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    Management of agitated patient in the Emergency Department – Adult

    Other, Psychiatric and Behaviour, Special Populations

    Last Updated Apr 27, 2021
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    By Julian Marsden, Brenna Mackay


    Violence towards health care workers is unfortunately common.
    40% of all violence-related claims in BC are submitted by health care workers despite only making up 5% of the workforce.

    • Up to 50% of health care workers will experience violence during their careers.
    • Violence and agitation = behaviours &/or actions that can cause harm or injury to another person.
    • The manifestations of violence and agitation are diverse and depend on a combination of extrinsic (environment, provider attitudes, and behaviour) and intrinsic (medical conditions, personality characteristics, mental distress) factors.

    High-risk factors

    —associated with agitation and violence include:

      • Alcohol or drug use disorders.
      • Young age.
      • Male.
      • Personal history of violence.
      • Chronic pain.
      • Poor communication among staff.
      • Lack of privacy.

    Signs of impending violence

      • Angry demeanor.
      • Loud/aggressive speech.
      • Provocative behaviour.
      • Tense posturing.
      • Pacing or frequently changing body position.

    ☎ Call the police

    —immediately if:

      • Acts destructively (ie. hitting things or destroying equipment).
      • Is armed,
      • Makes verbal or physical threats that you do not have the resources (security) to contain,

    Recommended Treatment

    Created and adapted from references 2, 4, 5.

    Criteria For Hospital Admission

    • If an underlying psychiatric or medical condition has been identified and requires inpatient management.
    • Patients should be observed post-sedation for further assessment and monitoring.
      • Degree of sedation (Glasgow coma scale).
      • Vitals.
      • Pupils.
      • Blood glucose.
      • ECG rhythm.
      • Adverse effects of antipsychotic meds: Neuroleptic Malignant Syndrome (NMS), extrapyramidal symptoms, hyperprolactinemia, postural hypotension, serotonin syndrome (link between SGAs and serotonin syndrome).

    Observe patients in alcohol withdrawal

    1/20 people with withdrawal symptoms may experience delirium tremens (DT)—increased risk of heart attack, stroke, or death.

    Criteria For Close Observation And/or Consult

    Level of Observation

    —consider patient’s:

    • Current mental state.
    • Risk assessment.
    • Medications and side effects.

    Views of the patient:

      • Low-level intermittent observation = every 30-60 mins.
      • High-level intermittent observation = every 15-30 mins.
        • Use in patients where there is no immediate risk, but you suspect they could become violent or aggressive.
      • Continuous observation: if patient presents immediate threat.
      • Multiprofessional continuous observation: highest risk patients. Need to be within eyesight of 2 or 3 staff.

    Criteria For Safe Discharge Home

    • Consider discharge in patients where the underlying concern has resolved.

    Quality Of Evidence?


    Moderate: Recommendations come from clinical guidelines and articles, which are in relative agreement on the management of agitation in the Emergency Department.


    Related Information


    Reference List

    Relevant Resources


    View all Resources


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