Emergency Management of Acute Psychosis
The competent management of an acutely psychotic patient who is agitated requires skill and experience. This chapter describes the clinical approach to agitation in acute settings, particularly the importance of non-pharmacological interventions such as verbal de-escalation and early use of oral medications in order to avoid behavioral escalation and prevent injury to patients and staff. To achieve the goal of a calm patient who can be evaluated, clinicians can chose from a variety of medications to treat agitation rapidly and effectively, including second-generation antipsychotics and inhaled loxapine. The chapter ends with a discussion of patient disposition including discharge from the acute setting.
KeywordsAgitation Diagnosis Symptomatic treatment Verbal de-escalation Restraint Project BETA Psychopharmacology Antipsychotics Benzodiazepines Inhaled loxapine Disposition
- 1.Emerson RW. Manners. Essays, first and second series, English traits representative men addresses. New York: Hearst’s International Library Co., Inc; 1914.Google Scholar
- 8.San L, Estrada G, Oudovenko N, Montanes F, Dobrovolskaya N, Bukhanovskaya O, et al. PLACID study: a randomized trial comparing the efficacy and safety of inhaled loxapine versus intramuscular aripiprazole in acutely agitated patients with schizophrenia or bipolar disorder. Eur Neuropsychopharmacol. 2018;28:710–8.CrossRefGoogle Scholar
- 20.Aldridge RW, Story A, Hwang SW, Nordentoft M, Luchenski SA, Hartwell G, et al. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet. 2018;391:241–50.CrossRefGoogle Scholar
- Holloman GH Jr, Zeller SL. Overview of Project BETA: best practices in evaluation and treatment of agitation. West J Emerg Med. 2012;13:1–2. – Introduction to the Project BETA from the American Association for Emergency Psychiatry (AAEP) who, in October 2010, embarked on developing guidelines for the assessment and management of agitation in acute care settings. (BETA stands for Best practices in Evaluation and Treatment of Agitation). Working groups tackled several topics (medical evaluation and triage, psychiatric evaluation, verbal de-escalation, psychopharmacology, use and avoidance of seclusion and restraint), all published in the Western Journal of Emergency Medicine.Google Scholar
- Wilson MP, Pepper D, Currier GW, Holloman GH Jr, Feifel D. The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project Beta psychopharmacology workgroup. West J Emerg Med. 2012;13:26–34. – The psychopharmacology recommendations from Project BETA.CrossRefGoogle Scholar