Agitated or combative patient

Background

  • Violence may occur without warning
  • Positive predictors of violence
    • Male gender
    • History of violence
    • Substance abuse
    • Psychiatric illness
    • 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)

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
  • 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)
  • Ketamine[3]
    • 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.[4]
    • 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:[5]
    • 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

External Links

Further Reading

References

  1. ↑ 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/.
  2. ↑ The Art of the ED Takedown EMDocs
  3. ↑ Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587
  4. ↑ Ketamine as Rescue Treatment for Difficulty-to-Sedate Severe Acute Behavioral Disturbance in the ED. Annals of EM. May 2016 67(5):581-587
  5. ↑ 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.
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