Volume 33 Number 2 February 2019

Hostile Workplace
Around-the-clock open access makes the emergency
department a haven for patients at risk for agitated
and aggressive behavior. The best strategy for
managing these dangerous and unpredictable situations
is to diffuse them before they escalate to violence.
Clinicians must be prepared to address the myriad
underlying factors that can cause agitation, many of
which can be life-threatening if left untreated.

Dangerous Creatures
The United States is home to a variety of potentially
dangerous species, including snakes, insects, spiders,
scorpions, and marine animals. Although time is of
the essence when managing cases of envenomation,
the culprit is often difficult or even impossible to
confirm. As such, emergency physicians must be
prepared to evaluate the severity of the patient’s
symptoms and render time-sensitive treatment with
limited information.

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

IN THIS ISSUE
Lesson 3 n Emergency Management of the Agitated Patient . . . . . . . 3
Critical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Critical Decisions in Emergency Medicine is the official
CME publication of the American College of Emergency
LLSA Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Physicians. Additional volumes are available.
Critical Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 EDITOR-IN-CHIEF
Michael S. Beeson, MD, MBA, FACEP
Critical ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Northeastern Ohio Universities,
Lesson 4 n Envenomation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Rootstown, OH

CME Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 SECTION EDITORS

Drug Box/Tox Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Joshua S. Broder, MD, FACEP
Duke University, Durham, NC
Andrew J. Eyre, MD, MHPEd
Brigham & Women’s Hospital/Harvard Medical School,
Contributor Disclosures. In accordance with the ACCME Standards for Commercial
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Support and policy of the American College of Emergency Physicians, all individuals with
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perceived by some as a real or apparent conflict of interest (eg, ownership of stock, grants, University of Maryland, Baltimore, MD
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should, in order, review the learning objectives, read the lessons as published in the print Steven J. Warrington, MD, MEd
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ASSOCIATE EDITORS
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 Hostile
Workplace
Emergency Management
of the Agitated Patient

LESSON 3

By Lynn P. Roppolo, MD, FACEP; Leilani Klinger, MD;

and Jedidiah Leaf, MD
Dr. Roppolo is a professor of emergency medicine at the University of Texas
Southwestern Medical Center in Dallas; Dr. Klinger is an emergency medicine
physician in community practice in San Antonio, Texas; and Dr. Leaf is an assistant
professor of emergency medicine at the University of Texas Southwestern Medical
Center in Dallas.

Reviewed by Walter L. Green, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Identify and quickly assess an agitated patient.
n What underlying etiologies can cause agitation?
2. Determine the best way to approach an agitated
patient. n How should the severity of a patient’s agitation
3. Evaluate the medication options for treating agitation. and risk of violent behavior be assessed?
4. Describe the indications for and risks associated with n How should emergency clinicians approach
the use of physical restraints. agitated patients?
5. Determine which agitated patients should be admitted
n What medications can be used to manage
and which can be safely discharged.
agitation?
FROM THE EM MODEL n When should a patient be physically restrained?
19.0 Procedures and Skills Integral to the Practice
n What is the appropriate disposition for an agitated
of Emergency Medicine
patient?
19.4.9 Psychobehavioral

Agitation is not a diagnosis but rather a symptom with a variety of potentially life-threatening etiologies.
Defined as excessive verbal or motor behavior that can be loud, hyperactive, disruptive, threatening, or combative,
agitation can result in physical and psychological trauma to both patients and clinicians.1-3 Frequent emergency
department overcrowding can result in high noise levels, long wait times, and high stress — all of which can increase
the risk of agitation and even violence.2,4,5 The emergency department is at high risk for workplace violence for a
number of well-documented reasons, including the simple truth that emergency providers are mandated by federal
law to medically evaluate every patient who seeks care.4

February 2019 n Volume 33 Number 2 3

 CASE PRESENTATIONS
■ CASE ONE
A 32-year-old man is brought in
for erratic and aggressive behavior. He
has a history of schizophrenia, and his
family is unsure if he has been taking
his medications. He has not seen a
psychiatrist for many years. When the
physician approaches, the patient yells,
“The Lord is coming! You have been
called as a disciple! Stop living in sin,
and embrace your faith!”
The family explains that he has
not bathed in a week and has had
very little to eat or drink. The patient
denies any fevers, chills, headaches,
cough, abdominal pain, back pain, or
any other symptoms. He has no other
medical history and denies a history of
smoking, alcohol use, or drug use.
His vital signs are blood pressure
126/80, heart rate 90, respiratory rate
16, temperature 36.6°C (97.9°F), and
oxygen saturation 99% on room air.
He is alert and oriented, disheveled in
Furthermore, its around-the-clock
availability makes the emergency
department a haven for patients at risk
for combative behavior, many of whom
are brought in against their will.2,4,6
Other factors that contribute to the risk
of workplace violence include limited
security, insufficient clinical staffing,
and a complacent mentality that accepts
violence as “just a part of the job.”6,7
The American College of Emergency
Physicians (ACEP) recognizes the risk of
violence in the emergency department
and believes that optimal care can only
be rendered when patients and clinicians
are protected. ACEP has encouraged
states to enact legislation to prosecute
those who commit violent acts against
health care workers, and has urged
hospitals to enact security systems and
develop written protocols that address
the management of these dangerous
situations.8
Despite these measures, studies
continue to document the ongoing threat
of emergency department violence and
its effects on health care providers. A
recent national survey of emergency
4 Critical Decisions in Emergency Medicine
appearance, but in no acute distress. He
has dry mucous membranes. His heart
sounds are regular, without evidence
of a murmur; his lungs are clear to
auscultation; and his extremities are
warm and well perfused. The patient
becomes increasingly agitated, however,
and refuses the nurse’s attempts to draw
his blood for laboratory studies.
■ CASE TWO
A physically agitated 26-year-old
woman arrives via ambulance. She is
pulling at her clothing and speaking
gibberish. The paramedics explain that
she became violent at a dance club earlier
in the evening and was arrested. On
arrival, the patient appears diaphoretic
and anxious. Her pupils are markedly
dilated. Her vital signs are blood pressure
160/99, heart rate 143, respiratory rate
24, temperature 38.0°C (100.4°F), and
oxygen saturation 98% on room air.
She refuses to answer the clinician’s
questions and is placed in a resuscitation
physicians from 65 programs revealed
that 78% had experienced at least one
violent workplace act in the previous
12 months, and 21% described being
physically assaulted by a patient.
Unfortunately, only 16% of the programs
reported offering any special training in
workplace violence.6
Significantly more violent events are
described by nurses than by doctors,
and nurses report feeling less safe than
doctors when dealing with combative
patients.9 In addition, violent events
appear to be significantly underreported;
hospital employees file safety reports an
estimated 42% of the time and police
reports only 5% of the time.9 In another
recent survey of New York emergency
medicine residents, 66% reported
being physically assaulted during their
training. (This startling statistic is the
largest reported incidence of physical
violence in the emergency department.)10
The best way to decrease hospital
violence is to prevent it before it occurs.
To do so, physicians and staff must
be better prepared to predict when a
situation is likely to escalate.11 In 2012,
room. The patient violently resists the
staff’s attempts to transfer her onto
another bed, so the decision is made
to physically restrain her.
■ CASE THREE
A developmentally delayed
42-year-old man is brought in by
EMS from a group home. He is
crying, combative, and yelling loudly,
requiring two paramedics to hold
him down. The patient’s heart rate
on a cardiac monitor is 130, with
a respiratory rate of 20. However,
his agitation prevents the nurse
from obtaining blood pressure or
temperature readings. There are no
signs of trauma, and he is moving all
four limbs purposefully. The nurse
prepares an intramuscular (IM) dose
of haloperidol and midazolam. She
would like to administer the sedatives
immediately but waits for the
physician to confirm the order.
the American Association of Emergency
Psychiatry published Project BETA (Best
Practices in Evaluation and Treatment
of Agitation), a series of articles written
by emergency medicine physicians and
psychiatrists. Project BETA provides
thorough but practical, evidence-based
recommendations for the evaluation and
treatment of agitated patients. These
guidelines, which form the foundation of
this review, provide strategies for making
the emergency department a safer place for
clinicians and patients alike.12-17
CRITICAL DECISION
What underlying etiologies can
cause agitation?
Agitation can stem from a multitude
of pathologies, including trauma,
withdrawal, toxidromes, endocrinopathies,
metabolic derangements, substance abuse,
infections, and neurological and mental
illnesses.4,13 Agitated behavior should be
prioritized and promptly evaluated with
the same urgency as any other high-risk
presentation, starting with an assessment
of the patient’s chief complaint and vital
signs. Any concerning sign or symptom
— abnormal vital signs (eg, an elevated bipolar disorders increased by 52%.18 violent behavior. Such measurements can
temperature), alterations in mental status, Although mentally ill patients be used to justify clinical decisions (eg,
trauma, acute psychosis (especially with frequently seek care for medication refills physical restraints or the administration
visual hallucinations), difficulty breathing, or acute exacerbations of their psychiatric of sedatives) and help emergency
or neurological deficits — should trigger illness, only 16.9% of emergency clinicians communicate with other health
concern for a life-threatening condition departments report having access to an care providers.
(Table 1).4,13 on-call psychiatrist.19 While physical One such tool is the Behavioral
Several metabolic and physiological aggression is rare, even in mentally ill Activity Rating Scale (BARS) (Table 2),
disturbances can produce delirium, which patients, violent acts are often associated a simple system that does not require
is frequently associated with agitation. For with substance abuse, environmental the patient to answer any questions.21 A
example, hypoglycemia, hypoxia, head stressors, or a history of violence.20 BARS score of 4 indicates a normal, calm
trauma, and infection can all manifest as Mentally ill patients who present state. Patients can rapidly escalate from
agitation.4,13 Any patient with a possible with agitation typically suffer from an a mild (BARS 5) to a severely (BARS 7)
intoxication or ingestion warrants a underlying psychiatric history. Some agitated state (ie, combative and violent
thorough medical evaluation, as clues in may report auditory hallucinations or behavior).
the history or clinical presentation can psychiatric complaints such as anxiety, The Brøset Violence Checklist is a
influence how the agitation should be depression, paranoia, or suicidal/ simple scale that scores patients based
addressed. homicidal ideations. on the presence (1) or absence (0) of six
Unfortunately, behavioral health variables (Table 3). Based on the sum
emergencies are on the rise. According CRITICAL DECISION of the score, a clinician can predict a
to the Agency for Healthcare Research patient’s risk of violence within the next
How should the severity of a
and Quality, emergency department 24 hours and the need for intervention.
patient’s agitation and risk of These scales and other similar
visits for depression, anxiety, and stress
reactions increased by 55.5% between violent behavior be assessed? instruments can be used to assign
2006 and 2013. Visits for substance Several validated scoring scales can be agitation levels that correspond to
abuse increased by 37% during the same used to describe the severity of a patient’s preformulated emergency department
period, and visits for psychosis and agitation and help predict the risk for interventions. Because acute presentations
are often dynamic, a patient’s agitation
TABLE 1. Life-Threatening Medical Causes of Acute Agitation4,13 and response to treatment should be
frequently reassessed and documented.
Thermoregulation Hypothermia
Although it is not uncommon for
Hyperthermia patients to verbally assault staff by
Respiratory Hypoxia arguing or using profanity, it is critical
Hypercarbia to understand that these scenarios can
Infection Meningitis, encephalitis, sepsis from other infections quickly escalate to violence.2,5,6 Health
Trauma Head injury care workers who experience verbal
Toxicological Adverse drug reaction threats and other forms of nonphysical
Drug overdose or intoxication violence are an estimated 7.17 times more
Sedative-hypnotic agent withdrawal
likely to experience physical violence than
those who have not.23 As such, patients
Metabolic Thyroid storm
who verbally assault staff must be treated
Hyperglycemia or hypoglycemia
with the same vigilance as any other
Electrolyte abnormalities
agitated patient to mitigate the risk of
Neurological Stroke bodily harm.
Subarachnoid hemorrhage
Encephalitis CRITICAL DECISION
Seizure (postictal) How should emergency clinicians
approach agitated patients?
TABLE 2. Behavioral Activity Rating Scale21 Initial Management
1 = Difficult or unable to arouse To minimize the risk of violence,
2 = Asleep but responds normally to verbal or physical contact agitated patients should be placed in
3 = Drowsy; appears sedated an appropriate area that minimizes
4 = Quiet and awake (normal level of activity)
additional stimulation and provides
5 = Signs of over (physical or verbal) activity; calms down with instructions
adequate space for clinical management.
6 = Extremely or continuously active; does not require restraint
Clinicians should only get close to a
7 = Violent; requires restraint
patient when it is safe to do so. Before

