 Welcome back to part 2 of the Agitated Patient. In this section, we'll discuss first the approach and then the work of the patient in the emergency department. When approaching an Agitated Patient, we need to do a two-prong approach. We need to make sure the patient is medically well. We also need to ensure the safety of the patient and their treating staff members. We need to start with patients ABC. We need to make sure the patient's airway is patent. They're oxygenating and ventilating properly, and they're given IV fluids if they're hypotensive. A set of vital signs should be done, including a bedside blood sugar, as we know earlier that hypoglycemia is a cause for acute agitation. In terms of safety, an agitated patient can potentially be a disruptive to the department and its treating staff. When you're taking a history, if you do not feel safe, please leave the room immediately and get help. You can also maintain safety by having security guards or police officer in attendance in the room. You also want to make sure that you are the closest to the door or the exit when interviewing the patient. Next, these are the ways to manage the agitation of an acutely agitated patient. First, you want to remove all external stimuli that can be causing the patient to be agitated. It might mean moving them to a room that's less noisy. That might mean dimming the lighting in the room. If whoever is accompanying the patient seems to be making them more agitated, you might have to ask them to step out. Conversely, if they're making the patient more calm, then you'll want them to be accompanying the patient still. Once the patient is in a quiet room, the next step is verbal de-escalation. That means speaking to the patient in a calm manner. In some cases, verbal de-escalation in a quiet room itself is enough to calm the patient down. If the patient does not calm down, then the patient needs a chemical sedation. There are different medication choices for sedation. It consists of benzodiazepines and short-acting antipsychotic. The roots of administration include PO, intramuscular, whereas intravenous is not really an option since the patient is unlikely to have had an intravenous line inserted at this point because of their agitation. If the patient takes PO or IM medication, depending on which one you choose, they will start to work in about 10 to 15 minutes. Once they calm down, you can start talking to them. If they refuse to take medication, then the patient needs to be physically restrained temporarily to receive the intramuscular injection. Usually one restraint is placed on each limb. Once the intramuscular injection is given, the patient should calm down and the physical restraints should be removed as soon as possible. Once the patient has calmed down, you can do your further work up. Bear in mind the causes that we discussed in Part 1. First, for history. Collateral information is very important. Once the patient has calmed, you can also get some more history. Remember the causes that we discussed. We want to ask about previous history of psychiatric illness, medical causes such as infection, endocrine causes such as thyrotoxicosis or hypoglycemia. Ask about new medications, substance use and withdrawal. On the physical examination, we want to start with vital signs. You want to look for toxidromes including sympathomimetic, anticholinergic and serotonin syndrome. You want to check for a fever that might point to a toxidrome or infection. A neurological examination needs to be done to look for focal neurological signs. Infoscience of meningitis or encephalitis. Depending on what your history might suggest, you may want to look for any other signs of infection on your physical exam. Lab work would depend on what you're looking for. Routine tests can be ordered as baseline. Specific drug levels such as aspirin, acetaminophen or any other drug that we can measure level that they have access to. An ECG should also be done to look for signs of arrhythmia, QRS interval and QT interval. A urinalysis and a chest x-ray might be done to look for infection. If a specific toxin or cause is suspected, there are also specific tests. TSH, T3 and T4 for thyrotoxicosis. CT head if an intracranial lesion is suspected. And a lumbar puncture if we're suspicious of a CNS infection. In terms of disposition, it all depends on what the patients cause for their agitation is. If it was a medical cause they need to be treated, usually in an in-hospital setting. If this is from an exacerbation of a psychiatric illness, they need to be referred to the psychiatric team. In summer we discuss the workup and approach of the patient who's agitated. While we need to treat the patient, we also need to ensure their safety and the safety of those in a department. While we make sure their ABC are looked after, we need to de-escalate them and offer medication to sedate them. We can then proceed with our further workup of either medical or psychiatric cause. We hope you find this useful. Thank you for watching.