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
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.
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.
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, ...