The management of agitation in the ED can be a distressing experience. The first time you encounter an upset, angry, or violent patient can feel overwhelming and uncomfortable. Rapid decision-making is often necessary; decisions may be based on limited information during an unfolding situation. Arming yourself with basic guidelines, a supportive team, and an opportunity for debrief can be helpful in the management of an unstable situation.
While data regarding prevalence is limited, many residents and medical students encounter agitated patients early in their training. A 2011 survey of emergency residents and attending physicians found that 78% experienced some form of workplace violence in the preceding 12 months . For a variety of reasons – wait times, intoxicants, stressful situations, and acute medical concerns – emergency department workers experience significant rates of physical and verbal abuse .
Before a discussion of practical guidelines, it’s important to keep the following in mind: violence and agitation has a broad differential and patients may be in legitimate physical or emotional distress. Aggressive behaviours, such as yelling, spitting, hitting, and biting are means of communicating discomfort and the fact that, for whatever reason, this patient is not okay. This is particularly true of patients with developmental delays, who may be unable to articulate their concerns eloquently. To that end, keeping an open mind to medical issues that may be underlying a patient’s presentation is of the utmost importance..
Agitated behavior, like many things in medicine, exists on a spectrum.
Table 1: Stages of Agitation and Response .
|Level of Agitation||Response|
|1. Agitation/Anxiety||1. Safety|
|2. Verbal Threats||2. Verbal De-escalation|
|3. Physical Threats||3. Physical Intervention|
|4. Resolution||4. Medication|
Level 1: Agitation and Safety
At this stage, the goal is to ensure that the environment is safe. While not always possible in a busy emergency department, a quiet, low-stimulation environment with weighted furniture and objects that cannot be thrown or weaponized is ideal. Remove stethoscopes, lanyards and other neckwear that can be used to choke. Increase space between you and the patient, and position yourself so that both you and the patient have access to an escape route.
If possible, observe the patient’s behavior before the interaction. Read previous notes and assessments to determine if there is a history of violent behaviour. Determine if there is a language barrier. Talk to nursing staff who have already interacted with the patient. Has the patient been searched, or could they be carrying a weapon? Do not interview potentially dangerous patients alone or in an area where nobody can see or hear you.
Early signs of agitation include pacing, clenched fists, and increased volume and vocalization. It is important to recognize these early signs of behavioural escalation and intervene. Trust your instincts: if you experience discomfort, have another team member or security available as backup. Simply having security present, or even “around and visible” can prevent escalation of violent behaviour.
During your assessment, keep in mind that a patient may have been waiting a long time to be seen, and apologizing for the delay is an easy way to establish rapport. Convey that you are here to help and they are in a safe space. Do not approach quickly or from behind, staying in the patient’s line of sight. If the patient is not capable of reasoning with you because of substance use, psychosis, or cognitive concerns you may need to be more directive with your words. Finally, kindly asking the patient to be seated so that you can discuss their needs may be helpful.
Level 2: Verbal Threats and De-escalation
Verbal de-escalation involves engagement of your patient, establishing a collaborative relationship, and talking them down from an agitated state. Use verbal de-escalation to reduce the risk of harm to yourself, your team, and your patient . The following consensus principles were developed as part of Project BETA (Best Practices in Evaluation and Treatment of Agitation).
|Table 2: Ten domains of de-escalation .|
|1. Respect Personal Space|
|2. Do not be provocative|
|3. Establish verbal contact|
|4. Be concise|
|5. Identify wants and feelings|
|6. Listen closely to what the patient is saying|
|7. Agree or agree to disagree|
|8. Lay down the law and set clear limits|
|9. Offer choices and optimism|
|10. Debrief the patient and staff|
In fairness, you’re not going to be able to recite this in your head with an agitated patient threatening you and your team. Knowing general principles and acknowledging your own fear, anger, and emotional reaction is key in managing agitated patients.
Identify what the patient wants. Are they angry or sad because a need is not being met, or fearful of something bad happening? A psychotic patient may have bizarre or paranoid delusions that are nonsensical. Imagining that these delusions are true will help you to understand why the patient is afraid and what they need to feel safe . Keep a safe distance and open stance so to not appear threatening or confrontational (hands visible, feet shoulder width apart, angled slightly to the side). Do not argue with the patient; never respond to an insult or raise your voice. It may even be helpful to lower your voice, as the patient is usually interested in what you have to say and may settle to listen. Keep sentences short. If there are multiple team members in the room, have one team lead the discussion.
