The First 5 Minutes in Managing the Dangerously Agitated Patient

Andy Little, DO and Reuben Strayer, MD

on Spotify

The summary below is from an episode of ERcast: Clinical Perspectives

Dangerous agitation is an immediate safety and resuscitation problem, not just a behavioral one. In the emergency department, the first minutes hinge on distinguishing routine agitation from patients who are violent or so altered that a time-critical medical cause must be found fast.

First Minutes of Dangerous Agitation

Dangerous versus routine agitation: Dangerous agitation means either an immediate threat to self or others or severe agitation with concern for a life-threatening medical cause, so management prioritizes speed over medication safety.
Adequate show of force: Safe control starts with at least five people, typically one for each limb and one for the head, while the physician directs rather than physically wrestling the patient.
High-risk restraint pitfalls: Compression of the neck, chest, or back can turn restraint into a fatal event, and hog-tie or hobble positioning should never be used. We lay out the practical approach in the episode.
Immediate oxygen application: A face-mask oxygen setup goes on right away because it both limits spitting escalation and buys time if hypoxia is contributing to the agitation.
Intramuscular ketamine first: For truly dangerous agitation, IM ketamine is the preferred agent because its pharmacokinetics are fast and its effectiveness is near 100%, often producing stillness within about 3 minutes.
Monitoring after dissociation: Any non-intubated patient dissociated with ketamine needs continuous resuscitation-level monitoring with special attention to ventilation, then the work shifts to causes like hyperthermia, hypoglycemia, and hypovolemia.

Subscribe to ERcast: Clinical Perspectives to listen to the episode.

References:

Gottlieb M, Long B, Koyfman A. Approach to the Agitated Emergency Department Patient. J Emerg Med. 2018;54(4):447-457. PMID: 29395692
Mulkey MA, Munro CL. Calming the Agitated Patient: Providing Strategies to Support Clinicians. Medsurg Nurs. 2021;30(1):9-13. PMID: 34092999
New A, Tucci VT, Rios J. A Modern-Day Fight Club? The Stabilization and Management of Acutely Agitated Patients in the Emergency Department. Psychiatr Clin North Am. 2017;40(3):397-410.PMID: 28800797

Faculty

Andy Little, DO
Dr. Andy Little is an emergency medicine physician and educator. He earned his medical degree from the Ohio University Heritage College of Osteopathic Medicine and completed his emergency medicine residency at OhioHealth Doctors Hospital Emergency Medicine Residency, where he served as Chief Resident. He has received multiple national awards, including recognition from the American Osteopathic Association, American College of Osteopathic Emergency Physicians, and Emergency Medicine Residents' Association.
Reuben Strayer, MD