Agitated or combative patient: Difference between revisions

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==Background==
==Background==
* '''Violence may occur without warning'''
*'''Violence may occur without warning'''
* Positive predictors of violence
*Positive predictors of violence
** Male gender
**Male gender
** History of violence
**History of violence
** Substance abuse
**Substance abuse
** Psychiatric illness
**Psychiatric illness
*** Schizophrenia, Psychotic depression
***Schizophrenia, Psychotic depression
*** Personality disorders - lack remorse for violent actions
***Personality disorders - lack remorse for violent actions
*** Mania - unpredictable because of emotional lability
***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
** Ethnicity, diagnosis, age, marital status, and education
**Ethnicity, diagnosis, age, marital status, and education
** Evaluation by psychiatrist, '''regardless of experience'''
**Evaluation by psychiatrist, '''regardless of experience'''


==Clinical Features==
==Clinical Features==
* Escalation behaviors include progression through:
*Escalation behaviors 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
**Schizophrenia
** Paranoid ideation
**Paranoid ideation
** Catatonic excitement
**Catatonic excitement
** Mania
**Mania
** Personality disorders (Borderline, Antisocial)
**Personality disorders (Borderline, Antisocial)
** Delusional depression
**Delusional depression
** Post-traumatic stress disorder
**Post-traumatic stress disorder
** Decompensating obsessive-compulsive disorders
**Decompensating obsessive-compulsive disorders
** Homosexual panic
**Homosexual panic
* Situational Frustration
*Situational Frustration
** Mutual hostility
**Mutual hostility
** Miscommunication
**Miscommunication
** Fear of dependence or rejection
**Fear of dependence or rejection
** Fear of illness
**Fear of illness
** Guilt about disease process
**Guilt about disease process
* Antisocial Behavior
*Antisocial Behavior
** Violence with no associated medical or psychiatric explanation
**Violence with no associated medical or psychiatric explanation
* Organic Diseases
*Organic Diseases
** Trauma (head)
**Trauma (head)
** Hypoxia
**Hypoxia
** Hypoglycemia or Hyperglycemia
**Hypoglycemia or Hyperglycemia
** Electrolyte abnormality
**Electrolyte abnormality
** Infection
**Infection
*** CNS infection (eg, herpes encephalitis)
***CNS infection (eg, herpes encephalitis)
*** AIDS
***AIDS
** Endocrine disorder
**Endocrine disorder
*** Thyrotoxicosis
***Thyrotoxicosis
*** Hyperparathyroidism
***Hyperparathyroidism
** Seizure (eg, temporal lobe, limbic)
**Seizure (eg, temporal lobe, limbic)
** Neoplasm (limbic system)
**Neoplasm (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
** Vitamin deficiency
**Vitamin deficiency
*** Folate
***Folate
*** Vitamin B12
***Vitamin B12
*** Niacin
***Niacin
*** Vitamin B6
***Vitamin B6
*** [[Wernicke-Korsakoff syndrome]]
***[[Wernicke-Korsakoff syndrome]]
** Delirium
**Delirium
** Dementia
**Dementia
** Cerebrovascular accident
**Cerebrovascular accident
** Vascular malformation
**Vascular malformation
** [[Hypothermia]] or hyperthermia
**[[Hypothermia]] or hyperthermia
** Anemia
**Anemia
* Drugs
*Drugs
** Adverse reaction to prescribed medication
**Adverse reaction to prescribed medication
** Alcohol (intoxication and withdrawal)
**Alcohol (intoxication and withdrawal)
** Amphetamines
**Amphetamines
** Cocaine
**Cocaine
** Sedative-hypnotics (intoxication or withdrawal)
**Sedative-hypnotics (intoxication or withdrawal)
** Phencyclidine (PCP)
**Phencyclidine (PCP)
** Lysergic acid diethylamide (LSD)
**Lysergic acid diethylamide (LSD)
** Anticholinergics
**Anticholinergics
** Aromatic hydrocarbons (eg, glue, paint, gasoline)
**Aromatic hydrocarbons (eg, glue, paint, gasoline)
** Steroids
**Steroids


==Evaluation==
==Evaluation==
* '''Screen for acute medical conditions that may contribute to the patient's behavior.'''
*'''Screen for acute medical conditions that may contribute to the patient's behavior.'''
** Always obtain:
**Always obtain:
*** Blood glucose
***Blood glucose
*** Vitals, including pulse oximetry
***Vitals, including pulse oximetry
** Consider:
**Consider:
*** 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)
***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
* '''Unnecessary diagnostic testing prolongs ED stay and delays definitive psychiatric care.'''
*'''Unnecessary diagnostic testing prolongs ED stay and delays definitive psychiatric care.'''
** '''Organic cause unlikely''' → ''may not'' require further workup
**'''Organic cause unlikely''' → ''may not'' require further workup
*** Younger than 40 years
***Younger than 40 years
*** Prior psychiatric history
***Prior psychiatric history
*** Normal physical examination
***Normal physical examination
**** Normal vital signs
****Normal vital signs
**** Calm demeanor
****Calm demeanor
**** Normal orientation
****Normal orientation
**** No physical complaints
****No physical complaints
** '''Organic cause more likely''' → ''does'' require further workup
**'''Organic cause more likely''' → ''does'' require further workup
*** Acute onset of agitated behavior
***Acute onset of agitated behavior
*** Behavior that waxes and wanes over time
***Behavior that waxes and wanes over time
*** Older than 40 years with new psychiatric symptoms
***Older than 40 years with new psychiatric symptoms
*** Elders (higher risk for delirium)
***Elders (higher risk for delirium)
*** History of substance abuse (intoxication or withdrawal)
***History of substance abuse (intoxication or withdrawal)
*** Persistently abnormal vital signs
***Persistently abnormal vital signs
*** Clouding of consciousness
***Clouding of consciousness
*** Focal neurologic findings
***Focal neurologic findings


