In this episode, I’ll discuss the ACEP clinical policy on adult patients presenting to the ED with severe agitation.
The issue of an extremely agitated patient in an emergency department has significant consequences for all present in the ED. The agitated patient is usually at risk of harming themselves and they cannot receive care for their underlying condition until the agitation is controlled, the staff are often at risk of harm from the patient, and the tremendous amount of clinical resources that must be mobilized to deal with a severely agitated patient are often drawn from other patient care activities, leaving surrounding patients with less attention until the agitation is resolved.
The American College of Emergency Medicine recently published a clinical policy focused on the following critical question:
Is there a superior parenteral medication or combination of medications for the acute management of adult out-of-hospital or emergency department patients with severe agitation?
The policy authors were unable to identify any high-quality class 1 randomized controlled trials or meta-analyses of randomized trials to base an answer to this question on, so no level A recommendations could be offered. However the policy authors were able to make some level B recommendations based on moderate scientific evidence and level C recommendations based on their expert consensus.
The level B recommendations are:
For more rapid and efficacious treatment of severe agitation in the emergency department, use a combination of droperidol and midazolam or an atypical antipsychotic in combination with midazolam. If a single agent must be administered, use droperidol or an atypical antipsychotic due to the adverse effect profile of midazolam alone.
and
For efficacious treatment of severe agitation in the emergency department, use the above agents as described or haloperidol alone or in combination with lorazepam.
The level C recommendations are:
In situations where safety of the patient, bystanders, or staff is a concern, consider ketamine (intravenous or intramuscular) to rapidly treat severe agitation in the ED (Consensus recommendation).
In addition, the authors could make no recommendations on what the best strategy for dealing with severe agitation in the out-of-hospital setting is nor could they give a recommendation on the use of specific agents in patients above the age of 65 years.
While the policy authors did not include medication doses in their recommendations, the text of the policy does summarize the doses of medications used in the studies the authors relied on to make their recommendations. Commonly studied regimens that match the recommendations of the policy authors were 5-mg intravenous droperidol plus 5-mg intravenous midazolam, or 10-mg intravenous droperidol alone, or 10-mg intravenous olanzapine alone, or 5-mg intravenous olanzapine plus 5-mg intravenous midazolam. Unfortunately IV access is not always possible in severely agitated patients and there were fewer high quality studies that used the intramuscular route so in patients without IV access there is less certainty which combination is ideal.
Regarding ketamine, the authors acknowledge that the literature supporting its use is “uniformly flawed” and this is why it only appears in a level C recommendation for a specific type of patient. The expert opinion of the policy authors is that although ketamine has a non-zero risk of laryngospasm, respiratory depression, and need for intubation, its reliably fast action outweighs these risks “in situations where the safety of the patient, bystanders, and staff necessitate a more rapid and reliable treatment of agitation than provided by other therapeutic options.”
Members of my Hospital Pharmacy Academy have access to practical training on the treatment of severe agitation in ED patients as well as agitated delirium in ICU patients. You can get immediate access to this and hundreds of other trainings and resources to help in your practice at pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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