February 2019 n Volume 33 Number 2 5


TABLE 3. Brøset Violence
Checklist22
Confusion 1 point
0 points
Irritability 1 point
0 points
Boisterousness 1 point
0 points
Physical threats 1 point
0 points
Verbal threats 1 point
0 points
Attacks on objects 1 point
0 points
Score 0: Low risk of violence
Score 1-2: Moderate risk of violence à
Preventative measures should be taken.
Score ≥3: High risk of violence à
Preventative measures are required.
evaluating a patient’s ABCs (airway,
breathing, and circulation), it is
important to ensure that the situation is
under control and adequate staffing is
available to provide restraint if needed.
Physical restraints and sedation
increase the risk of harm to both patients
and staff and should be used only as
a last resort.12 A model in which the
physician promptly identifies agitated
behavior and intervenes immediately
through a less coercive approach can
help mitigate symptoms and reduce the
need for physical restraint.
Initial priorities include ensuring
the safety of the patient and staff;
de-escalating the situation; providing
pharmacotherapy to calm the patient,
if needed; and identifying any life-
threatening problems that warrant
immediate attention. Whenever possible,
a brief patient history should be taken
and a physical examination, including a
mental status evaluation, vital sign and
oxygen saturation measurements, and
bedside point-of-care glucose testing,
should be initiated. In addition, it is
crucial to address pain, a symptom that
is often overlooked in agitated patients.
Mentally ill patients whose
presentation is consistent with an
ongoing psychiatric disease seldom
require a medical workup. Alternatively,
those whose symptoms are inconsistent
with a previous diagnosis warrant
6 Critical Decisions in Emergency Medicine
further evaluation.13 Red flags that
can indicate a nonpsychiatric etiology
include extremes of age, vital sign
abnormalities, trauma, delirium,
visual hallucinations, neurological
abnormalities, acute intoxication/
ingestion, substance withdrawal
symptoms, and comorbidities (eg,
immunosuppression) that can place
patients at risk for serious pathologies.13
Delirium is an acute medical
emergency with multiple life-threatening
etiologies that can be easily confused
with underlying psychiatric conditions
or chronic cognitive issues. Patients
with delirium typically have an altered
level of awareness and problems with
directing, focusing, sustaining, or shifting
attention.24 In such cases, the medical
workup should target the underlying
condition and may include directed
laboratory studies, neuroimaging (eg,
CT scan of the head), or a lumbar
puncture (to evaluate for infection), as
indicated. Patients who are taking high
doses of antipsychotics or have ingested
medications in an apparent suicide
attempt may also require an ECG.
Psychiatric Assessment
The acute psychiatric evaluation of
an agitated patient is aimed at diffusing
the situation and determining the most
likely cause of the agitation. Once
the patient is under control and able
to communicate, and medical causes
for the agitation have been ruled out,
a more extensive assessment can be
completed. Patients who are intoxicated
or too sedated to undergo a mental
health evaluation should be monitored
closely, and the assessment can be
postponed until the patient is able to
communicate.14
When initiating a psychiatric
evaluation, priorities include establishing
an initial differential diagnosis,
identifying safety concerns, and
developing an appropriate treatment
and disposition plan.14 Although the
initial assessment may be performed by
an emergency clinician, a more detailed
examination typically requires the
assistance of a psychiatry consultant
(often a social worker who specializes in
behavioral emergencies). In particular, it
is important to determine if the patient’s
agitation is due to an underlying
psychiatric disorder and identify any
psychotic features.
Suicidal and homicidal risk should
also be ascertained. In many cases,
verbal de-escalation, with or without
pharmacotherapy, may be all that is
necessary to calm the patient. Laws
that support an emergency physician’s
decision to place a patient on
involuntary status or provide medical
interventions (eg, pharmacotherapy for
agitation) without the patient’s consent
typically relate to concerns about
physical safety, significant impairment in
self-care, or the need for treatment in the
presence of a mental disorder.14
De-escalation Process
Words can be used to powerful
effect to calm combative patients while
the clinician assesses for life-threatening
etiologies. The clinician must engage
the patient, establish a collaborative
relationship, and verbally de-escalate
the situation.15 Only one person should
attempt the initial de-escalation, and
measures should be taken to ensure
the process is safe and respectful of the
patient’s space. 3,13
Clinicians should greet and call
patients by name; ask affirmative,
open-ended questions; and emphasize
that the emergency department is a safe
place. It is important to listen patiently
with sincere respect and kindness,
as nonverbal communication must
be congruent with what is actually
being said. Any words or actions that
may be perceived as confrontational
or demeaning should be avoided.
When appropriate, simple gestures
like providing a blanket or pillow or
offering the patient a snack or beverage
can go a long way toward building a
therapeutic relationship. 9
Clear limits must also be set;
patients should understand which
behaviors are acceptable — and which
will not be tolerated. The physician can
help coach the patient on how to stay in
control, but there should be reasonable
consequences for noncompliance.
The de-escalation process often
takes the form of a verbal loop, in which
the physician listens to the patient,
responds in a way that validates the
patient’s concerns, and states the next
steps. Oftentimes, this message must
be reiterated at a later time, when the
patient is more receptive.15 Although the
de-escalation process can take 5 minutes
or longer, it is a valuable investment that
can prevent time-consuming problems
later in the course of treatment,
including oversedation or injury.
CRITICAL DECISION
What medications can be used
to manage agitation?
When medications are required, the
goal should be to calm the patient (not
simply restrain movement) to pave the
way for a proper clinical assessment.16
Some agents, including benzodiazepines,
can cause oversedation, which can
make it difficult for patients to answer
questions or cooperate with an
examination. Furthermore, oversedation
can lead to respiratory depression
in those with underlying respiratory
conditions or if given in combination
with other central nervous system
depressants.
Oral medications are preferred
to parentally administered drugs,
especially for the treatment of mild
agitation. IM administration is reserved
for severely agitated patients who
pose an immediate threat. In such
cases, five additional staff members
should restrain the patient, and the IM
injection should be placed in the lateral
thigh or the superior lateral quadrant of
the gluteal muscle.
If a patient’s agitation is believed
to be the result of a medical condition
(eg, hypoxia, hypoglycemia), treatment
should be focused on the underlying
pathology, rather than on the agitation
itself. However, if the cause of the
patient’s behavior cannot be immediately
identified, a pharmacological intervention
may be required (Table 4).
Benzodiazepines
Benzodiazepines act on GABA
receptors, the brain’s primary inhibitory
neurotransmitters.16 As a result, well-
known side effects include sedation,
respiratory depression, and hypotension,
which can be more dramatic in those
suffering from an underlying respiratory
disorder or are under the influence of
alcohol. Benzodiazepines are the treatment
of choice for patients under the influence
of any drug that causes a sympathomimetic
response (eg, cocaine, methamphetamines)
and for the management of withdrawal
from alcohol or certain sedative-hypnotic
drugs. They are also the treatment
of choice for agitation of unknown
etiology.15,16
Typical Antipsychotics
Haloperidol and droperidol, two
first-generation (typical) antipsychotics
sometimes used to treat agitation, can
cause QT prolongation, especially with
repeat dosing. When combined with
certain other drugs, these agents can
lead to life-threatening arrhythmias.
Because fatal arrhythmias have been
associated with the use of droperidol,
the FDA placed a black-box warning on
this once commonly used drug, which
is now unavailable to most emergency
physicians.16 Haloperidol is permitted
in oral and IM forms; however, some
physicians still administer the drug by IV.
Other side effects associated
with the use of typical antipsychotics
include extrapyramidal symptoms
(eg, tardive dyskinesia, akathisia,
dystonia, parkinsonism) and neuroleptic
malignant syndrome. To minimize
the risk of side effects, these agents
are often coadministered with other
medications, including antihistamines
or benzodiazepines.16 However, there
is no evidence to support the use of
both agents with haloperidol, as the
combination may cause oversedation.
Atypical Antipsychotics
Second-generation (atypical)
antipsychotics (eg, olanzapine,
ziprasidone, aripiprazole, risperidone,
and quetiapine) have fewer side effects
than first-generation agents because they
are more selective in the brain receptors
they antagonize.
It is important to remember that
all antipsychotics can reduce the
seizure threshold to varying degrees.
Clozapine is the atypical agent most
frequently associated with seizures, while

TABLE 4. Medications for Agitation16

General Considerations Medication Recommendations
Agitation due to Intoxication due to stimulant drugs without Benzodiazepine
intoxication psychosis
Intoxication due to stimulant drugs with Antipsychotic (SGA* preferred) plus benzodiazepine — use caution
psychosis with an SGA like olanzapine, which is very sedating.
Intoxication due to alcohol Benzodiazepines should be avoided if there are no symptoms of
withdrawal due to respiratory depression. Antipsychotics such as
haloperidol are preferred.
Agitation due to a Psychosis present in a patient with a psychiatric Antipsychotic (SGA* preferred). Add a benzodiazepine, if needed —
psychiatric illness disorder use caution with an SGA like olanzapine, which is very sedating.
Agitation associated Delirium due to a benzodiazepine or alcohol Benzodiazepine
with delirium withdrawal
Delirium not due to a benzodiazepine or Antipsychotic (SGA* preferred or haloperidol at low doses).
alcohol withdrawal (Note: Treat the underlying Benzodiazepines can exacerbate delirium.
medical condition; if delirium is due to acute
ingestion, symptoms may be self-limited.)
Agitation of No psychosis Benzodiazepine
unknown etiology Psychosis present Antipsychotic
*SGA = second-generation antipsychotic

