Approach to the Agitated Emergency Department Patient

Michael Gottlieb, Brit Long, Alex Koyfman
Journal of Emergency Medicine 2018, 54 (4): 447-457

BACKGROUND: Acute agitation is a common occurrence in the emergency department (ED) that requires rapid assessment and management.

OBJECTIVE: This review provides an evidence-based summary of the current ED evaluation and management of acute agitation.

DISCUSSION: Acute agitation is an increasingly common presentation to the ED and has a broad differential diagnosis including metabolic, neurologic, infectious, toxicologic, and psychiatric etiologies. Missed diagnosis of a dangerous etiology of the patient's agitation may result in severe morbidity and mortality. Assessment and management of the agitated patient should occur concurrently. Focused history and physical examination are recommended, though control of the patient's agitation may be required. All patients should receive a point-of-care glucose test, with additional testing depending upon the specific patient presentation. Initial management should involve verbal de-escalation techniques, followed by pharmacologic interventions, with physical restraints reserved as a last resort. Pharmacologic options include first-generation antipsychotics, second-generation antipsychotics, benzodiazepines, and ketamine. Finally, the management of pediatric, pregnant, and elderly patients warrants special consideration.

CONCLUSION: Acute agitation is an important presentation that requires prompt recognition and treatment. A focused and thorough examination coupled with appropriate management strategies can assist emergency clinicians to safely and effectively manage these patients.


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