Managing Acute Agitation and Psychotic Symptoms in the Emergency Department

It is fairly common for adolescents with a presenting problem of acute agitation to present to the Emergency Department. These patients present challenges with respect to both differential diagnosis and management. Furthermore, with many adolescents having extended stays in emergency departments, it is important for ED physicians to have a basic familiarity with diagnosis and treatment. In this paper, we present a primer on the conditions underlying acute agitation and review approaches to management in the emergency department. Psychotic disorders, such as schizophrenia, are distinct from other conditions presenting with psychotic symptoms, which can range from depression to substance use to non-psychiatric medical conditions. Agitation, a state of excessive verbal and physical activity, can accompany any of these conditions. Unlike the case for adults, practice guidelines do not exist, and there is no fully agreed upon expert consensus yet. Emergency physicians should have a working knowledge of antipsychotic medications and need to consider pharmacological as well as non-pharmacological treatments for optimal management.