The first principle in dealing with aggression and agitation in the ED is to acknowledge the risk and to plan to deal with it proactively. Cross-functional, multidisciplinary teams including physicians, nurses, security personnel, and others who interact with patients should try to evaluate the experience of patients in the ED setting, to identify potential causes of aggravation, and to have a proactive plan for dealing with aggression and violence when they arise. Each person should have a clear plan for how such situations should be handled.

A corollary of such planning is to have well-designed and universally practiced protocols for the ED evaluation and management of psychiatric conditions, especially for drug and alcohol abuse and withdrawal. These are dealt with separately in Chapter 69.

Be alert that a medical or psychiatric problem is emerging that is inadequately treated. The most likely culprit is acute withdrawal, which may occur while the medical workup is in progress. It may be necessary to treat withdrawal simultaneously with this evaluation. Remember to consider the diagnosis of akathisia, which may be contributing to agitation. Akathisia is severe restlessness, which is most often seen in the first few months of initiating neuroleptic therapy or after an increase in dose; patients wish to be continually pacing or walking around the examining room. Somewhat paradoxically, increasing the patient’s medication dose only worsens the symptoms; treatment includes dose adjustment, β