On Call: Delirium & Agitation

Evaluation

Interview

  • Safety of Staff is Paramount
  • Call Security if Necessary
  • Patients Should Always Be Disarmed Before Any Interaction
  • No Potentially Dangerous Objects Should Be Available
  • Do Not Let Patient Sit Between the Physician & the Exit

Risk Factors for Violence

  • History of Violence
  • Male Gender
  • Alcohol/Drug Abuse

Signs of Impending Violence

  • Provocative Behavior
  • Angry Demeanor
  • Loud, Aggressive Speech
  • Tense Posturing
  • Frequently Changing Body Position/Pacing
  • Aggressive Acts (Pounding Wall, Throwing Objects)
  • Verbal Threats

Assess for Medical Causes that May Be Contributing

  • Hypoxia
  • Inadequate Pain Control
  • Hypoglycemia
  • Infection
  • Drug Overdose
  • Intracranial Hemorrhage

Delirium Prevention & Treatment

Agitation/Aggression Management

General Approach

  • Initial Nonpharmacologic Attempts are Preferred, Unless Violent or a Danger to Self/Others
  • Immediate Sedation:
    • Start with a Rapid-Onset Antipsychotic or Benzodiazepine
    • Avoid Opioids & Benzodiazepines in the Setting of Delirium as Able – Can Worsen Delirium
    • First Generation (Typical) Antipsychotics Have Risk for QT Prolongation Which Should Be Monitored
  • Continued Sedation:
    • May Require Continued Sedation Once Safety Achieved
  • Consider Physical Restraints if an Imminent Harm to Self or Others
    • Should Be Considered a Last Resort

Nonpharmacologic Techniques

  • Frequent Reorientation & Reassurance
  • Listen to the Patient & Be Attentive/Receptive
  • Be Honest & Straightforward
  • Avoid Arguing or Condescending
  • Respect Personal Space
  • Use Concise & Simple Language
  • Offer a Chair
  • Use of a Bedside Sitter

Pharmacologic Therapy: Immediate Sedation

  • First Generation (Typical) Antipsychotics:
    • Droperidol: 2.5-5 mg IM/IV
      • More Rapid Onset of Action & Greater Efficacy Over Haloperidol for Acute Psychosis & Agitation
    • Haloperidol (Haldol): 2-5 mg IM/IV
  • Benzodiazepines:
    • Midazolam (Versed): 2.5-5 mg IM/IV
      • More Rapid Onset of Action but Shorter Duration than Lorazepam
    • Lorazepam (Ativan): 2-4 mg IM/IV
  • Combination Therapy:
    • Droperidol 5 mg & Midazolam 5 mg
    • Haloperidol 5 mg & Lorazepam 2 mg
    • *Combination Therapy Achieves More Rapid Sedation
  • May Consider Ketamine – Use Evolving

Pharmacologic Therapy: Continued Sedation