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Move toward the shouting and the odd behavior.

Agitation: excessive verbal behavior, excessive motor behavior, heightened arousal, purposeless movements, pacing, hand wringing, hair pulling, discomfort in one’s own skin.

4 objectives: ensure safety of patient, staff, and others; help the patient manage emotions and distress; avoid use of restraints; avoid coercive interventions. AVOID restraints if you can.

De-escalation: respect personal space, do not be provacative, establish verbal contact, keep it concise and simple, identify wants/feelings, listen to what the patient is saying, agree or agree to disagree, set clear limits and establish acceptable behaviors, offer choices and optimism (option of taking medication), debrief the patient and the staff.

What Mediators Can Teach Physicians About Managing ‘Difficult’ Patients – The American Journal of Medicine, Editorial: view difficult patients as syndromes, not a species. Situation is volatile: escalation or de-escalation is seconds away, calling someone out for bad behavior makes matters worse, exercise neutrality, name the concern to create alliance and avoid adversity, apologize.


First generation: haloperidol & droperidol. Droperidol: recent annals article using 10mg with no complications. Haldol is black-box as well right now

Second generation: olanzapine, ziprasizone, aripirazole, oral only (risperidone, quetiapine).

IV Olanzapine (Zyprexa): as effective as IV halidol. Similiar history as FDA approved for IM, though not IV. Few studies, less SE compared to haldol. Start at 2.5mg-5mg, max daily dose of 20mg. Higher doses have higher risk of sedation. (Martel 2015)

Benzos (dia/lora/clonea)

Ketamine. Dosing 40-400mg IM, 50-200mg IV. No over-sedation, 2/3 required additional doses.


Agitated, Psychotic, and Strong, Stephen Schenkel, The Crashing Patient Conference 2015.

Intravenous Olanzapine: Faster than IM Olanzapine, safer than IV haloperidol, Josh Farkas, PulmCrit

285. Psychotropic Medications and Rapid Tranquilization