Go back

INDEX

    Management of agitated patient in the Emergency Department – Adult

    Other, Psychiatric and Behaviour, Special Populations

    Last Reviewed on Apr 27, 2021
    Read Disclaimer
    By Julian Marsden,Brenna Mackay

    Context

    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?

    Justification

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

    Moderate

    Related Information

    OTHER RELEVANT INFORMATION

    Reference List

    Relevant Resources

    RELEVANT CLINICAL RESOURCES

    View all Resources

    RESOURCE AUTHOR(S)

    COMMENTS (0)

    Add public comment…