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Psychotropic medications are prescribed for patients with mental health conditions such as schizophrenia, bipolar affective disorder, depression, and anxiety. Psychotropic medications are also commonly prescribed for pain, dementia, sleep disorders, and behavioral issues. Emergency physicians should be aware of both the potential applications of these medications in the ED and also the common side effects, adverse reactions, and drug interactions associated with long-term use. Antipsychotics, anxiolytics, antidepressants, and mood stabilizers comprise the major subgroups within the generic class of psychotropic medications. Antipsychotics and anxiolytics are more frequently used in the acute setting, whereas antidepressants and mood stabilizers are more likely to be encountered as an outpatient medication in ED patients.

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Management of the agitated ED patient is complex. The emergency physician not only must consider the safety of the agitated patient, other ED patients and visitors, and health care providers, but also must rapidly assess and treat potentially life-threatening conditions in the agitated individual. Acute undifferentiated agitation may be caused by organic as well as psychiatric and toxicologic conditions. It is critical to control agitation rapidly and safely in order to allow further patient assessment. This should be done in a nonpunitive fashion, with respect, and in accordance with an ED treatment plan.

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An ideal sedative for rapid tranquilization would be easily administered, have a rapid onset of action, be well tolerated with a good side effect profile, and have no addictive properties. Current options for sedation include both antipsychotics and anxiolytics. Both traditional and atypical antipsychotics are effective.1–3 Several of the novel, atypical antipsychotics are available in rapid-dissolving oral formulations that may prove as effective for rapid tranquilization as parenteral formulations.4,5 IM routes of administration are preferred for patient and provider safety despite minor delays in the onset of action. In cases in which agitation is moderate, rapid-dissolving oral formulations or IV preparations may be considered. Most anxiolytics used for sedation are benzodiazepines. Although benzodiazepines are safer than barbiturates, the risk of respiratory suppression may be increased in patients with concomitant ingestion of depressants such as alcohol, or with hepatic or pulmonary insufficiency. Haloperidol or ketamine may also be considered for agitation or agitated delirium.6 A suggested algorithm for the management of acute undifferentiated agitation is outlined in Figure 285-1. Based on U.S. Food and Drug Administration (FDA) black box warnings (bold text warnings that highlight potential serious adverse reactions and/or restrict safe use), droperidol and haloperidol are not recommended for use in patients who are known or suspected to have cardiac arrhythmias or QT prolongation, and olanzapine and ziprasidone are not recommended for use in patients with a history of dementia.

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Figure 285-1.
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Suggested algorithm for the ED management of patients with acute undifferentiated agitation. *Droperidol dosing may be repeated if clinically indicated. Consider reduced dosing in the elderly; lorazepam, 1 milligram IM, haloperidol, 2 milligrams IM, ...

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