Lesson 1 of9
In Progress


Jimmy October 25, 2021


Violence in the Emergency Department

  • 12 million visits across Emergency Departments (ED) each year are related to mental health disorders 
  • Incidence of violence in the hospital is highest in the ED 
  • 71% of ED providers have witnessed assault in the ED 
    • 97% of assailants are patients in the ED
  • 25% of ED staff feel safe at work “sometimes, rarely, or never”
    • Post-traumatic stress disorder, mood disorders, feeling unsafe at work


  • Agitation
    • Extreme form of arousal associated with verbal/motor activity
      • Screaming, thrashing without regard for futility, pain, or fatigue

Also known as excited delirium



  • Intracranial infection
  • Trauma
  • Neuroleptic malignant syndrome
  • Serotonin syndrome
  • Thyrotoxicosis
  • Hypoxia
  • Hyperthermia
  • Hypoglycemia


  • Sympathomimetic
  • Alcohol intoxication


Exacerbation of psychiatric disorder


  • Not a “one-size fits all” disease state
  • The wrong treatment can worsen/kill the patient
    • Requires nuance in therapy, rapid control of the situation, resuscitation

Undesired Outcomes

Trauma from restraintsAsphyxiation from prone positioningAspiration
RhabdomyolysisTdP from QTc prolongationLactic acidosis
Cardiac arrest from sympathetic surgeTakotsubo cardiomyopathyUnnecessary intubation

Clinical Trials

FDA has determined that agitated/intoxicated ED patients are not eligible from exception from informed consent by either them or their family members

Beyond 5 + 2…

“The combination of a neuroleptic, haloperidol (5 mg) and a benzodiazepine anxiolytic, lorazepam (2-4 mg) is often used and may be more effective in combination than either single agent used alone. Repeat dosing at 30-45 min if symptoms are not under control…”

Emergency Medicine – A Comprehensive Study Guide. Tintinalli JE, et al. American College of Emergency Physicians. 6th ed. 

“Rapid tranquilization involves …haloperidol 5-10 mg intramuscularly or intravenously…Benzodiazepines are helpful adjuncts…in providing rapid tranquilization, particularly for combativeness or severe agitation. Lorazepam 1-2 mg is frequently mixed with haloperidol 5 mg in the same syringe and administered intramuscularly or intravenously for this purpose…

Rosen’s Emergency Medicine – Concepts and Clinical Practice. Marx JA, et al. Elsevier Saunders. 8th Ed. 

Ideal Medication