In a busy emergency department (ED), agitation requires immediate attention and intervention. This chapter addresses methods of verbal de-escalation for the patient who is agitated, but still in control, or who can regain control without the need for restraints or medication, but who, without some verbal intervention, could escalate into full-blown agitation and behavioral dyscontrol. Verbal de-escalation takes no more than five or ten minutes. The best treatment for agitation is to prevent it, or prevent it from escalating. This chapter addresses techniques of verbal de-escalation that the emergency physician can quickly learn and implement as an alternative to seclusion and restraint. Ultimately, verbal de-escalation improves staff morale and patient adherence, because it uses a non-coercive, patient-centered approach. Verbal de-escalation takes no more than five to ten minutes and enhances the doctor-patient relationship, while seclusion and restraint require more staff and takes more time to implement.

As the prevalence of mental illness increases in the United States, emergency medical services' (EMS) role in the care of the psychiatric patient continues to grow. The goal of EMS systems is safe transport of the psychiatric patient to the hospital for further evaluation and care. The cooperative patient can usually be transported without physical or chemical restraint, or law enforcement assistance. In cases of the extremely violent or agitated patient in whom de-escalation techniques have proved futile, law enforcement may elect to use an electronic control device (ECD) to subdue the patient. Refusal of care in the psychiatric patient poses a challenging dilemma. The violent and agitated patient clearly lacks decision-making capacity. Thus EMS personnel need to determine decision making capacity in the difficult prehospital environment. Organic causes of abnormal behavior, such as hypoglycemia, should always be considered.

To manage the agitated patient, it's critical to understand the origin of the behavior. This doesn't mean theorizing about the neurobiological underpinnings. Offering to inject the patient with an antipsychotic would not usually be welcomed as a first intervention. No specific medication is approved by the FDA for control of agitation and combative behavior. Droperidol is another very effective agent, although recent FDA black box warnings about the risk for cardiac arrhythmias and case reports of sudden death reported with its use have led to greater caution. Antipsychotics often provide non-specific but effective control of violent behavior regardless of its cause. Haloperidol is the most studied agent. Agitation of delirium is generally responsive to monotherapy with antipsychotics, and haloperidol is the agent with which physicians have the most experience and for which efficacy is best supported by the medical literature.