Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach

Abstract

Objective:To present the essential guidelines for pharmacological management of patients with psychomotor agitation in Brazil.Methods:This is a systematic review of articles retrieved from the MEDLINE (PubMed), Cochrane Database of Systematic Reviews, and SciELO databases published from 1997 to 2017. Other relevant articles in the literature were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools.Results:Of 5,362 articles retrieved, 1,731 abstracts were selected for further reading. The final sample included 74 articles that met all inclusion criteria. The evidence shows that pharmacologic treatment is indicated only after non-pharmacologic approaches have failed. The cause of the agitation, side effects of the medications, and contraindications must guide the medication choice. The oral route should be preferred for drug administration; IV administration must be avoided. All subjects must be monitored before and after medication administration.Conclusion:If non-pharmacological strategies fail, medications are needed to control agitation and violent behavior. Once medicated, the patient should be monitored until a tranquil state is possible without excessive sedation.Systematic review registry number:CRD42017054440.

Brazilian guidelines for the management of psychomotor agitation. Part 1. Non-pharmacological approach

“…It is also very important to point out that the approach of an agitated patient must always start with the least less coercive measure. Conversely, if agitation is severe, pharmacological measures should be taken (for more details see Part 2 of these Guidelines, on pharmacological approach105). Finally, if all measures fail, physical restraint should be used for patient protection, and always be accompanied by rapid tranquilization.…”

The Management of Psychiatric Emergencies in Situations of Public Calamity

“…The exit route from the room must be at the back of the professional who attends the patient and should be completely unobstructed so that it can be used in the case of a threat that cannot be managed ( 29 , 30 ). It is important to note that doctors and other health professionals will care for patients who may be in crisis and who may behave in an unpredictable manner ( 29 , 30 ). Objects that are potentially dangerous should always be removed ( 24 , 28 ).…”

“…The number of patients must not exceed the number of beds available, given that an excess number of patients can increase the tension between patients and staff ( 25 ). Whenever the management team engages with patients exhibiting agitated and violent behaviors, an effort must be made to manage the treatment in a less restrictive physical environment ( 25 ), such as in a small specialized observation unit with adequate space, equipment, security, and trained staff ( 13 , 25 , 30 , 31 ). This is a small, specialized observation unit with suitable space, equipment, safety, and trained teams ( 25 , 31 ).…”

The Impact of Mental Illness Stigma on Psychiatric Emergencies

“…In the emergency room, care must be taken with physical restraint, which should only be used as a last resort to protect the patient in cases of psychomotor agitation (7,61). Before physical restraint is considered, all other techniques should be employed, especially verbal de-escalation.…”