February 2019 n Volume 33 Number 2 7

 TABLE 5. Side Effects of Commonly Used Antipsychotics for Agitation32
Anticholinergic
Atypical
Olanzapine +++
Quetiapine ++
Risperidone + (rare)
Ziprasidone + +
Typical
Haloperidol + +++
risperidone and haloperidol appear to
confer a relatively low risk.25 If a patient
with a history of seizures requires an
antipsychotic for psychosis, the benefits
of haloperidol outweigh its risks. Of note,
the coadministration of a benzodiazepine
may help mitigate the risk of seizure.
Indications and Precautions
Antipsychotic medications (Table 5)
should be avoided in patients who
are actively seizing, hyperthermic,
or demonstrating other signs of
anticholinergic toxicity. Atypical
antipsychotics, which can effectively
treat acute agitation with relatively
few extrapyramidal side effects, are
preferred over haloperidol.16 Caution
should be used, however; some second-
generation antipsychotics pose risks
that can influence the management of
certain patients. For example, ziprasidone
causes the most QT prolongation of any
antipsychotic drug. Although olanzapine
has more anticholinergic side effects than
other antipsychotics, it is more sedating
and available in both oral dissolving
tablets (ODT) (for mild agitation) and IM
(for severe agitation) formulations.
Antipsychotics can be used in
agitated patients with suspected alcohol
intoxication, as benzodiazepines can
further increase the risk for respiratory
depression.16 Because of their ability
to address underlying psychosis,
antipsychotics are also preferred for
patients whose agitation is thought to
stem from a mental illness. Risperidone
is the agent of choice for any agitated
patient willing to take an oral
medication, followed by olanzapine
ODT.16 IM ziprasidone or olanzapine
can be used to manage severe agitation
caused by a psychotic condition.15
Midazolam, which has a quicker
onset and shorter duration than
8 Critical Decisions in Emergency Medicine
Extrapyramidal Hyperglycemia
+ +++
+ +++
++ ++
+ ++
++
lorazepam, is being used more frequently
for the treatment of agitation. A
recent comparison of IM midazolam,
olanzapine, ziprasidone, and haloperidol
for the treatment of acute agitation found
that midazolam achieved more effective
sedation than antipsychotics. Olanzapine
achieved more effective sedation
than haloperidol at 15 minutes.26 It is
also important to keep in mind that
populations with pharmacokinetic
sensitivities (eg, elderly patients) require
different dosing regimens.27
Ketamine
Ketamine IM also has been
recommended for the treatment of severe,
uncontrollable agitation. In one recent
study, 4 mg/kg IM ketamine (either alone
or combined with 2 mg IV midazolam
to prevent ketamine-induced emergence
phenomenon) was used in the prehospital
setting for the rapid sedation of agitated
patients. Ketamine was chosen because of
its fast onset, high efficacy rate, and low
hemodynamic and respiratory side effects.
Nearly every patient who was treated with
the drug (50/52) was adequately sedated
within an average of 2 minutes. Significant
respiratory depression occurred in three
subjects (6%). In all three cases, the
patients had also received midazolam.28
Despite these promising results,
ketamine has not yet been accepted
universally by the emergency medicine
community for controlling severe
agitation. The drug may be of greatest
benefit to patients with excited delirium
whose agitation cannot be de-escalated.
CRITICAL DECISION
When should a patient be
physically restrained?
The Centers for Medicare and
Medicaid Services support the use of
seclusion and restraint only after less
QT Prolongation Sedation
+ +++
+ +++
+ ++ (initially)
++
+ +
restrictive measures have failed.17 These
methods should never be imposed
as a means of coercion, discipline,
convenience, or retaliation.17 In
addition to complying with specific
documentation requirements, health care
professionals must follow specific rules
and regulations. Clinicians should avoid
combining restraints and seclusion, and
patients who are a danger to themselves
should not be placed in seclusion.
Restraints, which must be ordered
by a licensed medical practitioner and
not “as needed,” should be discontinued
as soon as the patient regains self-
control. Continuous visual monitoring
is essential. The patient should be
examined by a trained clinician within
1 hour of the restraint order, and
a follow-up order is required if the
restraint lasts longer than 1 hour. In
addition, a face-to-face encounter with
the ordering physician or designee is
necessary if the restraint lasts longer
than 1 hour for a child younger than
10 years, 2 hours for a patient between
10 and 18 years old, or 4 hours for an
adult older than 18 years.29 To prevent
complications, close cardiac, pulse
oximetry, and end-tidal CO2 monitoring
are mandatory. In addition, frequent
assessments of vital signs, agitation
level, and mental status are required.17,29
Precautions
Ideally, physical restraints should be
implemented by a team of five people,
including security or police officers
trained to manage combative patients,
the nurse responsible for administering
medication, and/or the clinician in
charge of the patient’s care. One person
should be stationed at each limb and
a fifth should be available to hold the
patient’s head. If only two limbs can be
tied down, the contralateral arm and
leg should be secured with one arm
tied upward and the other downward,
which theoretically decreases the
amount of force and momentum that
struggling can generate.4 The preferred
position for restraint is supine, as
placing a patient prone or in hobble
restraints (binding/handcuffing the
wrists, binding the ankles, and then
attaching the wrists to the ankles) can
compress the neck and chest wall,
increasing the risk for asphyxiation.4
Measures should be taken to prevent
any undue pressure on the airway, neck,
or chest. Ideally, the physician should
not take part in physically restraining
the patient, but rather should continue
to attempt to verbally de-escalate the
situation while explaining what is
happening.4 An oxygen mask can be
applied over the face of any spitting
patient to prevent bodily fluid exposure.
The most common complication of
this approach is skin breakdown at the
site of the restraints. Rhabdomyolysis
and acidosis also become possibilities
in patients who continue to fight the
restraints.4 In addition, restrictive
positioning can interfere with
respiratory compensation for acidemia,
which can be severe enough to cause
cardiac arrest.30 To help avoid these
complications, physical restraints
should always be combined with
medications to calm the patient and
continuous monitoring.
CRITICAL DECISION
What is the appropriate
disposition for an agitated
patient?
Patients who pose a threat or are
too impaired by their psychosis to care
for themselves should be admitted to
inpatient psychiatry. Once this decision
is made, hospital staff should remain
with the patient until a transfer can be
arranged.  
Most cases of delirium require
medical management and inpatient
admission. However, if the cause of
the agitation can be reversed in the
emergency department and no further
workup is warranted, the patient can
be discharged if the physician deems it
appropriate. For example, patients who
were agitated due to drugs or alcohol
can potentially be sent home after a
period of observation, assuming they
are clinically sober upon discharge and
have a safe ride home. Although certain
medications may prolong the patient’s
stay, safety is always more important
than an expeditious disposition.
Disposition becomes difficult
when a patient refuses treatment that
the clinician considers necessary. To
better appreciate this scenario, it is
helpful to understand the concept of
capacity. Decision-making capacity
refers to a patient’s ability to make
informed, logical choices that could be
reasonably construed as being in his or
her best interest. This requires patients
to understand, process, and deliberate
over information relayed by health
care providers and make reasonable
decisions based on that information.31
In many instances, it is relatively
easy to ascertain whether a patient
possesses decision-making capacity.
However, capacity is not an all-or-
nothing concept; it is a dynamic
process that can fluctuate over time.
When patients’ cognitive skills are
compromised by drugs, alcohol, or
delirium, for example, their thought
processes can change.
Despite the common misconception
that only a trained psychiatrist can
accurately measure a patient’s capacity,
most emergency physicians are well-
equipped to make such judgments.
If uncertainty exists, however, a
low threshold to consult psychiatry
should be maintained. If a psychiatrist
is unavailable, it is reasonable to
detain patients until their decision-
making capacity can be more clearly
n When managing any agitated patient, clinicians should evaluate for
life-threatening etiologies while using a noncoercive approach aimed at
de-escalation.
n Physicians should make every attempt to identify reversible causes of
agitation, including medical illness or drug toxicity or withdrawal.
n Emergency department safety protocols can reduce the risk of violence and
facilitate a more effective and efficient response by hospital staff.
ascertained. In these situations, thorough
documentation is paramount.
Summary
Agitated patients who present to the
emergency department should be treated
as high risk. Clinicians must recognize
when a situation has the potential to
become violent, and also be prepared to
address the numerous life-threatening
medical conditions that can lead to
agitation. When managing such cases,
Project BETA recommends using a
noncoercive approach with an emphasis
on de-escalation. Physical restraints
should be used only as a last resort.
Medications should be administered
based on the level and etiology of a
patient’s agitation. Every attempt should
be made to mitigate injury to patients,
visitors, and staff, while minimizing
other complications (eg, oversedation)
that can arise from interventions used to
control agitation.
REFERENCES
1. Zeller SL. New guidelines shake up treatment of
agitation. Psychiatric Times website. http://www.
psychiatrictimes.com/psychiatric-emergencies/new-
guidelines-shake-treatment-agitation. Published
March 27, 2012. Accessed August 8, 2018.
2. Gates GM, Ross CS, McQueen L. Violence:
recognition, management and prevention. J Emerg
Med. 2006;31(3):331-337.
3. Frueh BC, Knapp RG, Cusack KJ, et al. Patients’
reports of traumatic or harmful experiences
within the psychiatric setting. Psychiatr Serv. 2005
Sep;56(9):1123-1133.
4. Rossi J, Swan MC, Isaacs ED. The violent or
agitated patient. Emerg Med Clin North Am. 2010
Feb;28(1):235-256.
5. Kowalenko T, Walters BL, Khare RK, Compton
S; Michigan College of Emergency Physicians
Workplace Violence Task Force. Workplace
violence: a survey of emergency physicians in
the state of Michigan. Ann Emerg Med. 2005
Aug;46(2):142-147.
6. Behnam M, Tillotson RD, Davis SM, Hobbs
GR. Violence in the emergency department: a
national survey of emergency medicine residents
and attending physicians. J Emerg Med. 2011
May;40(5):565-579.
February 2019 n Volume 33 Number 2 9
 CASE RESOLUTIONS
■ CASE ONE
The clinician was able to calm the
schizophrenic man by gently initiating
conversation. The patient agreed to
take a tablet for his “nerves” and
ate the sandwich offered to him. He
received a psychiatric consultation
in the emergency department and
was discharged with an outpatient
psychiatry follow-up.
■ CASE TWO
The combative woman was placed
in four-point restraints after receiving
multiple doses of midazolam and
haloperidol for severe agitation. She
subsequently became obtunded with
respiratory depression and required
intubation. Blood was drawn for
laboratory studies, and IV fluids were
initiated for tachycardia. The patient’s
basic laboratory workup revealed a
creatinine level of 1.7 mg/dL and a
creatine kinase level of 32,000 U/L.
Her urine drug toxicology screen was
positive for amphetamines. She was
admitted to the medical ICU, where
she received ventilatory support and
further treatment for rhabdomyolysis.
An inpatient psychiatric evaluation
was performed after she was medically
stabilized.
■ CASE THREE
While making eye contact with
the developmentally delayed man, the
attending physician gently reassured
him that the team was there to help
him. The physician agreed to withhold
the physical restraints and clear the
room, except for one police officer,
if the patient remained cooperative.
Through a dialogue with the patient,
the physician discovered that the man
suffered from a speech impediment,
had been sexually abused at his group
home, and was afriad to return. After a
long discussion, the patient relaxed and
did not require sedatives, diagnostic
studies, or a psychiatric evaluation.
He was willing to meet with a social
worker and law enforcement, and was
transferred to a new group home
4 hours later.

