From the Guidelines
Treatment for an agitated patient should begin with non-pharmacological approaches, such as creating a calm environment and using de-escalation techniques, and if medication is necessary, benzodiazepines like lorazepam or midazolam are often first-line for acute agitation, as recommended by the Annals of Emergency Medicine 1. When managing agitation, it's essential to consider the underlying cause, which may include psychiatric disorders, substance intoxication or withdrawal, medical conditions, pain, or environmental factors.
- Non-pharmacological approaches should be used whenever possible, including verbal restraint strategies, such as those outlined in Fishkind’s “Ten Commandments of De-escalation” 1.
- A calming physical environment with decreased sensory stimulation and removal of potential weapons can also improve the chances of successful de-escalation 1.
- If medication is necessary, the choice of agent depends on the patient's specific condition, with benzodiazepines like lorazepam (0.5-2mg orally or IM) or midazolam (2.5-5mg IM) often used for acute agitation, and antipsychotics such as haloperidol (2-5mg orally or IM) or risperidone (1-2mg orally) for patients with psychosis, as recommended by the Annals of Emergency Medicine 1.
- In elderly patients, it's crucial to start with lower doses and monitor closely for adverse effects.
- Throughout treatment, it's essential to monitor vital signs, level of sedation, and response to interventions, and to address the underlying cause of agitation to provide effective long-term management.
From the FDA Drug Label
Pediatric patients may exhibit a sensitivity to benzyl alcohol, polyethylene glycol and propylene glycol, components of lorazepam injection Paradoxical excitation was observed in 10% to 30% of the pediatric patients under 8 years of age and was characterized by tremors, agitation, euphoria, logorrhea, and brief episodes of visual hallucinations.
The treatment for a patient with agitation may include lorazepam (IM), but it's essential to note that paradoxical excitation can occur, especially in pediatric patients under 8 years of age, characterized by tremors, agitation, euphoria, logorrhea, and brief episodes of visual hallucinations 2.
- Haloperidol (PO) may also be considered for treating agitation, but its use requires careful monitoring due to potential side effects such as leukopenia, neutropenia, and agranulocytosis 3.
- It's crucial to weigh the benefits and risks of each medication and consider the patient's specific condition, age, and medical history before making a treatment decision.
From the Research
Treatment Options for Agitation
The treatment for a patient with agitation typically involves a step-wise approach, starting with non-coercive de-escalation strategies and progressing to pharmacologic interventions and physical restraints as necessary 4, 5. The goal of treatment is to ensure patient autonomy, safety, and medical well-being.
De-escalation Techniques
De-escalation techniques are a crucial part of managing agitation, and can help reduce aggressive behavior, improve compliance, and lead to better outcomes 6, 7. Verbal de-escalation involves a 3-step approach: verbal engagement, collaborative relationship establishment, and verbal de-escalation out of the agitated state 7. The main objectives of de-escalation are to ensure safety, help the patient manage emotions and distress, avoid restraint, and avoid coercive interventions that escalate agitation 7.
Pharmacologic Interventions
Pharmacologic options for treating agitation include:
- Ketamine 4, 5
- Benzodiazepines (such as lorazepam, diazepam, and midazolam) 4, 5, 8
- Antipsychotics (such as haloperidol, olanzapine, and ziprasidone) 4, 5, 8, 6
- Atypical antipsychotics (such as aripiprazole and quetiapine) 8, 6
Special Considerations
Special consideration is needed when managing agitation in certain patient populations, such as pediatric, pregnant, and elderly patients 5. Additionally, the use of physical restraints should be reserved as a last resort 4, 5.