View source for Agitated or combative patient

==Background==
*'''Violence may occur without warning'''
*Positive predictors of violence
**Male gender
**History of violence
**Substance abuse
**Psychiatric illness
***[[Schizophrenia]], Psychotic [[depression]]
***[[Personality disorders]] - (e.g. antisocial personality disorder patients may lack remorse for violent actions_
***[[bipolar disorder|Mania]] - unpredictable because of emotional lability
**Increased waiting duration (for evaluation, results, treatment, etc)
*Factors that '''do not''' predict violence
**Ethnicity, diagnosis, age, marital status, and education
**Evaluation by psychiatrist, regardless of experience

==Clinical Features==
*Escalation behaviors may include progression through:
**Anger, resistance, aggression, hostility, argumentativeness, violence

==Differential Diagnosis==
''FIND ME (functional, infectious, neurologic, drugs, metabolic, endocrine)''
*Psychiatric
**[[Schizophrenia]], paranoid ideation, catatonic excitement
**[[Bipolar disorder|Mania]]
**Personality disorders ([[borderline personality disorder|borderline]], [[antisocial personality disorder|antisocial]])
**Delusional [[depression]]
**Post-traumatic stress disorder
**Decompensating obsessive-compulsive disorders
*Situational Frustration
**Mutual hostility
**Miscommunication
**Fear of dependence or rejection
**Fear of illness
**Guilt about disease process
*Antisocial Behavior
**Violence with no associated medical or psychiatric explanation
*Organic Diseases
**[[Head trauma]]
**[[Hypoxia]]
**[[Hypoglycemia]] or [[hyperglycemia]]
**[[Electrolyte abnormality]]
**Infection
***CNS infection (eg, herpes [[encephalitis]])
***[[AIDS]]
**Endocrine disorder
***[[Thyrotoxicosis]]
***[[Hyperparathyroidism]]
**[[Seizure]] (eg, temporal lobe, limbic)
**[[CNS tumor]] (limbic system)
**Autoimmune Disease
***[[Limbic encephalitis]]
***[[Multiple sclerosis]]
**[[Porphyria]]
**[[Wilson's disease]]
**Huntington’s disease
**Sleep disorders
**[[Vitamin deficiencies]] (e.g. folate, B12, niacin, B6)
**[[Delirium]]
**[[Dementia]]
**[[Cerebrovascular accident]]
**Vascular malformation (e.g. [[AVM]])
**[[Hypothermia]] or [[hyperthermia]]
**[[Anemia]]
*Tox
**Adverse reaction to prescribed medication
**[[Alcohol]] (intoxication and withdrawal)
**[[Amphetamines]]
**[[Cocaine]]
**[[Sedative/Hypnotics]] (intoxication or withdrawal)
**[[Phencyclidine]] (PCP)
**[[Lysergic acid diethylamide (LSD)]]
**[[Anticholinergics]]
**Aromatic [[hydrocarbons]] (eg, glue, paint, gasoline)
**[[Steroids]]

==Evaluation==
*Screen for acute medical conditions that may contribute to the patient's behavior.
**Always obtain:
***Blood glucose
***Vitals, including pulse oximetry
**Consider:
***Metabolic panel: serum electrolytes, thyroid function
***Toxicology screen and blood alcohol levels
***Ammonia level
***Urine analysis
***[[Lumbar puncture]] (CNS infection)
***Aspirin and acetaminophen levels (intentional ingestion)
***Medication levels (sub- vs super-therapeutic)
***[[Electrocardiogram]] (elders, intentional ingestion).
***Cranial imaging
***Electroencephalography
*Unnecessary diagnostic testing prolongs ED stay and delays definitive psychiatric care.
**Organic cause unlikely &rarr; ''may not'' require further workup
***Younger than 40 years
***Prior psychiatric history
***Normal physical examination
****Normal vital signs
****Calm demeanor
****Normal orientation
****No physical complaints
**Organic cause more likely &rarr; ''does'' require further workup
***Acute onset of agitated behavior
***Behavior that waxes and wanes over time
***Older than 40 years with new psychiatric symptoms
***Elders (higher risk for delirium)
***History of substance abuse (intoxication or withdrawal)
***Persistently abnormal vital signs
***Clouding of consciousness
***Focal neurologic findings

