Episode 197: Acute Agitation

We discuss an approach to the acutely agitated patient and review medications commonly used.

Jonathan Kobles, MD
Brian Gilberti, MD

June 3rd, 2024 Download Leave a Comment Tags: , ,

Show Notes


Definition and Scope: Agitation encompasses behaviors from restlessness to severe altered mental states. It’s a common emergency department presentation, often linked with acute medical or psychiatric emergencies.

Significance: Patients with agitation are at high risk for morbidity and mortality, necessitating prompt and effective management to prevent harm to themselves and healthcare providers.

A Changing Paradigm in Describing Agitation

Terminology Shift: Move away from terms like ‘excited delirium’ due to their politicization and stigmatization. Focus on describing agitation by severity and underlying causes.

Agitation as a Multifactorial Process

Complex Nature: Recognize agitation as a result of various factors, including medical, psychiatric, and environmental influences.

Recognizing Agitation

Signs and Symptoms: Identify agitation early by monitoring for behaviors such as hostility, pacing, non-compliance, and verbal aggression.

Initial Evaluation

Severity Assessment: Determine the severity of agitation and prioritize reversible causes and life-threatening conditions.

Diagnostic Steps: Perform vital signs check, blood glucose levels, ECG, and a targeted medical screening exam.

Life Threats

Immediate Concerns: Identify and address immediate life threats such as hypoxia, hypoglycemia, trauma, and acute neurological emergencies.

Forming a Differential Prior to Treatment

Prioritization: Severe agitation requires immediate treatment to facilitate further evaluation and reduce risk of harm.

Physician/Staff Safety

Safety Measures: Ensure personal and team safety by maintaining a calm environment and preparing for potential violence.

Multimodal Approach

Self-check In: Physicians should mentally prepare and approach the situation calmly to ensure effective management.

Verbal De-escalation: Use techniques focused on safety, therapeutic alliance, and patient autonomy to manage agitation non-pharmacologically.

Medication Administration

Oral/Sublingual Medications: Consider oral medications for less severe cases to maintain patient autonomy and avoid invasive procedures.

IM or IV Medications: Use intramuscular or intravenous medications for rapid control in severe cases.

Specific Medication Regimens

PO Regimens:

Medications: Antipsychotics like Zyprexa (olanzapine) 5-10 mg, benzodiazepines like Ativan (lorazepam) 1-2 mg.

Benefits: Empower patients with a sense of autonomy, avoid injection-related trauma.


Olanzapine: Onset in 15-45 minutes, peak effect in 1-2 hours, duration 12-24 hours.

Lorazepam: Onset in 30-60 minutes, peak effect in 2 hours, duration 6-8 hours.

IV/IM Regimens:

Medications: Droperidol, haloperidol, midazolam, ketamine.

ACEP 2023 Guidelines: Recommend droperidol with midazolam or an atypical antipsychotic for severe agitation.

Pharmacokinetics (IM):

Haloperidol: IM onset in 15, time to sedation ~25 minutes, can last for 2 hours

Droperidol: IM onset in 5-10 minutes, duration 2-4 hours but can last as long as 12 hours

Midazolam: IM onset ~15 minutes, , duration 20 minutes – 2 hours.

Lorazepam: IM onset ~15-30 minutes, , duration up to 3 hours

Ketamine: IM onset in ~5 minutes, duration 5-30 minutes.

Special Situations

Elderly/Dementia: Optimize environment, use non-pharmacologic measures, avoid benzodiazepines to reduce delirium risk.

Parkinson’s Disease: Avoid antipsychotics that can precipitate a Parkinsonian crisis.

Autism/Pediatrics: Engage caregivers, create a calming environment, avoid aggressive measures.

Alcohol Withdrawal: Utilize benzodiazepines and phenobarbital.

Re-dosing and Physical Restraints

Re-dosing: Use the lowest effective dose, consider continuous monitoring, and reassess frequently.

Physical Restraints: Employ as a last resort, ensuring close monitoring for any adverse effects.

Final Points

Clinical Leadership: Physicians should lead with clear communication, planning, and support for the team.

Continuous Learning: Regular debriefing and assessment after each incident to improve future responses.


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