Current Controversies in Agitation Management in the Emergency Department

As consultants and psychiatric providers in the Emergency Department (ED), CL psychiatrists are often called to assist with agitation management. In some instances, our involvement follows interventions already made by Emergency Medicine (EM) while in others, our recommendations may conflict with the instincts of the primary team. As volume in the ED grows and the potential for injury to staff increases, EM providers are more readily seeking out alternative approaches to agitation management, which may challenge our practices as psychiatrists. Among these, the use of ketamine for agitation management is increasing nationwide, some EDs are starting to deliver intramuscular olanzapine intravenously (a practice for which there is currently no approved indication), and reports are even emerging of patients being intubated for agitation. In addition to these newer management strategies, novel and sometimes controversial diagnostic labels are emerging for agitated patients. One such example is “excited delirium,” an ill-defined, controversial term applied to increasing numbers of patients by clinical and non-clinical entities, often in a discriminatory manner.

Scott R. Beach, MD, is Program Director for the MGH/McLean Adult Psychiatry Residency and a psychiatrist in the psychiatric ED at Massachusetts General Hospital in addition to the consultation service. Dr. Beach will review the literature on the use of ketamine for agitation, addressing the potential benefits as seen by emergency medicine providers as well as some concerns noted by psychiatrists.

Kim Hartney, MD, is Chief of Psychiatry at Tampa General Hospital and an attending in the psychiatric ED and inpatient consultation service. Dr. Hartney will discuss the historical use of intravenous olanzapine for indications other than agitation, offer insights and cautions about its potential use in agitated patients, draw parallels between its use and the emergence of intravenous haloperidol in the 1970s and discuss her own experience with getting intravenous olanzapine added to her hospital’s formulary.

John B. Taylor, MD, MBA is Lead Medical Director for Behavioral Health for AuthorCare, and an attending psychiatrist in the psychiatric ED and inpatient consultation services at MGH. He will describe the phenomenon of excited delirium, reviewing the heterogeneity captured by the entity, offering historical perspective, introducing the controversy of applying that diagnostic label to disenfranchised populations, and suggesting possible alternative classifications.

Finally, Anne Gross, MD, is the Medical Director of the Psychiatric Emergency Services at Oregon Health Services University. Dr. Gross will offer guidance for navigating conversations with colleagues in emergency medicine surrounding these and other controversies including when is a psychiatric patients “medically cleared”, and provide tips for educating and working with colleagues from other specialties in order to best serve our psychiatric patients.