Agitated or combative patient

Background

• Positive predictors of violence
  • Male gender
  • History of violence
  • Substance abuse
  • Psychiatric illness
    • Schizophrenia, Psychotic depression
    • Personality disorders - lack remorse for violent actions
    • 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

Differential Diagnosis

• FIND ME (functional, infectious, neurologic, drugs, metabolic, endocrine)
• Psychiatric
  • Schizophrenia
  • Paranoid ideation
  • Catatonic excitement
  • Mania
  • Personality disorders (Borderline, Antisocial)
  • Delusional depression
  • Post-traumatic stress disorder
  • Decompensating obsessive-compulsive disorders
  • Homosexual panic
• 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
  • Trauma (head)
  • Hypoxia
  • Hypoglycemia or Hyperglycemia
  • Electrolyte abnormality
  • Infection
    • CNS infection (eg, herpes encephalitis)
    • AIDS
  • Endocrine disorder
    • Thyrotoxicosis
    • Hyperparathyroidism
  • Seizure (eg, temporal lobe, limbic)
  • Neoplasm (limbic system)
  • Autoimmune Disease
    • Limbic encephalitis
    • Multiple sclerosis
  • Porphyria
  • Wilson’s disease
  • Huntington’s disease
  • Sleep disorders
  • Vitamin deficiency
    • Folate
    • Vitamin B12
    • Niacin
    • Vitamin B6
    • Wernicke-Korsakoff syndrome
  • Delirium
  • Dementia
  • Cerebrovascular accident
  • Vascular malformation
  • Hypothermia or hyperthermia
  • Anemia
• Drugs
  • 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 and vitals, including pulse oximetry
  • Consider:
    • Metabolic panel: serum electrolytes, thyroid function
    • Toxicology screen and blood alcohol levels
    • 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 → may not require further workup
    • Younger than 40 years
    • Prior psychiatric history
    • Normal physical examination
      • Vital signs
      • Calm demeanor
      • Normal orientation
      • No physical complaints
  • Organic cause more likely → 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
  • Violence may occur without warning
  • Patients should be screened for weapons and disarmed
  • Clinician should 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 management techniques
  • Adopt an honest, straightforward manner
  • Adopt a nonconfrontational, attentive, and receptive demeanor
  • Respond in a calm and soothing tone
  • Ask questions about violence directly
    • Suicidal or homicidal ideations and plans
    • Possession of weapons
    • History of violent behavior
    • Current use of intoxicants
  • Avoid argumentation, machismo, and condescension
    • Do not threaten to call security -- invites patient to challenge with violence
    • Do not attempt to deceive (eg, about estimated wait times) -- invites violence when lie is uncovered
    • Do not downplay or deny threatening behavior
    • Do not hesitate to leave the room and summon help
• Physical restraints
  • Do not restrain for convenience or punishment
  • Indications for seclusion or restraint
    • Imminent danger to self, others, or environment
    • Part of ongoing behavioral treatment
  • Contraindications to seclusion
    • Unstable patient who requires close monitoring
    • Patient is self-harming (suicidal, self-mutilating, ingestion of toxins)
• Chemical restraints (rapid tranquilization)
  • Offer voluntary administration to patient
  • Benzodiazipines
    • lorazepam
      • Elimination without active metabolites
      • Onset: 5-20 min (IV), 15-30 min (IM)
      • Duration: 6-8 H
    • midazolam
      • Onset: 15 min (IM)
      • Duration: 2 H
  • Neuroleptics
    • Neuroleptic malignant syndrome is rare
    • Treat extrapyramidal symptoms with diphenhydramine or benztropine
    • Risk of QTc prolongation and torsades de pointes
    • Typical, low potency - greater sedation, hypotension, anticholinergic effects
      • chlorpromazine and thioridazine
    • Typical, medium potency
      • loxapine and molindone
    • Typical, high potency - greater EPS
      • butyrophenones: haloperidol and droperidol
    • Atypical - less sedation and EPS
      • olanzapine, ziprasidone, and aripiprazole
      • Increased risk of death in elderly with dementia-related psychosis

See Also

• Altered mental status
• Excited delirium