7. Ray MM. The dark side of the job: violence in
the emergency department. J Emerg Nurs. 2007
Jun;33(3):257-261.
8. American College of Emergency Physicians.
Protection from physical violence in the emergency
department environment. Policy statement.
Ann Emerg Med. 2011 Oct;58(4):405.
9. Kowalenko T, Gates D, Gillespie GL, Succop P,
Mentzel TK. Prospective study of violence against ED
workers. Am J Emerg Med. 2013 Jan;31(1):197-205.
10. Schnapp BH, Slovis BH, Shah AD, et al. Workplace
violence and harassment against emergency
medicine residents. West J Emerg Med. 2016
Sep;17(5):567-573.
11. Workplace violence prevention: screening
for the early detection of risk of harm to self
or others. Perspectives. 2017 Oct;13(10):11.
https://www.jointcommission.org/assets/1/6/
Oct2017PerspectivesArticle_WPVscreening.pdf.
Accessed July 8, 2018.
12. Holloman GH Jr, Zeller SL. Overview of Project
BETA: best practices in evaluation and treatment of
agitation. West J Emerg Med. 2012 Feb;13(1):1-2.
13. Nordstrom K, Zun LS, Wilson MP, et al. Medical
evaluation and triage of the agitated patient:
consensus statement of the American Association
for Emergency Psychiatry Project BETA medical
evaluation workgroup. West J Emerg Med. 2012
Feb;13(1):3-10.
14. Stowell KR, Florence P, Harman HJ, Glick RL.
Psychiatric evaluation of the agitated patient:
consensus statement of the American Association
for Emergency Psychiatry Project BETA psychiatric
evaluation workgroup. West J Emerg Med. 2012
Feb;13(1):11-16.
15. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal
de-escalation of the agitated patient: consensus
statement of the American Association for Emergency
Psychiatry Project BETA de-escalation workgroup.
West J Emerg Med. 2012 Feb;13(1):17-25.
16. Wilson MP, Pepper D, Currier GW, Holloman
GH Jr, Feifel D. The psychopharmacology of
agitation: consensus statement of the American
Association for Emergency Psychiatry Project BETA
psychopharmacology workgroup. West J Emerg Med.
2012 Feb;13(1):26-34.
17. Knox DK, Holloman GH Jr. Use and avoidance of
seclusion and restraint: consensus statement of the
American Association for Emergency Psychiatry
Project BETA seclusion and restraint workgroup.
West J Emerg Med. 2012 Feb;13(1):35-40.
18. Weiss AJ, Barrett ML, Heslin KC, Stocks C. Trends
in emergency department visits involving mental
and substance use disorders, 2006-2013. Healthcare
Cost and Utilization Project website. https://
www.hcup-us.ahrq.gov/reports/statbriefs/sb216-
Mental-Substance-Use-Disorder-ED-Visit-Trends. 25. Hedges D, Jeppson K, Whitehead P. Antipsychotic
jsp?utm_source=AHRQ&utm_medium=EN-1&utm_ medication and seizures: a review. Drugs Today
term=&utm_content=1&utm_campaign=AHRQ_ (Barc). 2003 Jul;39(7):551-557.
EN1_10_2017. Published 2016. Accessed August 11, 26. Klein LR, Driver BE, Miner JR, et al. Intramuscular
2018. midazolam, olanzapine, ziprasidone, or haloperidol
19. American College of Emergency Physicians. Waits for treating acute agitation in the emergency
for care and hospital beds growing dramatically department. Ann Emerg Med. 2018 Oct;72(4):374-385.
for psychiatric emergency patients. ACEP website.
27. Nassisi D, Korc B, Hahn S, Bruns J Jr, Jagoda A. The
http://newsroom.acep.org/2016-10-17-Waits-for-
evaluation and management of the acutely agitated
Care-and-Hospital-Beds-Growing-Dramatically-for-
elderly patient. Mt Sinai J Med. 2006 Nov;73(7):
Psychiatric-Emergency-Patients. Published October
976-984.
17, 2016. Accessed August 9, 2018.
28. Scheppke KA, Braghiroli J, Shalaby M, Chait R.
20. Varshney M, Mahapatra A, Krishnan V, Gupta R,
Prehospital use of i.m. ketamine for sedation of violent
Deb KS. Violence and mental illness: what is the
true story? J Epidemiol Community Health. 2016 and agitated patients. West J Emerg Med. 2014
Nov;15(7):736-741.
Mar;70(3):223-225.
29. Masters KJ. Physical restraint: a historical review and
21. Swift RH, Harrigan EP, Cappelleri JC, Kramer D,
Chandler LP. Validation of the behavioural activity current practice. Psychiatric Annals. 2017;47(1):52-55.
rating scale (BARS)TM: a novel measure of activity 30. Hick JL, Smith SW, Lynch MT. Metabolic acidosis in
in agitated patients. J Psychiatr Res. 2002 Mar- restraint-associated cardiac arrest: a case series.
Apr;36(2):87-95. Acad Emerg Med. 1999 Mar;6(3):239-243.
22. Almvik R, Woods P, Rasmussen K. The Brøset 31. Good B, Walsh RM, Alexander G, Moore G.
Violence Checklist: sensitivity, specificity, and Assessment of the acute psychiatric patient in the
interrater reliability. J Interpers Violence. 2000 emergency department: legal cases and caveats.
Dec 1;15(12):1284-1296. West J Emerg Med. 2014 May;15(3):312-317.
23. Lanza ML, Zeiss RA, Rierdan J. Non-physical 32. https://bpac.org.nz/BPJ/2011/november/docs/
violence: a risk factor for physical violence in health bpj_40_antipsychotics_pages_14-23.pdf. Accessed
care settings. AAOHN J. 2006 Sep;54(9):397-402. August 10, 2018; and Glick ID, He X, Davis JM. First-
24. American Psychiatric Association. DSM-5 generation antipsychotics: current status.
development: delirium. Prim Psychiatry. 2006 Dec 1;13(12):51-58.
n Failing to recognize that medications used to treat agitation have
potentially serious side effects. Caution should be used when administering
benzodiazepines to patients with alcohol intoxication, as these agents can
precipitate respiratory depression.
n Neglecting to show empathy toward agitated patients. Failing to treat these
patients with courtesy can lead to ill feelings and exacerbate violent behavior.
n Attempting to initiate physical restraints on a severely agitated patient
without a coordinated team approach and the prompt administration of an
IM medication.

10 Critical Decisions in Emergency Medicine

 The Critical Procedure
Superficial Cervical Plexus
Regional Anesthesia
By Steven Warrington, MD, MEd
Dr. Warrington is the director of the Emergency Medicine Residency Program and academic chair
of the Department of Emergency Medicine at Orange Park Medical Center in Orange Park, Florida.

Ultrasound-guided regional anesthesia of the superficial cervical plexus is a particularly useful

technique for managing acute injuries of the acromioclavicular joint, clavicle, auricle of the
ear, and skin overlying the lateral neck. The superficial cervical plexus gives rise to the greater
auricular, lesser occipital, suprascapular, and transverse cervical nerves.

Contraindications
n Allergy to anesthetic
n Infection overlying the site
Benefits and Risks
As with other methods of delivering
regional anesthesia, this approach
can obviate the need for systemic
medications. Regional anesthesia of
the superficial cervical plexus carries
minimal risks, aside from procedure
failure or an allergic reaction. Primary
complications include the risk of
infection, an inadvertent intravascular
injection, or vascular damage that can
lead to a hematoma and/or swelling.
Clinicians must also avoid injecting
the anesthesia too deeply, an error that
can lead to an unintended block of
the phrenic nerve, cervical plexus, or
brachial plexus.
Alternatives
Common alternatives to regional
anesthesia include systemic medications
such as anxiolytics, analgesics, and
sedation protocols.
Reducing Side Effects
Side effects can be reduced with the
use of standard precautions (eg, sterile
technique) and clear communication
with the patient and staff. In addition,
the laterality of the needle pathway
should be confirmed, and aspiration
should occur prior to injection. The
anesthetic must be chosen carefully
based on the patient’s level of
discomfort and the duration of the
procedure.
Proper patient positioning can
also increase the probability of
success. Typically, the patient should
be in a supine position; the head
should be turned away from the
affected side or in a lateral decubitus
position. The patient’s neck and
upper chest should be exposed so
that the relative length and position
of the sternocleidomastoid (SCM)
can be assessed.

TECHNIQUE
1. Select the anesthetic agent based on the SURFACE LANDMARKS
clinical situation (eg, ideal duration of block) 1. Sternal notch
and prepare the equipment. 2. Superior pole of the
2. Clean and drape the site. thyroid cartilage
3. Identify anatomical landmarks on
2 1 3. Mastoid process
ultrasound, including the SCM, the levator (---) Dotted line: posterior
scapulae muscle, and nearby vasculature. lateral border of the SCM
4. Approach from the posterior lateral aspect * Injection point at which the
under ultrasound guidance. The needle external jugular crosses the
should be inserted fairly superficially and SCM at the level of the thyroid
positioned just under the SCM. 3 * cartilage (about halfway
5. Aspirate and ensure the extravascular between SCM insertion at the
positioning of the needle. Slowly deposit 5 to clavicle and mastoid process).
10 mL of anesthetic underneath the SCM. The white outline denotes the
Avoid penetrating the deeper fascial layer. typical area of anesthesia.

February 2019 n Volume 33 Number 2 11

 The LLSA Literature Review

Unexpected Delivery
By Todd Jaffe, MD; and Andrew J. Eyre, MD, MHPEd
Massachusetts General Hospital, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
Gupta AG, Adler MD. Management of an unexpected delivery in the emergency department. Clin Ped Emerg Med. 2016 Jun;17(2):89-98.

Unexpected deliveries are rare, albeit stressful, emergency department events for
which clinicians must always be prepared. Although the vast majority of newborns
(90%) require minimal interventions (eg, warming, drying, or stimulation) as they
transition to the extrauterine environment, emergency physicians must recognize
when and how to resuscitate the remaining 10%.

In November 2015, the American
Heart Association (AHA) published
new guidelines that highlight important
factors that must be addressed in the
initial management of newborns,
including the infant’s gestational age,
tone, and respiratory effort. If these three
components are reassuring (ie, the patient
is a full-term, crying newborn with good
tone), the neonate can likely be placed
with the mother and routine care may
be continued. However, if these elements
are concerning or cannot be adequately
addressed, further investigation and
intervention are appropriate (Figure 1).
As with any resuscitation, it is
paramount to effectively manage
the neonate’s airway, breathing, and
circulation.
Airway
Deep suctioning of the nasopharynx
should generally be avoided given the
potential risk of bradycardia or a vagal
response. In addition, the updated
guidelines discourage routine tracheal
intubation for depressed newborns
with meconium-stained amniotic fluid.
The recommendations emphasize the
importance of augmenting the patient’s
respiratory effort with positive-pressure
ventilation (PPV). Intubation can be
considered if there is no improvement.
Breathing
Clinicians should evaluate the
patient’s heart rate and supplement with
PPV when indicated. Specifically, PPV
with a bag-valve-mask (BVM) should
be initiated if the heart rate falls below
100 bpm or the patient’s respiratory
effort is inadequate. Preductal oxygen
monitoring, which provides up-to-date
oxygen saturation levels, can be achieved
by placing a pulse oximetry probe on the
right upper extremity. If the infant’s heart
rate remains low and/or saturations do not
improve, it may be appropriate to place
an advanced airway using an endotracheal
tube (ETT) or laryngeal mask airway.
Circulation
Careful circulatory monitoring
is a critical component of newborn
resuscitation. The patient’s heart rate
should be monitored with a three-lead
ECG. If the heart rate remains below
60 bpm despite adequate ventilation

Critical Decisions in Emergency Medicine’s series of LLSA reviews features articles from ABEM’s 2019 Lifelong Learning and
Self-Assessment Reading List. Available online at acep.org/moc/llsa and on the ABEM website.

