Critical Issues in the Evaluation and Management of Adult Out-of-Hospital or Emergency Department Patients Presenting With Severe Agitation

Official 2023 guideline for severe agitation from the American College of Emergency Physicians.

Strength

Recommendations

Acute Management

Level B

For more rapid and efficacious treatment of severe agitation in the emergency department, use a combination of droperidol and midazolam or an atypical antipsychotic in combination with midazolam. If a single agent must be administered, use droperidol or an atypical antipsychotic due to the adverse effect profile of midazolam alone.

Level B

For efficacious treatment of severe agitation in the emergency department, use the above agents as described or haloperidol alone or in combination with lorazepam.

Safety

Level C

In situations where safety of the patient, bystanders, or staff is a concern, consider ketamine (intravenous or intramuscular) to rapidly treat severe agitation in the ED (consensus recommendation).

Out-of-Hospital

Level C

No recommendations for or against the use of specific agents in the out-of-hospital setting can be made at this time (consensus recommendation).

Geriatric Patient

Level C

No recommendation for or against the use of specific agents in patients above the age of 65 years can be made at this time (consensus recommendation).

Literature

Original/Primary Reference

Thiessen MEW, Godwin SA, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Out-of-Hospital or Emergency Department Patients Presenting with Severe Agitation. October 6, 2023. Ann Emerg Med. 2024;83(1):e1-e30.

What do the ratings mean?

Level A

Generally accepted principles for patient management that reflect a high degree of clinical certainty (ie, based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues).

Level B

Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (ie, based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies).

Level C

Other strategies for patient management that are based on Class III studies, or in the absence of any adequate published literature, based on panel consensus.