a bed. The rules governing this process are very complex and, at times, elusory. Exclusionary criteria add yet another layer of complexity and add to the patient’s overall length of stay in the ED and can trigger the problem of ED boarding. A protracted discussion is beyond the scope of this chapter. However, facilities can deny patients for a myriad of reasons ranging from preex isting medical conditions (i.e., pregnancy or intellectual delay), to inability to manage the patient’s medical comorbidities (i.e., patients requiring peritoneal dialysis), to requiring specific laboratory or ancillary testing irrespective of clinical need, to facility issues (i.e., requiring patients in the same room to be of the same gender). ED staff should familiarize themselves with the exclusionary criteria of local inpatient facilities. Failure to do so will lead to increased lengths of stay and further strain the ED staff and the patient. DISPOSITION The evaluation of the patient presenting with mental health complaints in the ED is a challenging process, because the complaints can indicate a medical issue, mental issue, or both. By following a rigorous process for evaluation and testing selection and seeking psychiatric consultation when needed, the emergency provider can untangle the case fairly reliably. There are three types of disposition for patients with mental health complaints. The first and simplest is a discharge. Problems may arise in terms of destination of discharge for individuals with housing inse curity and inability to buy prescribed medications. Providers should be familiar with local pharmacy and supermarket generic/cheaper lists and discount programs and apps to help selected patients offset costs. The second potential disposition is an admission, whether psychiatric or medical. Bed availability is the main issue in this scenario, with inpatient facility shortages even for patients with insurance coverage. The extent of this problem has made headlines nationally. The third possibility is described differently across facilities and can be viewed as a reassessment or a brief observation period. This option may be the most useful for individuals who present with substance intoxication or crises expected to resolve in a period of time that is below the typical admission duration, but places pressure of increased length of stay and potential jurisdiction and liability issues on ED staff. Lastly, cooperation between psychiatry and emergency medicine fol lows the same principles for any successful collaboration.

expected to resolve in a period of time that is below the typical admission duration, but places pressure of increased length of stay and potential jurisdiction and liability issues on ED staff. Lastly, cooperation between psychiatry and emergency medicine fol lows the same principles for any successful collaboration. We invite open communication and an effort to avoid stigma to enhance and optimize care for individuals with mental illness, one of the most vulnerable populations we are responsible for as a medical community. REFERENCES The complete reference list is available online at www.TintinalliEM.com. CHAPTER Acute Agitation Michael Wilson 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 Tintinalli_Sec24_p1933-1966.indd 1937 8/2/19 5:19 PM

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 Tintinalli_Sec24_p1933-1966.indd 1937 8/2/19 5:19 PM 1938 SECTION 24: Psychosocial Disorders 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 agita tion. 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. ” In another study conducted at a medium-size university teaching hospital, university police had to respond an average of twice daily to violent incidents. 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 proto col is the Sedation Assessment Tool (Table 287-1).17 In the single study assessing the Sedation Assessment Tool scoring system, patients who could not be calmed by verbal de-escalation or oral medication were administered medication at values of +2 or +3.  SAFETY FIRST There are few reliable predictors of when agitated patients will become aggressive or violent, although community studies and risk stratifica tion tools have indicated that historical factors, such as which patients have been violent in the past, are reasonable predictors of which patients will become violent again. 18,19 “Safety first” starts with the planning for, and recognition of, agitation. Although agitated patients may not always become aggressive, patients who are aggressive should only be approached by hospital security or police. If not immedi ately available, maintaining a safe distance and attempting verbal de-escalation should occur until security resources arrive.