12 Critical Decisions in Emergency Medicine

and the placement of an advanced airway,
chest compressions should be initiated
AHA Neonatal Resuscitation Algorithm — 2015 Update
(3 compressions to 1 breath). The two- Antenatal counseling
thumb compression technique is preferred. Team briefing and
If bradycardia persists, the clinician should equipment check
evaluate for other reversible causes and prepare
for the potential administration of medication. Birth
If peripheral IV access cannot be obtained,
an emergent umbilical venous catheter (UVC)
Infant stays with the mother
or intraosseous needle can be used. Further for routine care: Warm and
Team gestation?
resuscitation efforts include the administration YES maintain normal temperature,
Good tone?
of epinephrine (IV or ETT), crystalloid solution, Breathing or crying? position airway, clear
and blood (10 mL/kg) if there is concern for secretions if needed, dry.
NO Ongoing evaluation
hypovolemia.

1 minute
Additional Considerations Warm infant and maintain normal
temperature, position airway, clear
Delayed umbilical cord clamping (30-
secretions if needed, dry, stimulate
60 seconds after birth) is recommended for
uncomplicated deliveries. Although newborn
temperatures should typically remain between Apnea or gasping? NO Labored breathing or
36.5°C (97.7°F) and 37.5°C (99.5°F), there HR below 100 bpm? persistent cyanosis?
may be specific circumstances in which
therapeutic hypothermia is indicated (eg, YES YES
when there is a concern for hypoxic-ischemic
Position and clear airway
encephalopathy). PPV
SpO2 monitor
SpO2 monitor
Glucose monitoring may be especially Supplementary O2 as needed
Consider ECG monitor
appropriate for infants with risk factors for Consider CPAP
glucose dysregulation. Newborns should
undergo prenatal laboratory tests and
NO Postresuscitation care
additional standard-of-care treatments, HR below 100 bpm?
Team debriefing
including the administration of vitamin K
and erythromycin eye drops; however, these YES
interventions do not need to occur in the Check chest movement
emergency department. In addition, Apgar Ventilation corrective steps
scores should be assessed and documented. if needed
ETT or laryngeal mask if needed

KEY POINTS NO
HR below 60 bpm?
n Although 90% of neonates require
relatively minimal interventions, YES
emergency clinicians must be Intubate if not already done
prepared to employ additional Chest compressions
resuscitation efforts, if needed. Coordinate with PPV
n Management of the patient’s airway, 100% O2
breathing, and circulation remain ECG monitor
essential components of newborn Consider emergency UVC
resuscitation.
n Monitoring should include the use
of a three-lead ECG and oxygen HR below 60 bpm?
saturation probe (placed on the right
upper extremity). YES
n PPV with a BVM is a cornerstone Targeted Preductal SpO2
IV epinephrine if HR persistently After Birth
of neonatal management and should below 60 bpm
be initiated if the patient’s heart rate Consider hypovolemia 1 min 60%-65%
drops below 100 bpm. Consider pneumothorax 2 min 65%-70%
n Cardiopulmonary resuscitation 3 min 70%-75%
(3 compressions to 1 breath) should 4 min 75%-80%
be initiated if the neonate’s heart rate 5 min 80%-85%
drops below 60 bpm. 10 min 85%-95%

February 2019 n Volume 33 Number 2 13

 The Critical Image
A 57-year-old man with hypertension and diabetes presents with By Joshua S. Broder, MD, FACEP
intermittent, left lower-quadrant pain that radiates to his left testicle. Dr. Broder is an associate professor and the
residency program director in the Division
The pain began approximately 24 hours ago when he was at rest but resolved
of Emergency Medicine at Duke University
over the course of the day. The pain has recurred and is now more severe. Of Medical Center in Durham, North Carolina.
note, the patient reports having similar right-sided pain 3 weeks ago, which
has now resolved. He appears uncomfortable and notes mild dysuria but no
fever or hematuria.
A Stones visible in the urinary bladder or at the UVJ
His vital signs are blood pressure 185/109,
heart rate 82, respiratory rate 18, temperature
36.8°C (98.2°F), and oxygen saturation 99%
on room air. His left lower quadrant is mildly
tender to palpation. He has no costovertebral
angle tenderness, and an examination of his
scrotum is normal, with no hernia or testicular
swelling or tenderness. Laboratory tests reveal
a serum creatinine level of 2.3 mg/dL, with
no previous values for comparison. Urinalysis
demonstrates no evidence of infection.
The patient undergoes a noncontrast
abdominal CT scan, which reveals what the Sacrum
radiologist interprets as a left ureterovesicular CT gantry
junction (UVJ) stone and an additional
bladder stone. The patient is seen by a A. Initial CT, axial slice. The patient is placed in the supine position, as
urologist in the emergency department, his indicated by the position of the sacrum relative to the CT gantry. This is the
standard position for a general abdominal evaluation with noncontrast CT.
pain is controlled, and he is discharged with a
Two high-density calcifications are seen; it is unclear whether they lie freely in
urology follow-up. the bladder or are lodged at the UVJ.
He returns to the emergency department
48 hours later, complaining of ongoing left B
flank pain and anuria for 24 hours. Repeat
laboratory tests show a serum creatinine
level of 8.0 mg/dL. A renal ultrasound shows
mild left hydronephrosis. The emergency
physician reviews the previous CT images
and performs a repeat CT scan, using a renal
stone protocol.

CASE RESOLUTION Stones

The patient underwent an emergency visible
cystoscopy with removal of the in the
obstructing stones and stenting of urinary
the bilateral ureters. His creatinine bladder
values improved within 24 hours. or at
the UVJ

à
B. Initial CT, coronal slice.

14 Critical Decisions in Emergency Medicine

 C F

Normal
right kidney

Stones
visible in
the urinary
bladder
or at
D the UVJ

Left
kidney
with
moderate F. Follow-up CT, coronal slice.
hydro-
nephrosis

KEY POINTS
n When assessing ureteral stones, the emergency physician
should evaluate for ureteral obstruction. Hydronephrosis
and hydroureter are important clues that indicate this
pathology; however, these findings are not always present.
n When the patient is in the supine position, stones lodged
at the UVJ (and causing obstruction) can be difficult to
distinguish from free stones in the bladder (not causing
C, D. Ultrasound of kidneys, second visit. The left kidney obstruction). Prone positioning can help differentiate
these two scenarios on CT. Mobile, nonobstructing stones
shows mild hydronephrosis; the right appears normal.
will settle into the urinary bladder with gravity; immobile,
obstructing stones will not.
n Ultrasound can also be used to assess stone mobility.
E
n An early diagnosis of bilateral ureteral obstruction would
Sacrum have prompted immediate cystoscopy and might have
prevented the deterioration of the patient’s renal function
and subsequent return to the emergency department.

CT gantry
Stones do not settle into the bladder
by gravity; therefore, they must be
lodged at the UVJ
à
E. Follow-up CT, axial slice. The patient is placed in the prone
position, as indicated by the location of the sacrum relative to the
CT gantry. This position, which is commonly used for the CT
assessment of renal stones, elevates the UVJ relative to the bladder,
allowing any stones to rest in the dependent portion of the bladder
(unless they are lodged at the UVJ). In this position, it is evident that
both stones are immobile and obstructing the UVJ bilaterally.

February 2019 n Volume 33 Number 2 15

 A 36-year-old man's status post resuscitation from cardiac arrest from an unknown cause; an ECG
was obtained immediately after the return of pulses.

The Critical ECG

Atrial fibrillation, ventricular rate 100, diffuse ischemia, possible acute By Amal Mattu, MD, FACEP
posterior myocardial infarction (MI). The irregularly irregular rhythm in the Dr. Mattu is a professor, vice chair, and
director of the Emergency Cardiology
absence of distinct atrial activity is likely to be atrial fibrillation. ST-segment Fellowship in the Department of
Emergency Medicine at the University
depression is noted in the inferior, anterior, and lateral leads, which is
of Maryland School of Medicine in
consistent with diffuse ischemia. Tall R waves in the right precordial leads Baltimore.
with large upright T waves are characteristic of a posterior MI; however, the
expected horizontal ST-segment depression in leads V1 to V2 is absent. Although posterior leads could have helped clarify
whether the patient was having an acute posterior wall MI, they were not done.

This patient overdosed on heroin and suffered a respiratory arrest, followed by cardiac arrest. During the prehospital
resuscitation, he received a total of 3 mg of atropine, 3 mg of epinephrine, sodium bicarbonate, dextrose, and naloxone.
The ischemic changes noted in the ECG could be related to intrinsic cardiac ischemia, but the findings could also be related
to ischemia resulting from the resuscitation efforts, particularly the epinephrine. Epinephrine is known to induce atrial
dysrhythmias, ventricular dysrhythmias, and overt ischemic changes on ECG. These changes are often transient, as they were
in this case. (The arrhythmia and all signs of ischemia gradually resolved over the ensuing 2 hours.) A cardiac catheterization
demonstrated no significant coronary disease. Unfortunately, the patient never regained normal neurological function.

From Mattu A, Brady W. ECGs for the Emergency Physician 2. London: BMJ Publishing; 2008. Reprinted with permission.

16 Critical Decisions in Emergency Medicine

 Dangerous
Creatures
Envenomation

LESSON 4

By Kathleen Cowling, MS, DO, FACEP; and Thomas Ferreri, MD

Dr. Cowling is chief of the Department of Emergency Medicine and director of the
Emergency Medicine Residency Program, and Dr. Ferreri is an emergency medicine
resident at Central Michigan University College of Medicine in Saginaw, Michigan.
Reviewed by Nathaniel Mann, MD
OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Identify the animals that most commonly cause n What clues can help clinicians determine if a
envenomation in the United States. snake is venomous?
2. Describe the most important components of the n How should snakebites be evaluated and
history and physical examination when managing an
managed in the emergency department?
envenomation.
n How should Hymenoptera stings be addressed in
3. Summarize the laboratory and diagnostic studies
indicated for various envenomation scenarios. the emergency department?
4. Explain the treatment modalities for envenomation, n What clinical features can help differentiate a
and indications for each. black widow envenomation from a brown recluse
5. Assess the disposition requirements for a patient envenomation?
suffering from envenomation. n How should spider bites be evaluated and
managed?
FROM THE EM MODEL
6.0 Environmental Disorders n How should scorpion stings be evaluated, graded,
6.1 Bites and Envenomation and treated?

