Trauma Bay Adult Acute Agitation Management
Purpose:
Traumatically injured patients presenting to the emergency department (ED) experiencing acute agitation have the potential to harm themselves, hospital staff, and others. Safe and expeditious management of agitation is imperative to prevent potential further harm. However, treatment of acute agitation is challenging due to the heterogenicity of the patient population, cause or source of agitation, and the available therapeutic treatment options.
There are two critical factors that are essential to the management of agitation – early recognition and targeted intervention to the etiology driving the patient’s acutely agitated state. This treatment protocol is designed to help streamline the care of this difficult patient population.
Background/Definitions:
Acutely agitated and/or violent behaviors displayed by trauma patients interfere with the required medical care of the patient. Acute agitation is a medical emergency. Determining the cause or causes of agitation will allow for a more informed management strategy for the patient. However, because of constraints on time, limited information, and lack of patient engagement, one must assess and identify the underlying cause(s) expeditiously. The goal of acute agitation treatment is to calm the patient in the least invasive way, without causing oversedation.
Per policy TX-1, the philosophy of Nebraska Medicine is to reduce/limit the use of physical and chemical restraint while maintaining the safety and preserving dignity, rights, and wellbeing of patients. Nebraska Medicine respects the patient’s right to be free of restraints of any form that are not medically necessary. If a patient’s condition necessitates the use of restraints, the safety and wellbeing of the patient and medical staff caring for the patient is the primary focus of the medical team.
· Severe Agitation:
o Currently violent or aggressive, attacking people and/or objects.
· Moderate Agitation:
o Physically or verbally threatening, difficult to redirect, extremely active, however, not violent.
· Mild Agitation:
o Signs of overt physical or verbal activity but redirectable.
· De-escalation:
o A combination of both verbal and nonverbal strategies intended to calm the patient down to cooperate with their care.
· Sedation and Analgesia:
o Use of pharmacologic agents to create a drug-induced state to reduce physiologic and psychological stress to a patient undergoing medical, surgical, or diagnostic procedures.
Common Medical Causes of Acute Agitation
|
Type |
Examples |
|
Neurological |
Traumatic brain injury, intracranial hemorrhage, seizure/post-ictal, stroke, encephalopathy |
|
Infectious |
Meningitis, sepsis, urinary tract infection (elderly) |
|
Metabolic |
Electrolyte disturbance, hypoglycemia |
|
Respiratory |
Hypoxia |
|
Toxicological |
Environmental toxin, medication reaction, illicit drug use |
|
Endocrine |
Thyrotoxicosis, myxedema coma |
|
Other |
Hyper- or hypothermia, acute pain |
Practice Recommendations for Medical Management:
· De-escalation should always be attempted prior to medication management and physical restraint.
· Restraint may only be imposed to ensure the immediate physical safety of the patient, staff or others and must be discontinued as soon as safely possible, regardless of the scheduled expiration of the order.
· TX_01 will be followed if/when restraint use is required.
· Follow the management considerations, listed in the table below, using the preferred agent(s) as listed in Attachment A. Preferred agents show better clinical properties, including onset of action, efficacy, and lower incidence of adverse effects.
Management Considerations for Agitation
|
Severity of Agitation |
Preferred Route of Administration |
Dosing Considerations |
Special Populations |
|
Severe |
IV, when able IM, if IV not available |
Maximize dose of first agent used, allowing for the onset and effects of the previous dose prior to administering second dose |
Dosing adjustments may be required for elderly, renally/hepatically impaired, and/or when given medication(s) prior to arrival. Lower doses may be required when using concomitant sedating medications. |
|
Moderate |
IV, when able IM, if IV not available |
Smaller doses may be sufficient (as compared to what is required for severe agitation) If able/known, use a patient’s home regimen when patients can tolerate oral therapy. |
|
|
Mild |
PO |
If able/known, use a patient’s home regimen when patients can tolerate oral therapy. |
Attachment A – Preferred Treatment Options for Acute Agitation (Trauma Bay)
Preferred Treatment Options: *
|
Preferred Options |
Medication |
Dose |
Soft Max (Single Dose) |
Onset |
Time to Peak |
Duration |
Patient Considerations |
|
Midazolam |
2-5 mg IV |
5 mg IV |
IV: 1-5 min |
IV: 3-5 min |
IV: 1-2 hours |
Hypotension with larger doses (IV). Delayed onset of action (IM). |
|
|
5-10 mg IM |
10 mg IM |
IM: 15 min |
IM: 30-60 min |
IM: 1-2 hours |
|||
|
Olanzapine |
2.5-5 mg IV |
5 mg IV |
IV: 5-10 min |
15-45 min |
2 hours |
Possible hypotension and respiratory depression with IV use. Caution when used with benzodiazepines due to risk of over-sedation. MAX 30 mg/24 hrs (Cumulative for all routes of administration) |
|
|
10 mg IM |
10 mg IM |
IM: 15 min |
|||||
|
Haloperidol |
5 mg IV/IM |
5 mg |
IV: 3-20 min |
IV: 30 min |
2-4 hours |
Risk of EKG changes Can lower seizure threshold |
|
|
IM: 15 min |
IM: 20-30 min |
||||||
|
Dexmedetomidine |
0.1-0.7 mcg/kg/hr IV, titrate to response |
MAX rate 0.7 mcg/kg/hr IV |
5-15 min |
60 min |
60-240 min (Dose dependent, after drip stopped) |
Restricted for Use in Non-Intubated Patients. Only approved indication is refractory agitated delirium unresponsive to other pharmacologic agents or with contraindications to other pharmacologic agents. Only available with IV access. Can cause bradycardia. Bolus dosing not allowed outside of OR. Restricted to ED, ICU, and OR use only. |
*Subject to drug availability/restrictions secondary to national drug shortage
Management Considerations for Ketamine:
At Nebraska Medicine, ketamine is restricted to the following indications:
· Induction for rapid sequence intubation
· Ventilator management
· Procedural sedation
· Subanesthetic analgesia (restricted ordering to anesthesiology, pain management, emergency medicine, and pediatric critical care medicine)
If ketamine is required for the use of acute agitation, the institutional policy, MS_15 for procedural sedation or MP_33 for subanesthetic ketamine for pain management, will need to be followed. A provider must remain at bedside.
