Enfoque inicial del paciente agitado en el servicio de urgencias
El DSM-5 define la agitación como una actividad psicomotora excesiva, asociada con una sensación de tensión interna, que se caracteriza por conductas repetitivas y no dirigidas a metas. Por su parte, expertos internacionales en agitación la definen como un estado de inquietud, donde predominan carac...
- Autores:
-
Zabaleta Morelo, Silvana María
Londoño Herrera, Juan Pablo
- Tipo de recurso:
- Fecha de publicación:
- 2025
- Institución:
- Universidad de Antioquia
- Repositorio:
- Repositorio UdeA
- Idioma:
- OAI Identifier:
- oai:bibliotecadigital.udea.edu.co:10495/47702
- Acceso en línea:
- https://hdl.handle.net/10495/47702
- Palabra clave:
- Trastornos Mentales
Mental Disorders
Trastornos Psicóticos
Psychotic Disorders
Agitación Psicomotora
Psychomotor Agitation
Conducta Agresiva
Aggressive Behavior
https://id.nlm.nih.gov/mesh/D001523
https://id.nlm.nih.gov/mesh/D011618
https://id.nlm.nih.gov/mesh/D011595
https://id.nlm.nih.gov/mesh/D014754
ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades
- Rights
- openAccess
- License
- http://creativecommons.org/licenses/by-nc-sa/4.0/
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Enfoque inicial del paciente agitado en el servicio de urgencias |
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Initial approach to the agitated patient in the emergency department |
| title |
Enfoque inicial del paciente agitado en el servicio de urgencias |
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Enfoque inicial del paciente agitado en el servicio de urgencias Trastornos Mentales Mental Disorders Trastornos Psicóticos Psychotic Disorders Agitación Psicomotora Psychomotor Agitation Conducta Agresiva Aggressive Behavior https://id.nlm.nih.gov/mesh/D001523 https://id.nlm.nih.gov/mesh/D011618 https://id.nlm.nih.gov/mesh/D011595 https://id.nlm.nih.gov/mesh/D014754 ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| title_short |
Enfoque inicial del paciente agitado en el servicio de urgencias |
| title_full |
Enfoque inicial del paciente agitado en el servicio de urgencias |
| title_fullStr |
Enfoque inicial del paciente agitado en el servicio de urgencias |
| title_full_unstemmed |
Enfoque inicial del paciente agitado en el servicio de urgencias |
| title_sort |
Enfoque inicial del paciente agitado en el servicio de urgencias |
| dc.creator.fl_str_mv |
Zabaleta Morelo, Silvana María Londoño Herrera, Juan Pablo |
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Zabaleta Morelo, Silvana María Londoño Herrera, Juan Pablo |
| dc.subject.decs.none.fl_str_mv |
Trastornos Mentales Mental Disorders Trastornos Psicóticos Psychotic Disorders Agitación Psicomotora Psychomotor Agitation Conducta Agresiva Aggressive Behavior |
| topic |
Trastornos Mentales Mental Disorders Trastornos Psicóticos Psychotic Disorders Agitación Psicomotora Psychomotor Agitation Conducta Agresiva Aggressive Behavior https://id.nlm.nih.gov/mesh/D001523 https://id.nlm.nih.gov/mesh/D011618 https://id.nlm.nih.gov/mesh/D011595 https://id.nlm.nih.gov/mesh/D014754 ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| dc.subject.meshuri.none.fl_str_mv |
https://id.nlm.nih.gov/mesh/D001523 https://id.nlm.nih.gov/mesh/D011618 https://id.nlm.nih.gov/mesh/D011595 https://id.nlm.nih.gov/mesh/D014754 |
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ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| description |
