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10. Emergency Management of Acute Psychosis
Keywords
AgitationDiagnosisSymptomatic treatmentVerbal de-escalationRestraintProject BETAPsychopharmacologyAntipsychoticsBenzodiazepinesInhaled loxapineDispositionEssential Concepts
During all steps of the emergency evaluation of a psychotic patient, ensure the safety of the patient, staff, and other patients in the emergency department (ED).
Agitation is a behavioral emergency that needs to be treated aggressively. Even better: recognize who is at risk for agitation and offer medications early (before agitation) to prevent further behavioral escalation and violence. However, the ultimate goal of the emergency evaluation is diagnosis, so avoid oversedation.
The most important determination in the ED will be if a psychotic patient is medically ill or delirious; intoxicated or withdrawing; or if the patient suffers from a primary psychiatric illness. The three are not mutually exclusive.
Verbal de-escalation should be the first-line, gold-standard approach to agitation.
There is no one best medication or medication combination that treats all agitation. The best choice depends on the acuity of the agitation, its etiology, and patient cooperativeness.
Oral antipsychotic preparations (including rapidly acting preparations) or inhaled loxapine should be offered prior to moving to short-acting intramuscular antipsychotics.
Do not use antipsychotics if there is concern for catatonia or NMS.
Physical restraints should never be used lightly, but they can be lifesaving if needed.
For acutely manic patients, valproate loading is a safe and effective strategy to quickly control mania. Treatment can be initiated in the emergency department.
Do not discharge a patient with psychosis from the ED unless you are confident about your diagnosis and the feasibility of your follow-up plan.
“Coolness and absence of heat and haste indicate fine qualities.” [1]
– Ralph Waldo Emerson, American transcendentalist, 1803–1882
The emergency evaluation and treatment of a psychotic patient has several goals that I discuss in this chapter: (1) excluding medical etiologies for symptoms; (2) rapid stabilization of the acute crisis; (3) avoiding coercion; (4) treating in the least restrictive setting; (5) forming a therapeutic alliance; and (6) appropriate disposition and after-care plan [2]. In the emergency setting, you might have to treat psychotic patients before you have a firm (or any) diagnosis. Consider diagnosis to be a reiterative process, and the process outlined below is not necessarily linear and sequential. At all times, remember Emerson’s quote and approach psychotic patients calmly and without haste. Leadership matters: the way you compose yourself in the emergency room impacts the patient and your team. Managing agitation optimally and fast is critical to avoid complications (patient injury, staff injury).
Initial Stabilization for Safety
First, you need to decide where in the ED acutely psychotic patients need to go: Can they simply wait in the general waiting area with a family member until they can be seen, should they be secured in a locked room, do they need to be restrained, do they need an observer to monitor them, or do they need to go to the medical side (if the psychiatric ED is separate from the medical ED)?
Symptoms of psychosis are often very disturbing to patients and may lead to poor judgments regarding safe behavior. Agitation is a combination of physical signs involving aimless movements that suggest internal emotional distress. Staring intensely, hand wringing, fidgeting, pacing, clenched fists, shadowboxing, posturing, and pounding on doors or walls are all signs of agitation. Some patients may arrive agitated or combative, whereas others are calm until they recognize that their families have coaxed them into going to the ED under false pretenses. Patients might agree to an evaluation if they perceive that you are at least considering “letting them go” after the evaluation. Never promise that you will let a patient go if the patient talks with you, but inform the patient that talking with you is a sine qua non for possible release. Pleading the 5th in the ED is not a good choice for a patient!
Tip
A psychotic patient in the ED should be viewed as potentially violent until proven otherwise. To gauge potential for violence, review all accompanying materials before you go to see the patient.
The best management of agitation is preventing it in the first place. A series of interventions can be offered to decrease a patient’s distress and avoid further behavioral escalation. Offers of food and drink, warm blankets, a trip to the restroom, or a more comfortable place to wait may decrease anxiety and help you to form an alliance. As importantly, consider offering medications very early, perhaps at first contact to prevent agitation to begin with. Most patients who come to the ED are distressed, so low-dose oral lorazepam or a low-dose of an oral antipsychotic may settle patients. Acknowledge the patient’s power to make (some) decisions and provide information about the ED process in a calm voice. Clear limit-setting about safe behaviors in the ED also sets the stage for offers of medication if the patient is unable to behave in a safe manner. . Verbal de-escalation should be standard practice [3]. If a patient appears agitated, keep yourself safe by maintaining at least an arm’s distance from the patient, meet in a location where you can leave the room quickly, and limit the items in the room that could be picked up or thrown.