==Management==

===Risk assessment===
*Screen for weapons and disarm prior to entrance to ED
*'''Violence may occur without warning'''
*Be aware of surroundings
**Signs of anger, resistance, aggression, hostility, argumentativeness, violence
**Accessibility of door for escape
**Presence of objects that may be used as weapons

===Verbal de-escalation techniques===
*Be honest and straightforward; Ask about violence directly
**Suicidal or homicidal ideations and plans
**Possession of weapons
**History of violent behavior
**Current use of intoxicants
*Be nonconfrontational, attentive, and receptive
**Respond in a calm and soothing tone
**Express concern/worry about the patient
*Three Fs framework:
**I understand how you could feel that way.
**Others in that situation have felt that way, too.
**Most have found that _____ helps."
*Avoid argumentation, machismo, and condescension
*'''Do not ''threaten'' ''' to call security &mdash; Invites patient to challenge with violence
*'''Do not ''deceive'' ''' (eg, about estimated wait times) &mdash; Invites violence when lie is uncovered
*'''Do not ''command'' ''' to calm down &mdash; Invites further escalation
*'''Do not ''downplay'', ''deny'', or ''ignore'' '''threatening behavior
*'''Do not ''hesitate'' ''' &mdash; Leave and call for help if necessary

===Chemical Restraints (Rapid Tranquilization)===
*Offer voluntary administration to patient &mdash; increased sense of control may calm patient
*If need to temporary physical restraint the patient: One arm up, one arm down, tie legs to opposite side of bed. [https://emcrit.org/emcrit/human-bondage-chemical-takedown/ Reference with video]
*Suggested protocol for continued agitation: antipsychotic Q5 min x 2, then ketamine IM
**E.g. [[Droperidol]] 5mg (or [[haloperidol]] 5mg) IM Q5 min x 2, then [[ketamine]] 300mg IM
*[[Ketamine]], at a dose of 4-6 mg/kg IM, achieves sedation in 2-10 minutes. Few medications, if any, reliably achieve effective sedation this quickly following a single dose. <ref> Westafer, Lauren. “Patients with Severe Agitation in the ED.” ACEP NOW, vol. 42, no. 12, https://www.acepnow.com/article/which-sedatives-are-best-for-managing-severe-agitation-in-the-emergency-department/.</ref>.
*Other protocols involve combination therapy<ref>[http://www.emdocs.net/the-art-of-the-ed-takedown/ The Art of the ED Takedown EMDocs]</ref>.
*Neuroleptics ([[Antipsychotics]])
**Atypical antipsychotics
***Less sedation and [[EPS]] (than typical)
***Increased mortality in elderly with dementia-related psychosis
***[[olanzapine]], [[ziprasidone]], and [[aripiprazole]]
**Typical antipsychotics (low potency)
***Greater sedation, hypotension, anticholinergic effects (than high-potency)
***[[chlorpromazine]] and [[thioridazine]] 
**Typical antipsychotics (medium potency)
***[[loxapine]] and [[molindone]]
**Typical antipsychotics (high potency)
***Greater [[EPS]] (than low-potency)
***[[butyrophenones]]: [[haloperidol]] and [[droperidol]]
**Cautions
***[[Neuroleptic malignant syndrome]] &mdash; rare
***[[Extrapyramidal symptoms]] &mdash; treat with [[diphenhydramine]] or [[benztropine]]
***[[QTc prolongation]] and [[torsades de pointes]]
*[[Ketamine]]<ref>Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587</ref>
**4-6mg/kg IM or 1mg/kg IV
*[[Benzodiazepines]]
**''"There is increasing evidence that benzodiazepines alone and in combination with antipsychotics are associated with higher rates of adverse effects.''<ref>Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587</ref>
**[[Lorazepam]] &mdash; Eliminated without active metabolites
***Onset: 5-20 min (IV), 15-30 min (IM)
***Duration: 6-8 H
**[[Midazolam]]
***Onset: 15 min (IM)
***Duration: 2 H
*Typical intramuscular dosing for adult patients:<ref>Klein LR, Driver BE, Miner JR, et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018;72(4):374-385.</ref>
**Haloperidol 5-10mg IM, ziprasidone 20mg IM, olanzapine 10mg IM, and midazolam 5mg IM.
***In order from slowest to quickest time to effect

