Management of the Agitated PatientAdam Watchorn

July 28, 2011

Learning Goals

• Causes of Agitation

• Verbal De-escalation

• Physical Restraints and Conducted Electrical Weapons

• Chemical Sedation

CAUSES OF AGITATION

WHAT ARE THE MOST COMMON CAUSES OF AGITATION IN THE ED?

Causes of agitation• Organic

– Substance related

• Cocaine, Amphetamines, Alcohol– Medical conditions

• Hypoxia, hypoglycemia, brain injury, pain stimulus, CNS infection– Rare: brain tumors, thyroid disorders, hyperparathyroidism, Wilson’s disease, Huntington disease

• Psychiatric

–Psychosis•Manic episode• Schizophrenia

• Non-organic and Non-psychiatric – Personality disorders

CAUSES OF AGITATION

WHAT CAUSES OF AGITATION CAN WE REVERSE IN THE ED?

Reversible or Potentially Treatment Conditions

GOT IVS • Glucose – hypoglycemia• Oxygen – hypoxia• Trauma – brain, pain• Infectious – meningitis, encephalitis• Vascular – stroke, SAH• Seizure

45MCC: “I feel sick to my stomach”

PMHx: Smoker, ETOHPsychHx: none

After waiting 45 min he left for a smoke

He returned and became angry, demanding to be seen and uttering threats

Staff tried to calm him but he left irate

Within minutes….this happened

COULD THIS HAVE BEEN PREVENTED?

28M BIBPSmashed store windows and lit car on fire

4 officers required to restrain him

He’s already TASERED twice

PMHx: BipolarMeds: Lithium, Celexa

He continues to struggle against 4 RCMP officers without any sign of tiring

Security is called to help

He is diaphoretic and extremely agitated and violent

When would you consider physical restraints?

Indications for Physical Restraints

Patients are not responding to verbal techniques, are not cooperative and refusing oral treatment plus– At risk to harming themselves or staff– Delaying diagnosis and treatment

DOCUMENT THIS!!!

What are some complications?

Complications of physical restraints

Local trauma

Aspiration

Rhabdomyolysis

Positional Asphyxia

I’ve been TASERED!

A) None

B) ECG

C) ECG, Troponins

D) ECG, Troponins, ECHO

I’ve been TASERED!

A) None

B) ECG

C) ECG, Troponins

D) ECG, Troponins, ECHO

What evaluations are needed in the ED after a TASER device activation?

AAEM Clinical Policy Statement 2010– No support for routine laboratory studies, ECGs, or

prolonged ED observation for ongoing cardiac monitoring in an asymptomatic awake and alert patient (Level of Recommendation: Class A)

– “….no evidence of dangerous lab abnormalities, physiological changes, or immediate or delayed cardiac ischemia or dysrhythmias after exposure to TASER electical discharges of up to 15 seconds.”

The patient is now physically restrained but continues to struggle in the seclusion room

The nurses manage to get some vital signs

40.8, 156, 186/94

WHAT IS YOUR MANAGEMENT PLAN?

Management

Medical Emergency: Resuscitation room

Agitation: Benzodiazepines +/- Intubation

Hyperthermia: COOL – fluids, ice

Acidosis: Bicarb 1-2 amps?

DESPITE YOUR MANAGEMENT PLAN HE CONTINUES TO STRUGGLE THEN SUDDENLY GOES LIMP

MONITOR SHOWS ASYSTOLE

EXCITED DELIRIUM SYNDROME

Described in literature as a combination of:• Acute drug intoxication• Mental illness• Struggle with law enforcement• Physical, chemical or TASER restraint• Sudden unexpected death

Why do these patients die?

Multifactorial• Positional asphyxia• Hyperthermia and acidosis• Catecholamine-induced fatal arrhythmias• Stress cardiomyopathy

WHAT’S YOUR FAVOURITE CHEMICAL SEDATION?

75MAdmitted 8 days ago for NSTEMI

36.5, 62, 136/74, 96%Bizarre behaviourAgitated and aggressive

Meds:LWMH, B-blocker, ACEI, Statin, ASA

PMHx: CAD, DM, COPD, Depression

Why is he agitated?

How would you manage this patient?

Oral is the best!

Risperidone 2mg + Ativan 2mg

Haldol 5mg + Ativan 2mg

5 – 10 mg IM q30min

Acute Extrapyramidal Syndromes

Haldol injection IM = 5% chanceHigher with repeat injections

Cogentin 1-2 mg IV (IM,PO)Benadryl 25-50 mg IV (IM,PO)

Should long QT intervals worry us?

Proportion (%) of abnormal QT intervalsDORM STUDY

Drop 10 mg Midaz 10 mg Drop 5 mg + Midaz 5 mg

0

2

4

6

8

10

12

14

16

67

14

IS THERE A BENEFIT OF COMBINING HALDOL AND ATIVAN?

SEDATION MORE RAPID WITH COMBINATION

% PATIENTS WITH EPS SYMPTOMS

Haldol 5 mg Ativan 2 mg Haldol 5 mg + Ativan 2 mg

0

5

10

15

20

25

20

3

6

WHAT MEDICATION WORKS THE FASTEST?

Mean time to sedation, min

Midaz 5 mg Haldol 5 mg Ativan 2 mg0

5

10

15

20

25

30

35

18.3

28.3

32.2

However, no mention of side effects…..

Another study with MIDAZOLAM showed:

20% required supplemental oxygen

50% required rescue medication

BOTTOM LINE:FAST but UNPREDICTABLE

WHY WOULD YOU CHOOSE OLANZEPINE OVER HALDOL?

SUMMARY OF CHEMICAL SEDATION

ORAL FIRSTRISPERIDONE 2.5 MG + ATIVAN 2 MG

UNDIFFERENTIATED AGITATION1) HALDOL 2 – 10 MG + ATIVAN 2-4 MG2) MIDAZOLAM 5-10 MG

AGITATION RELATED TO PSYCHOSIS1) HALDOL 2-10 MG + ATIVAN 2-4 MG2) OLANZEPINE 10 MG

55MBIBA collared/boardedFell down flight of stairs

Smells of AlcoholGCS 12 (E3, V4, M5)36.1, 76, 172/86Large scalp hematoma

Becomes AGITATED and AGGRESSIVE to staff and pulls out his IV and and pulls off his collar

What are your management priorities?

Management

• Agitation: Sedation Intubation– Protect C-spine– Facilitate CT scan

• Prevent Hypoxia and Hypotension

Take away points

1) Your voice + Oral Meds when possible2) Perform an early assessment because:– Agitation + Abnormal VS = emergency– Agitation + Head trauma = emergency

3) Be aware of the complications with restraints and chemical sedation

4) Choose your weapon wisely (Haldol, Ativan, Midazolam, Olanzepine, etc)

Questions

Thanks for listening!Thanks to Colleen Carey!