期刊名称：Journal of Education and Teaching in Emergency Medicine
印刷版ISSN：2474-1949
出版年度：2020
卷号：5
期号：4
页码：1-26
DOI：10.21980/J85352
出版社：University of California Press
摘要：Audience: This scenario was developed to educate emergency medicine residents about the diagnosis and management of the agitated psychiatric patient. Introduction: The prevalence of agitation among patients in the emergency department is increasing, with an estimated 1.7 million events occurring annually in the United States.1 There are various methodologies for de-escalation, including verbal and chemical de-escalation and physical restraints. Chemical and/or physical restraints are sometimes necessary to ensure patient and staff safety when verbal de-escalation is ineffective, particularly since agitation isthe leading cause of hospitalstaff injuries.2 Chemical restraints have been shown to be less physically traumatizing to patients.3 4 Adverse events associated with physical restraints include persistent psychological distress, blunt chest trauma, aspiration, respiratory depression, and asphyxiation leading to cardiac arrest.5 In regards to chemical restraints, adverse event reporting has been heterogeneous among studies, but the most consistent reported events involve respiratory compromise such as desaturation, airway obstruction, and respiratory depression.3 A study measuring QTc (corrected QT interval) after high-dose intramuscular ziprasidone or haloperidol did not demonstrate any QTc longer than 480 msec.6 Other events linked to chemical restraints include uncommon cardiovascular events and extrapyramidal side effects from medications.3 The main classes of medications utilized for chemical restraint include first-generation antipsychotics (eg, haloperidol and droperidol), secondgeneration antipsychotics (olanzapine, quetiapine, risperidone, aripiprazole, and ziprasidone), benzodiazipenes(eg, lorazepam and midazolam), and N-methyl-D-aspartic acid (NMDA) receptor antagonists (eg, ketamine).,7,8 It is important to exclude other medical causes of agitation, consider the differential diagnoses, and then select a medication that is tailored to address underlying etiologies while remaining cognizant of the side effect profiles of these chemical agents.
