A 29-year-old man is brought to the emergency department by police after he broke into a radio station and started yelling about being a "child of nature destined to reverse global warming and save the planet." He is initially cooperative with the nurse taking his vital signs but then starts pacing around the room and raising his arms with clenched fists, motioning toward the hospital staff. His speech is rapid, loud, and difficult to interrupt. Medical records indicate a history of depression treated with antidepressants and a hospitalization 2 years ago following a suicide attempt. Temperature is 37 C (98.6 F), blood pressure is 142/85 mm Hg, pulse is 96/min, and respirations are 20/min. Administering which of the following medications is the most appropriate initial step in pharmacological management of this patient?
This patient shows acutely agitated behavior that poses a safety risk to the emergency department staff. Diagnostic possibilities include a manic episode with psychotic features (eg, grandiose delusions, hyperactivity, pressured speech), substance-induced psychosis, psychosis due to another medical condition, and other psychotic disorders.
If verbal deescalation is unsuccessful, administering a benzodiazepine (eg, lorazepam) would be the most appropriate pharmacotherapy to manage this patient's escalating agitation and can be administered intramuscularly for a more rapid effect. Administration of a first- or second-generation antipsychotic (eg, haloperidol, olanzapine, risperidone, ziprasidone) is another option for management of acute agitation. The first-generation antipsychotic haloperidol is often coadministered with lorazepam to achieve more rapid sedation in severely agitated, combative patients.
When the patient is calmer and cooperative, further workup (eg, urine drug screen, chemistries, complete blood count, thyroid function tests) would be indicated to rule out substance-related and medical causes of psychosis.
(Choices A, C, and F) Carbamazepine, lithium, and valproate are mood stabilizers used in bipolar disorder. Although a manic episode of bipolar disorder is a diagnostic possibility in this patient with a history of severe depressive episodes, these medications would be ineffective in managing acute agitation. They must be taken orally and are typically titrated over several days to achieve a therapeutic blood level.
(Choice B) The second-generation antipsychotic clozapine is not used to manage acute agitation. It is typically reserved for treatment-resistant psychosis due to the risk of neutropenia/agranulocytosis.
(Choice E) Mirtazapine, an antidepressant that has sedating properties, would be ineffective in managing this patient's acute agitation and could worsen symptoms in a patient presenting with mania.
Educational objective:
Options for pharmacological management of an acutely agitated patient include the administration of a benzodiazepine and/or an antipsychotic agent. The benzodiazepine lorazepam is often used due to its rapid onset of action and intramuscular formulation.