Firmly and gently establish that you are in charge and you are uncomfortable or frightened by the patients behaviour. Ask direct questions about the possibility of violence. A patient may angrily demand to leave. The sense of powerlessness may be helped if you give choices, and you can offer a patient medication to help them feel calm. A patient with a psychotic history may know that an injection helps them feel in control and may, on occasion, ask for it.
|Table 3: Helpful statements.|
|“I feel frightened when you are pacing – if you were able to sit down I bet I could help understand what is troubling you.”|
|“I can see you’re quite uncomfortable – may I offer you some medication to help you feel calm?”|
|“Mr. X, I need to give you some medication to help you stay in control – would you prefer to take a pill or a needle?”|
|“Mr. X, you are having a psychiatric emergency. I’m going to give you some emergency medication to help you feel calm and we will be here to keep you safe every step of the way”.|
Level 3: Physical Threats and Intervention
Physical threats require physical intervention. Do not attempt to engage the patient. Security and/or police must be involved, which is why it may be helpful to have them present in advance. Restraint techniques will not be discussed here, but briefly: 
- Physical restraint can be very unpleasant, and patients may be in significant distress. Physical restraint must be therapeutic, and not punitive.
- Choose the least intrusive restraint that is sufficient for resolving the threat.
- Continue to use verbal de-escalation and reassurance..
- Chemical restraint should accompany physical restraint.
- Restraints can be physically dangerous, and frequent monitoring and reassessment with a plan to reduce restraint is a necessity.
Level 4: Resolution and Medication
Broadly, pharmacologic management of agitation includes the use of benzodiazepines, antipsychotics, or both. Side effects of these medications are common and include extrapyramidal symptoms [EPS], QTc prolongation, and neuroleptic malignant syndrome [NMS]. Benzodiazepines are less likely to cause EPS but may exacerbate delirium and sedation. They may lead to respiratory depression and should be used with caution in patients with decreased pulmonary reserve . For dosing, see the algorithm for pharmacologic management in the Wilson Paper .
Mild agitation that is not responding well to verbal de-escalation can often be managed with a low dose of oral or sub-lingual medication if a patient assents. In severe agitation where safety of your team is compromised, consider parenteral route administration.
Consider the etiology:
In agitated delirium, it is important to determine if ethanol or benzodiazepine withdrawal is suspected. In non-withdrawal delirium, benzodiazepines can exacerbate confusion or induce delirium, and treatment with antipsychotics is preferable. Patients at risk for delirium may also be at increased risk of extrapyramidal symptoms (EPS) and an atypical antipsychotic with lower D2 receptor blockade (loxapine, olanzapine) can be used first. Notably, withdrawal from these substances is life threatening and must be managed with benzodiazepines.
If you suspect ethanol intoxication, avoid further CNS depression; an antipsychotic can be helpful. Haloperidol has a low anticholinergic burden and is considered relatively non-sedating. Patients may calm to a point where they are able to sleep.
In patients with a known history of psychosis, an antipsychotic is often helpful. Atypical agents, such as olanzapine, can be more sedating. Haldoperidol and risperidone can be used, but a benzodiazepine may need to be added to increase sedation and reduce EPS. Olanzapine and lorazepam cannot be given together intramuscularly due to an increased risk of hypotension.
Rapid tranquillization is defined as – well, it’s basically what it sounds like. Different historical schemes have been described, with patients receiving over 100 milligrams of haloperidol in some settings. Standard practice is now to use a combination of antipsychotic and a benzodiazepine, with additional benzodiazepine later as needed.
This is where the “5 and 2” combination comes from, as haloperidol (5mg) and lorazepam (2mg) can be mixed in the same syringe. This can be used q30 minutes-2 hours to a maximum of 20mg of haloperidol per day.  The onset of action for IM lorazepam is 10 minutes, and haloperidol is 30-60 minutes, so physical restraints may be needed in the interim. See table 4 for pharmacokinetic properties of medications used in chemical restraints.