, and recognition of, agitation. Although agitated patients may not always become aggressive, patients who are aggressive should only be approached by hospital security or police. If not immedi ately available, maintaining a safe distance and attempting verbal de-escalation should occur until security resources arrive. Agitated patients should have a prepared place in a separate room away from potential weapons and sharp objects, and there should be an easy way of notifying security if the need arises. Rooms should ideally have more than one exit, and external stimuli such as loud noises should be minimized.  SHOW OF CONCERN Patients who require ongoing verbal de-escalation or who refuse medi cation may benefit from a show of concern.7 In this scenario, patients are approached with security agents and staff standing in a visible location outside the patient’s room. Oral medication is typically offered at this point, with the decision to use IM medication only if the patient continues to escalate and/or refuse medication. In the ED, this is typically done while awaiting medication or security at the bedside. PHARMACOLOGY  FIRST-GENERATION ANTIPSYCHOTICS The decision to administer IM or IV medication involuntarily requires a determination that the patient is not willing or capable of controlling behavior and that the patient is at risk of harm to self or others. The presumed etiology of agitation will most likely guide the best choice of medication (Figure 287-1). Haloperidol and lorazepam are perhaps the most common combination used in U.S. EDs.22,23 Haloperidol, first approved by the U.S. Food and Drug Administration in 1967, is a butyrophenone with primary activity at the dopamine 2 receptor. Haloperidol, like all antipsychotics, carries a black box warning about the risks of use for dementia-related psychosis. In addition, this medi cation lengthens QT intervals, is associated with motor-related side effects, and is likely not appropriate for use as a single agent. 24 IV use is off-label. There is no strong evidence that haloperidol alone is more effica cious than lorazepam in terms of number of people asleep or repeat injections and no strong evidence that the adverse effects of haloperidol are offset by concomitant use of lorazepam. 24,25 Concomitant use of promethazine is an acceptable alternative to lorazepam and is recom mended by the United Kingdom National Institute for Health and Care Excellence. 26 Although addition of promethazine has better support from randomized trials, a recent Cochrane review 24 found no evidence in one trial that there was any difference in acute dystonias by 12 hours after injection. Given both this and concerns over excessive sedation with the combination, an American expert consensus panel has recom mended second-generation antipsychotics instead of this combination (see below). Another medication in the butyrophenone class, droperidol, has often been used in the ED despite a Food and Drug Administration black box warning. 22,27-30 Both haloperidol and droperidol are thought to have minimal interactions with other medications, although droperidol has been implicated in respiratory depression in alcohol-intoxicated patients. 31 Droperidol may have a lower risk of movement-related side effects than haloperidol.32 When administering first-generation antipsychotics, identify and treat electrolyte disturbances, especially if using the IV route. Select an alternative agent if possible and provide continuous cardiac monitoring when administering the agent to patients receiving other QT c-prolonging medications.  KETAMINE Another potential medication for agitation treatment is ketamine, an N-methyl-d-aspartate antagonist that has long been used in the ED for procedural sedation.

ive agent if possible and provide continuous cardiac monitoring when administering the agent to patients receiving other QT c-prolonging medications.  KETAMINE Another potential medication for agitation treatment is ketamine, an N-methyl-d-aspartate antagonist that has long been used in the ED for procedural sedation. 33 The use of ketamine has been proposed as a treatment both for patients with excited delirium syndrome, a syn drome in which patients are at high risk of death if not emergently treated, 34,35 and for patients who have proven refractory to other antipsychotics.36 However, the routine use of ketamine for severely TABLE 287-1 Sedation Assessment Tool Scoring System Score Responsiveness Speech +3 Combative, violent, out of control Continual loud outbursts +2 Very anxious and agitated Loud outbursts +1 Anxious/restless Normal/talkative 0 Awake and calm/cooperative Normal –1 Asleep but rouses if name called Slurring or prominent slowing –2 Responds to physical stimulation Few recognizable words –3 No response to stimulation Nil Tintinalli_Sec24_p1933-1966.indd 1938 8/2/19 5:19 PM

