TOXIDome's Approach to the Agitated Patient

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Pharmacologic Interventions for Undifferentiated Agitation 
 
Introduction

• Agitated delirium also known as excited delirium syndrome – is a mental state characterized by violent behavior, speech changes, acute disorientation and abnormal thought process. 

 
Differential 

• Agitated delirium in the ED has many etiologies, must consider a very broad differential
  • Psychiatric - Acute psychosis, paranoia
  • Neurologic – intracranial pathology, encephalitis, idiopathic malignant catatonia, 
  • Medical – hypoxia, sepsis, meningoencephalitis, thyroid storm, pheochromocytoma, hypoglycemia, heat stroke
  • Trauma – SDH, SAH, epidural hematoma
  • And of course…Toxicology –sympathomimetic toxicity, anticholinergic syndrome, alcohol or benzodiazepine withdrawal syndromes, salicylate poisoning, serotonin syndrome, neuromalignant syndrome, hallucinogens, malignant hyperthermia
  • Others

 
Initial Approach

• Attempt to elicit history and physical exam, although may not be feasible
• Verbal redirection and de-escalation should be attempted first
• Physical exam and history can clue you in to potential ingestions/toxidromes

 
Pharmacologic Interventions

• Benzodiazepines and antipsychotics are the drug classes of choice
• Must consider onset of action, duration and route when making decision around these medications
• Tradition use of 5mg of IM haloperidol and 2mg of IM lorazepam may not always be the best choice as their onset of action may be delayed and as long as 20-40 minutes
• Be aware of repeat dosing (stacking of doses), may lead to respiratory depression
• Consider 5mg IM midazolam, onset usually 1-3 minutes, shorter acting and 2mg lorazepam
• Must consider side effects of antipsychotics, including QTc prolongation 

 
Ketamine for Acute Agitation

• Emerging evidence supports ketamine for this indication
• Dose: 4-6mg/kg IM
• Consider in patients that may have contraindications for other drug classes 

 
Core Concepts

• Keep your differential BROAD
• Attempt to obtain history and physical exam as this will guide your management
• Consider route, onset of action and duration of the various pharmaceutical options 
• Traditional 5mg IM Haldol and 2mg IM Ativan may not be best option given delayed onset of action
• Recommendation for fastest control is 5mg midazolam and 2mg lorazepam or ketamine IM