If a patient requires medication, follow the principles below in the next paragraph for acute treatment with medications. If done correctly, medications are a safe way to protect patients, caregivers, and other patients from injury. Appropriate use of medication also reduces the time that a patient might spend in physical restraints. Unfortunately, the ill-advised term “chemical restraint” is still used rather than emphasizing that medications are used to treat agitation. Physical restraint, a last resort in the management of acute agitation, can be necessary and lifesaving for extremely agitated patients and for the protection of your staff. In a typical ED, physical restraints are mostly needed for young patients under the influence of drugs or older, confused patients [4]. Many EDs have made progress in reducing the need for physical restraint which is a quality of care measure [5]. As a matter of respect for patients, follow protocols as they are a safeguard against overuse of the physical restraint tool.
Whenever possible, use oral medications including rapidly dissolving preparations in cooperative patients. Sublingual asenapine is a fast-acting alternative to an injection, if an oral medication is accepted [6]. The mid-potency antipsychotic loxapine is available as an aerosol that patients inhale using a small device [7]. Inhaled loxapine leads to rapid reduction of agitation, faster than intramuscular aripiprazole in one study that compared those two approaches [8]. Like oral medications, the loxapine spray requires a cooperative patient who can inhale the medicine correctly (it is not widely used in our geographic area). It should not be used in settings where patients cannot be intubated should bronchospasm occur from the inhalation. A show of force might convince patients to cooperate and accept oral medications or the loxapine inhaler, and not risk a fight. If intramuscular medication administration is required, many emergency room clinicians use haloperidol together with a benzodiazepine (and diphenhydramine for prophylaxis against dystonia) as a first-line treatment for agitated, psychotic patients, unless benzodiazepines are specifically contraindicated [9]. Intramuscular droperidol is quite effective for agitation [10] but has fallen out of favor because of concerns about QTc prolongation [11]. Several second-generation antipsychotics are available as short-acting intramuscular (IM) preparations (aripiprazole, olanzapine, and ziprasidone). Olanzapine in particular is quite effective in acute settings. (Do not confuse the short-acting intramuscular preparations with the long-acting injectables for maintenance treatment!) They offer good efficacy and, compared to haloperidol, a lower risk for acute dystonic reactions and akathisia [12]. The culture of the ED you are working in more so than the clinical picture is going to determine which antipsychotics are available. Increasingly, ketamine is used for the initial control of severe agitation [13]. I am more likely to use second-generation antipsychotic in the ED setting if schizophrenia is the reason for agitation (consistent with Lukens et al.) [14]. Olanzapine is a good choice because of its sedative-ataractic qualities (avoid concurrent benzodiazepines). Otherwise, I use the haloperidol-lorazepam combination, which has an excellent track record regarding both safety and efficacy for any acute behavioral emergency. In some situations, it is probably safer to use benzodiazepines alone – e.g., antipsychotics increase risks for neuroleptic malignant syndrome (NMS) in patients with amphetamine intoxication.
Key Point
Do not use antipsychotics if catatonia or NMS is a diagnostic possibility.
Agitation due to intoxications from unknown causes is sometimes managed initially with only benzodiazepines in order to avoid added cardiac toxicity from antipsychotics [15]. Agitated, alcohol-intoxicated patients, however, are often better treated with antipsychotics to avoid respiratory depression. Benzodiazepines are needed for alcohol withdrawal. Note that agitated patients in alcohol or benzodiazepine withdrawal might need substantially higher doses of benzodiazepines than commonly recommended for acute agitation from other causes. If patients are psychotic, however, benzodiazepines are often insufficient as they merely sedate without treating the psychotic state. Severe, nonresponsive agitation such as you can see in refractory mania may require a transfer to an intensive care unit for sedation using anesthetics (e.g., propofol) [16]. Do not use “rapid neuroleptization” (i.e., the use of large loading doses of antipsychotic), as this strategy does not confer any benefit and you end up giving unnecessarily high antipsychotic doses [17].
Key Point
There is no one best medication or medication combination for the management of agitation [11]. The best approach hinges on the clinical situation (acuity, etiology, cooperativeness).
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