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 wait times
- 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
- 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
Medical screening for acute medical conditions that may contribute to the patient's behavior.
- Blood glucose and pulse oximetry
- Consider
- Serum electrolyte
- Toxicology screening
- Serum ethanol level
- Thyroid function panel
- Cranial imaging
- Electroencephalography
- Lumbar puncture (if CNS infection)
- Aspirin and acetaminophen levels (if intentional ingestion)
- Medication levels (if levels would affect therapy)
- Electrocardiogram (in elders or if intentional ingestion).
Unnecessary diagnostic testing prolongs ED stay and delays definitive psychiatric care.
- May require no 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 - requires 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 (secondary to 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
- 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
- Typical, medium potency
- Typical, high potency - greater EPS
- Atypical - less sedation and EPS
- olanzapine, ziprasidone, and aripiprazole
- Increased risk of death in elderly with dementia-related psychosis