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
- 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
- Ketamine, at a dose of 3-5 mg/kg IM, achieves sedation in 2-10 minutes. Few medications, if any, reliably achieve effective sedation this quickly following a single dose. [1].
- Other protocols involve combination therapy[2].
- 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[3]
- 4-6mg/kg IM or 1mg/kg IV
- Benzodiazepines
- Typical intramuscular dosing for adult patients:[5]
- 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
- ↑ Westafer, Lauren. “Patients with Severe Agitation in the ED.” ACEP NOW, vol. 42, no. 12, https://www.acepnow.com/article/which-sedatives-are-best-for-managing-severe-agitation-in-the-emergency-department/.
- ↑ 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.