Stabilization and Management of the Acutely Agitated or Psychotic Patient

by Michelle Chan, Nidal Moukaddam, Veronica Tucci

Case Presentations

Case 1.  It is a quiet Wednesday night in the emergency department when you suddenly hear someone coming down the hall continuously spouting out a string of profanities.  You leave the comfort of your chair to see what the commotion is all about only to find a 37-year-old female brought in by police for altered mental status.  She is acutely agitated on presentation, spouting obscenities non-stop, refusing to answer questions and uncooperative with a physical exam.

Case 2.  As you are pondering your next step, you see the paramedics wheeled an older gentleman past you and into the next room.  You step into the next room to get a report.  The family is at the bedside and states the patient is an 82-year-old male with a history of hypertension and BPH who has been increasingly confused and aggressive over the past two days.  You note that he is mildly tachycardic when you hear the PA system announce, “Security is needed in the critical care hallway.”

Case 3.  A nurse pops her head into the room and requests your immediate assistance.  You follow him down the hall and see your charge nurse along with three security officers trying to hold down a male patient.  The patient, who appears to be in his late twenties, is actively kicking and trying to bite and spit at the medical staff.  He appears flushed and diaphoretic.

General Approach and Critical Bedside Actions

General Approach and Key Concepts

The first steps in evaluating any patient who presents to the emergency department are to assess and ensure that the patient’s airway, breathing, and circulation is intact.  However, when presented with an acutely agitated or psychotic patient, even before assessing the ABC’s, you should ask yourself if the patient poses an immediate threat to the safety of both your patient or your medical staff.

If you determine that the patient poses an imminent threat to self or staff, a number of factors should be considered prior to administration of medications in order to achieve rapid stabilization without over-sedation or use of undue force.  These factors include age, known psychiatric history, known or suspected substance abuse, and severity of agitation.  Case 3, above, is a common scenario in the ED where a patient clearly poses an immediate threat.  Clearly call out the medication(s) and dosage(s) you would like, and while it is being prepared, attempt de-escalation techniques.  Appropriate pharmacologic and non-pharmacologic agents will be further discussed under Emergency Treatment Options.

Once immediate safety has been established, make sure the patient is placed on monitors and a full set of vitals, including temperature, is acquired.  This should be followed by a thorough primary survey.  A commonly used mnemonic is “ABCDE,” where A = airway, B = breathing, C = circulation, D = disability, and E = exposure.  Disability refers to assessing a patient’s level of consciousness and quickly screening for reversible causes of altered mental status.  This includes examining pupils and checking blood glucose.  Hypoxemia and hypotension should be noted in the vitals.  Exposure is a critical bedside action that is easily neglected.  All patients who present with acute agitation or psychosis should be fully exposed and changed into a hospital gown.  This allows for rapid visual assessment for overt signs of trauma, as well as the opportunity to check for concealed weapons.

Differential Diagnoses

The differential for patients presenting with acute agitation or psychosis is long (see Table 1 for common causes), but is best divided into organic (primarily medical) and inorganic (primarily psychiatric) causes.

Table 1. Common Causes of Acute Agitation or Psychosis

Medical
Hypercalcemia
Hypercapnia
Hypoxia
Infection (encephalitis, meningitis, sepsis)
Substance-related (alcohol, hallucinogens, steroids, stimulants, synthetic marijuana)

Psychiatric
Bipolar disorder
Posttraumatic stress disorder
Psychotic depression
Schizophrenia spectrum disorders

 

History and Physical Examination Hints

History is often limited in patients presenting with acute agitation.  Whenever possible, gather collateral information from family, emergency personnel and police.  Key information to obtain include:

  • Past medical history
  • Past psychiatric history (include current psychotropic medications)
  • Allergies
  • Home medications
  • Social history (alcohol use, substance abuse, living situation, caregivers, etc.)
  • Recent health status (i.e., Has patient reported headaches in the past few days suggestive of a possible intracranial process or has an elderly patient reported dysuria suggestive of possible urosepsis)
  • Baseline mental status

Although it is often said that history is 80% of the diagnosis, in cases of acute agitation, a thorough physical examination is all the more important due a limited HPI and review of systems.  The physical exam of every acutely agitated patient should include a full neurologic exam and head-to-toe visualization for obvious signs of trauma or injury.  A full neurologic exam may not always be possible during the initial assessment but should be completed as soon as feasible and prior to disposition.

When dealing with acute undifferentiated agitation due to a limited history and physical, a number of key signs and symptoms may help to at least narrow the differential to organic vs. inorganic causes.  Organic causes of agitation tend to be associated with abnormal vital signs, disorientation, fluctuating symptoms, or signs of trauma, whereas, inorganic causes lack these features.

