Which Emergent Medication Should I Give Next? Repeated Use of Emergent Medications to Treat Acute Agitation

Veronica B Searles Quick,Ellen D Herbst,Raj K Kalapatapu

doi:10.3389/fpsyt.2021.750686

Veronica B Searles Quick, Ellen D Herbst + Show 1 more

Open Access

https://doi.org/10.3389/fpsyt.2021.750686

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Abstract

Agitation is a common symptom encountered among patients treated in psychiatric emergency settings. While there are many guidelines available for initial management of the acutely agitated patient, there is a notable dearth of guidelines that delineate recommended approaches to the acutely agitated patient in whom an initial medication intervention has failed. This manuscript aims to fill this gap by examining evidence available in the literature and providing clinical algorithms suggested by the authors for sequential medication administration in patients with persistent acute agitation in psychiatric emergency settings. We discuss risk factors for medication-related adverse events and provide options for patients who are able to take oral medications and for patients who require parenteral intervention. We conclude with a discussion of the current need for well-designed studies that examine sequential medication options in patients with persistent acute agitation.

Highlights

Agitation is a common presenting or comorbid condition among patients in psychiatric emergency settings [1] and exists on a continuum of severity, ranging from irritability to violence [2,3,4]
Published in 2016 Authors state it is not possible to make very specific evidence-based pharmacologic recommendations based on available studies, provide a series of consensus statements to be considered by practitioners: Lorazepam and first-generation antipsychotics are similar in efficacy
Since the need for guidance remains surrounding how to approach sequential medications in practice, we offer our own suggested sequential treatment algorithms (Figure 1) for persistent acute agitation that are consistent with data from available studies, using agents that are available in the United States

Summary

INTRODUCTION

Agitation is a common presenting or comorbid condition among patients in psychiatric emergency settings [1] and exists on a continuum of severity, ranging from irritability to violence [2,3,4]. IM monotherapy recommendations: Aripiprazole, droperidol (baseline ECG advised), olanzapine (avoid co-administration with benzodiazepines due to risk of sedation, respiratory depression and hypotension) Guideline recommends avoiding haloperidol monotherapy due to risk of EPS, lorazepam and diazepam due to lack of evidence, midazolam due to risk of respiratory depression, and levopromazine due to risk of cardiovascular adverse events including hypotension. Published in 2016 Authors state it is not possible to make very specific evidence-based pharmacologic recommendations based on available studies, provide a series of consensus statements to be considered by practitioners: Lorazepam and first-generation antipsychotics are similar in efficacy. ECG, electrocardiogram; EPS, extrapyramidal symptoms; ETOH, alcohol; IM, intramuscular; IV, intravenous; PO, oral

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