What is the recommended management of an acutely agitated patient?

Management of the Acutely Agitated Patient

Begin with verbal de-escalation and environmental modification before any pharmacologic or physical intervention, then use benzodiazepines (lorazepam 0.05-0.1 mg/kg) for suspected medical/intoxication causes or antipsychotics (haloperidol 5-10 mg IM) for psychiatric causes, reserving physical restraints only as a last resort when the patient poses imminent danger.

Immediate Safety and Assessment

Create a safe environment first:

• Maintain approximately two arm-lengths distance from the patient to respect personal space and reduce perceived threat 1
• Remove potential weapons from the environment or ensure continuous monitoring if removal is not feasible 1
• Ensure both patient and staff have unobstructed exit paths 1
• Remove glasses, pens, scissors, stethoscopes, and secure long hair before any potential restraint 1, 2
• Designate a single staff member to interact with the patient to avoid confusion from multiple voices 1

Assess for reversible medical causes immediately:

• Perform point-of-care glucose testing on all patients, as hypoglycemia is rapidly reversible and potentially fatal 1
• Obtain vital signs to identify fever, tachycardia, hypertension, or respiratory compromise 1
• Evaluate for pain, hypoxia, urinary retention, constipation, infections, dehydration, and electrolyte disturbances 3
• Assess cognitive function to distinguish delirium from primary psychiatric causes 1
• Review medications for side effects contributing to agitation 3

First-Line: Verbal De-Escalation (Always Attempt First)

Use these specific techniques before any medication or restraint:

• Approach with calm demeanor, visible unclenched hands, and an angled stance rather than direct confrontational posture 1
• Introduce yourself and orient the patient to the setting, explicitly reassuring them that help is coming 1
• Use simple, concise language and allow ample time for the patient to process and respond 1
• Employ reflective listening ("Tell me if I have this right...") and identify the patient's goals ("What helps you in moments like this?") 1
• Set clear, non-punitive limits ("Safety comes first; if you cannot stay safe we will...") and offer realistic choices to restore a sense of control 1
• Reduce sensory stimulation and eliminate obvious triggers 1
• Encourage family participation to calm the patient 4

Critical pitfall: Do not allow multiple staff members to speak simultaneously, as this increases confusion and agitation 1

Pharmacologic Management (When Verbal De-Escalation Fails)

For Suspected Medical/Intoxication-Related Agitation:

First-line: Benzodiazepines

• Lorazepam 0.05-0.1 mg/kg PO/IM/IV is preferred 1
• Onset: 5-15 minutes IV, 15-30 minutes IM, 20-30 minutes PO 1
• Duration: 6-8 hours 1
• Preferred for alcohol withdrawal, cocaine intoxication, and other substance-related agitation 1
• Has no active metabolites, reliable IM absorption, and no extrapyramidal side effects 1
• Contraindication: Avoid in patients with respiratory compromise 1

If benzodiazepine alone is insufficient for severe intoxication:

• Add haloperidol 5-10 mg IM 1

For Suspected Psychiatric-Related Agitation:

Mild-to-moderate agitation:

• Either benzodiazepine or antipsychotic may be used 1

Severe agitation:

• Haloperidol 5-10 mg IM is preferred 1
• Onset: 10-20 minutes IM, 45-60 minutes PO 1
• Higher risk of extrapyramidal symptoms but provides less sedation than benzodiazepines 1
• Contraindication: Avoid in anticholinergic delirium or intoxication, as it may worsen the condition 1

Alternative:

• Ziprasidone mesylate 10-20 mg IM is FDA-approved for acute agitation in schizophrenia, though it has greater capacity to prolong QT/QTc interval compared to other antipsychotics 5

Combination therapy:

• Haloperidol plus lorazepam or midazolam may be used for severe agitation in older adolescents (>16 years) 1

For Unknown Etiology:

• Administer either a benzodiazepine OR an antipsychotic 1
• If the initial dose fails, consider a second agent from the alternate class 1

Special Considerations for Elderly Patients:

• Address reversible causes first before any medication 3
• Use haloperidol 0.5-1 mg orally (much lower dose than younger adults) for delirium-related agitation 3
• Use lorazepam 0.25-0.5 mg orally (much lower dose) for anxiety or agitation 3
• Patients over 50 years may have more profound and prolonged sedation with lorazepam 1
• Implement multicomponent nonpharmacologic interventions as first-line treatment and avoid routine use of antipsychotics 3

Physical Restraints (Last Resort Only)

Indications for physical restraints:

• Patient is an acute danger to harm themselves or others 4
• Significant disruption of treatment plan 4
• Other less restrictive measures have failed or are not possible 4

Critical safety measures during restraint:

• Use supine positioning with head of bed elevated and free cervical range of motion to decrease aspiration risk 4
• If prone positioning is necessary, monitor for airway obstruction and minimize pressure on neck and back 4
• Continuous monitoring of restrained patients is mandatory 4
• Minimize covering of the patient's face or head 4
• Remove smoking materials from the patient 4
• In cases of suspected illicit stimulant use, chemical restraint may be preferable, as rapid increase in serum potassium from rhabdomyolysis may result in cardiac arrest 4

Monitoring requirements (Joint Commission guidelines):

• Licensed independent practitioner must perform in-person evaluation within 1 hour of restraint placement for all ages 4
• Renew restraint orders: every 1 hour for age <9 years, every 2 hours for age 9-17 years, every 4 hours for age >18 years 4
• Assessments every 15 minutes for vital signs, signs of injury, nutrition/hydration, extremity circulation and range of motion, hygiene/elimination, physical and psychological status, and readiness to discontinue restraint 4

Post-Intervention Monitoring and Debrief

Monitoring after medication or restraint:

• Monitor vital signs, level of sedation, and respiratory status closely 1
• Have airway support equipment readily available 1
• Watch for extrapyramidal symptoms with antipsychotics 1
• Monitor for respiratory depression, especially with IV lorazepam 1

Debrief with the patient:

• Following any involuntary intervention, conduct a debrief to explain the rationale, solicit their perspective, and discuss alternative strategies for future episodes 1
• This practice supports psychological recovery and reduces trauma 1

Critical Pitfalls to Avoid

• Do not bypass verbal de-escalation and proceed straight to chemical or physical restraint unless imminent danger exists 1
• Do not use bargaining, deception, or coercion; maintain honesty and transparency 1
• Do not make assumptions about dangerousness based on race or cultural background 1
• Do not face the patient directly in an aggressive posture 1
• Only sedate the agitated and uncooperative patient who cannot be managed by other means 4
• Avoid physical restraints in elderly patients, as they worsen delirium and outcomes 3
• Discontinue antipsychotics immediately once agitation resolves—do not continue unnecessarily 3