Agitation Management


Agitation Management, Calming the Agitated Patient, Verbal De-escalation, Verbal Deescalation

  • Management
  • General Approach in All Cases
  1. See Agitated Delirium
  2. See Calming the Agitated Patient
  3. See Physical Restraint
  4. Isolate patient with a safe room (with minimal stimulation)
    1. Be prepared with strong, large, burly security guards at the ready in case of dangerous Agitation
      1. Make use of facility security, and police as needed
      2. At least 5 responders should be present if patient requires restraint
    2. Remove all unnnecessary equipment from the room
    3. Remove all items that could be used as weapons
    4. Staff should maintain a safe distance from patient until patient contained or adequate help available
      1. Maintain closest access to door for safe exit
  5. Consider alternatives to sedation or restraints (see Verbal Deescalation below)
  6. Approach Agitated Patients with plans for each of three presentations (see below)
    1. Agitated but cooperative
    2. Disruptive, but not dangerous
    3. Agitated Delirium
  • Management
  • Verbal De-escalation approach (for agitated, but non-dangerous patients)
  1. One person initiates de-escalation
  2. Maintain a safe distance for both patient and provider (2 arms lengths)
  3. Stand with hands visible and at an angle to patient (less confrontational)
  4. Introduce yourself and call the patient by their preferred name
  5. Maintain a calm voice and ask open-ended questions
  6. Speak in clear, concise sentences and use simple vocabulary
  7. Tell the patient you wish to help them
  8. Agree with the patient when possible
  9. Listen patiently and approach with kind demeanor
  10. Avoid a confrontational, demeaning, coersive approach
  11. Do not threaten the patient (e.g. with restraints)
  12. Set clear limits of what behaviors will not be tolerated (e.g. assault)
  13. Tell the patient that their behavior is frightening to the staff and others
  1. Assign a volunteer to talk to the patient and distract them
  2. Provide a calm, quieter, comfortable setting with dimmed lights to help de-escalate Agitation
  3. Offer food, drink, warm blanket, phone call and other comforts to those able to reason
  4. Offer Nicotine Replacement as needed
  5. Benzodiazepines for Alcohol Withdrawal Protocol or anxiety
  6. Apologize for delays (in some cases, days for boarding psychiatric patients)
  7. Express empathy and compassion
  • Management
  • Disruptive patients who are not dangerous (agitated drunk, acute Psychosis)
  1. See Sedation of the Violent Patient
  2. Have staff available in case of escalation and need for Physical Restraint
  3. Consider non-medication options used above for cooperative patients
  4. Common calming agents (adult doses), primarily if concurrent Psychosis (see descriptions below)
    1. Midazolam 5 mg IM
    2. Olanzapine (Zyprexa) 10 mg ODT or IM
    3. Ziprasidone (Geodon) 10-20 mg IM
    4. Risperidone 2 mg orally
    5. Haldol 5 mg with Midazolam 2 mg and Benadryl 25 mg IM (may be repeated once in 30 minutes)
      1. Alcohol Withdrawal (B52)
    6. Droperidol 5 mg with Midazolam 2 mg IM (and may be repeated once in 3-5 minutes)
  1. See Agitated Delirium
  2. Physical Restraint allows access to patient for IM Injection
    1. Requires at least 5 strong responders (one for each limb and one for head)
    2. Consider applying an oxygen mask at face to block spit and supply oxygen
  3. Intramuscular Chemical Restraint
    1. See Chemical Restraint
    2. Ketamine 2 mg IV or 5 mg IM
    3. Allows for Intravenous Access and maintained chemical sedation
    4. Then administer Benzodiazepines after IV Access is available
  4. Consider Rapid Sequence Induction and intubation for a sick or injured, Agitated Patient
  • References
  1. Shanks, Ginsburg and Leaf (2023) Crit Dec Emerg Med 37(9): 4-10
  2. Strayer in Herbert (2017) EM:Rap 17(6):10-11