anxious and agitated Loud outbursts +1 Anxious/restless Normal/talkative 0 Awake and calm/cooperative Normal –1 Asleep but rouses if name called Slurring or prominent slowing –2 Responds to physical stimulation Few recognizable words –3 No response to stimulation Nil Tintinalli_Sec24_p1933-1966.indd 1938 8/2/19 5:19 PM CHAPTER 287:  Acute Agitation      1939 agitated patients is not well studied,37 and most importantly, dose regimens have not been validated. Some suggest a dose of 4 to 5 milligrams/kg IM or 1 to 2 milligrams IV . 38-41 In the prehospital setting, use of ket amine for severely agitated patients may result in increased adverse air way events requiring intubation upon arrival in the ED. 38-41 Cole et al 38 reported that 39% of patients who received 5 milligrams/kg IM required ED intubation. Severe hypersalivation was another reported complication. Although ketamine administered in the ED setting may be generally well tolerated with few vital sign abnormalities, other potential drawbacks include the inability of the patient to participate in their own care or provide history, the fact that ketamine is not a specific treatment for agitation, and the need for frequent redosing. In addition, there is some evidence from one small trial that the use of ketamine may worsen psychosis. 43 A recent clinical policy from the American College of Emergency Physicians stated that ketamine may be a “reasonable option” in the treatment of agitated patients, although it noted that there are no methodologically rigorous trials that support its use. Identify and correct any underlying medical condition Avoid BZN 1. Oral 2nd-generation Antipsychotics risperidone 2 mg olanzapine 5–10 mg 2. Oral 1st-generation Antipsychotics haloperidol (low dose) § 3. Parenteral 2nd-generation Antipsychotics olanzapine 10 mg IM ziprasidone 10–20 mg IM 4. Parenteral 1st-generation Antipsychotics haloperidol (low dose)§ IM or IV (with caution)† § There is strong evidence that doses > 3 mg/day in patients with delirium are associated with significant risk of EPS, 46 so patients receiving > 3 mg/day should be assessed carefully for EPS. †See FDA guidelines.18 1. Oral Benzodiazepines lorazepam 1–2 mg chlordiazepoxide 50 mg diazepam 5–10 mg 2. Parenteral Benzodiazepines lorazepam 1–2 mg IM or IV Avoid BZN if possible 1. Oral 1st-generation Antipsychotics haloperidol 2–10 mg 2. Parenteral 1st-generation Antipsychotics haloperidol 2–10 mg IM 1. Oral 2nd-generation Antipsychotics risperidone 2 mg‡ olanzapine 5–10 mg‡ 2. Oral 1st-generation Antipsychotics haloperidol 2–10 mg with BZN 3. Parenteral 2nd-generation Antipsychotics olanzapine 10 mg IM ‡ ziprasidone 10–20 mg IM‡ 4. Parenteral 1st-generation Antipsychotics haloperidol 2–10 mg IM with BZN ‡If an antipsychotic alone does not work sufficiently, add lorazepam 1–2 mg (oral or parenteral). No Psychosis Evident Same as agitation due to withdrawal Psychosis Evident Same as for primary psychiatric disorder Based on response to interventions, medication is now required Agitation associated with delirium ETOH or BZN withdrawal not suspected ETOH or BZN withdrawal is suspected CNS Stimulant CNS Depressant (e.g., ETOH) Agitation associated with psychosis in patient with known psychiatric disorder Undifferentiated agitation or complex presentation Agitation due to Intoxication Protocol for Treatment of Agitation FIGURE 287-1. A suggested algorithm for the treatment of acute agitation. BZN = benzodiazepine; EPS = extrapyramidal side effects; ETOH = alcohol; FDA = U.S. Food and Drug Administration. Low-dose haloperidol is considered <3.0 milligrams/d.

presentation Agitation due to Intoxication Protocol for Treatment of Agitation FIGURE 287-1. A suggested algorithm for the treatment of acute agitation. BZN = benzodiazepine; EPS = extrapyramidal side effects; ETOH = alcohol; FDA = U.S. Food and Drug Administration. Low-dose haloperidol is considered <3.0 milligrams/d. [Reproduced with permission from Wilson MP, Pepper D, Currier GW, et al: The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project Beta Psychopharmacology Workgroup. West J Emerg Med 13: 26–34, 2012.]  SECOND-GENERATION ANTIPSYCHOTICS Given the side effects of first-generation antipsychotics, second-generation antipsychotics have been recommended by multiple expert panels as better first-line agents in patients who are not intoxicated with alcohol, 5,7 although their efficacy may be similar to first-generation antipsychotics in reducing agitation. 8 Certain second-generation antipsychotics may also be as effective as benzodiazepines. In a recent prospective nonrandomized study, for instance, 10 milligrams IM olanzapine achieved equally rapid sedation as 5 milligrams IM midazolam. 44 Current guidelines also recommend that medication be administered at a dose that promotes calming but not sleep, as sleeping patients cannot generally be evaluated by physicians and nursing staff for disposition. 3,45 Second-generation antipsychotics antagonize dopamine 2 recep tors to a lesser degree than first-generation antipsychotics and have a relatively higher affinity for other receptor types such as serotonin. Although second-generation antipsychotics such as olanzapine have a risk of side effects that is comparable to the use of haloperidol plus Tintinalli_Sec24_p1933-1966.indd 1939 8/2/19 5:19 PM