This is the current release of the guideline.

Definitions for the strength of evidence (Class I-III) and strength of recommendations (Level A-C) are repeated at the end of the "Major Recommendations" field.

1. What testing is necessary in order to determine medical stability in alert, cooperative patients with normal vital signs, a noncontributory history and physical examination, and psychiatric symptoms?

   Level A recommendations. None specified.

   Level B recommendations. In adult emergency department (ED) patients with primary psychiatric complaints, diagnostic evaluation should be directed by the history and physical examination. Routine laboratory testing of all patients is of very low yield and need not be performed as part of the ED assessment.

   Level C recommendations. None specified.

2. Do the results of a urine drug screen for drugs of abuse affect management in alert, cooperative patients with normal vital signs, a noncontributory history and physical examination, and a psychiatric complaint?

   Level A recommendations. None specified.

   Level B recommendations. None specified.

   Level C recommendations.

   1. Routine urine toxicologic screens for drugs of abuse in alert, awake, cooperative patients do not affect ED management and need not be performed as part of the ED assessment.
   2. Urine toxicologic screens for drugs of abuse obtained in the ED for the use of the receiving psychiatric facility or service should not delay patient evaluation or transfer.

3. Does an elevated alcohol level preclude the initiation of a psychiatric evaluation in alert, cooperative patients with normal vital signs and a noncontributory history and physical examination?

   Level A recommendations. None specified.

   Level B recommendations. None specified.

   Level C recommendations.

   1. The patient's cognitive abilities, rather than a specific blood alcohol level, should be the basis on which clinicians begin the psychiatric assessment.
   2. Consider using a period of observation to determine if psychiatric symptoms resolve as the episode of intoxication resolves.

4. What is the most effective pharmacologic treatment for the acutely agitated patient in the ED?

   Level A recommendations. None specified.

   Level B recommendations.

   1. Use a benzodiazepine (lorazepam or midazolam) or a conventional antipsychotic (droperidol* or haloperidol) as effective monotherapy for the initial drug treatment of the acutely agitated undifferentiated patient in the ED.
   2. If rapid sedation is required, consider droperidol* instead of haloperidol.
   3. Use an antipsychotic (typical or atypical) as effective monotherapy for both management of agitation and initial drug therapy for the patient with known psychiatric illness for which antipsychotics are indicated.
   4. Use a combination of an oral benzodiazepine (lorazepam) and an oral antipsychotic (risperidone) for agitated but cooperative patients.

   Level C recommendations. The combination of a parenteral benzodiazepine and haloperidol may produce more rapid sedation than monotherapy in the acutely agitated psychiatric patient in the ED.

   *Refer to the discussion of droperidol in the original guideline document.

Definitions:

Strength of Evidence

Strength of evidence Class I--Interventional studies including clinical trials, observational studies including prospective cohort studies, aggregate studies including meta-analyses of randomized clinical trials only

Strength of evidence Class II--Observational studies including retrospective cohort studies, case-controlled studies, aggregate studies including other meta-analyses

Strength of evidence Class III--Descriptive cross-sectional studies, observational reports including case series and case reports, consensus studies including published panel consensus by acknowledged groups of experts

Strength of Recommendations

Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on "strength of evidence Class I" or overwhelming evidence from "strength of evidence Class II" studies that directly address all the issues)

Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on "strength of evidence Class II" studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of "strength of evidence Class III" studies)

Level C recommendations. Other strategies for patient management based on preliminary, inconclusive, or conflicting evidence, or, in the absence of any published literature, based on panel consensus

There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2006 Jan

American College of Emergency Physicians - Medical Specialty Society

American College of Emergency Physicians

Clinical Policies Subcommittee on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department

ACEP Clinical Policies Committee

Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department Members: Thomas W. Lukens, MD, PhD, (Chair); Stephen J. Wolf, MD; Jonathan A. Edlow, MD; Samina Shahabuddin, MD; Michael H. Allen, MD, (American Association for Emergency Psychiatry); Glenn W. Currier, MD, MPH, (American Association for Emergency Psychiatry); Andy S. Jagoda, MD, (Chair, Clinical Policies Committee)

American College of Emergency Physicians (ACEP) Clinical Policies Committee (Oversight Committee) Members: William C. Dalsey, MD (Chair, 2000-2002, Co-Chair 2002-2003); Andy S. Jagoda, MD (Co-Chair 2002-2003, Chair, 2003-2006); Wyatt W. Decker, MD; Jonathan A. Edlow, MD; Francis M. Fesmire, MD; Steven A. Godwin, MD; Sigrid A. Hahn, MD (EMRA Representative 2003-2004); John M. Howell, MD; Shkelzen Hoxhaj, MD (EMRA Representative 2002-2003); J. Stephen Huff, MD; Edwin K. Kuffner, MD; JoAnn Lazarus, RN, MSN, CEN (ENA Representative 2003); Thomas W. Lukens, MD, PhD; Benjamin E. Marett, RN, MSN, CEN, CNA, COHN-S (ENA Representative 2002); Donna L. Mason, RN, MS, CEN (ENA Representative 2005); Michael Moon, RN, CNS, MSN, CEN (ENA Representative 2004); Anthony M. Napoli, MD (EMRA Representative 2004-2006); Devorah Nazarian, MD; Scott M. Silvers, MD; Edward P. Sloan, MD, MPH; Robert L. Wears, MD, MS (Methodologist); Stephen J. Wolf, MD (EMRA Representative 2001-2002, committee member 2003-2006); John T. Finnell, II, MD, MSc (Liaison Member for Emergency Medical Informatics Section); Susan M. Nedza, MD, MBA (Board Liaison 2001-2003); John Skiendzielewski, MD (Board Liaison 2003-2004); Cherri D. Hobgood, MD (Board Liaison 2004-2006); Rhonda R. Whitson, RHIA, Staff Liaison, Clinical Policies Committee and Subcommittees

Not stated

American Association for Emergency Psychiatry - Medical Specialty Society

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on February 13, 2006. The information was verified by the guideline developer on April 6, 2006. This summary was updated by ECRI Institute on October 2, 2007, following the U.S. Food and Drug Administration (FDA) advisory on Haloperidol.