Which Emergent Medication Should I Give Next? Repeated Use of Emergent Medications to Treat Acute Agitation

Agitation is a common symptom encountered among patients treated in psychiatric emergency settings. While there are many guidelines available for initial management of the acutely agitated patient, there is a notable dearth of guidelines that delineate recommended approaches to the acutely agitated patient in whom an initial medication intervention has failed. This manuscript aims to fill this gap by examining evidence available in the literature and providing clinical algorithms suggested by the authors for sequential medication administration in patients with persistent acute agitation in psychiatric emergency settings. We discuss risk factors for medication-related adverse events and provide options for patients who are able to take oral medications and for patients who require parenteral intervention. We conclude with a discussion of the current need for well-designed studies that examine sequential medication options in patients with persistent acute agitation.

Managing acute agitation and aggression in the world of drug shortages

Acute agitation and aggression create safety risks for both patients and staff, often leading to psychiatric emergencies. Quick and appropriate treatment is necessary to achieve safe and effective outcomes. Unfortunately, there are several factors that hinder timely interventions, such as medication shortages and delay in staff preparedness. Ultimately, the goal of managing acute agitation and aggression in the clinical setting is to de-escalate the situation and prevent harm to patients and staff. This article will explore useful interventions in realizing treatment goals for the management of agitation and aggression in adults while navigating limitations faced in practice.

Hyperactief delier bij een 11-jarige jongen met juveniele neuronale ceroid lipofuscinose en SARS-CoV-2-infectie

Hyperactive delirium in an 11-year-old boy with juvenile neuronal ceroid lipofuscinosis and a SARS-CoV-2 infection An 11-year-old boy with juvenile neuronal ceroid lipofuscinosis (JNCL) is admitted because of acute agitation and hallucinations. Upon admission, the patient takes lorazepam, which does not induce the expected rest. A PCR-test had a positive result for SARS-CoV-2. Juvenile neuronal ceroid lipofuscinosis (JNCL) is a rare neurodegenerative disease in children and adolescents. Hallucinations are a known symptom in the course of the disease. In the case discussed in this article, however, the pronounced hallucinations fit within a broader clinical picture of a hyperactive delirium. A delirium is by definition provoked by a physical cause. In the presented case, JNCL was an existing risk factor for a delirium, the SARS-CoV-2 infection and lorazepam were presumably the triggering factors. Recent literature shows that an asymptomatic or mildly symptomatic SARS-CoV-2 infection can also trigger a delirium. Treatment consists of treating the physical cause (if possible), supportive measures for the patient and context, as well as medication. The antipsychotics risperidone and haloperidol are recommended. Within the context of JNCL, cautious initiation of a second-generation antipsychotic, such as risperidone, along with great alertness to possible side effects, such as extrapyramidal symptoms and neuroleptic malignant syndrome, are advised. For the young patient in the discussed case risperidone was started, supplemented with olanzapine as rescue medication. The medication had a good effect and no side effects were observed.