We were excited to read the article by Michael Wilson et al1 in the March 2012 issue of theWestern Journal of Emergency Medicine regarding pharmacologic strategies for the management of agitated patients in the emergency setting. This article highlights several important points including the optimal management of stimulant-induced agitation and the feasibility of and reasons for differentiating acute alcohol intoxication from withdrawal, as optimal pharmacologic interventions for each might vary.
In this article, the authors discuss several aspects of seclusion and restraint, including review of the Centers for Medicare and Medicaid Services guidelines regulating their use in medical behavioral settings, negative consequences of this intervention to patients and staff, and a review of quality improvement and risk management strategies that have been effective in decreasing their use in various treatment settings.
In this article, the authors review the use of a variety of first-generation antipsychotic drugs, second-generation antipsychotic drugs, and benzodiazepines for treatment of acute agitation, and propose specific guidelines for treatment of agitation associated with a variety of conditions, including acute intoxication, psychiatric illness, delirium, and multiple or idiopathic causes.
Agitation is an acute behavioral emergency requiring immediate intervention. Traditional methods of treating agitated patients, ie, routine restraints and involuntary medication, have been replaced with a much greater emphasis on a noncoercive approach. Experienced practitioners have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought possible. In the new paradigm, a 3-step approach is used. First, the patient is verbally engaged; then a collaborative relationship is established; and, finally, the patient is verbally de-escalated out of the agitated state.
It is difficult to fully assess an agitated patient, and the complete psychiatric evaluation usually cannot be completed until the patient is calm enough to participate in a psychiatric interview. Nonetheless, emergency clinicians must perform an initial mental status screening to begin this process as soon as the agitated patient presents to an emergency setting.
Author Affiliation Kimberly Nordstrom, MD, JD Denver Health Medical Center, University of Colorado Denver, Department of Psychiatry, Denver, Colorado Leslie S Zun, MD Mount Sinai Hospital, Chicago Medical School, Department of Emergency Medicine, Chicago, Illinois Michael P Wilson, MD, PhD UC San Diego Health System, Department of Emergency Medicine, San Diego, California Victor Stiebel MD […]
