Agitated or combative patient: Difference between revisions
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== Background == | ==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_ | |||
***[[bipolar disorder|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 | |||
**[[Bipolar disorder|Mania]] | |||
**Personality disorders ([[borderline personality disorder|borderline]], [[antisocial personality disorder|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. [https://emcrit.org/emcrit/human-bondage-chemical-takedown/ Reference with video] | ||
*Suggested protocol for continued agitation: antipsychotic Q5 min x 2, then ketamine IM | |||
** | **E.g. [[Droperidol]] 10mg (or [[haloperidol]] 5mg) IM Q5 min x 2, then [[ketamine]] 300mg IM | ||
*** | **Other protocols involve combination therapy<ref>[http://www.emdocs.net/the-art-of-the-ed-takedown/ The Art of the ED Takedown EMDocs]</ref>. | ||
*** | *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]]<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 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.''<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> | ||
*** | **[[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:<ref>Klein LR, Driver BE, Miner JR, et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018;72(4):374-385.</ref> | |||
**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 | |||
==See Also== | |||
*[[Altered mental status]] | |||
*[[Excited delirium]] | |||
* | *[[Sedation (main)]] | ||
* | |||
* | |||
== | ==External Links== | ||
== Further Reading == | ==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. | *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. [https://www.uptodate.com/contents/assessment-and-emergency-management-of-the-acutely-agitated-or-violent-adult Assessment and emergency management of the acutely agitated or violent adult]. UpToDate. Feb 16, 2017. | *Moore GP, Pfaff JA. [https://www.uptodate.com/contents/assessment-and-emergency-management-of-the-acutely-agitated-or-violent-adult Assessment and emergency management of the acutely agitated or violent adult]. UpToDate. Feb 16, 2017. | ||
== References == | ==References== | ||
<References/> | <References/> | ||
[[Category:Psychiatry]] | [[Category:Psychiatry]] |
Revision as of 09:20, 17 June 2022
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 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
- Seizure (eg, temporal lobe, limbic)
- CNS tumor (limbic system)
- Autoimmune Disease
- 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
- 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
- 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 10mg (or haloperidol 5mg) IM Q5 min x 2, then ketamine 300mg IM
- Other protocols involve combination therapy[1].
- 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)
- 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
- Atypical antipsychotics
- Ketamine[2]
- 4-6mg/kg IM or 1mg/kg IV
- Benzodiazepines
- Typical intramuscular dosing for adult patients:[4]
- Haloperidol 5-10mg IM, ziprasidone 20mg IM, olanzapine 10mg IM, and midazolam 5mg IM.
- In order from slowest to quickest time to effect
- Haloperidol 5-10mg IM, ziprasidone 20mg IM, olanzapine 10mg IM, and midazolam 5mg IM.
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
See Also
External Links
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.
References
- ↑ The Art of the ED Takedown EMDocs
- ↑ Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587
- ↑ Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587
- ↑ Klein LR, Driver BE, Miner JR, et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med. 2018;72(4):374-385.