How should you manage agitation?

From the Guidelines

To manage agitation, benzodiazepines like lorazepam or antipsychotics such as haloperidol should be considered as effective monotherapy for the initial drug treatment of the acutely agitated undifferentiated patient in the ED, as recommended by the Annals of Emergency Medicine 1. When managing agitation, it is crucial to prioritize the patient's safety and the safety of others by removing potential hazards and maintaining a calm environment. De-escalation techniques, including verbal restraint strategies, should be employed to try to calm the patient before considering medication. Some key verbal restraint strategies include:

• Respecting personal space
• Minimizing provocative behavior
• Establishing verbal contact
• Being concise
• Identifying the patient's goals and expectations
• Using active listening
• Agreeing or agreeing to disagree
• Setting clear limits and expectations
• Offering choices and optimism
• Debriefing the patient and staff after an intervention 1. If medication is necessary, the choice between benzodiazepines and antipsychotics depends on the suspected etiology of agitation and the severity of the agitation. For mild to moderate agitation, benzodiazepines like lorazepam (0.5-2mg) or midazolam (2.5-5mg) can be effective, while for agitation with psychosis, antipsychotics such as haloperidol (2-5mg) may be more suitable 1. In cases where rapid sedation is required, droperidol may be considered instead of haloperidol 1. Regular reassessment is essential to determine the effectiveness of the intervention and to make adjustments as needed, prioritizing the patient's morbidity, mortality, and quality of life.

From the FDA Drug Label

ZYPREXA IntraMuscular is indicated for the treatment of acute agitation associated with schizophrenia and bipolar I mania Efficacy was demonstrated in 3 short-term (24 hours of IM treatment) placebo-controlled trials in agitated adult inpatients with: schizophrenia or bipolar I disorder (manic or mixed episodes) “Psychomotor agitation” is defined in DSM-IV as “excessive motor activity associated with a feeling of inner tension. ” Patients experiencing agitation often manifest behaviors that interfere with their diagnosis and care, e.g., threatening behaviors, escalating or urgently distressing behavior, or self-exhausting behavior, leading clinicians to the use of intramuscular antipsychotic medications to achieve immediate control of the agitation.

To manage agitation, intramuscular antipsychotic medications, such as ZYPREXA IntraMuscular, can be used to achieve immediate control of the agitation. The treatment is indicated for acute agitation associated with schizophrenia and bipolar I mania. Key considerations include:

• Definition of psychomotor agitation: excessive motor activity associated with a feeling of inner tension
• Behaviors that may require treatment: threatening behaviors, escalating or urgently distressing behavior, or self-exhausting behavior
• Treatment goal: immediate control of the agitation 2

From the Research

Management of Agitation

To manage agitation, the following steps can be taken:

• Non-coercive de-escalation strategies should be used first, as stated in the study 3
• Pharmacologic interventions can be used, with options including ketamine, benzodiazepines, and antipsychotics, as mentioned in 3
• Physical restraints may be necessary in some cases, but patient autonomy, safety, and medical well-being should be prioritized, as emphasized in 3

Pharmaceutical Options

Various pharmaceutical options are available for managing agitation, including:

• Haloperidol, which can be used alone or in combination with antihistaminergic and anticholinergic drugs, as discussed in 4
• Benzodiazepines, such as lorazepam, diazepam, and midazolam, which have a more pronounced sedating activity, as noted in 4
• Atypical antipsychotics, such as aripiprazole, ziprasidone, and olanzapine, which are better tolerated and can be effective in managing agitation, as shown in 5 and 6

Non-Pharmacologic Interventions

Non-pharmacologic interventions can also be effective in managing agitation, including:

• Frequent and sufficient reality orientation, as suggested in 7
• Validation therapy, which can help improve the individual's quality of life, as mentioned in 7
• Strategies that improve the individual's quality of life, such as providing a calm and supportive environment, as emphasized in 7