Agitated or combative patient: Difference between revisions
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*** [[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
**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>

Revision as of 13:41, 29 March 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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