El DSM-5 define la agitación como una actividad psicomotora excesiva, asociada con una sensación de tensión interna, que se caracteriza por conductas repetitivas y no dirigidas a metas. Por su parte, expertos internacionales en agitación la definen como un estado de inquietud, donde predominan características internas como hiperreactividad, pensamientos acelerados y tensión emocional, además de características externas como hiperactividad motora, verbal y dificultades en la comunicación. Se considera entonces que la agitación es un síndrome clínico complejo, inespecífico, de etiología variada, con diferentes niveles de gravedad y características de presentación. Por otro lado, la agresividad se define como la predisposición o voluntad para infligir daño a través de conductas verbales o físicas que pueden resultar en un daño físico o psicológico de sí mismo, de otros o del entorno. Por su parte, la violencia se considera un subtipo extremo de agresividad, en el que predominan las conductas físicas con la intención clara de causar daño físico grave. [Tomado del desarrollo]. |
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Zabaleta SM, Londoño JP. Enfoque inicial del paciente agitado en el servicio de urgencias. [Internet]. Medellín: Perlas Clínicas, Facultad de Medicina, Universidad de Antioquia; 2025 [Acceso día de mes de año]. DOI: https://doi.org/10.59473/medudea.pc.2025.103 |
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10.59473/medudea.pc.2025.103 |
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Zabaleta SM, Londoño JP. Enfoque inicial del paciente agitado en el servicio de urgencias. [Internet]. Medellín: Perlas Clínicas, Facultad de Medicina, Universidad de Antioquia; 2025 [Acceso día de mes de año]. DOI: https://doi.org/10.59473/medudea.pc.2025.103 10.59473/medudea.pc.2025.103 |
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Martínez-Raga J, Amore M, Di Sciascio G, Florea RI, Garriga M, Gonzalez G, et al., 1st International Experts’ Meeting on Agitation: Conclusions Regarding the Current and Ideal Management Paradigm of Agitation. Front Psychiatry. 2018 Feb 27;9:54. doi: 10.3389/fpsyt.2018.00054. Du M, Wang X, Yin S, Shu W, Hao R, Zhao S, et al. De-escalation techniques for psychosis-induced aggression or agitation. Cochrane Database Syst Rev. 2017 Apr 3;4(4):CD009922. doi: 10.1002/14651858.CD009922.pub2. Mantilla C, Rodríguez M, Paz A. Guías básicas de atención médica prehospitalaria. Urgencia psiquiátrica. Centro Regulador de Urgencias 2019. Secretaría Distrital de Salud de Bogotá. Tadros A, Kiefer C. Violence in the Emergency Department: A Global Problem. Psychiatr Clin North Am. 2017 Sep;40(3):575-584. Miller CWT, Hodzic V, Weintraub E. Current Understanding of the Neurobiology of Agitation. West J Emerg Med. 2020 Jul 2;21(4):841-848. doi: 10.5811/westjem.2020.4.45779. Gazzaniga M. Emoción. En: Cognitive Neuroscience: The Biology of the Mind. 2018. Vieta E, Garriga M, Cardete L, Bernardo M, Lombraña M, Blanch J, et al. Protocol for the management of psychiatric patients with psychomotor agitation. BMC Psychiatry. 2017 Sep 8;17(1):328. doi: 10.1186/s12888-017-1490-0. Baldaçara L, Diaz AP, Leite V, Pereira LA, Dos Santos RM, et al. Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach. Braz J Psychiatry. 2019 Jul-Aug;41(4):324-335. doi: 10.1590/1516-4446-2018-0177. 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):11-6 Berg AZ, Bell CC, Tupin J. Clinician safety: assessing and managing the violent patient. New Dir Ment Health Serv. 2000 Summer;(86):9-29. doi: 10.1002/yd.23320008604. PMID: 10885262. Nordstrom K, Zun LS, Wilson MP, Stiebel V, Ng AT, Bregman B, Anderson EL. Medical evaluation and triage of the agitated patient: consensusstatement of the American association for emergency psychiatryproject Beta medical evaluation workgroup. West J Emerg Med.2012;13:3-10 Freudenreich O, Schulz SC, Goff DC. Initial medical work-up of first-episode psychosis: a conceptual review. Early Interv Psychiatry 2009; 3:10. Wolfe C, McCoin N. Management of the Agitated Patient. Emerg Med Clin North Am. 2024 Feb;42(1):13-29. doi: 10.1016/j.emc.2023.06.010. Epub 2023 Jul 28. PMID: 37977745 Roppolo LP, Morris DW, Khan F, Downs R, Metzger J, Carder T, Wong AH, Wilson MP. Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation). J Am Coll Emerg Physicians. 2020 Jul 3;1(5):898-907 Price O, Baker J, Bee P, Lovell K. Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression. Br J Psychiatry 2015; 206:447. Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT. 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 Price O, Baker J, Bee P, Lovell K. Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression. Br J Psychiatry 2015; 206:447 Wilson MP, Pepper D, Currier GW, Holloman GH, Feifel D. The psychopharmacology of agitation: Consensus statement of the American Association for emergency psychiatry project BETA psychopharmacology workgroup. West J Emerg Med. 2012;13(1):26–34. Allen MH, Currier GW, Carpenter D, Ross RW, Docherty JP. The expert consensus guideline series. Treatment of behavioral emergencies 2005. J Psychiatr Pract 2005; 11 Suppl 1:5. Berzlanovich AM, Schöpfer J, Keil W. Deaths dueto physical restraint. Dtsch Arztebl Int 2012; 109(3):27–32. DOI: 10.3238/arztebl.2012.0027. Rice MM, Moore GP. Management of the violent patient. Therapeutic and legal considerations. Emerg Med Clin North Am 1991; 9:13. Fernández V, Murcia E, Sinisterra J, Casal C, Gómez MC. Manejo inicial del paciente agitado. Emergencias, 2009; 21:121- 132. 3. |
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Zabaleta Morelo, Silvana MaríaLondoño Herrera, Juan Pablo2025-10-12T23:26:20Z2025Zabaleta SM, Londoño JP. Enfoque inicial del paciente agitado en el servicio de urgencias. [Internet]. Medellín: Perlas Clínicas, Facultad de Medicina, Universidad de Antioquia; 2025 [Acceso día de mes de año]. DOI: https://doi.org/10.59473/medudea.pc.2025.103https://hdl.handle.net/10495/4770210.59473/medudea.pc.2025.103El DSM-5 define la agitación como una actividad psicomotora excesiva, asociada con una sensación de tensión interna, que se caracteriza por conductas repetitivas y no dirigidas a metas. Por su parte, expertos internacionales en agitación la definen como un estado de inquietud, donde predominan características internas como hiperreactividad, pensamientos acelerados y tensión emocional, además de características externas como hiperactividad motora, verbal y dificultades en la comunicación. Se considera entonces que la agitación es un síndrome clínico complejo, inespecífico, de etiología variada, con diferentes niveles de gravedad y características de presentación. Por otro lado, la agresividad se define como la predisposición o voluntad para infligir daño a través de conductas verbales o físicas que pueden resultar en un daño físico o psicológico de sí mismo, de otros o del entorno. Por su parte, la violencia se considera un subtipo extremo de agresividad, en el que predominan las conductas físicas con la intención clara de causar daño físico grave. [Tomado del desarrollo].22 páginasapplication/pdfUniversidad de Antioquia, Facultad de MedicinaMedellín, Colombiahttp://creativecommons.org/licenses/by-nc-sa/4.0/info:eu-repo/semantics/openAccessAttribution-NonCommercial-ShareAlike 4.0 Internationalhttp://purl.org/coar/access_right/c_abf2Enfoque inicial del paciente agitado en el servicio de urgenciasInitial approach to the agitated patient in the emergency departmentArtículo de revistahttp://purl.org/coar/resource_type/c_6501http://purl.org/coar/resource_type/c_3e5ahttp://purl.org/redcol/resource_type/ARTREFTexthttp://purl.org/coar/version/c_b1a7d7d4d402bcceinfo:eu-repo/semantics/contributionToPeriodicalinfo:eu-repo/semantics/draftMartínez-Raga J, Amore M, Di Sciascio G, Florea RI, Garriga M, Gonzalez G, et al., 1st International Experts’ Meeting on Agitation: Conclusions Regarding the Current and Ideal Management Paradigm of Agitation. Front Psychiatry. 