Participants 396
Background
Prevalence
Violence in the Emergency Department
- 12 million visits across Emergency Departments (ED) each year are related to mental health disorders
- Incidence of violence in the hospital is highest in the ED
- 71% of ED providers have witnessed assault in the ED
- 97% of assailants are patients in the ED
- 25% of ED staff feel safe at work “sometimes, rarely, or never”
- Post-traumatic stress disorder, mood disorders, feeling unsafe at work
Definitions
- Agitation
- Extreme form of arousal associated with ↑ verbal/motor activity
- Screaming, thrashing without regard for futility, pain, or fatigue
- Extreme form of arousal associated with ↑ verbal/motor activity
Also known as excited delirium
Causes
Medical
- Intracranial infection
- Trauma
- Neuroleptic malignant syndrome
- Serotonin syndrome
- Thyrotoxicosis
- Hypoxia
- Hyperthermia
- Hypoglycemia
Toxicologic
- Sympathomimetic
- Alcohol intoxication
Psychiatric
Exacerbation of psychiatric disorder
Challenges
- Not a “one-size fits all” disease state
- The wrong treatment can worsen/kill the patient
- Requires nuance in therapy, rapid control of the situation, resuscitation
Undesired Outcomes
| Trauma from restraints | Asphyxiation from prone positioning | Aspiration |
| Rhabdomyolysis | TdP from QTc prolongation | Lactic acidosis |
| Cardiac arrest from sympathetic surge | Takotsubo cardiomyopathy | Unnecessary intubation |
Clinical Trials
FDA has determined that agitated/intoxicated ED patients are not eligible from exception from informed consent by either them or their family members
Beyond 5 + 2…
“The combination of a neuroleptic, haloperidol (5 mg) and a benzodiazepine anxiolytic, lorazepam (2-4 mg) is often used and may be more effective in combination than either single agent used alone. Repeat dosing at 30-45 min if symptoms are not under control…”
Emergency Medicine – A Comprehensive Study Guide. Tintinalli JE, et al. American College of Emergency Physicians. 6th ed.
“Rapid tranquilization involves …haloperidol 5-10 mg intramuscularly or intravenously…Benzodiazepines are helpful adjuncts…in providing rapid tranquilization, particularly for combativeness or severe agitation. Lorazepam 1-2 mg is frequently mixed with haloperidol 5 mg in the same syringe and administered intramuscularly or intravenously for this purpose…
Rosen’s Emergency Medicine – Concepts and Clinical Practice. Marx JA, et al. Elsevier Saunders. 8th Ed.
Ideal Medication
