Option 1: Severe agitation with signs of potential violence

When the patient sees you in the doorway, she immediately starts yelling and shaking a fist. You calmly introduce yourself and ask if you could spend a few minutes discussing her concerns. She does not engage in the conversation, continues yelling, then throws an empty pudding container toward you—clear signs of potential for violence.

Question: What do you do next?

Make your choices, then click on the explanation bubbles for more information.

• Immediately call for the behavioral emergency response team or security.
• Perform a rapid assessment of the level of agitation, e.g., using the Behavioral Activity Rating Scale (BARS).

That's right—both of the above!

Question: What characterizes each level of agitation?

Think of typical characteristics for each, then click on the explanation bubbles for more information.

• Mild agitation (BARS score ≈ 5)
• Moderate agitation (BARS score ≈ 6)
• Severe agitation (BARS score ≈ 7)

The patient's level of agitation influences the initial management approach.

First, don't forget to breathe. This may seem obvious, but caring for a patient with agitation is difficult, especially when every case feels so different. Next, make an initial management strategy based on the patient's level of agitation (which you just rapidly assessed).

For all patients, initiate de-escalation techniques and, once it is safe to do so, obtain standard diagnostics (e.g., vital signs, SpO₂, point of care glucose) to check for reversible causes. Then tailor the initial management depending on the patient's level of agitation.

Question: What is the recommended approach for each of the following groups?

Think of your management strategy, then click on the explanation bubbles for more information.

• Cooperative patients (mild agitation)
• Uncooperative but nonviolent patients (moderate agitation)
• Aggressive or violent patients (severe agitation)

Question: What is your next step in management for this patient?

Make your choice, then click on the explanation bubble to reveal the answer.

• Leave the room for 10 minutes to allow the patient to calm down.
• Immediately place the patient in wrist restraints so she cannot throw any more pudding.
• Consider a parenteral calming agent for the patient. Maintain a calm and nonthreatening attitude while staying out of arm's reach.

Always begin attempts to calm patients with de-escalation techniques. Proceed to oral or parenteral calming agents if the patient is uncooperative. Avoid physical restraints unless necessary to ensure patient and/or staff safety.

The choice of calming medication for an agitated patient is often determined by the etiology of the agitation. Review the following flowchart for a basic decision-making paradigm.

Pharmacotherapy

Now activate the table quiz to test your understanding of pharmacotherapy for agitation.

Hopefully your swift intervention resolved the patient's agitation, but sometimes physical restraints are necessary. If you must use physical restraints to protect patient and/or staff safety, be aware of the risks.

For more information, see “Physical restraints.”

Want to explore the other scenario? Jump over to “Option 2: Restless but no imminent signs of violence.” You can also return to the main module; see “Restless state wrap-up.”