Dosing recommendations:
· Sub-Anesthetic Ketamine for Pain
o Must be ordered by emergency medicine provider (while patient is in the ED).
o Use dosing recommendations per MP_33
· Procedural Sedation
|
Dose |
Soft Max (Single Dose) |
Onset |
Time to Peak |
Duration |
|
0.5 mg/kg IV |
1 mg/kg |
30-60 sec |
5-10 min |
1-2 hours (recovery) |
|
2 mg/kg IM |
3 mg/kg IM |
3-4 min |
5-30 min |
3-4 hours (recovery) |
· (MS_15) Medical Staff: Procedural Sedation and Analgesia Administration Guidelines (Non-Anesthesiology Providers)
· (TX_01) Care of Patients: Restraint Use
o Attachment A: Alternative Interventions to Restraints
· (TX_24) Admission, Transfer and Discharge for Define Levels of Care
· (MP_33) Medication Policy and Guidelines: Low-Dose (Sub-anesthetic) Ketamine for Pain in Non-Intubated Patients
Key Contributors:
· Krysta Baack, PharmD | Department of Pharmacy, Emergency Medicine | Principal Author
· Nathan Sutera, PharmD | Department of Pharmacy, Psychiatric Emergency Services | Author
· Zach Bauman, DO | Division of Acute Care Surgery, Faculty | Author
Last Updated:
July 2024
References:
1. Roppolo LP, Morris DW, Khan F, et al. Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation). JACEP Open 2020; 1:898-907.
2. Zareifopoulos N and Panayiotakopoulos G. Treatment options for acute agitation in psychiatric patients: theoretical and empirical evidence. Cureus 2019; 11(11): e6152.
3. Curry A, Malas N, Mroczkowski M, et al. Updates in the assessment and management of agitation. Focus (Am Psychiatr Publ) 2023; 21(1): 35-45.
4. Lexicomp. (2024). Midazolam: dosage & administration. In Lexi-Drugs Online. Retrieved [June 27, 2024.] from https://online.lexi.com.
5. Lexicomp. (2024). Olanzapine: dosage & administration. In Lexi-Drugs Online. Retrieved [June 27, 2024.] from https://online.lexi.com.
6. Lexicomp. (2024). Haloperidol: dosage & administration. In Lexi-Drugs Online. Retrieved [June 27, 2024.] from https://online.lexi.com.
7. Lexicomp. (2024). Dexmedetomidine: dosage & administration. In Lexi-Drugs Online. Retrieved [June 27, 2024.] from https://online.lexi.com.
8. Lexicomp. (2024). Droperidol: dosage & administration. In Lexi-Drugs Online. Retrieved [June 27, 2024.] from https://online.lexi.com.
9. Lexicomp. (2024). Lorazepam: dosage & administration. In Lexi-Drugs Online. Retrieved [June 27, 2024.] from https://online.lexi.com.
10. Lexicomp. (2024). Ketamine: dosage & administration. In Lexi-Drugs Online. Retrieved [June 27, 2024.] from https://online.lexi.com.
11. Li M, Martinelli AN, Oliver WD, et al. Evaluation of ketamine for excited delirium syndrome in the adult emergency department. J Emerg Med. 2019; S0736-S4679(19)30802-9.
12. O'Brien ME, Fuh L, Raja AS, et al. Reduced-dose intramuscular ketamine for severe agitation in an academic emergency department. Clin Toxicol (Phila). 2020;58(4):294-298.