During our most recent conference, Dr. Corey Goldstein, one of our emergency medicine faculty who is also trained in psychiatry, gave an informative talk on how to approach patients presenting with anxiety related disorders – including generalized anxiety disorder, panic attacks/panic disorder, PTSD, and OCD).  He finished with an update on the treatment of acutely agitated patients and discussed the Beta Guidelines, developed by the American Association of Emergency Psychiatry. 

In this week’s blog post, I will cover three takeaways and learning pearls from this lecture that can easily be implemented into my next ED shift.  These can be generalized out to all patients who present with a psychiatric complaint. 

#1 Get your own history, do a focused physical exam, and don’t forget to do a basic mental status exam.

  • We should perform and document a basic mental status exam when we evaluate patients who present with any psychiatric complaint.
    • General – Is the patient in acute distress? Is their eye contact poor, fair, or good? Are they cooperative?
    • Affect – What is their observed emotional response? What is the range and intensity?
    • Thought Process – Is it logical and goal directed?
    • Thought Content – Is there SI or HI or psychosis?  If there is SI or HI, is it passive or active, is there intent and a plan?
    • Speech – What is the rate and tone?  Is it pressured or there minimal speech?
    • Insight and Judgement – How much awareness do they have of their situation and surroundings? Do they understand the risks and benefits of their decision making?  Can they act appropriately within the current context?
    • Cognition – Are they alert and fully oriented?
  • Taking time to obtain and process a good H and P, and the patient’s mental status exam can aid in developing an appropriate assessment, plan, and disposition. You may gain critical information to help determine if this is an organic disease process or a primary psychiatric disorder. You may be able to better determine and justify if the patient is a threat to themselves, a threat to others, or is unable to care for themselves (gravely disabled). This is particularly important in care settings that do not have 24/7 psychiatric coverage.  The emergency physician should do their own history, physical exam, mental status exam, and work with the crisis evaluator to gather additional information in order to properly formulate a plan.  In addition, collateral history may be a necessity to develop a disposition.   

#2 In the right circumstance, consider prescribing “bridging” medications upon discharge from the ED, utilizing appropriate discussion with a follow up provider.  Generally, this will be a primary care physician, psychiatrist, or psychiatric APP. 

  • Proper evaluation of patients with psychiatric complaints provides the emergency physician an opportunity to intervene and help lower risk patients who will be discharged and are awaiting follow up. This may include medication management and/or referral to psychotherapy.  As above, the crisis evaluator or social worker can be of major help in this process. 
  • Emergency physicians are not advised to start new antidepressants (which are utilized as the mainstay of anti-anxiety treatment) without adequate follow up as there is a small but significant risk of causing manic symptoms.  Exceptions to this are:
    • Patients who have reliable follow up and we have communicated with the outpatient provider who is agreeable with the plan.
    • Restarting a previously well-tolerated anti-depressant – with reliable outpatient follow up.  If they have been off for more than a few days, consider starting a lower dose, even if the patient tolerated a higher dose in the past – in order to reduce start up adverse effects and minimize risk.  Remember to discuss the possible adverse effects such as manic symptoms, anxiety, insomnia, etc. 

  • Additionally:
    • When the diagnosis is unclear, if the EP does not feel comfortable prescribing benzodiazepines, or if the patient is unable to take a benzodiazepine, newer generation antipsychotic medications such as low dose olanzapine (2.5mg to 5mg at night) or quetiapine (50mg to 100mg at night), may be reasonable as “off label” and brief interventions for patients who are acutely anxious or having more significant difficulty with sleep.  As always, some sort of follow up should be clearly documented.  Always discuss sedation as a likely adverse effect and caution against driving, as well as the more uncommon but possible adverse effect of EPS such as akathisia. 
    • For patients without a substance use disorder history, we may consider a very short course of benzodiazepines for severe anxiety until reliable follow up.  This should only be done with a significant comfort level by the EP.  Be mindful that regular use of benzodiazepines can quickly cause physical dependence and the prescription should clearly state that the patient should not drive or make important decisions after taking one.  If a benzodiazepine is appropriate, Clonazepam at lower dose (0.25mg to 0.5mg PRN) is optimal as it is longer acting and may have lower rates of abuse.  Never give benzodiazepine prescriptions to patients concurrently taking opioid medications and always look at the Prescription Monitoring Program data to ensure that a benzodiazepine is appropriate. 

#3 Utilize the Beta Guidelines, developed by the American Association of Emergency Psychiatry for patients who need treatment for acute agitation – instead of reflexing to the old 5 and 2. 

  • The general Beta Guideline recommendations include:
    • First, attempt to diagnose the most likely cause of their agitation and target medication to that disease.
    • Verbal escalation and reducing environmental stimulation should always be attempted if possible and safe.
    • Medications should be used to calm patients, not induce sleep.
    • Patients should be involved in the process of selecting medications, if possible.
    • Oral medications are preferred if the patient is cooperative.

When pharmacologic restraint is required, select medications based on the patient presentation. I have include a flow sheet below.

  • Agitation due to intoxication of most recreation drugs besides alcohol
    • Benzodiazepines are considered first line
    • Second generation antipsychotic can be considered if benzodiazepines are insufficient
  • Agitation due to intoxication with ETOH
    • First or second generation antipsychotic
      • Haloperidol, Risperidone or Olanzapine PO
      • Haloperidol, Olanzapine or Ziprasidone IM
    • Avoid benzodiazepines if possible
  • Agitation due to psychiatric Illness
    • Second generation antipsychotic
      • Risperidone or Olanzapine PO first line
      • Olanzapine or Ziprasidone IM second line
    • If initial antipsychotic is insufficient, addition of benzodiazepine is preferred to additional doses of the same antipsychotic
  • Agitation in a patient with known dementia or delirium
    • Second generation antipsychotic
      • Risperidone or Olanzapine PO first line
      • Olanzapine or Ziprasidone IM second line
    • Avoid benzodiazepines
Flow sheet and guidelines form:
Wilson MP, Pepper D, Currier GW, Holloman GH Jr, Feifel D. The psychopharmacology of agitation: consensus statement of the american association for emergency psychiatry project Beta psychopharmacology workgroup. West J Emerg Med. 2012;13(1):26-34. doi:10.5811/westjem.2011.9.6866

A few final important notes to remember when managing a patient with acute agitation:

  • Safety is number one priority
  • Have a plan when entering the room
  • Remember it may take up to 15 minutes to see affects from these IM drugs
  • Many people will de-escalate with either a benzodiazepine OR and antipsychotic and most patient don’t need both


Thank you to Dr. Goldstein for a great lecture and helping me edit this post.

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