Ep 115 Emergency Management of the Agitated Patient

The podcast addresses the assessment and management of agitated patients in the emergency department, distinguishing between mild, moderate, and severe cases. It emphasizes that agitation is a symptom, not a diagnosis, and urges clinicians to identify underlying medical or psychiatric causes. Non-pharmacologic de-escalation techniques and the judicious use of physical restraints are discussed, alongside intramuscular ketamine, haloperidol, and midazolam as pharmacological options. Dr. David Barbic shares insights from his research, highlighting the need for thorough patient assessment and cautioning against a one-size-fits-all approach to ketamine dosing. The speakers also explore differences in managing agitation in elderly patients, advocating for avoiding benzodiazepines in this population.

Outlines

Part 1: Introduction, Clinical Context

Part 2: Categorization, Diagnosis

Part 3: De-escalation, Team Coordination

Part 4: Physical Restraints, Safety Protocols

Part 5: Pharmacological Interventions

Part 6: Medical Workup, Resuscitation

Part 7: Summary, Future Outlook

Sign in to continue reading, translating and more.

Continue

Emergency Medicine Cases

Part 1: Introduction, Clinical Context

The Complexities and Dangers of Managing Agitated Patients in the ED

Initial Case Presentation: A Violent Young Man in the ED

Prioritizing Medical Assessment Over Psychiatric Assumptions in Agitated Patients

Part 2: Categorization, Diagnosis

Categorizing Agitation: Mild, Moderate, and Severe to Guide Treatment Strategies

Identifying Excited Delirium: Recognizing Severe Agitation and Potential Medical Threats

Part 3: De-escalation, Team Coordination

Non-Pharmacologic Approaches: Verbal De-escalation and Team Coordination

Preparing the Team: Establishing Roles and Knowing When to Call a Code White

Part 4: Physical Restraints, Safety Protocols

Physical Restraints: Minimizing Use and Prioritizing Calming Medications

Safe Restraint Techniques: Avoiding Dangerous Holds and Proper Application

Minimizing Agitation Time: Rapid Medication Delivery and Recognizing Punitive Elements

Part 5: Pharmacological Interventions

Oxygen Masks and Routes of Administration: IM Injections Preferred

Medication Choices: Oral Lorazepam for Mild Agitation, Haloperidol and Midazolam for Moderate

Tailoring Medication Dosages: Considering Cause of Agitation and Monitoring Resources

Managing Severely Agitated Patients: Ketamine or High-Dose Haloperidol and Midazolam

Antipsychotics: Haloperidol as the Primary Choice in the ED

Haloperidol and Seizure Threshold: Reassessing the Evidence

Ketamine's Safety: Normalizing Vital Signs in Agitated Patients

Alternative Medications: Inhaled Loxapine and Intramuscular Dexmedetomidine

Part 6: Medical Workup, Resuscitation

Diagnosing the Underlying Cause: A Stepwise Approach to Agitation

Logistics of Managing Severely Agitated Patients: From Control to Resuscitation

Comprehensive Examination: Disrobing the Patient to Identify Underlying Issues

Airway Considerations: Delayed Sequence Intubation and Paralytics

Part 7: Summary, Future Outlook

Agitation as a Cardinal Presentation: Thorough Assessment and Workup

Ketamine Dosing: Tailoring to Patient Weight and Ongoing Research

Future Aspirations: Reducing Prejudice and Improving Care for Agitated Patients

Ep 115 Emergency Management of the Agitated Patient

Emergency Medicine Cases

Part 1: Introduction, Clinical Context

00:18The Complexities and Dangers of Managing Agitated Patients in the ED

The Complexities and Dangers of Managing Agitated Patients in the ED

00:56Initial Case Presentation: A Violent Young Man in the ED

Initial Case Presentation: A Violent Young Man in the ED

02:26Prioritizing Medical Assessment Over Psychiatric Assumptions in Agitated Patients

Prioritizing Medical Assessment Over Psychiatric Assumptions in Agitated Patients