While many animals produce poisons, only those with venom-producing glands and the means to deliver the
toxin to another animal are considered venomous.1,2 The United States is home to a variety of these potentially
dangerous species, including snakes, insects, spiders, scorpions, and marine animals. The order Hymenoptera,
which includes bees, wasps, hornets, yellow jackets, and ants, accounts for the largest percentage of deaths
secondary to envenomation, followed by snakes and spiders.2

February 2019 n Volume 33 Number 2 17

 CASE PRESENTATIONS
■ CASE ONE
A 27-year-old California man
presents with a painful lesion on his
right foot and generalized muscle
aches. He explains that he was
removing patio furniture from a
shed in his backyard when he felt
a sudden pinprick sensation on his
foot. When he looked down, he saw
a small spider scurry away and later
noticed a nest of eggs underneath
one of the cushions.
Upon arrival 2 hours later, the
patient’s vital signs and ABCs
(airway, breathing, and circulation)
are stable. He complains of nausea
and vomiting but denies abdominal
pain, fatigue, or changes in urine.
The physician notes a lesion on the
lateral aspect of the dorsum of the
patient’s right foot that has central
pallor with surrounding erythema,
as well as muscle stiffness in the
lower extremities and a board-
like abdomen; the examination is
otherwise unremarkable. Diagnostic
studies are ordered, including a CBC;
a comprehensive metabolic panel
(CMP); lipase, uric acid, creatine
kinase (CK), and D-dimer levels; a
urinalysis; and an abdominal CT.
CRITICAL DECISION
What clues can help clinicians
determine if a snake is
venomous?
An estimated 5.4 million snakebites
occur each year worldwide, as many as
half of which lead to envenomation.3
Snakebites cause an estimated 81,000
to 138,000 deaths and three times as
many amputations annually.3 While
most of these injuries occur in Africa,
Asia, and Latin America, envenomation
caused by rattlesnakes, water moccasins,
copperheads (Viperidae family; pit viper
subfamily), and coral snakes (Elapidae
family) are of significant concern in the
United States.2,4
A physical description of a snake can
be tremendously valuable to clinicians
treating a snakebite and can help
18 Critical Decisions in Emergency Medicine
■ CASE TWO
A 22-year-old Arizona woman
arrives via ambulance after being stung
by a “yellow scorpion” while hiking
with friends. EMS relays that the
patient had seizure-like activity, so they
administered lorazepam (4 mg IV).
Upon arrival, the patient’s vital
signs are heart rate 120, blood
pressure 115/75, respiratory rate 18,
and oxygen saturation 95% on
2 L/min nasal cannula. She is placed
on a cardiopulmonary monitor and
given a 1-L bolus of normal saline.
She is protecting her airway, has
normal bilateral lung sounds, and
has equal pulses in the upper and
lower extremities bilaterally. She can
communicate in short sentences and
complains of pain and swelling in
her right hand, where she was stung,
and in her left arm, where she had no
injury. Her hiking companions show
a picture of the scorpion, which the
emergency physician identifies as an
Arizona bark scorpion (Figure 1).
The patient is anxious and restless,
with slow, conjugate, roving eye
movements. She is experiencing
myoclonic jerking of the upper
extremities and fasciculation of
determine whether the offending reptile
is poisonous. A photograph taken from a
safe distance can assist in identification,
but at no point should anyone attempt
to handle a snake — even a dead
one.5,6 Case reports have described
envenomations inflicted by deceased
snakes, whose bite reflexes can remain
intact postmortem.5-7
Many physical features can help
differentiate venomous pit vipers,
including cottonmouths, copperheads,
and rattlesnakes, from nonvenomous
snakes. Vipers (crotalid subfamily)
have broad, triangular heads (Figure 2),
elliptical pupils, a single row of
subcaudal tail plates, and heat-sensing
pits between their eyes and nostrils.2
The presence of a rattle is unique to
rattlesnakes (Figure 3).
The iconic banding pattern of
her tongue. Concerned about
envenomation, the clinician orders
diagnostic studies, treats the
patient’s pain with morphine
(4 mg IV), treats the myoclonus
with lorazepam (4 mg IV), and
calls Poison Control.
■ CASE THREE
A 6-year-old North Carolina girl
is brought in by her grandmother
for a possible snakebite. The patient
was playing in her rural, forested
backyard near a woodpile when
she suddenly screamed. When the
grandmother got to her, she saw a
thick, light brown-patterned snake
slithering under the woodpile.
On arrival, the patient is anxious,
somewhat tearful, and nauseated.
Her vital signs are normal except for
a heart rate of 125. An examination
of her right foot reveals erythema
and swelling with what appear to
be two puncture wounds. An IV
is established, and pain control
with weight-based morphine and
an antiemetic is provided. A CBC,
CMP, coagulation studies, and a
D-dimer level are ordered, and a
20-mL/kg bolus of normal saline is
initiated.
venomous coral snakes (Figure 4), in
which the red stripe abuts the yellow
stripe, is often recalled by the rhyme
“Red next to yellow, you’re a dead fellow.
Red next to black, venom they lack.” It
is important to note that this coloration
is only true of coral snakes in the US
and does not apply to reptiles in other
countries.2 Because variations in the
color and width of their stripes can be
misleading, snakes with this appearance
should never be handled.
CRITICAL DECISION
How should snakebites be
evaluated and managed in
the emergency department?
Approximately 25% of pit viper bites
(Figure 5) are considered “dry,” meaning
that no venom is delivered when the
reptile strikes.8 Wet bites, which deliver
an injection of venom, cause localized
pain that progresses to proximal edema.2
Systemic signs, including nausea,
vomiting, sweating, and hypotension,
can also develop.2,8 Pit viper venom
contains thrombin-like glycoproteins,
which disrupt the coagulation cascade
and can lead to a life-threatening
coagulopathy.5 Some varieties
(eg, Mojave and tiger rattlesnakes, and
some timber rattlesnakes) also produce
neurotoxin variants.
Envenomation from coral snakes
is more likely to cause neurological
symptoms accompanied by descending
flaccid paralysis.6,9,10 The patient may
be drowsy and have bulbar paralysis
with associated ptosis, ophthalmoplegia,
or dysphagia.6,9,10 These symptoms are
typically mediated by a variety of toxins
that affect acetylcholine receptors.
Clinical Evaluation
When managing any snakebite, the
emergency physician should first evaluate
the patient’s ABCs. A thorough history
should include details about the snake’s
appearance and variety, if possible; time
elapsed since the bite; total number of
bites; symptoms; and the status of the
patient’s last tetanus vaccination.2 The
American Association of Poison Control
Centers (800-222-1222) and the local zoo
or herpetologist can provide tremendous
insight, expertise, and help in treating
these cases.2
The wound should be immobilized
above heart level and cleaned and
FIGURE 1. Arizona Bark Scorpion
irrigated with normal saline.2 Pressure
immobilization is recommended
for coral snake bites but not for
pit viper envenomation.5,9,11-13 The
physical examination should include
continuous monitoring of vital signs
and close inspection of the wound.
Unlike coral snake bites, pit viper bites
are often painful secondary to swelling
and inflammation. Therefore, regular
pulse checks distal to the site of the
puncture should be performed, and
the leading edge of erythema/edema
should be marked every 30 minutes.2,4
Regular and detailed neurological
evaluations with close monitoring
of respiratory effort are necessary
for any patient with a coral snake
bite.9 For both pit viper and coral
snake envenomations, pain should
be addressed appropriately with
narcotics, and the tetanus vaccine
should be given.5,9
Acute Management
While it is important to be
familiar with the appropriate initial
management of a snakebite, it is also
key for witnesses, first responders,
and physicians to understand what
not to do in such cases. Tourniquets,
incision-and-oral suction, mechanical
suction, and surgery are no longer
recommended.5,6,14,15 One study found
that mechanical suction devices
decreased total body venom by only
2%.16
FIGURE 2. Copperhead Snake
Pertinent laboratory tests include
a CBC, prothrombin time, partial
thromboplastin time, and international
normalized ratio (INR) to assess for
coagulopathy; CMP, CK level, and
urinalysis to evaluate for rhabdomyolysis;
fibrin split products and D-dimer level to
evaluate for disseminated intravascular
coagulation (DIC); and an ECG.5,17
Any patient suffering from coral snake
envenomation should also undergo
testing for pulmonary function and
arterial blood gases, as well as waveform
capnography, to assess for potential
respiratory failure.9
CroFab Crotalidae Polyvalent
Immune Fab (Ovine) (FabAV) is
currently the only FDA-approved
antivenom for the treatment of pit
viper envenomation.5 In the past, it
was suggested that only patients with
moderate to severe envenomation or
injuries that pose an airway threat
should receive CroFab.5,18,19 However,
new guidelines recommend treating even
mild cases with antivenom if the effects
(eg, edema, erythema, and pain) are
progressive.6,19,20 Patients treated with
CroFab appear to have lower pain scores
and require less narcotic analgesia.20
When considering the use of
antivenom, it is crucial to discuss the
case with medical toxicology or a snake
expert prior to administration.8 Patients
with pit viper bites should generally
receive a loading bolus dose (typically
4-12 vials) followed by a maintenance
dose of approximately 2 vials every
6 hours (for a total of 3 doses).8
February 2019 n Volume 33 Number 2 19
 FIGURE 3. Rattlesnake
Because coral snake bites can cause
descending paralysis and respiratory
failure, early intubation and ventilator
support are recommended if the
patient’s forced vital capacity (FVC) is
less than 50% of the predicted value
on pulmonary function testing.9 When
available, coral snake antivenom
should be administered to any patient
with clinical signs of coral snake
envenomation. 9,21-24 Alternative
treatments include anticholinergic agents
like atropine and neostigmine, which can
be used even if antivenom later becomes
available.9
Patient Disposition
Stable patients who have been
bitten by a pit viper (Figure 6) can
be discharged home, assuming repeat
laboratory studies are within normal
limits after 8 to 12 hours. However, the
FIGURE 5. Edema Caused by a Pit Viper Bite
20 Critical Decisions in Emergency Medicine
FIGURE 4. Coral Snake
patient should be cautioned to return
if signs of coagulopathy develop or the
pain cannot be relieved by elevating the
extremity.5
Any patient with a suspected
coral snake envenomation requires a
12- to 24-hour observation period,
as neurological complications can
be delayed.9 Patients who receive
antivenom for a coral snake or pit viper
envenomation require hospital admission
for further evaluation.5,9
CRITICAL DECISION
How should Hymenoptera
stings be addressed in the
emergency department?
Order Hymenoptera contains
arthropods that are subclassified as
winged or nonwinged. Winged insects
include the Apidae family (honeybees
FIGURE 6. Cottonmouth (Water Moccasin) Snake
and bumble bees) and the Vespidae
family (yellow jackets, hornets, and
wasps); the wingless variety includes the
Formicidae family (ants). From 2008
to 2015, nearly 30% of all animal-
related deaths were due to Hymenoptera
envenomation, a figure that has remained
constant over the past 20 years.25
Patient Presentation
Because treatment depends on the
severity of the patient’s symptoms rather
than on the source of the bite or sting, it
is less vital to identify the specific culprit
when assessing cases of Hymenoptera
envenomation.
Patients may initially present with
a topical, local reaction — a painful
and erythematous lesion at the site of
the bite or sting — that generally erupts
within minutes to hours of inoculation
(Figure 7).26 Larger local reactions,

