We had a big day on the consult service with Clinical Problems in Consultation Psychiatry (CPCP) presentations yesterday including medical student Amy Walz’s on obesity and antidepressants and psychiatry resident Dr. Matthew Klein’s on Psychiatry Emergency Medications for Agitated Patients, which is the subject of today’s post.
When we say “managing agitation,” we mean that an atmosphere of safety should begin with an attitude of respect between health care givers and patients.
Dr. Klein’s treatment is thorough and up-to-date. It’s also a handy reference for those of us who are involved in the management of violent patients. These situations happen in emergency rooms, intensive care units, general hospital units, as well as psychiatric wards across the country.
They also happen in jails and prisons, which was the subject of Dr. George Dawson’s recent post on what’s happening after a new law was passed in Minnesota requiring patients with psychiatric illness to be transferred from jail to the state psychiatric facility at Anoka in no more than 48 hours. Problems with violent incidents have increased in frequency.
Obviously there’s more to managing agitation besides psychotropic drugs, verbal deescalation being another approach. We have a Code Green team here that is specifically assigned to manage potentially violent situations with patients, using nonviolent methods.
A key concept to internalize right away is to always think about what could be causing the agitation. It could be primary psychiatric illness, delirium, pain, long wait times in crowded emergency rooms, and more. A history of previous violent episodes continues to be the best predictor for future violence.
A prominent psychiatrist who is an outstanding educator recently advocated banning haldol, which some of you remember and about which I wrote a couple of posts and ran a quick poll. Suffice it to say that, for now, haldol will remain a safe and effective tool to manage violent agitation.
Olanzapine might seem to be the best choice for managing agitation based on Dr. Klein’s excellent review. However, it must not be used within a couple of hours of the administration of benzodiazepines, which can be difficult to predict given the common use of this sedative initially by many physicians before psychiatric consultants are called, especially in Code Green crises. In the elderly demented population, the anticholinergic effect could actually worsen agitation.
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