Part 2: Categorization, Diagnosis

05:31Categorizing Agitation: Mild, Moderate, and Severe to Guide Treatment Strategies

Categorizing Agitation: Mild, Moderate, and Severe to Guide Treatment Strategies

07:32Identifying Excited Delirium: Recognizing Severe Agitation and Potential Medical Threats

Identifying Excited Delirium: Recognizing Severe Agitation and Potential Medical Threats

Part 3: De-escalation, Team Coordination

11:12Non-Pharmacologic Approaches: Verbal De-escalation and Team Coordination

Non-Pharmacologic Approaches: Verbal De-escalation and Team Coordination

13:32Preparing the Team: Establishing Roles and Knowing When to Call a Code White

Preparing the Team: Establishing Roles and Knowing When to Call a Code White

Part 4: Physical Restraints, Safety Protocols

17:31Physical Restraints: Minimizing Use and Prioritizing Calming Medications

Physical Restraints: Minimizing Use and Prioritizing Calming Medications

21:43Safe Restraint Techniques: Avoiding Dangerous Holds and Proper Application

Safe Restraint Techniques: Avoiding Dangerous Holds and Proper Application

25:27Minimizing Agitation Time: Rapid Medication Delivery and Recognizing Punitive Elements

Minimizing Agitation Time: Rapid Medication Delivery and Recognizing Punitive Elements

Part 5: Pharmacological Interventions

27:11Oxygen Masks and Routes of Administration: IM Injections Preferred

Oxygen Masks and Routes of Administration: IM Injections Preferred

31:39Medication Choices: Oral Lorazepam for Mild Agitation, Haloperidol and Midazolam for Moderate

Medication Choices: Oral Lorazepam for Mild Agitation, Haloperidol and Midazolam for Moderate

35:04Tailoring Medication Dosages: Considering Cause of Agitation and Monitoring Resources

Tailoring Medication Dosages: Considering Cause of Agitation and Monitoring Resources

39:50Managing Severely Agitated Patients: Ketamine or High-Dose Haloperidol and Midazolam

Managing Severely Agitated Patients: Ketamine or High-Dose Haloperidol and Midazolam

44:16Antipsychotics: Haloperidol as the Primary Choice in the ED

Antipsychotics: Haloperidol as the Primary Choice in the ED

47:49Haloperidol and Seizure Threshold: Reassessing the Evidence

Haloperidol and Seizure Threshold: Reassessing the Evidence

53:36Ketamine's Safety: Normalizing Vital Signs in Agitated Patients

Ketamine's Safety: Normalizing Vital Signs in Agitated Patients

55:01Alternative Medications: Inhaled Loxapine and Intramuscular Dexmedetomidine

Alternative Medications: Inhaled Loxapine and Intramuscular Dexmedetomidine

Part 6: Medical Workup, Resuscitation

58:37Diagnosing the Underlying Cause: A Stepwise Approach to Agitation

Diagnosing the Underlying Cause: A Stepwise Approach to Agitation

1:00:09Logistics of Managing Severely Agitated Patients: From Control to Resuscitation

Logistics of Managing Severely Agitated Patients: From Control to Resuscitation

1:02:59Comprehensive Examination: Disrobing the Patient to Identify Underlying Issues

Comprehensive Examination: Disrobing the Patient to Identify Underlying Issues

1:04:06Airway Considerations: Delayed Sequence Intubation and Paralytics

Airway Considerations: Delayed Sequence Intubation and Paralytics

Part 7: Summary, Future Outlook

1:06:36Agitation as a Cardinal Presentation: Thorough Assessment and Workup

Agitation as a Cardinal Presentation: Thorough Assessment and Workup

1:11:44Ketamine Dosing: Tailoring to Patient Weight and Ongoing Research

Ketamine Dosing: Tailoring to Patient Weight and Ongoing Research

1:13:20Future Aspirations: Reducing Prejudice and Improving Care for Agitated Patients

Future Aspirations: Reducing Prejudice and Improving Care for Agitated Patients