Agitated or combative patient: Difference between revisions
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*** Focal neurologic findings
*** Focal neurologic findings


==Management==
== Management ==


* Risk assessment
=== Risk assessment ===
** Screen for weapons and disarm prior to entrance to ED
 
** '''Violence may occur without warning'''
* Screen for weapons and disarm prior to entrance to ED
** '''Be aware of surroundings'''
* '''Violence may occur without warning'''
*** Signs of anger, resistance, aggression, hostility, argumentativeness, violence
* '''Be aware of surroundings'''
*** Accessibility of door for escape
** Signs of anger, resistance, aggression, hostility, argumentativeness, violence
*** Presence of objects that may be used as weapons
** Accessibility of door for escape
* Verbal management techniques
** Presence of objects that may be used as weapons
** Be honest and straightforward
 
** Be nonconfrontational, attentive, and receptive
=== 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
** Respond in a calm and soothing tone
** Ask about violence directly
* '''Three Fs framework''':
*** Suicidal or homicidal ideations and plans
** I understand how you could '''feel''' that way.
*** Possession of weapons
** Others in that situation have '''felt''' that way, too.
*** History of violent behavior
** Most have '''found''' that _____ helps."
*** Current use of intoxicants
* '''Avoid argumentation, machismo, and condescension'''
** '''Three Fs framework''':
* '''Do not ''threaten'' ''' to call security — Invites patient to challenge with violence
*** I understand how you could '''feel''' that way.
* '''Do not ''deceive'' ''' (eg, about estimated wait times) — Invites violence when lie is uncovered
*** Others in that situation have '''felt''' that way, too.
* '''Do not ''command'' ''' to calm down — Invites further escalation
*** Most have '''found''' that _____ helps."
* '''Do not ''downplay'', ''deny'', or ''ignore'' '''threatening behavior
** '''Avoid argumentation, machismo, and condescension'''
* '''Do not ''hesitate'' ''' — Leave and call for help if necessary
** '''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
=== Physical restraints ===
** '''Do not ''command'' ''' to calm down — Invites further escalation
 
** '''Do not ''downplay'', ''deny'', or ''ignore'' '''threatening behavior
* '''Not for convenience or punishment'''
** '''Do not ''hesitate'' ''' — Leave and call for help if necessary
* Indications for seclusion or restraint
* Physical restraints
** Imminent danger to self, others, or environment
** '''Not for convenience or punishment'''
** Part of ongoing behavioral treatment
** Indications for seclusion or restraint
* Contraindications to seclusion
*** Imminent danger to self, others, or environment
** Patient is unstable and requires close monitoring
*** Part of ongoing behavioral treatment
** Patient is self-harming (suicidal, self-mutilating, toxin ingestion)
** Contraindications to seclusion
* Caveats
*** Patient is unstable and requires close monitoring
** Allow for adequate chest expansion for ventilation
*** Patient is self-harming (suicidal, self-mutilating, toxin ingestion)
** Sudden death has occurred in the prone or hobble position
** Caveats
 
*** Allow for adequate chest expansion for ventilation
=== Chemical restraints ===
*** Sudden death has occurred in the prone or hobble position
 
* Chemical restraints (rapid tranquilization)
* AKA: Rapid tranquilization
** Offer voluntary administration to patient — may calm patient by giving sense of control
* Offer voluntary administration to patient — increased sense of control may calm patient
** Benzodiazipines
* Benzodiazipines
*** [[lorazepam]] — Eliminated without active metabolites
** [[lorazepam]] — 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
** Neuroleptics
* Neuroleptics (Antipsychotics)
*** [[Neuroleptic malignant syndrome]] is rare
** [[Neuroleptic malignant syndrome]] — rare
*** Treat [[extrapyramidal symptoms]] with [[diphenhydramine]] or [[benztropine]]
** [[Extrapyramidal symptoms]] — treat with [[diphenhydramine]] or [[benztropine]]
*** Risk of [[QTc prolongation]] and [[torsades de pointes]]
** [[QTc prolongation]] and [[torsades de pointes]]
*** Typical, low potency — greater sedation, hypotension, anticholinergic effects
** Atypical antipsychotics
**** [[chlorpromazine]] and [[thioridazine]]  
** Less sedation and [[EPS]] (than typical)
*** Typical, medium potency
*** Increased mortality in elderly with dementia-related psychosis
**** [[loxapine]] and [[molindone]]
*** [[olanzapine]], [[ziprasidone]], and [[aripiprazole]]
*** Typical, high potency — greater [[EPS]]
** Typical, low potency Antipsychotics
**** [[butyrophenones]]: [[haloperidol]] and [[droperidol]]
*** Greater sedation, hypotension, anticholinergic effects (than high-potency)
*** Atypical — less sedation and [[EPS]]
*** [[chlorpromazine]] and [[thioridazine]]  
**** [[olanzapine]], [[ziprasidone]], and [[aripiprazole]]
** Typical, medium potency
**** Increased mortality in elderly with dementia-related psychosis
*** [[loxapine]] and [[molindone]]
** Typical, high potency
*** Greater [[EPS]] (than low-potency)
*** [[butyrophenones]]: [[haloperidol]] and [[droperidol]]


==Disposition==
==Disposition==

Revision as of 18:07, 24 February 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

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

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 (eg, intoxication)
      • After appropriate observation and behavior disturbance has concluded
    • No other significant problem requiring acute intervention
    • Patient is in control and no longer violent

External Links

See Also

References

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