Agitated or combative patient: Difference between revisions
Line 123: Line 123:


* Risk assessment
* Risk assessment
** Screen for weapons and disarm prior to entrance to ED
** '''Violence may occur without warning'''
** '''Violence may occur without warning'''
** Screen for weapons and disarm prior to entrance to ED
** '''Be aware of surroundings'''
** '''Be aware of surroundings'''
*** Signs of anger, resistance, aggression, hostility, argumentativeness, violence
*** Signs of anger, resistance, aggression, hostility, argumentativeness, violence
Line 138: Line 138:
*** History of violent behavior
*** History of violent behavior
*** Current use of intoxicants
*** Current use of intoxicants
** May try the '''Three Fs framework''':
** '''Three Fs framework''':
*** I understand how you could '''feel''' that way.
*** I understand how you could '''feel''' that way.
*** Others in that situation have '''felt''' that way, too.
*** Others in that situation have '''felt''' that way, too.
*** Most have '''found''' that _____ helps."
*** Most have '''found''' that _____ helps."
** '''Avoid''' argumentation, machismo, and condescension
** '''Avoid argumentation, machismo, and condescension'''
** '''Do not ''threaten'' ''' to call security
** '''Do not ''threaten'' ''' to call security — Invites patient to challenge with violence
*** Invites patient to challenge with violence
** '''Do not ''deceive'' ''' (eg, about estimated wait times) — Invites violence when lie is uncovered
*** Just leave and call for help if necessary — '''Do not hesitate'''
** '''Do not ''command'' ''' to calm down — Invites further escalation
** '''Do not ''deceive'' ''' (eg, about estimated wait times)
** '''Do not ''downplay'', ''deny'', or ''ignore'' '''threatening behavior
*** Invites violence when lie is uncovered
** '''Do not ''hesitate'' ''' — Leave and call for help if necessary
** '''Do not ''command'' ''' to calm down
*** Invites further escalation
** '''Do not''' downplay, deny, or ignore threatening behavior
* Physical restraints
* Physical restraints
** '''Do not''' restrain for convenience or punishment
** '''Not for convenience or punishment'''
** Indications for seclusion or restraint
** Indications for seclusion or restraint
*** Imminent danger to self, others, or environment
*** Imminent danger to self, others, or environment
Line 165: Line 162:
** Offer voluntary administration to patient — may calm patient by giving sense of control
** Offer voluntary administration to patient — may calm patient by giving sense of control
** Benzodiazipines
** Benzodiazipines
*** [[lorazepam]]
*** [[lorazepam]] — Eliminated without active metabolites
**** Elimination without active metabolites
**** Onset: 5-20 min (IV), 15-30 min (IM)
**** Onset: 5-20 min (IV), 15-30 min (IM)
**** Duration: 6-8 H
**** Duration: 6-8 H

Revision as of 01:30, 22 February 2017

Background

  • Violence may occur without warning
  • Beware escalation behaviors
    • progression through anger, resistance, aggression, hostility, argumentativeness, violence
  • 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

Clinical Features

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
    • 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
      • 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
        • Normal 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
    • 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 management techniques
    • Be honest and straightforward
    • Be nonconfrontational, attentive, and receptive
    • Respond in a calm and soothing tone
    • Ask about violence directly
      • Suicidal or homicidal ideations and plans
      • Possession of weapons
      • History of violent behavior
      • Current use of intoxicants
    • 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 — Invites patient to challenge with violence
    • Do not deceive (eg, about estimated wait times) — Invites violence when lie is uncovered
    • Do not command to calm down — Invites further escalation
    • Do not downplay, deny, or ignore threatening behavior
    • Do not hesitate — Leave and call for help if necessary
  • 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
  • Chemical restraints (rapid tranquilization)

Disposition

External Links

See Also

References

Retrieved from "https://www.wikem.org/w/index.php?title=Agitated_or_combative_patient&oldid=124058"