Agitated or combative patient: Difference between revisions
| Line 88: | Line 88: | ||
==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: | ||
*** Blood glucose | |||
*** Vitals, including pulse oximetry | |||
** Consider: | ** Consider: | ||
*** Metabolic panel: serum electrolytes, thyroid function | *** Metabolic panel: serum electrolytes, thyroid function | ||
| Line 99: | Line 101: | ||
*** 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 → | ** '''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 | ||
**** Calm demeanor | **** Calm demeanor | ||
**** Normal orientation | **** Normal orientation | ||
**** No physical complaints | **** No physical complaints | ||
** Organic cause more likely → | ** '''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 | ||
Revision as of 01:16, 22 February 2017
Background
- Violence may occur without warning
- Beware escalation behaviors
- progression through anger, resistance, aggression, hostility, argumentativeness, violence
- 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
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
- 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
- Always obtain:
- 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
- Organic cause unlikely → may not require further workup
Management
- Risk assessment
- Violence may occur without warning
- Screen for weapons and disarm prior to entrance to ED
- 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
- Be nonconfrontational, attentive, and receptive
- Respond in a calm and soothing tone
- Ask about violence directly
- Suicidal or homicidal ideations and plans
- Possession of weapons
- History of violent behavior
- Current use of intoxicants
- May try the 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
- Just leave and call for help if necessary — Do not hesitate
- 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
- 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
- Patient is unstable and requires close monitoring
- Patient is self-harming (suicidal, self-mutilating, toxin ingestion)
- Chemical restraints (rapid tranquilization)
- Offer voluntary administration to patient — may calm patient by giving sense of control
- 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 mortality in elderly with dementia-related psychosis