Causes of Agitation in Patients

Agitated Patients

• Agitated patients may present with verbally and/or physically threatening behavior, and may be restless, crying, confused, and appear out of control.

Causes of Agitation

• Agitated behavior may be related to mental illness.
• Agitation may be caused by drug use, particularly stimulants such as cocaine.
• Alcohol withdrawal may contribute to agitation.
• Head trauma may also contribute to agitation.

Excited Delirium Syndrome

• Agitated patients may be experiencing excited delirium syndrome.
• It is important to evaluate agitated patients for possible excited delirium syndrome when managing their care.

Characteristics of Excited Delirium Syndrome

• Patients may exhibit extremely aggressive or violent behavior.
• They may display constant physical activity, appearing restless.
• Individuals may be unresponsive to the presence of authorities, such as police or firefighters.
• They may be attracted to bright lights, loud sounds, and their own reflections in glass or mirrors.
• Patients may be naked or near naked.
• Rapid breathing is a common symptom.
• Profuse sweating is a characteristic of the syndrome.
• Individuals may show little response to pain.
• They may exhibit superhuman strength.
• Patients may feel hot to the touch.

TASER Use in Law Enforcement

• Law enforcement agencies use TASER as a non-lethal method to temporarily incapacitate individuals who exhibit threatening behavior.

Medical Considerations for TASERed Patients

• When approaching a patient who has been TASERed, evaluate them for possible excited delirium syndrome.
• Patients with excited delirium syndrome typically continue to be agitated again after being TASERed.

Treatment Approach

• Ensure adequate personnel are present to handle the situation and physically manage the patient if necessary.
• Secure the scene and implement universal precautions to maintain safety.
• Calm the patient by speaking softly and non-threateningly, avoiding loud noises and sudden movements.

Restraint Methods

• Use the least restrictive method of restraint to ensure patient safety and well-being.
• Prioritize provider safety when dealing with a patient exhibiting inappropriate behavior.
• Allow patients to correct their behavior, if possible, before using restraints.

Restraint Techniques

• Use restraints only when unable to calm the patient and they pose a threat to themselves or others.
• Avoid placing the patient in a prone position (face down) when using restraints.
• Use a supine or recovery position instead.

Chemical Restraint

• Administer ketamine (4 mg/kg IM, maximum dose 400 mg) if chemical restraint is necessary.
• Ketamine can be administered in the mid-shaft anterolateral aspect of the thigh or the lateral deltoid muscle of the shoulder.
• Ketamine can be administered through clothing if necessary.

Managing Agitation or Aggression

• If patient becomes agitated or aggressive as ketamine effects wear off, or if ketamine is not available, alternative medications can be used.

Options for Vascular Access

• If vascular access is available:
  • Administer lorazepam (Ativan) 2mg IV slowly over 1 minute
  • Administer midazolam (Versed) 5mg IV

Options for No Vascular Access

• If vascular access is NOT available:
  • Administer lorazepam (Ativan) 2mg IM
  • Administer midazolam (Versed) 10mg IM or IntraNasal

Repeating Medication

• Both medications may be repeated in 3-5 minutes if indicated.

Monitoring and Treatment

• Monitor patient's cardiac rhythm, ETCO2, and SpO2 during treatment.
• Administer supplemental O2 if indicated by the patient's condition.
• Treat any medical complaints according to the appropriate protocol(s).
• Identify disrhythmias indicative of metabolic acidosis, such as a wide QRS and/or loss of P waves.
• Consider administering sodium bicarbonate, 1 mEq/kg IV/IO, if disrhythmias indicative of metabolic acidosis are present.

Agitated Patients and Excited Delirium Syndrome

• Agitated patients may be experiencing excited delirium syndrome, exhibiting verbally and/or physically threatening behavior, restlessness, confusion, and appearing out of control.
• Possible causes of agitated condition include mental illness, drug use (especially stimulants like cocaine), alcohol withdrawal, and head trauma.

Identifying Excited Delirium Syndrome

• Patients with excited delirium syndrome may demonstrate:
  • Extremely aggressive or violent behavior
  • Constant physical activity and restlessness
  • Unresponsiveness to police/fire presence
  • Attraction to bright lights, loud sounds, and their own reflections
  • Naked or near-naked state
  • Rapid breathing
  • Profuse sweating
  • Little response to pain
  • Superhuman strength
  • Hot to the touch

Treatment

• Ensure sufficient personnel on the scene to handle the situation and physically manage the patient if necessary.
• Secure the scene and use universal precautions.
• Attempt to calm the patient down using soft speech and non-threatening movements.
• Use the least restrictive method of restraint, prioritizing provider safety.
• If restraint is necessary, use a supine or recovery position, and avoid prone (face down) positioning.

Chemical Restraint

• Administer ketamine, 4 mg/kg IM (maximum dose 400 mg), if chemical restraint is indicated and available.
• Ketamine can be administered through clothing in the mid-shaft anteriolateral aspect of the thigh or the lateral deltoid muscle of the shoulder.

Alternative Medications

• If ketamine is not available or the patient becomes agitated as its effects wear off:
  • If vascular access is available:
    • Administer lorazepam (Ativan), 2 mg IV slowly over 1 minute
    • OR administer midazolam (Versed), 5 mg IV
  • If vascular access is not available:
    • Administer lorazepam (Ativan), 2 mg IM
    • OR administer midazolam (Versed), 10 mg IM / IntraNasal
• Repeat medications in 3-5 minutes if indicated.

Additional Care

• Perform Universal Initial Adult Patient Assessment / Care.
• Ensure a maintainable airway.
• Obtain a blood glucose level and treat with dextrose 50% (D50W) if indicated.
• Monitor cardiac rhythm, ETCO2, and SpO2, and give supplemental O2 if indicated.
• Treat any medical complaint per the appropriate protocol(s).
• Consider giving sodium bicarbonate, 1 mEq/kg IV/IO, if the patient exhibits disrhythmias indicative of metabolic acidosis.

Managing Agitated Patients with Excited Delirium

• If a patient is exhibiting signs of excited delirium and has a fever (temperature ≥ 104°F/40°C or feels hot to the touch), attempt to cool them down.

Cooling Measures

• Remove as much clothing as possible.
• Move the patient to a cooler environment or use a fan to blow on them.
• Apply ice packs to the neck, axillae, and groin areas if available.

Temperature Monitoring

• Take and document a baseline temperature before administering cold normal saline.
• Take and document a temperature at the time of patient transfer in the ED.

Medication Administration

• Establish vascular access and administer cold (34°F) normal saline, 30 mL/kg IV/IO (maximum 2 Liters).
• If Ativan or Versed have not been given, and the patient is shivering, administer midazolam (Versed), 5 mg IV/IO or 10 mg IM/IntraNasal.
• If the patient is agitated and/or in pain after midazolam, and systolic BP remains ≥ 90 mmHg, administer morphine sulfate, 5 mg IV/IO/IM.
• Morphine may be repeated every 5 minutes as needed, up to a maximum of 20 mg.