Abstract
A 32-year-old male with a past history of paranoid schizophrenia and methamphetamine use presents to the emergency department requesting help. He is vague in his requests for help and seems paranoid about staff harming him. He is not taking his psychiatric medication. He is directable in triage, but after being placed into a room begins to escalate. By the time the physician and nurse go to see him, he attempts to strike the physician. He is talking loudly and breaks a portable computer. Security must be called immediately to the bedside.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of great importance
Powney MJ, Adams CE, Jones H. Haloperidol for psychosis-induced aggression or agitation (rapid tranquillisation). Cochrane Database Syst Rev. 2012;11:CD009377. doi:10.1002/14651858.CD009377.pub2.
• Wilson MP, Pepper D, Currier GW, Holloman GH, Feifel D. The psychopharmacology of agitation: Consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West JEM. 2012;XIII(1):26–34. This reference provides the AAEP consensus guidelines for appropriate medication use in agitated patients.
Zeller SL, Wilson MP. Management of agitation. Paradigm. 2015; 12–5.
Holloman GH, Zeller SL. Overview of project BETA: best practices in evaluation and treatment of agitation. West J Emerg Med. 2012;13(1):1–2.
• Nordstrom K, Zun LS, Wilson MP, et al. Medical evaluation and triage of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup Journal Issue. West J Emerg Med. 2012;13(1):3–10. This reference provides the AAEP consensus guidelines for appropriate medical workup of an agitated patient.
Vilke GM, Wilson MP. Agitation: what every emergency physician should know. Emerg Med Rep. 2009;30(19):233–44.
Zeller SL, Holloman GH, Wilson MP. Management of agitation, chapter in section 10. In: Tasman A, Lieberman JA, Kay J, First MB, Riba MB, editors. Emergency psychiatry and violence. Psychiatry. 4th ed. Oxford: Wiley Publishing; 2014.
Kansagra SM, Rao SR, Sullivan AF, Gordon JA, Magid DJ, Kaushal R, Camargo CA Jr, Blumenthal D. A survey of workplace violence across 65 US emergency departments. Acad Emerg Med. 2008;15:1268–74.
Anglin DD, Kyriacou N, et al. Residents’ perspectives on violence and personal safety in the emergency department. Ann Emerg Med. 1994;23(5):1082–4.
Emergency Nurses Association Institute for Nursing Research: emergency department violence surveillance study. 2015. https://www.ena.org/practice-research/research/Documents/ENAEDVSReportNovember2011.pdf. Accessed 25 Sept 2015.
Zeller SL, Rhoades RW. Systematic review of assessment measures and pharmacologic treatments for agitation. Clin Therapeut. 2010;32(3):403–25.
Wilson MP, Minassian A, Bahramzi M, Campillo A, Vilke GM. Despite expert recommendations, second-generation antipsychotics are not often prescribed in the emergency department. J Emerg Med. 2014;46(6):808–13.
Campillo A, Castillo E, Vilke GM, Hopper A, Ryan V, Wilson MP. First generation antipsychotics are still preferred in the emergency department but are often not administered with adjunctive medications. J Emerg Med. (in press).
Marco CA, Vaughan J. Emergency management of agitation in schizophrenia. Am J Emerg Med. 2005;23:767–76.
Marder SR. A review of agitation in mental illness: treatment guidelines and current therapies. J Clin Psychiatry. 2006;67(suppl 10):13–21.
Richmond JS, Berlin JS, Fishkind A, Holloman GH, Zeller SL, Wilson MP, Rifai MA, Ng AT. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;XIII(1):17–25.
Isbister GK. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010;56:392–401.
Wilson MP, Sloane C. Chemical restraints, physical restraints, and other demonstrations of force. In: Jesus J, Rosen P, Adams J, Derse A, Wolfe R, Grossman S, editors. Ethical problems in emergency medicine: a discussion-based review. Oxford: Wiley; 2012. p. 139–48.
Tolia V, Wilson MP. The medical clearance process for psychiatric patients presenting acutely to emergency departments. In: Zun LS, Chepenik LG, Mallory MNS, editors. Behavioral emergencies: a handbook for emergency physicians. Cambridge: Cambridge University Press; 2013. p. 19–24.
Huf G, Alexander J, Allen MH, Raveendran NS. Haloperidol plus promethazine for psychosis-induced aggression. Cochrane Database Syst Rev. 2009;3:CD005146. doi:10.1002/14651858.CD005146.pub2.
Gault TI, Gray SM, Vilke GM, Wilson MP. Graded Evidence-based Medicine Summaries for the Journal of Emergency Medicine (GEMS for JEM): are oral medications effective in the management of acute agitation? J Emerg Med. 2012;43(5):854–9.
•• Currier GW, Chou JCY, Feifel D, Bossie CA, Turkoz I, Mahmoud RA, Gharabawi GM. Acute treatment of psychotic agitation: a randomized comparison of oral treatment with risperidone and lorazepam versus intramuscular treatment with haloperidol and lorazepam. J Clin Psychiatry. 2004;65:386–94. This reference provides some of the strongest evidence to date that oral medication is useful in an emergent setting.
Wilson MP, Chen N, Vilke GM, Castillo EM, MacDonald KS, Minassian A. Olanzapine in ED patients: differential effects on oxygenation in patients with alcohol intoxication. Am J Emerg Med. 2012;30:1196–201.
Currier GW, Allen MH. Physical and chemical restraint in the psychiatric emergency service. Psychiatr Serv. 2000;52(6):717–9.
Lavoie FW. Consent, involuntary treatment, and the use of force in an urban emergency department. Ann Emerg Med. 1992;21:25–32.
Weiss AP, Chang G, Rauch SL, Smallwood JA, Schechter M, Kosowsky J, et al. Patient and practice-related determinants of emergency department length of stay for patients with psychiatric illness. Ann Emerg Med. 2012;60(2):162–71.
D’Onofrio G, Becker B, Woolard RH. The impact of alcohol, tobacco, and other drug use and abuse in the emergency department. Emerg Med Clin N Am. 2006;24:925–67.
Martel M, Sterzinger A, Miner J, Clinton J, Biros M. Management of acute undifferentiated agitation in the emergency department: a randomized double-blind trial of droperidol, ziprasidone, and midazolam. Acad Emerg Med. 2005;12(12):1167–72.
Nobay F, Simon BC, Levitt MA, Dresden GM. A prospective, double-blind, randomized trial of midazolam versus haloperidol versus lorazepam in the chemical restraint of violent and severely agitated patients. Acad Emerg Med. 2004;11:744–9.
Knott JC, Taylor DM, Castle DJ. Randomized clinical trial comparing intravenous midazolam and droperidol for sedation of the acutely agitated patient in the emergency department. Ann Emerg Med. 2006;47(1):61–7.
Author information
Authors and Affiliations
Corresponding author
Additional information
This article is part of the Topical Collection on Behavioral Health.
Rights and permissions
About this article
Cite this article
Wilson, M.P., Nordstrom, K. & Vilke, G.M. The Agitated Patient in the Emergency Department. Curr Emerg Hosp Med Rep 3, 188–194 (2015). https://doi.org/10.1007/s40138-015-0087-5
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40138-015-0087-5