If non-pharmacologic interventions are ineffective, it is time to start thinking about medications to help increase safety. The vast majority of agitation cases in the ED can be managed with one agent. If one agent is ineffective, then the requirement for more than two agents is infinitesimal.
Typical and atypical antipsychotics have been shown to be effective in the management of acute agitation, regardless of whether the agitation is due to dementia or delirium. With respect to the typical antipsychotics, potency does not predict performance in the treatment of agitation (Breitbart et al. 1996; Lanctot et al. 1998). We recommend becoming familiar with one antipsychotic as your “go to” and one as your back-up agent. Using one agent on a regular basis will give you confidence in dosing and allow the staff you are working to become familiar with it, leading to fewer errors (wrong medication or wrong dose) and fewer delays (medication has to be brought from the pharmacy). Our preference is to start with haloperidol, for the following reasons:
- ? It is available in both oral (PO) and intramuscular (IM) formulations, with little to no dose adjustment necessary. Agitated patients may refuse medication but it is very easy to instruct the staff to “give haloperidol 5 mg PO (orally) STAT (immediately) and if PO is refused, “give haloperidol 5 mg IM STAT.” This is much easier than telling the staff to “give risperidone 1 mg PO STAT, and if PO refused, give haloperidol 5 mg IM.”
- ? There is no established maximum for haloperidol, so if it is not successful at first, you can give an additional dose soon after without fear that you will reach a ceiling above which it is no longer safe to give.
- ? It is widely available in most hospital systems and therefore it is likely that it will be readily available quickly. Although you may prefer using trifluoperazine for agitation, it is unlikely that you will be able to obtain it within a time frame that is of any use to your patient.