Table 4: Pharmacokinetics of antipsychotics [8, 10].
|Initial Dose (mg)||Onset (min)||TMax (hr)||T ½ (hr)||Repeat||Max Dose (24 hr, mg)|
|Lorazepam (SL)||2||10||20-30 min.||12-15||2||12|
|Olanzapine||10||15-45||15-45 min.||30||q20 min.||30|
|Haloperidol||2-5||30-60||STAT||12-36||4||10 (NB. QTc prolongation)|
Violence is a growing concern in busy emergency departments. You can respond effectively by understanding basic approaches. A team debrief following each episode will aid the process of learning and improvement.
Keep the following points in mind:
- Agitation has a broad differential and may be a patient’s only means of communicating physical distress.
- Recognizing agitation early and de-escalating the situation is easier and less distressing than dealing with a physically violent patient. Prevention is essential.
- Do not hesitate to have security or another team member present during your assessment.
- Match the level of response with the level of agitation. Use physical restraint if necessary to protect yourself and your team, but the least amount possible and with close monitoring reassessment. Chemical restraints should be used in conjunction with physical restraint.
For another take on the agitated patient, be sure to check out previous BoringEM posts on this topic: The Agitated Patient in the ED: Assessment & Mild Agitation and The Agitated Patient in the ED: Moderate & Severe Agitation.[bg_faq_start]
- Behnam, M. et al. (2011). Violence in the emergency department: a national survey of emergency medicine residents and attending physicians. Journal of Emergency Medicine, May; 40(5):565-79. doi: 10.1016/j.jemermed.2009.11.007.
- Taylor, J. L. and Rew, L. (2011). A systematic review of the literature: workplace violence in the emergency department. Journal of Clinical Nursing, 20: 1072–1085. doi: 10.1111/j.1365-2702.2010.03342.x
- Lofchy, J. S. (2010), Chapter 15: Emergency Assessment In: Goldbloom, D. S. (2010). Psychiatric Clinic Skills, Revised 1st Ed. Toronto, ON: Center for Addiction and Mental Health
- Richmond, J. S. Berlin, J. S. Fishkind, A. B. Holloman, G. H. Zeller, S. L. Wilson, M. P. Aly Rifai, M. Ng, A. T. (2012). Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. Western Journal of Emergency Medicine, Vol. 9(1) 17-25
- Fishkind, A. (2002). Calming agitation with words, not drugs: 10 commandments for safety. Current Psych. 2002;1(4). Available at: http://www. currentpsychiatry.com/pdf/0104/0104_Fishkind.pdf.
- Elgin, S. H. (1999) Language in Emergency Medicine: A Verbal Self-Defense Handbook. Bloomington, IN: XLibris Corporation
- Knox, D. K. Holloman, G. H. Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup. Western Journal of Emergency Medicine, Vol. 9(1) 35-40
- Wilson, M. P. Pepper, D. Currier, G. W. Holloman, G. H. Feifel, D. (2012). The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. Western Journal of Emergency Medicine, Vol. 9(1) 26-34
- Zacher, J. L. Roche-Desilets, J. (2005) Hypotension secondary to the combination of intramuscular olanzapine and intramuscular lorazepam. Journal of Clinical Psychiatry, Vol. 66(12):1614-1615
- Marder, S. R. (2006). A review of agitation in mental illness: treatment guidelines and current therapies. Journal of Clinical Psychiatry, Vol. 67 Suppl. 10:13-21
Reviewing with the Staff | Dr. Jodi Lofchy MD FRCPC
Dr. Lofchy is the Director Psychiatry Emergency Services, UHN; Associate Professor, Department of Psychiatry, University of Toronto. She works at Toronto Western Hospital-University Health Network. On twitter she is: @jodilofchy
Managing the agitated patient in the ED is a challenging and often stressful aspect of emergency medicine. Dr. Fage has highlighted an approach to both verbal and pharmacologic intervention. There are new atypical antipsychotics on the horizon but our emergency repertoire needs to select for agents with short onsets of action and multiple routes available – ideally IM routes for the extremely agitated patient. If sedation is a goal, knowing when to add a benzodiazepine (and when not to!) is important.
Primary prevention is key; to work in a safe environment, with a trained team and psychiatric consultants nearby is ideal. We realize that not all residency programs offer this education and we are working to standardize an approach to teaching about agitation to all trainees.