==Management==
==Management==


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


===Verbal management techniques===
===Verbal management 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
** Possession of weapons
**Possession of weapons
** History of violent behavior
**History of violent behavior
** Current use of intoxicants
**Current use of intoxicants
* Be nonconfrontational, attentive, and receptive
*Be nonconfrontational, attentive, and receptive
** Respond in a calm and soothing tone
**Respond in a calm and soothing tone
* '''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 — Invites patient to challenge with violence
*'''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 ''deceive'' ''' (eg, about estimated wait times) — Invites violence when lie is uncovered
* '''Do not ''command'' ''' to calm down — Invites further escalation
*'''Do not ''command'' ''' to calm down — Invites further escalation
* '''Do not ''downplay'', ''deny'', or ''ignore'' '''threatening behavior
*'''Do not ''downplay'', ''deny'', or ''ignore'' '''threatening behavior
* '''Do not ''hesitate'' ''' — Leave and call for help if necessary
*'''Do not ''hesitate'' ''' — Leave and call for help if necessary


===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
*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
* Neuroleptics ([[Antipsychotics]])
*Neuroleptics ([[Antipsychotics]])
** Atypical antipsychotics
**Atypical antipsychotics
*** Less sedation and [[EPS]] (than typical)
***Less sedation and [[EPS]] (than typical)
*** Increased mortality in elderly with dementia-related psychosis
***Increased mortality in elderly with dementia-related psychosis
*** [[olanzapine]], [[ziprasidone]], and [[aripiprazole]]
***[[olanzapine]], [[ziprasidone]], and [[aripiprazole]]
** Typical antipsychotics (low potency)
**Typical antipsychotics (low potency)
*** Greater sedation, hypotension, anticholinergic effects (than high-potency)
***Greater sedation, hypotension, anticholinergic effects (than high-potency)
*** [[chlorpromazine]] and [[thioridazine]]  
***[[chlorpromazine]] and [[thioridazine]]  
** Typical antipsychotics (medium potency)
**Typical antipsychotics (medium potency)
*** [[loxapine]] and [[molindone]]
***[[loxapine]] and [[molindone]]
** Typical antipsychotics (high potency)
**Typical antipsychotics (high potency)
*** Greater [[EPS]] (than low-potency)
***Greater [[EPS]] (than low-potency)
*** [[butyrophenones]]: [[haloperidol]] and [[droperidol]]
***[[butyrophenones]]: [[haloperidol]] and [[droperidol]]
** Cautions
**Cautions
*** [[Neuroleptic malignant syndrome]] — rare
***[[Neuroleptic malignant syndrome]] — rare
*** [[Extrapyramidal symptoms]] — treat with [[diphenhydramine]] or [[benztropine]]
***[[Extrapyramidal symptoms]] — treat with [[diphenhydramine]] or [[benztropine]]
*** [[QTc prolongation]] and [[torsades de pointes]]
***[[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>
*[[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
**4-6mg/kg IM or 1mg/kg IV
* [[Benzodiazepines]]
*[[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>
**''"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
**[[Lorazepam]] &mdash; Eliminated 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
** [[Midazolam]]
**[[Midazolam]]
*** Onset: 15 min (IM)
***Onset: 15 min (IM)
*** Duration: 2 H
***Duration: 2 H


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


==Disposition==
==Disposition==
* Admit or commit when...
*Admit or commit when...
** Harm to self
**Harm to self
** Harm to others
**Harm to others
** Cannot care for self
**Cannot care for self
** Uncooperative, refusing to answer questions
**Uncooperative, refusing to answer questions
** Intoxicated
**Intoxicated
** Psychotic
**Psychotic
** Organic brain syndrome
**Organic brain syndrome
* Consider discharge when...
*Consider discharge when...
** Temporary organic syndrome has concluded (eg, intoxication)
**Temporary organic syndrome has concluded (eg, intoxication)
** No other significant problem requiring acute intervention
**No other significant problem requiring acute intervention
** Patient is in control and no longer violent
**Patient is in control and no longer violent


==See Also==
==See Also==
* [[Altered mental status]]
*[[Altered mental status]]
* [[Excited delirium]]
*[[Excited delirium]]
*[[Sedation (main)]]
*[[Sedation (main)]]


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==Further Reading==
==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.
*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.
*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==

Revision as of 01:12, 24 July 2017

Background

  • Violence may occur without warning
  • 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

  • Escalation behaviors 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
    • 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; 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
  • 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)

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 or commit when...
    • Harm to self
    • Harm to others
    • Cannot care for self
    • Uncooperative, refusing to answer questions
    • Intoxicated
    • Psychotic
    • Organic brain syndrome
  • 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. ↑ Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587
  2. ↑ Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587
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