FIGURE 7. Localized Reaction
to Hymenoptera Envenomation
FIGURE 8. Allergic Response
to a Wasp Sting
FIGURE 9. Localized Reaction to a Bee Sting
which arise in approximately 10% of
these cases, peak at 48 hours and are
characterized by larger and longer-
lasting erythema.26-28
Anaphylaxis, the most life-
threatening manifestation of a
Hymenoptera envenomation, is of
primary concern. About 17% of
all anaphylactic reactions occur
secondary to Hymenoptera venom
allergies.29 While an allergic response
(Figure 8) can cause a multitude of
symptoms, anaphylaxis generally
affects the integumentary (flushing,
urticaria, and edema), cardiovascular
(light-headedness, hypotension, and
circulatory collapse), and respiratory
(wheezing, stridor, and shortness of
breath) systems.26,30-33
If signs of anaphylaxis or
hemodynamic instability (eg, shortness
of breath, hypotension, or a severe
urticarial reaction) are present, rapid
treatment is required. It is particularly
important to assess the patient’s
oropharynx, as signs of angioedema
can progressively worsen and quickly
lead to airway compromise.
Eliciting any history regarding
a previous allergic reaction is key.2
Details should also be gathered about
the circumstances of the attack, the
location(s) and estimated number of
bites or stings, and the identity of
the offending insect, if possible.2 The
physical examination should include an
evaluation of the patient’s vital signs,
respiratory status, and injuries, including
measurements of the surrounding
erythema.
Acute Management
Few laboratory study results alter
the treatment options for Hymenoptera
envenomation. Any stingers embedded
in the patient’s skin should be removed
to prevent a foreign-body reaction.26,34
Local skin reactions can be treated
with a combination of a cold compress,
an oral steroid, an antihistamine, or a
nonsteroidal anti-inflammatory agent.26
The tetanus vaccine is unnecessary; there
are no published reports of a tetanus
infection secondary to Hymenoptera
envenomation.26
Anaphylaxis, if present, is an acute,
life-threatening emergency. An inspection
of the ABCs is the priority, with early
intubation and ventilator support in
cases of marked respiratory distress,
stridor, or edema of the oropharynx.35-40
Simultaneously, the patient should be
given epinephrine 1:1000 0.01 mg/
kg intramuscularly (IM). (In such
cases, the IM route is preferred over
subcutaneous administration.) Patients
who fail to respond to multiple doses of
IM epinephrine should be placed on an
epinephrine drip.35,38,41 In addition, the
patient should be given an antihistamine,
steroid, and H2 blocker, with the
addition of a β2 agonist if wheezing is
present.2
Any patient with a localized reaction
(Figure 9) should be observed in the
emergency department but can discharged
with specific return precautions and
a prescription for an epinephrine
autoinjector. Those treated with
epinephrine should be monitored for a
longer period of time before disposition.
CRITICAL DECISION
What clinical features can help
differentiate a black widow
envenomation from a brown
recluse envenomation?
Although the majority of spiders
are venomous, very few pose a risk to
humans.2 Among the exceptions to this
rule are the black widow (Latrodectus
mactans) and the brown recluse
(Loxosceles reclusa).
February 2019 n Volume 33 Number 2 21

FIGURE 10. Black Widow
FIGURE 12. Brown Recluse Spider Bite
Identification
Black widow spiders (Figure 10)
are found throughout the US (except
Alaska), typically outdoors.2 They are
approximately 1.5 inches in length,
hairless, and shiny black with a
telltale red marking on the abdomen
that resembles an hourglass.2,42
Brown recluse spiders (Figure 11),
as the name implies, are solitary
and most commonly found in the
southern, western, and midwestern
United States. Bites from these small
(1-inch) arthropods typically occur
indoors.43,44 Although some have a
violin-shaped mark on their back,
it can be difficult to recognize.2,42
Brown recluses also have a distinct eye
pattern composed of six eyes with a
pair in front and a pair on each side, a
unique identifying feature.43
Neither spider is likely to attack
unless provoked or in defense of a
nest.42
22 Critical Decisions in Emergency Medicine
FIGURE 11. Brown Recluse
Black Widow Bites
Patients who are bitten by black
widow spiders often describe at-risk
outdoor activities, such as gardening,
working near a woodpile, or cleaning
the garage.45,46 Although the initial injury
can resemble a target lesion with central
clearing and surrounding circumferential
erythema, it can also appear as a wheal-
and-flare pattern.45,47,48 Latrodectism
describes the culmination of symptoms that
arise after a black widow envenomation,
including muscle spasms, nausea, vomiting,
headache, and dyspnea.49
Muscle rigidity is often localized to
the chest if the bite occurs on an arm and
localized to the abdomen if it occurs on
a lower extremity, with the latter often
creating a surgically rigid abdomen.2,45,50,51
Rare but life-threatening complications
of black widow envenomation include
pulmonary edema, cardiomyopathy,
rhabdomyolysis, and cardiovascular
collapse.52-54
Brown Recluse Bites
The bite of the brown recluse most
often occurs on the arm, thorax, or
thigh.43 While often initially painless,
these injuries can produce significant pain
2 to 8 hours after the bite.43,51 The skin
lesion begins as an erythematous plaque
or papule that is self-resolving (Figure 12);
however, 10% of cases progress to
necrosis, characterized by red or blue
central coloration with the eventual
development of an eschar.43,55,56 Systemic
loxoscelism describes the constitution of
symptoms that can arise from a brown
recluse spider bite, including fever,
malaise, nausea, vomiting, rash, myalgia,
seizure, and altered mental status. Severe
cases can progress to an acute hemolytic
reaction, renal failure, and DIC.57
CRITICAL DECISION
How should spider bites be
evaluated and managed?
Depending on the location of the bite
and the elapsed time, airway or circulatory
compromise can occur.2 If the patient
is stable, a history should be obtained,
including a detailed review of the
symptoms, the circumstances surrounding
the envenomation, and the anatomical
location and time of the bite.2 A detailed
clinical evaluation should assess for muscle
rigidity and potential abdominal sequelae.
Appropriate diagnostic studies are
dependent on the patient’s history, physical
examination, and presentation. If there are
concerns for more serious complications
such as rhabdomyolysis, DIC, or hemolytic
anemia, testing should include a CBC,
reticulocyte count, Coombs test, lactate
dehydrogenase, serum haptoglobin, CMP,
calcium, phosphate, uric acid, CK, urine
dipstick, coagulation, fibrinogen, D-dimer,
and ECG.43
Black widow bites should be cleaned
with soap and water.2 The patient should
be given pain medication and have their
tetanus updated.48,51,52 Benzodiazepines
for rigidity and pain control may also be
required, as these bites can lead to severe
muscle spasms.48,51,52 Although antivenom
is available, it has many deleterious side
effects and is reserved for severe cases.52
Similarly, a brown recluse bite that
causes no systemic complications can be
cleaned with soap and water, ice should be
applied, and the patient’s tetanus status
should be updated.43 No antivenom for
brown recluse envenomation is available
in the US.43 Systemic symptoms should be
controlled with antiemetic, antipyretic,
and narcotic medications, if necessary.
More severe complications should be
treated appropriately based on each
individual case.
Patient Disposition
Any patient with an unconfirmed
black widow envenomation should be
observed for 6 hours and discharged
if no concerning symptoms develop.2
Those with signs of envenomation,
and children or patients with pre-
existing cardiovascular disease, should
be admitted to the hospital for further
evaluation and monitoring.2
Patients suffering from a brown
recluse envenomation can be discharged
home if only local symptoms are present.
Those who develop severe complications
secondary to the bite should be admitted
to the hospital.43
CRITICAL DECISION
How should scorpion stings
be evaluated, graded, and
treated?
Scorpions are the oldest terrestrial
animals to use pedipalps (claws)
to trap prey and tails to inject and
envenomate.2,58 The Arizona bark
scorpion (Centruroides sculpturatus)
and the striped bark scorpion
(Centruroides vittatus) are the most
clinically important in the US. Another
FIGURE 13. Striped Bark Scorpion
variety of scorpion, Tityus trinitatis, is
known to cause pancreatitis but is not
indigenous to the US.2
Arizona bark scorpions, which are
found in the southwestern United States,
range from yellow to brown in color.58
One physical trait that differentiates
these venomous scorpions from
nonpoisonous varieties is the subnuclear
tooth at the base of the stinger.58-60
Striped bark scorpions (Figure 13) can
be identified by the black stripes located
on the thorax.58
Arizona bark or striped bark
scorpion stings are graded according
to the severity of symptoms. Grade I
injuries include pain or paresthesia
localized at the site of the sting
(Figure 14).58 Grade II envenomation
is associated with pain or paresthesia
localized at the site of the sting as well
as at a secondary remote site.58 Grade III
injuries must meet the conditions for
Grade II and include either cranial nerve
involvement (eg, nystagmus, dysphagia,
drooling, dysarthria) or somatic
skeletal neuromuscular involvement
(writhing, fasciculation, jerking, tetanic-
like features). These stings are also
associated with autonomic irregularities
(eg, sali­va­tion, vomiting, bronchospasm,
diaphoresis, tachycardia).58,61 Grade IV
is assigned when all aspects of Grade III
are present.58
Acute Management
The ABCs must be evaluated
first when managing any patient
suffering from a suspected scorpion
envenomation. Close monitoring of vital
FIGURE 14. Local Reaction to a Scorpion Sting
signs and cardiopulmonary monitoring
are also necessary. Early contact with
Poison Control should be established,
and the physician should attempt to
identify the variety of scorpion that
inflicted the sting and the timeline of the
encounter.
Patients may be unaware that they
have been stung by a scorpion, so it
is important to ask questions about
recent travel to endemic areas in the
southwestern United States.58 The
physical examination should include a
detailed inspection of the sting site. A
“tap test,” which measures the severity
of local tenderness when the affected
area is lightly tapped, can be helpful for
evaluating an Arizona bark scorpion
sting.2,58,59,62,63 Moreover, the physician
must complete and document a thorough
neurological examination, judiciously
testing all 12 cranial nerves.
The laboratory and diagnostic
studies appropriate for a scorpion
sting are dependent on the grade of
the envenomation. Grades I and II
do not require a further diagnostic
workup. Patients with a Grade III or
IV envenomation should undergo, at
minimum, a CBC, CMP, CK level,
and urinalysis; other tests should
be considered based on the clinical
circumstances.58
Once Poison Control has been
called, the sting site should be cleaned,
and a tetanus vaccine should be given,
if not up to date.58,64 If there is no
neuromuscular involvement, pain from a
Grade I envenomation can be managed
February 2019 n Volume 33 Number 2 23
 CASE RESOLUTIONS
■ CASE ONE
The California man’s symptoms
(a target-like lesion at the site of
envenomation with muscle spasms)
were suspected to be caused by
a black widow bite. Laboratory
tests were ordered to evaluate
for rhabdomyolysis and DIC,
both documented, albeit rare,
complications of black widow spider
envenomation. The patient remained
hemodynamically stable but had
continued muscle pain, nausea,
vomiting, and abdominal rigidity.
An IV was established, and he
was given morphine, ondansetron,
and lorazepam, which improved his
symptoms. Although his laboratory
test values were all within normal
limits and the abdominal CT was
unremarkable, the patient was
admitted to the hospital for further
treatment of his persistent systemic
symptoms.
with nonsteroidal anti-inflammatory
medication; a Grade II envenomation
can be managed with an opioid,
preferably fentanyl.58,64
Benzodiazepines are appropriate
only if there is no consideration for the
use of antivenom.58,64 Bark scorpion
antivenom should not be administered
in conjunction with morphine or
benzodiazepines. Morphine causes an
increase in histamine release, which
can contribute to anaphylaxis, while
lorazepam may act in conjunction
with antivenom to diminish the
patient’s excitatory response, leading to
respiratory failure.
Patients with neuromuscular
involvement, indicating a Grade III or
Grade IV envenomation, should receive
antivenom. Antivenom is not necessarily
lifesaving because scorpion stings are
seldom fatal, but it does reduce the
length and severity of symptoms.58,64
Scorpion antivenom is allergenic;
therefore, the clinician should obtain
consent and prepare materials for
the treatment of anaphylaxis prior to
administration.
24 Critical Decisions in Emergency Medicine
■ CASE TWO
The Arizona woman with a Grade IV
Arizona bark scorpion envenomation
was treated with antivenom and
soon became unresponsive and
hypotensive with a blood pressure of
80/55. Although her pulses remained
intact, bag-valve-mask ventilation was
required.
The infusion was stopped out of
concern for anaphylaxis secondary
to antivenom administration, and
the patient was given epinephrine
(0.3 mg IM), diphenhydramine
(50 mg IV), ranitidine (50 mg IV),
and methylprednisolone (125 mg IV).
Although her blood pressure improved,
intubation was required for airway
protection. The antivenom infusion was
restarted at a lower rate, and the patient
was admitted to the ICU. She was
extubated 2 days later and discharged
home after 6 days in the hospital.
Summary
Because envenomation can cause
myriad symptoms, emergency physicians
must have a broad knowledge regarding
the different environments and scenarios
that can lead to poisonous bites and
stings. An assessment of the ABCs,
vital sign monitoring, a detailed history
and physical examination, and an
appropriate diagnostic workup are key.
It is also vital to update the patient’s
tetanus vaccination, if needed.
Disposition should be determined
based on the offending species,
n When envenomation is suspected, early contact with Poison Control should be
established (800-222-1222).
n Remember to update the patient’s tetanus status when needed.
n Stop the antivenom infusion if symptoms of anaphylaxis develop.
n Observe for rare but serious complications, including DIC, renal failure, or an
acute hemolytic reaction, when managing any spider bite envenomation.
■ CASE THREE
Based on her puncture wounds
and swelling, the 6-year-old girl’s
symptoms were believed to be the
result of a pit viper envenomation.
While laboratory results were
pending, the extremity was elevated
and immobilized. The borders of the
wound were marked, and CroFab
(8 vials IV bolus) was administered
based on the patient’s age and the
extent of the symptoms. The erythema
and swelling continued to progress
beyond the margins of the initial
measurement, and the laboratory tests
were notable for an INR of 2.4.
The girl was admitted to the
pediatric ICU, where she received
further scheduled doses of antivenom
over the next 24 hours. Her
symptoms slowly improved, and she
was transferred to the floor on day 3
and discharged in stable condition
2 days later.
severity of symptoms, laboratory and
imaging results, and required treatment.
Remember that it is always wise to
contact Poison Control when managing
any suspected envenomation.
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February 2019 n Volume 33 Number 2 25
 CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1
Credits™, and 5 AOA Category 2-B credits for completing this activity in its