2018 Feb 27;9:54. doi: 10.3389/fpsyt.2018.00054.Du M, Wang X, Yin S, Shu W, Hao R, Zhao S, et al. De-escalation techniques for psychosis-induced aggression or agitation. Cochrane Database Syst Rev. 2017 Apr 3;4(4):CD009922. doi: 10.1002/14651858.CD009922.pub2.Mantilla C, Rodríguez M, Paz A. Guías básicas de atención médica prehospitalaria. Urgencia psiquiátrica. Centro Regulador de Urgencias 2019. Secretaría Distrital de Salud de Bogotá.Tadros A, Kiefer C. Violence in the Emergency Department: A Global Problem. Psychiatr Clin North Am. 2017 Sep;40(3):575-584.Miller CWT, Hodzic V, Weintraub E. Current Understanding of the Neurobiology of Agitation. West J Emerg Med. 2020 Jul 2;21(4):841-848. doi: 10.5811/westjem.2020.4.45779.Gazzaniga M. Emoción. En: Cognitive Neuroscience: The Biology of the Mind. 2018.Vieta E, Garriga M, Cardete L, Bernardo M, Lombraña M, Blanch J, et al. Protocol for the management of psychiatric patients with psychomotor agitation. BMC Psychiatry. 2017 Sep 8;17(1):328. doi: 10.1186/s12888-017-1490-0.Baldaçara L, Diaz AP, Leite V, Pereira LA, Dos Santos RM, et al. Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach. Braz J Psychiatry. 2019 Jul-Aug;41(4):324-335. doi: 10.1590/1516-4446-2018-0177.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):11-6Berg AZ, Bell CC, Tupin J. Clinician safety: assessing and managing the violent patient. New Dir Ment Health Serv. 2000 Summer;(86):9-29. doi: 10.1002/yd.23320008604. PMID: 10885262.Nordstrom K, Zun LS, Wilson MP, Stiebel V, Ng AT, Bregman B, Anderson EL. Medical evaluation and triage of the agitated patient: consensusstatement of the American association for emergency psychiatryproject Beta medical evaluation workgroup. West J Emerg Med.2012;13:3-10Freudenreich O, Schulz SC, Goff DC. Initial medical work-up of first-episode psychosis: a conceptual review. Early Interv Psychiatry 2009; 3:10.Wolfe C, McCoin N. Management of the Agitated Patient. Emerg Med Clin North Am. 2024 Feb;42(1):13-29. doi: 10.1016/j.emc.2023.06.010. Epub 2023 Jul 28. PMID: 37977745Roppolo LP, Morris DW, Khan F, Downs R, Metzger J, Carder T, Wong AH, Wilson MP. Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation). J Am Coll Emerg Physicians. 2020 Jul 3;1(5):898-907Price O, Baker J, Bee P, Lovell K. Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression. Br J Psychiatry 2015; 206:447.Richmond JS, Berlin JS, Fishkind AB, Holloman GH Jr, Zeller SL, Wilson MP, Rifai MA, Ng AT. 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):17-25Price O, Baker J, Bee P, Lovell K. Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggression. Br J Psychiatry 2015; 206:447Wilson MP, Pepper D, Currier GW, Holloman GH, Feifel D. The psychopharmacology of agitation: Consensus statement of the American Association for emergency psychiatry project BETA psychopharmacology workgroup. West J Emerg Med. 2012;13(1):26–34.Allen MH, Currier GW, Carpenter D, Ross RW, Docherty JP. The expert consensus guideline series. Treatment of behavioral emergencies 2005. J Psychiatr Pract 2005; 11 Suppl 1:5.Berzlanovich AM, Schöpfer J, Keil W. Deaths dueto physical restraint. Dtsch Arztebl Int 2012; 109(3):27–32. DOI: 10.3238/arztebl.2012.0027.Rice MM, Moore GP. Management of the violent patient. Therapeutic and legal considerations. Emerg Med Clin North Am 1991; 9:13.Fernández V, Murcia E, Sinisterra J, Casal C, Gómez MC. Manejo inicial del paciente agitado. Emergencias, 2009; 21:121- 132. 3.Perlas ClínicasTrastornos MentalesMental DisordersTrastornos PsicóticosPsychotic DisordersAgitación PsicomotoraPsychomotor AgitationConducta AgresivaAggressive Behaviorhttps://id.nlm.nih.gov/mesh/D001523https://id.nlm.nih.gov/mesh/D011618https://id.nlm.nih.gov/mesh/D011595https://id.nlm.nih.gov/mesh/D014754ODS 3: Salud y bienestar. 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