Agitated or combative patient: Difference between revisions

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**Substance abuse
**Substance abuse
**Psychiatric illness
**Psychiatric illness
***Schizophrenia, Psychotic depression
***[[Schizophrenia]], Psychotic [[depression]]
***Personality disorders - lack remorse for violent actions
***[[Personality disorders]] - (e.g. antisocial personality disorder patients may lack remorse for violent actions_
***Mania - unpredictable because of emotional lability
***[[bipolar disorder|Mania]] - unpredictable because of emotional lability
**Increased '''waiting''' duration (for evaluation, results, treatment, etc)
**Increased '''waiting''' duration (for evaluation, results, treatment, etc)
*Factors that '''do not''' predict violence
*Factors that '''do not''' predict violence
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==Clinical Features==
==Clinical Features==
*Escalation behaviors include progression through:
*Escalation behaviors may include progression through:
**anger, resistance, aggression, hostility, argumentativeness, violence
**Anger, resistance, aggression, hostility, argumentativeness, violence


==Differential Diagnosis==
==Differential Diagnosis==
*FIND ME (functional, infectious, neurologic, drugs, metabolic, endocrine)
''FIND ME (functional, infectious, neurologic, drugs, metabolic, endocrine)''
*Psychiatric
*Psychiatric
**[[Schizophrenia]], paranoid ideation, catatonic excitement
**[[Schizophrenia]], paranoid ideation, catatonic excitement
**[[Bipolar disorder|Mania]]
**[[Bipolar disorder|Mania]]
**Personality disorders ([[borderline personality disorder|borderline]], [[antisocial personality disorder|antisocial]])
**Personality disorders ([[borderline personality disorder|borderline]], [[antisocial personality disorder|antisocial]])
**Delusional depression
**Delusional [[depression]]
**Post-traumatic stress disorder
**Post-traumatic stress disorder
**Decompensating obsessive-compulsive disorders
**Decompensating obsessive-compulsive disorders
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**Endocrine disorder
**Endocrine disorder
***[[Thyrotoxicosis]]
***[[Thyrotoxicosis]]
***Hyperparathyroidism
***[[Hyperparathyroidism]]
**[[Seizure]] (eg, temporal lobe, limbic)
**[[Seizure]] (eg, temporal lobe, limbic)
**[[CNS tumor]] (limbic system)
**[[CNS tumor]] (limbic system)
**Autoimmune Disease
**Autoimmune Disease
***Limbic encephalitis
***[[Limbic encephalitis]]
***[[Multiple sclerosis]]
***[[Multiple sclerosis]]
**[[Porphyria]]
**[[Porphyria]]
**Wilson’s disease
**[[Wilson's disease]]
**Huntington’s disease
**Huntington’s disease
**Sleep disorders
**Sleep disorders
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**[[Dementia]]
**[[Dementia]]
**[[Cerebrovascular accident]]
**[[Cerebrovascular accident]]
**Vascular malformation
**Vascular malformation (e.g. [[AVM]])
**[[Hypothermia]] or [[hyperthermia]]
**[[Hypothermia]] or [[hyperthermia]]
**[[Anemia]]
**[[Anemia]]
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**[[Lysergic acid diethylamide (LSD)]]
**[[Lysergic acid diethylamide (LSD)]]
**[[Anticholinergics]]
**[[Anticholinergics]]
**Aromatic hydrocarbons (eg, glue, paint, gasoline)
**Aromatic [[hydrocarbons]] (eg, glue, paint, gasoline)
**[[Steroids]]
**[[Steroids]]


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***Metabolic panel: serum electrolytes, thyroid function
***Metabolic panel: serum electrolytes, thyroid function
***Toxicology screen and blood alcohol levels
***Toxicology screen and blood alcohol levels
***Lumbar puncture (CNS infection)
***Ammonia level
***Urine analysis
***[[Lumbar puncture]] (CNS infection)
***Aspirin and acetaminophen levels (intentional ingestion)
***Aspirin and acetaminophen levels (intentional ingestion)
***Medication levels (sub- vs super-therapeutic)
***Medication levels (sub- vs super-therapeutic)
***Electrocardiogram (elders, intentional ingestion).
***[[Electrocardiogram]] (elders, intentional ingestion).
***Cranial imaging
***Cranial imaging
***Electroencephalography
***Electroencephalography
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**Presence of objects that may be used as weapons
**Presence of objects that may be used as weapons


===Verbal management techniques===
===Verbal de-escalation techniques===
*Be honest and straightforward; Ask about violence directly
*Be honest and straightforward; Ask about violence directly
**Suicidal or homicidal ideations and plans
**Suicidal or homicidal ideations and plans
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*Be nonconfrontational, attentive, and receptive
*Be nonconfrontational, attentive, and receptive
**Respond in a calm and soothing tone
**Respond in a calm and soothing tone
**Express concern/worry about the patient
*'''Three Fs framework''':
*'''Three Fs framework''':
**I understand how you could '''feel''' that way.
**I understand how you could '''feel''' that way.
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===Chemical Restraints (Rapid Tranquilization)===
===Chemical Restraints (Rapid Tranquilization)===
*Offer voluntary administration to patient — increased sense of control may calm patient
*Offer voluntary administration to patient — 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
*Suggested protocol for continued agitation: antipsychotic Q5 min x 2, then ketamine IM
**E.g. [[Droperidol]] 10mg (or [[haloperidol]] 5mg) IM Q5 min x 2, then [[ketamine]] 300mg IM
**E.g. [[Droperidol]] 10mg (or [[haloperidol]] 5mg) IM Q5 min x 2, then [[ketamine]] 300mg IM
*[[Ketamine]], at a dose of 3-5 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]])
*Neuroleptics ([[Antipsychotics]])
**Atypical antipsychotics
**Atypical antipsychotics
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***Onset: 15 min (IM)
***Onset: 15 min (IM)
***Duration: 2 H
***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===
===Physical restraints===
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==Disposition==
==Disposition==
===Admit===
*Admit or commit when...
*Admit or commit when...
**Harm to self
**Harm to self
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**Psychotic
**Psychotic
**Organic brain syndrome
**Organic brain syndrome
===Discharge===
*Consider discharge when...
*Consider discharge when...
**Temporary organic syndrome has concluded (eg, intoxication)
**Temporary organic syndrome has concluded (eg, intoxication)
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==See Also==
==See Also==
*[[Sedation (main)]]
*[[Altered mental status]]
*[[Altered mental status]]
*[[Excited delirium]]
*[[Excited delirium]]
*[[Sedation (main)]]
*[[Acute psychosis]]


==External Links==
==External Links==

Latest revision as of 19:49, 11 January 2024

Background

  • Violence may occur without warning
  • Positive predictors of violence
    • Male gender
    • History of violence
    • Substance abuse
    • Psychiatric illness
    • 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)

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 → 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 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 — 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

Chemical Restraints (Rapid Tranquilization)

  • Offer voluntary administration to patient — 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. Reference with video
  • Suggested protocol for continued agitation: antipsychotic Q5 min x 2, then ketamine IM
  • Ketamine, at a dose of 3-5 mg/kg IM, achieves sedation in 2-10 minutes. Few medications, if any, reliably achieve effective sedation this quickly following a single dose. [1].
  • Other protocols involve combination therapy[2].
  • Neuroleptics (Antipsychotics)
  • Ketamine[3]
    • 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.[4]
    • Lorazepam — 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:[5]
    • 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

See Also

External Links

Further Reading

References

  1. ↑ 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/.
  2. ↑ The Art of the ED Takedown EMDocs
  3. ↑ Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587
  4. ↑ Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587
  5. ↑ 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.
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