Sedation and Intubation of Agitated Patients in the Emergency Department

Background: Deep sedation, paralysis, and intubation (DSPI) in the management of agitated patients has been described in emergency department (ED) settings. To date, no studies systematically define the cohort of patients who undergo DSPI due to agitation associated with psychiatric etiologies. This retrospective study aims to identify and describe patients with psychiatric agitation resulting in DSPI at a large academic medical center. 

Methods: All adult ED visits at Massachusetts General Hospital were screened over a two-year period for intensive care admissions related to psychiatric morbidity, defined by ED psychiatric consultation orders, behavioral restraint orders, and psychiatric diagnoses at discharge including substance use. Individual chart reviews were used to identify psychiatric ICU admissions associated with DSPI directly related to agitation. Statistical analyses were descriptive given the anticipated small sample size. The study proposal was reviewed by the institutional IRB and categorized as a quality improvement project.

Results: Out of 195,092 unique ED visits, 189 resulted in ICU admissions related to psychiatric morbidity. Of these, DSPI was used to manage psychiatric agitation in three cases. All three unique patients were male and undomiciled with prior diagnoses of post-traumatic stress disorder and multiple substance use disorders. Two were intoxicated on arrival. Time to first mechanical restraint ranged from 0.5 to 26 hours post-arrival; time to intubation ranged from 9.9 to 63 hours post-arrival. By the point of intubation, all patients had received >1 antipsychotic agent. Indications for intubation included refractory agitation, sedation-related respiratory events, and concern for medical sequelae of extreme agitation. Hospital length of stay ranged from 5 to 23 days. No patients were subsequently admitted to inpatient psychiatric facilities. 

Discussion: DSPI for psychiatric agitation in the ED was a rare outcome at a single large academic medical center with an event frequency of 1.5 per 100,000 ED visits. Male gender, undomiciled status, and history of substance use and trauma-related disorders were common among all three identified cases, and may represent putative risk factors for severe refractory psychiatric agitation. Three distinct indications for intubation were identified in the three cases; their relative frequency and clinical correlates could be more rigorously described in a larger sample. Increasing sample size would also enable case-control comparisons to identify variables associated with refractory versus treatment-responsive agitation. 

Conclusion: Sedation and intubation in the management of psychiatric agitation was an uncommon occurrence in the study setting. Indications for DSPI included management of refractory agitation, sedation-related adverse events, and concern for medical sequelae of severe agitation. Trauma-related and substance use disorders as well as socioeconomic deprivation may be prevalent in this population of interest, which may be better characterized by identification of larger patient cohorts to enable case-control comparisons.