Emergency Diagnostic Tests and Interpretation

Blood work, diagnostic tests, and imaging should be guided based on history and physical exam.  Depending on your institution, laboratory tests required for medical clearance should also be taken into account.  A basic metabolic panel and CBC, although not standard, is typically ordered for most patients with acute undifferentiated agitation or psychosis.

A urine pregnancy should be ordered on all women of childbearing age.  When urine is unobtainable, consider a qualitative hCG or substituting blood for urine on a point-of-care pregnancy test.

In cases of suspected ingestion or substance abuse, consider checking acetaminophen and salicylate levels, as well as an EKG and measurable levels of prescription drugs to which the patient has access.

Emergency Treatment Options

The goals for the treatment of acute agitation is early recognition, intervention before escalation into more violent behavior, and stabilization of life-threatening conditions.  Therapy should be aimed at decreasing agitation and psychosis to the greatest extent possible without oversedation in order to allow for further assessment of the patient to determine the underlying cause.  Interventions can be divided into nonpharmacologic and pharmacologic strategies.

Non-pharmacologic strategies include environmental interventions, de-escalation techniques, mechanical restraints, and seclusion.  Environmental conditions are often difficult to control in the ED, but the concept is simple: create a safe space that minimizes stimulation.  This means screening patients for weapons, removing objects that could be used as weapons (pens, chairs, or other loose objects), finding space away from the noise and activity of the ED when possible, and dimming room lights.  De-escalation techniques involve both verbal and non-verbal methods.  Once again, the concepts are simple and should be applied as first-line techniques in the management of acutely agitated or psychotic patients.  Successful use of de-escalation techniques will vary from situation to situation, but many times hinges on the ability to establish rapport with the patient quickly.  Often times this can be accomplished by addressing a patient’s basic needs of safety, hunger, and comfort.  Provide reassurance that the patient is in a safe place, offer food, water or warm blankets, and make sure to address pain management.  It is equally important to be mindful of personal space and avoid the threatening or confrontational behavior.  Verbal de-escalation techniques involve maintaining a calm and respectful demeanor while acknowledging the patient’s anger, frustration or agitation.

Although environmental and de-escalation strategies can be very effective, many times, acutely agitated or psychotic patients will require some form of pharmacologic intervention.  The two major classes of drugs used for this purpose are antipsychotics and benzodiazepines.  They may be used in combination or as monotherapy and are available in many formulations.  In the case of acute agitation or psychosis, these medications are most often given parenterally, either intramuscularly or intravenously for rapid tranquilization.  Refer to Table 2 for common agents and doses.
Choice of medication(s) varies greatly depending on personal preference; however, the two most commonly used agents are haloperidol and lorazepam.  In patients with a known history or high suspicion for underlying psychosis, monotherapy with an antipsychotic such as haloperidol may be considered.  Whereas, in patients with undifferentiated agitation or psychosis, monotherapy with a benzodiazepine may be a better option due to its added anxiolytic effects and usefulness in cases of substance-related psychosis such as phencyclidine (PCP) use or alcohol withdrawal.

When the above interventions fail to stabilize an acute agitated or psychotic patient, physical restraints and/or seclusion may be necessary.  It is important to understand, however, that these are methods of last resort and should never be used out of convenience or as a form of punishment.  Seclusion differs from placing the patient in a safe and less stimulating environment in that seclusion involves involuntary confinement.  Both seclusion and physical restraints are associated with increased morbidity and mortality.

Pediatric, Geriatric, Pregnant Patient and Other Considerations

Geriatrics

With age comes an increased risk for dementia which is a potential cause of acute agitation and psychosis in the geriatric population.  Although effective in the management of psychosis, FDA issued a black box warning for olanzapine and ziprasidone regarding their use in elderly patients with dementia-related psychosis due to increased mortality in this population.

Disposition Decisions

Once stabilization of a patient’s acute agitation or psychosis is achieved, disposition should be guided by the underlying cause of agitation.  Organic causes of agitation or psychosis such as sepsis, acute intracranial hemorrhage or severe metabolic disturbances warrant hospitalization until stabilization of the underlying cause is also achieved.  Whereas, patients who present with substance-induced psychosis may be eligible for discharge if the patient is no longer clinically intoxicated and back to baseline mental status.

If after medical evaluation is complete, and no medical cause of agitation or psychosis can be determined, patients must then be evaluated for psychiatric causes.  Admission criteria for acute psychosis due to an underlying psychiatric disorder primarily involves whether or not the patient is at high risk for continued harm to self or others.  Admission is also strongly considered for first episodes of psychosis due to inorganic causes.

References and Further Reading