===Physical restraints===
*Not for convenience or punishment
*Indications for seclusion or restraint
**Imminent danger to self, others, or environment
**Part of ongoing behavioral treatment
*Contraindications to seclusion
**Patient is unstable and requires close monitoring
**Patient is self-harming (suicidal, self-mutilating, toxin ingestion)
*Caveats
**Allow for adequate chest expansion for ventilation
**Sudden death has occurred in the prone or hobble position

==Disposition==
===Admit===
*Admit or commit when...
**Harm to self
**Harm to others
**Cannot care for self
**Uncooperative, refusing to answer questions
**Intoxicated
**Psychotic
**Organic brain syndrome

===Discharge===
*Consider discharge when...
**Temporary organic syndrome has concluded (eg, intoxication)
**No other significant problem requiring acute intervention
**Patient is in control and no longer violent


<div style="display:none">
<!-- SMW MedicationDose annotations for chemical restraint medications -->
{{MedicationDose|drug=Droperidol|dose=5 mg IM q5min x2|route=IM|context=1st line antipsychotic for acute agitation|indication=Agitated or combative patient|notes=Monitor QTc}}
{{MedicationDose|drug=Haloperidol|dose=5-10 mg IM|route=IM|context=Antipsychotic for acute agitation|indication=Agitated or combative patient|notes=Risk of EPS, NMS, QTc prolongation}}
{{MedicationDose|drug=Ketamine|dose=4-6 mg/kg IM or 1 mg/kg IV|route=IM/IV|context=Rescue sedation for severe agitation|indication=Agitated or combative patient|onset=2-10 min (IM)|notes=Achieves sedation faster than most other agents}}
{{MedicationDose|drug=Midazolam|dose=5 mg IM|route=IM|context=Benzodiazepine for agitation|indication=Agitated or combative patient|onset=15 min (IM)|duration=2 hours|notes=Increasing evidence of higher adverse effects with benzodiazepines}}
{{MedicationDose|drug=Lorazepam|dose=2 mg IV/IM|route=IV/IM|context=Benzodiazepine for agitation|indication=Agitated or combative patient|onset=5-20 min (IV), 15-30 min (IM)|duration=6-8 hours|notes=No active metabolites}}
{{MedicationDose|drug=Ziprasidone|dose=20 mg IM|route=IM|context=Atypical antipsychotic for agitation|indication=Agitated or combative patient}}
{{MedicationDose|drug=Olanzapine|dose=10 mg IM|route=IM|context=Atypical antipsychotic for agitation|indication=Agitated or combative patient|notes=Increased mortality in elderly with dementia-related psychosis}}
</div>
==See Also==
*[[Sedation (main)]]
*[[Altered mental status]]
*[[Excited delirium]]
*[[Acute psychosis]]

==External Links==


==Further Reading==
*Heiner JD and Moore GP.  The Combative Patient.  In: Marx J, Walls R, Hockberger R, eds.  Rosen's Emergency Medicine: Concepts and Clinical Practice.  8th ed.  Philadelphia, PA: Elsevier/Saunders; 2014: 188: 2414-2421.
*Moore GP, Pfaff JA.  [https://www.uptodate.com/contents/assessment-and-emergency-management-of-the-acutely-agitated-or-violent-adult Assessment and emergency management of the acutely agitated or violent adult].  UpToDate.  Feb 16, 2017.

==References==
<References/>

[[Category:Psychiatry]]