Agitated or combative patient

Background

• Violence may occur without warning
• Positive predictors of violence
  • Male gender
  • History of violence
  • Substance abuse
  • Psychiatric illness
    • Schizophrenia, Psychotic depression
    • Personality disorders - (e.g. antisocial personality disorder patients may 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 may 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
• 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
  • Head trauma
  • Hypoxia
  • Hypoglycemia or hyperglycemia
  • Electrolyte abnormality
  • Infection
    • CNS infection (eg, herpes encephalitis)
    • AIDS
  • Endocrine disorder
    • Thyrotoxicosis
    • Hyperparathyroidism
  • Seizure (eg, temporal lobe, limbic)
  • CNS tumor (limbic system)
  • Autoimmune Disease
    • Limbic encephalitis
    • Multiple sclerosis
  • Porphyria
  • Wilson's disease
  • Huntington’s disease
  • Sleep disorders
  • Vitamin deficiencies (e.g. folate, B12, niacin, B6)
  • Delirium
  • Dementia
  • Cerebrovascular accident
  • Vascular malformation (e.g. AVM)
  • Hypothermia or hyperthermia
  • Anemia
• Tox
  • 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
    • 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
  • E.g. Droperidol 5mg (or haloperidol 5mg) IM Q5 min x 2, then ketamine 300mg IM
• Ketamine, at a dose of 4-6 mg/kg IM, achieves sedation in 2-10 minutes. Few medications, if any, reliably achieve effective sedation this quickly following a single dose. .
• Other protocols involve combination therapy.
• Neuroleptics (Antipsychotics)
  • Atypical antipsychotics
    • Less sedation and EPS (than typical)
    • Increased mortality in elderly with dementia-related psychosis
    • olanzapine, ziprasidone, and aripiprazole
  • Typical antipsychotics (low potency)
    • Greater sedation, hypotension, anticholinergic effects (than high-potency)
    • chlorpromazine and thioridazine
  • Typical antipsychotics (medium potency)
    • loxapine and molindone
  • Typical antipsychotics (high potency)
    • Greater EPS (than low-potency)
    • butyrophenones: haloperidol and droperidol
  • Cautions
    • Neuroleptic malignant syndrome — rare
    • Extrapyramidal symptoms — treat with diphenhydramine or benztropine
    • QTc prolongation and torsades de pointes
• Ketamine
  • 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.
  • 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:
  • 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

Droperidol 5 mg IM q5min x2 IM — Monitor QTc Haloperidol 5-10 mg IM IM — Risk of EPS, NMS, QTc prolongation Ketamine 4-6 mg/kg IM or 1 mg/kg IV IM/IV (onset 2-10 min (IM)) — Achieves sedation faster than most other agents Midazolam 5 mg IM IM (onset 15 min (IM), duration 2 hours) — Increasing evidence of higher adverse effects with benzodiazepines Lorazepam 2 mg IV/IM IV/IM (onset 5-20 min (IV), 15-30 min (IM), duration 6-8 hours) — No active metabolites Ziprasidone 20 mg IM IM Olanzapine 10 mg IM IM — Increased mortality in elderly with dementia-related psychosis

See Also

• Sedation (main)
• Altered mental status
• Excited delirium
• Acute psychosis

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.
• Moore GP, Pfaff JA. Assessment and emergency management of the acutely agitated or violent adult. UpToDate. Feb 16, 2017.