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
- Droperidol: 2.5-5 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
- Midazolam (Versed): 2.5-5 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
- Antipsychotic Medication:
- Haloperidol (Haldol)
- Quetiapine (Seroquel)
- Risperidone (Risperdal)
- Olanzapine (Zyprexa)
- Continuous IV Sedation:
- Dexmedetomidine (Precedex) Generally Preferred
- *See Pharmacology & Anesthesia: IV Anesthesia