QUESTIONS entirety. Submit your answers online at acep.org/cdem; a score of 75% or better
is required. You may receive credit for completing the CME activity any time within
3 years of its publication date. Answers to this month’s questions will be published
in next month’s issue.

1 Who is most likely to be victimized in the emergency

department by a violent patient? 6 A 36-year-old woman presents with agitation
and manic behavior. According to her
roommate, she has been awake for the past
A. Nurses
B. Other patients 36 hours after experimenting with some
C. Physicians drugs. Her vital signs are blood pressure
152/94, pulse rate 131, respiratory rate 19,
D. Social workers
temperature 37.2°C (99.0°F), and oxygen
saturation 99% on room air. A urine toxicology
2 Which risk factors are associated with agitated or
violent patient behavior?
screen is pending. What is the safest drug to
reduce her agitation?
A. Female gender
A. Haloperidol
B. Longer wait times
B. Midazolam
C. Morning presentation
C. Morphine sulfate
D. Traumatic injuries
D. Olanzapine

3 A disheveled, mildly agitated 78-year-old man with

a history of COPD and substance abuse arrives via
ambulance. He is kicking at the nursing staff but does
not respond to commands. His mucous membranes
are dry, his pulse is thready but regular, and his
breath sounds show end-expiratory wheezes. His
vital signs are blood pressure 132/80, pulse rate 101,
respiratory rate 26, temperature 37.0°C (98.6°F), and
oxygen saturation 82% on room air. What should be
the first step in his management?
A. Activate the hospital protocol to initiate physical
restraints
B. Administer 4 mg IM midazolam
C. Administer 10 mg IM haloperidol
D. Place the patient on oxygen
7 Which life-threatening arrhythmia is associated
with the administration of antipsychotic
medications to an agitated patient?
A. Atrial fibrillation
B. Second-degree Mobitz I heart block
C. Torsades de pointes
D. Ventricular tachycardia
8 When is it appropriate to use physical
restraints to manage an agitated patient?
A. As soon as medications can be administered
to aid the restraint process
B. Every time a patient’s behavior escalates to
severe agitation
C. Only as a last resort when less coercive

4 Which pathological process is unlikely to manifest as

agitation?
measures have failed and the safety of the
patient and staff are at risk
D. Only in patients older than 18 years or
A. A closed head injury with a subdural hematoma
B. An opioid overdose younger than 65 years
C. Hypoglycemia with a blood glucose level of 44
D. Sepsis
9 What is the most common complication that
arises from the use of physical restraints?

5 What should be the first step when managing any A. Asphyxia

agitated patient? B. Rhabdomyolysis
A. Alert the police C. Shoulder dislocation
B. De-escalate the situation D. Skin breakdown
C. Provide chemical restraints
D. Provide physical restraints

26 Critical Decisions in Emergency Medicine


10 Which of the following is an indication for
inpatient psychiatric admission? 15 Which of the following presentations is of particular
concern in patients with coral snake envenomation?
A. Anaphylaxis
A. A history of schizophrenia
B. Alcohol withdrawal B. Coagulopathy
C. Homicidal ideations C. Neurological symptoms accompanied by
D. Worsening confusion in a patient with a history descending flaccid paralysis
of dementia D. Pain secondary to inflammation and swelling

11 A patient who has been stung on the left leg by

an Arizona bark scorpion complains of pain in her
left upper and lower extremities. In the absence
16 What should be the first step when evaluating an
envenomation?
A. Assess the patient’s vital signs
of any other clinical findings, what scorpion B. Call Poison Control
envenomation grade should be assigned? C. Confirm that the patient’s airway is protected
A. Grade I D. Identify the offending animal
B. Grade II
C. Grade III
D. Grade IV 17 What clinical feature can help differentiate a black
widow envenomation from a brown recluse spider
bite?

12 Why is fentanyl preferred over morphine to treat

scorpion envenomation in patients who are also
likely to receive antivenom?
A. Muscle rigidity
B. Pain at the bite site
C. Vomiting
A. Fentanyl causes an increase in histamine D. Weakness
B. Fentanyl causes an increase in serotonin
C. Morphine causes an increase in histamine
D. Morphine causes an increase in serotonin 18 Which of the following correctly pairs the spider with
the term used to describe the symptoms caused by its
bite?

13 A patient who was bitten by an unidentified

snake develops ptosis, slurred speech,
fasciculation, and eventual respiratory failure.
A. Black widow — loxoscelism
B. Black widow — theraphosidism
C. Brown recluse — latrodectism
What physical trait is the snake most likely to
D. Brown recluse — loxoscelism
have?

19
A. A pit on the face between the eyes and nose
B. A red-black-yellow color pattern
C. A red-yellow-black color pattern
D. A triangular head
Which of the following steps should be avoided when
managing a brown recluse bite?
A. Administration of antivenom
B. Administration of the tetanus vaccination
C. Observation to ensure no systemic involvement

14 A patient with a reported bee allergy presents

with hypotension, wheezing, and altered mental
status. What medication should be administered
D. Thorough cleaning of the bite with soap and water

first?
A. Albuterol
20
What initial diagnostic test is indicated when coral
snake envenomation is suspected?
A. Abdominal CT
B. Diphenhydramine B. EEG
C. Epinephrine C. MRI
D. Famotidine D. Pulmonary function testing

ANSWER KEY FOR JANUARY 2019, VOLUME 33, NUMBER 1

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
D B A C C C C B B C B D D D C C D A C C

February 2019 n Volume 33 Number 2 27

 Drug Box
BALOXAVIR MARBOXIL
By Frank LoVecchio, DO, MPH, FACEP
Maricopa Medical Center, Phoenix, Arizona
Baloxavir marboxil is used to treat influenza A and
B viruses, including strains that are resistant to
standard antiviral agents. It is the only “one and
done” oral medication used to manage acute
influenza.
Mechanism
The drug impedes the replication of the influenza
virus by inhibiting the endonuclease activity
of a selective polymerase acidic protein that is
required for viral gene transcription.
Adult Dosing
Weight 40 to <80 kg: 40 mg as a single oral dose
within 48 hours of symptom onset
Weight ≥80 kg: 80 mg as a single oral dose within
48 hours of symptom onset
The manufacturer provides no dosage adjustments
for adults with renal impairment (creatinine
clearance <50 mL/minute).
Note: Avoid administering with dairy products,
calcium-fortified beverages, polyvalent cation-
containing laxatives, antacids, or oral supplements
(eg, calcium, iron, magnesium, selenium, zinc).
Baloxavir marboxil can be taken with or without
food.
Precautions
The most common side effect is diarrhea (2%).
The drug is contrain­dicated in those with
a hypersensitivity to any component of its
formulation.
Pregnancy
Adverse events have not been observed in animal
reproduction studies. Untreated influenza infections
are associated with an increased risk of fetal and
maternal complications and death; however, other
influenza treatments are recommended for women
who are pregnant or ≤2 weeks postpartum.
Tox Box
CHLORINE GAS POISONING
By Christian A. Tomaszewski, MD, MS, MBA, FACEP
University of California, San Diego
Chlorine is a green-yellow gas that is heavier than air and acts as a pulmonary
irritant. Occupational exposures are common when the chemical is released
in transportation or industrial accidents. The gas can also be inadvertently
liberated when household products (eg, bleach or swimming pool chlorine) are
mixed with ammonia or acidic cleaning agents.
Mechanism
• Chlorine dissolves in lung water to produce hydrochloric and hypochlorous
acids.
• Hypochlorous acid dissociates to unpaired nascent oxygen, which causes
a free radical cascade.
Presentation
LOW concentrations (1-15 ppm) affect the upper airway and can cause:
• Cough
• Dyspnea
• Sore throat
• Eye irritation
HIGH concentrations (>30 ppm) or prolonged exposures affect the lower
airway and can cause:
• Hemoptysis
• Wheezing
• Pneumonitis
• Pulmonary edema
Evaluation and Decontamination
Patients should undergo pulse oximetry monitoring and chest radiography.
Blood tests have little value. There is little risk of secondary contamination. When
assessing a serious exposure, disrobe the patient and irrigate the skin and eyes.
Treatment
• Airway
— High-flow oxygen as needed
— Inhaled beta agonists for bronchospasm
• Potential antidote
— Nebulized 2% sodium bicarbonate (1 mL of 7.5% or 8.4% added to
3 mL saline) may help if administered early.
— The role of steroids is unproven.
Asymptomatic patients may be discharged. Consider observation for serious
symptomatic exposures, which can be complicated by delayed pulmonary
edema.